A 38-year-old female at 35-week and 6-day gestation presented at the gyno-obstetrics emergency room of our institute early morning with abdominal pain in the epigastrium. The pain suddenly appeared and aggravated over an hour. Her obstetric history was G 4 P 0+3+0+2, and she has a history of gestational complications. In her first pregnancy, placental abruption occurred at 39 weeks, and the neonate (weight, 4900 g) was born dead after a caesarean operation. The second pregnancy had a diagnosis of severe preeclampsia at 37 weeks, and the neonate (weight, 3800 g) was born after performing a caesarean operation. Finally, in her third pregnancy, she had preterm labour at 36 weeks, and the neonate (weight, 3400 g) was born after a caesarean operation.
During physical examination, the patient was hemodynamically stable, and the bowel sounds were verified during abdominal auscultation. She had an evident general malaise characterized by abdominal pain in the epigastrium associated with bilious vomiting. The clinical evaluation showed active gestation without foetal well-being.
After clinical evaluation, the doctor decided to initiate analgesic and antispasmodic treatment (sodium metamizole, 1 g/2 mL + scopolamine butylbromide, 20 mg/mL + ranitidine 50 mg + hydration with 0.9% NaCl x 1 L). Pain persisted in the patient 1 h after pharmacological treatment despite the administration of analgesics. Foetal heartbeats were 138 per min. Therefore, the patient was referred to the Surgery and General Internal Medicine department.
The Surgery department evaluated the pregnant patient and noted evident pain in the epigastrium and right hypochondrium. They suspected biliary colic, and accordingly, requested auxiliary laboratory tests (Table 1) and imaging studies (abdominal ultrasound) to rule out acute biliary conditions.
The General Internal Medicine department evaluated the patient as she continued to present with severe abdominal pain and suggested optimizing analgesia with the use of opiates. They too suspected biliary colic.
Three hours after admission, the patient continued to experience pain despite the new drug therapy. The abdominal ultrasound report (Table 2) showed probable intestinal involvement associated with foetal bradycardia of 80-90 beats per minute (BPM). Accordingly, the attending gynaecologist decided to admit the patient to the operating room, and obstetric and surgical intervention was performed (Graphic 01).
Obstetric intervention: A median infraumbilical incision was made. Transverse segmental hysterotomy was performed, a female newborn was delivered by a paediatrician. A hysterorrhaphy in 2 planes was made with ligation of both uterine tubes before the surgeons intervened.
Surgical intervention: The surgeons detected necrosis of intestinal loops of the jejunum, ileum, cecum, ascending colon, and proximal 2/3 of the transverse colon (Fig. 1). Surgical resection of the entire necrotized intestinal segment was decided. Side-to-side anastomosis between the duodenum and the transverse colon was performed, and subsequently, the cavity was washed with heated physiological serum. Finally, points were placed at the meso-level of the jejunum to close the anastomotic gap and the wall was sutured (Fig. 1A, B, C).
Postoperatively, the patient was moved to the Intensive Care Unit for normalization of homeostasis, post-sepsis stabilization, and compulsory parenteral nutrition. The patient recovered successfully; a central venous catheter was maintained for nutritional support. The patient was discharged from the hospital and transferred to the Short Intestine Unit of a specialized hospital in Lima, Peru.