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A case of complete small bowel obstruction complicated by preterm labor and sepsis
Abstract Number: S 73
Abstract Type: Case Report/Case Series
Small bowel obstruction (SBO) in pregnancy is a rare event with a reported 6% maternal and 26% fetal mortality rate. Acute recognition of this surgical emergency is paramount as delays in treatment increase maternal and fetal morbidity and mortality. Complications include preterm delivery, post-operative sepsis and prolonged paralytic ileus. Thoracic epidurals are well known to be the gold standard for postoperative pain management as well as lumbar epidurals for labor analgesia. In addition thoracic epidurals have been shown to significantly reduce the duration of postoperative ileus. Here we present a case of SBO with perforation during pregnancy complicated by preterm labor, sepsis and ileus that was successfully managed with a thoracic epidural for postoperative pain and labor analgesia.
A 21 year old female in the 27th week of her first pregnancy presented to the emergency room with an acute abdomen and obstipation for two days. The patient has had two prior surgeries including an open appendectomy and an ovarian cystectomy. MRI confirmed the clinical suspicion of complete small bowel obstruction and she was immediately taken to the operating room (OR) for an emergency exploratory laparotomy (ELAP). A preoperative thoracic epidural was placed followed by general endotracheal anesthesia via a rapid sequence induction with cricoid pressure. Surgeons found that a small bowel internal hernia, resulted in perforation and necrosis of a large portion of the bowel and resected 20cm of bowel accordingly. Fetal heart rate monitoring was done immediately prior to incision and after completion of the procedure and they were both reassuring.
Approximately 12 hrs post-op she went into preterm labor which resulted in a vaginal delivery. She also developed a fever and additional empiric antibiotics were started when she progressed into sepsis shortly after delivery. She did not require vasopressors and was resuscitated adequately with fluids and later admitted to the medical intensive care unit for monitoring.
For approximately 72 hours in midst a complicated post-op course the thoracic patient-controlled epidural analgesia safely provided excellent postoperative pain and labor analgesia with bupivicaine 0.125% and hydromorphone 20mcg per ml set at 3ml/hr with four 2 ml boluses an hour. She did not develop any CNS infections or prolonged ileus.