Sigmoide Volvulus on Pregnancy in the General Surgery Service of the Sikasso Hospital, Mali

Sigmoid volvulus on pregnancy is a rare surgical emergency. We report two cases treated in the General Surgery Department of Sikasso Hospital between January 2009 and December 2017. The mean age was 34.8 years and the gestational age ranged from 28 to 30 weeks. The evolution time was 4 days. The 2 patients were referred to us by gynecologist-obstetricians. They were oper-ated after a short-term resuscitation. Inoperative the volvulus of the sigmoid was alone in 1 case; he was associated with a hail volvulus in the other. The volvated loop was necrotic in 1 case (small and sigmoid). A patient benefited from the Hartmann operation associated with a small bowel resection with end-to-end anastomosis. Simple sigmoidal detorsion was performed in one patient. We did not register a maternal death. The follow-up was simple in the 2 patients who gave birth vaginally.


Case Report
They have been expressed as clinical cases.

Observation N˚ I
Ms. F., aged 32, with no background particular pathological conditions, was sent by the obstetric gynecologist for abdominal pain on pregnancy of 30 SA. This pain was associated with postprandial vomiting late, a stoppage of materials and gases for 3 days. At admission the general condition was good, the temperature at 37˚C, the pulse = 98 beats/min, the blood pressure was 130/80 mmHg. Examination has shown abdominal asymmetry the inspection, a diffuse pain all over the abdomen without defense, uterine height to 20 cm. Percussion found a tympanism in the epigastrium and the left hypochondrium. An accentuation of the noiseshydro-aerials was found at the auscultation, the Fetal heart sounds were regular at 144 beats/min. With the vaginal touch, the cervix was long, posterior and closed. The rectal bulb was empty at Rectal touch.
The abdominopelvic ultrasound showed a digestive distension with intravenous effusion peritoneal associated with intrauterine pregnancyscalable of 30SA The suites were simple. The patient gave birth bylane 45 days later from a newborn to term in which the examination was normal.

Observation N˚ 2
Ms. F.D., 30 years old, was sent to the emergency room by the Kadiolo health  We proceed to a suction of liquid, a Resection of the small bowel with end-to-end anastomosis.
A sigmoidectomy followed by a colostomy.
Hartmann. The postoperative course was simple after the operation. The patient gave birth by lane two months later from a newborn to term.
Restoration of continuity has been achieved. Six months later, the aftermath of the recovery was simple.

Comment
The frequency of pregnancy occlusion is estimated at 1/3600 pregnancies; the main reported causes were the flanges and the volvulus of the sigmoid [4].
Intestinal occlusion by sigmoid volvulus is very rare during pregnancy [5]. In 8 years we found 2 cases. According to Khanna (India)  The 4-day consultation period of our study was Twice as long as that of Goundo (2006) who had does his work on sigmoid volvulus in general [8].
This could be explained by the difficulty of diagnosis of intestinal obstruction during pregnancy the signs are falsely attributed to a threat premature delivery.
The clinical diagnosis is based on the triad: pain, stopping of materials and gases, vomiting and physical signs. Biological signs are not specific. Ultrasound allows to objectify a digestive distension, intraperitoneal effusion and a pregnant uterus specifying the age of pregnancy and fetus vitality according to Musoke (Uganda) the first intension examination [9]. But this is the X-ray of the abdomen without preparation which breaks the positive diagnosis of volvulus, the fear of irradiation of some authors remains unfounded because it takes ten times the dose an ASP to have 0.01 Gray that is the dose with a congenital malformation risk of 1/1000 [3].
Treatment consists in lifting the obstacle, avoiding the recurrence, allowing the pregnancy to progress to term if possible; in any case the mother's life is the priority. All our patients benefited fromtocolysis, from a resuscitation of 30 minutes to 2 hours.
According to Twité [3], the management of an occlusion on Pregnancy requires essential rehydration to ensure uterine blood flow and maintain the fetal vitality. Surgical treatment was the resection plus Hartmann-type colostomy once.
This technique was the most used according to the literature [10] [11] [12] despite having rare cases of remissions pontaneous reported by De U in India [11]. This attitude is explained by the delayed diagnosis and therapeutic that results in local conditions (necrosis, unprepared colon) and general preventing endoscopic detorsion. In all cases, the gesture minimum would increase the chance of having suites simple operatives for the mother and the fetus [13].
The operative sequences were simple in both cases, they gave birth normally.
We did not have any maternal or fetal deaths. Wamoto in Japan also reported a death case in utero fetal and maternal death postoperatively immediate [14]. Fetal mortality is close to zero in the first quarter, it is 36% and 64% respectively in the second and third quarters of pregnancy [3].

Conclusion
The sigmoid volvulus on pregnancy is an entityrare and its care is multidisciplinary. Early diagnosis and management could improve the maternal-fetal prognosis.