Mesenteric vascular occlusion in late pregnancy

Abstract

Mrs. C. D. was first seen in the Prenatal Clinic on April 26, 1961. She was a 19-year-old, white, married gravida i, para 0, with typical signs of early pregnancy. It should be noted that the patient had no history of previous abdominal surgery. Physical examination revealed a somewhat obese girl with completely normal findings other than the presence of a 6 weeks intrauterine pregnancy. The prenatal course was completely uneventful until 32 weeks’ gestation when she exhibited a trace of glucose in a routine urine sample. At 34 weeks of gestation a routine urinalysis revealed the presence of a three plus glucose and a glucose tolerance test was planned for the postpartum period. The weight gain had been 10 Kg. At 35 weeks’ gestation, suddenly at midnight the patient began having intermittent abdominal pain with associated nausea and backache. Physical examination was essentially normal. The uterus was well relaxed and the fetal heart tones were normal and regular. Tenderness was present over the symphysis and the groins. A catheterized specimen of urine contained many white blood cells. The patient vomited for the first time during the examination. She was admitted to the hospital for the investigation of the pyuria and unexplained abdominal pain. Intravenous fluid was administered and she was given nothing by mouth. Four hours later the pain was localized to the left side of the uterus; the temperature was normal, the blood pressure was slightly elevated; and the pulse which had been 72 was now 120 per minute. Four hours later the uterus became tense and intermittent contractions occurred. White blood cell count was 20,000. The pain in the abdomen became more marked and the fetal heart tones became elevated to 20@ per minute. A vaginal examination with sterile precaution revealed the cervix to be 3 cm. dilated but thick. A tentative diagnosis of partial abruptio placentae was made and it was decided that immediate cesarean section was indicated. Under general anesthesia a laparotrachelotomy was done. Upon entering the peritoneal cavity, a moderate amount of serosanguineous fluid was observed. However, the significance of this finding was not realized at the time. A living 2,550 gram female infant was delivered which required 4 minutes of endotracheal resuscitation before adequate respiration and crying were established. Upon inspection of the placenta prior to removal it was found no abruptio had occurred. Following closure of the uterus, inspection of the adnexa and appendix revealed no acute pathologic lesion. It was at this time that an area of gangrenous small bowel was visualized, measuring approximately 9 inches in length and occurring 15 inches proximal to the ileocecal valve. The section of bowel was deep purple in color, edematous, and exuding the serosanguineous fluid previously mentioned. There were no adhesions, volvulus, or intussusception. Excision of the gangrenous bowel and endto-end anastomosis was then performed. Following this the patient had a rapid recovery