Acute intestinal obstruction due to extrinsic compression by previa myoma and ectopic pregnancy: a case report

Our patient comes from a rural area. Her admission in a context of surgical digestive emergency led to minimum examinations and the realization of an emergency laparotomy. The limits of this management remain the inadequacy of the diagnostic capability and the difficulty of accessibility to the sanitary structures, resulting in late consultation. But the advantage of the emergency intervention was the discovery and treatment of the ruptured ectopic pregnancy and massive myomas.

Abdominal-pelvic pain, a frequent reason for emergency consultation in pregnant women, may have several origins, obstetric, urological, or digestive [1, 2, 7, 9, 10]. AIO during pregnancy is a rare digestive surgical emergency [4‐6, 9, 10]. Its incidence varies between 1 out of 3600 and 1 out of 66,431 pregnancies [1, 5, 6, 9]. The misdiagnosis of AIO during pregnancy leads to high maternal-fetal morbidity and mortality [5, 6]. In most cases, the AIO is linked to flanges or adhesions (in the case of a history of abdominal surgery), intestinal volvulus, intussusception, strangulated hernias, or inflammatory or neoplastic processes [2‐6, 9, 10]. The diagnostic difficulty of AIO on pregnancy has been reported by several authors [1, 3, 5, 8, 9]. In our case, ectopic pregnancy was unknown and the discovery was intraoperative. AIO is even rarer in the first trimester of pregnancy, as the risk increases with increasing uterine size [1, 9]. During pregnancy, the AIO would be enhanced by the reduction of intestinal peristalsis, the constipation increased by hormonal impregnation, which leads to the hypotonia of the intestinal musculature, and to the anatomical modification of a sequel flange [4, 5]. In our patient, extrinsic mechanical compression by a previa, myoma was responsible for intestinal obstruction. This kind of intestinal obstruction by uterine myoma previa is little described in the literature [7]. This condition occurs predominantly in three periods of pregnancy: from 16 to 20 weeks when the uterus becomes abdominal and pelvic area; from 32 to 36 weeks when the head of the fetus descends into the pelvis, and during the immediate postpartum period by a sharp decrease in the volume of the uterus [1, 4, 5, 9].

The association of ruptured tubal ectopic pregnancy and AIO has also been described by Singh et al. [10]. For these authors, AIO was caused by adherence to a small loop on a broken tubal pregnancy; they concluded that it was difficult to establish an etiologic diagnosis of AIO during pregnancy [10]. The absence of vaginal bleeding and anamnestic data related to pregnancy led us to AIO on tumor, based on occlusive syndrome, palpation of an abdominal mass and radiological images (X-ray). Peroperative incidental discoveries in emergency digestive surgery are usual when modern imaging (computed tomography scan, magnetic resonance imaging) is not available [8]. In the case of an acute AIO-type surgical abdomen, indications of medical or surgical treatment are not affected by pregnancy [1, 2, 9]. Ruptured ectopic pregnancy alone can be responsible for intestinal obstruction due to ileus associated with hemoperitoneum or intestinal adhesions [10]. In the case of our patient, the mechanical compression by the myoma of the rectal and sigmoidal hinge was evident intraoperatively. In the sub-Saharan context, with limited resources, the initial diagnosis of ectopic pregnancy can be very difficult at the initial admission of the patient, especially if the classic signs are not found (irregular menstrual cycles, absence of metrorrhagia, concealment of possible sexual intercourse outside of a conjugal home in a patient divorced for 15 years). Some authors recommend education of other specialists in the detection of ectopic pregnancy in all women of childbearing age in order to reduce its mortality [10, 11].

The management of this emergency is often associated with a delay in diagnosis and is therefore therapeutic, aggravating the maternal and fetal prognosis [1, 5, 9].

In our context, taking into account the age of the patient (premenopausal), the difficulty of access to health facilities, the subsequent risk of developing another ectopic pregnancy on the left fallopian tube, operational difficulties, hemorrhagic risk on the polymyomatous uterus, and risk of malignancy, we opted for a total hysterectomy. In perimenopause and apart from any desire for pregnancy, hysterectomy is the most effective way to manage a voluminous and symptomatic myoma to prevent short or even other long-term complications [8, 12]. It is the alternative that provides an improvement in terms of better comfort of life and sexuality [12]. Some authors [7, 10] opted for conservative treatment for younger patients. Brazet et al. [7] performed a delayed myomectomy 6 weeks after cesarean section delivery in a 33-year-old woman at the first pregnancy, thus adhering to the recommendations of learned societies [12, 13].

Intestinal obstruction has various etiologies. In a woman, gynecological causes that present as digestive surgical emergency must be kept in mind.