Large Meckel's diverticulum complicating pregnancy with an intestinal obstruction

Abstract

Sir, The incidence of acute abdomen during pregnancy is 1 in 500–600 pregnancies 1 and intestinal obstruction occurs only in 1:3,000 to 1:16,000 pregnancies 2. The presence of a Meckel's diverticulum as the cause of obstruction is extremely rare. It requires always the extirpation of the diverticulum and bowel resection in 23% of cases and fetal mortality rate may be around 20% 3. Anatomic and physiologic changes during normal pregnancy can alter the presentation of symptoms making recognition of the disease more difficult 4. We recently observed a 35-year-old primigravida who presented in her 27th week of gestation with diffuse upper abdominal pain and vomiting, total intolerance to liquids and solid aliments during the previous five days, but no fever. The pregnancy had been normal. The clinical examination, blood analysis, fetal sonography, and monitoring at the emergency ward were all normal. After 24 hours of observation and conservative therapy, an increase of vomiting with fecaloid and bilious features was observed. Surgical intervention became necessary because of aggravation of her symptoms. Repeated sonography and magnetic resonance as well as leucocytosis lead to a suspicion of appendicitis. A small bowel obstruction related to a 10 cm Meckel's diverticulum which leaned against the intestinal surface and obstructing it was found (Figure 1). Jejunal dilatation in the proximal intestinal loops was solved with a small bowel resection and a latero-lateral anastomosis, following which the affected intestine recovered rapidly. The postoperative period was uneventful. No tocolytic treatment was needed and the pregnancy continued normally to term. Meckel's diverticulum obstructing small bowel. The presence of acute abdomen during the third trimester of pregnancy involves a diagnostic challenge, because of the special characteristics of the patients as well as the difficulty to correctly assess the symptoms. Pregnancy is a high-risk condition for the development of acute abdominal events 4 and the differential diagnosis can be complex 2, 5. Abdominal ultrasound is the diagnostic procedure of choice because of its non-invasiveness, speed and accuracy, although a wrong impression can be gained as in this case. The therapeutic algorithm is the same for pregnant and non-pregnant women. Conservative therapy is indicated first, with fluid and electrolyte replacement 2 and fetal and maternal monitoring. Unsuccessful medical treatment, aggravation of symptoms or signs of fetal distress justify early surgical exploration 1. A multidisciplinary team approach including a surgeon, an obstetrician, and a neonatologist is necessary, but simultaneous delivery may not be necessary 2. Meckel's diverticula have a high rate of perforation due to the often-delayed diagnosis, and early surgical intervention keeps maternal and fetal morbidity and mortality to a minimum 4.