Author information
Yadav Pramila*, Warke HS**, Gupta
AS***
(* Fourth Year Resident,
**Associate Professor, *** Professor)
Abstract
Obstructed
labour due to a fecolith in the rectum and colon is very rare. Fecoliths cause
many complications in pregnancy like dystocia, rupture uterus and
malpresentation. It may also compress the bowel and cause bowel perforation. We
are presenting a case of obstructed labour and malpresentation caused by a huge
fecolith.
Introduction
Fecolith
is fecal impaction in the rectum and colon. It causes significant patient
morbidity.[1] Patient commonly complaints of constipation.
It is
frequently secondary to poor bowel or dietary habits.[2] Bladder
stone and rectal fecoliths have been implicated as cause of soft tissue
dystocia.[3,4]
Case
report
A 22 years
old married woman, G4P3L1 IUFD2 with 26.5/7 weeks with IUFD with previous LSCS was referred to our hospital with
complaints of leaking per vaginum and decreased fetal movements since 12 hours.
She had not passed stool since 5-6 days. There was no history of bleeding per vaginum or pain in
abdomen. On presentation her general and systemic examination were normal.
Abdominal examination revealed a pfannensteil scar of previous LSCS, uterus was
26 weeks in size, deviated to right side, subserosal fibroid measuring 3x4 cm
was felt in the suprapubic region and FHS was absent. Vaginal speculum could
not be introduced due to a mass impacted in the vagina. On vaginal (PV)
examination a 10x9 cm mass impacted in the vagina was felt. Cervix could not be
felt. Provisional diagnosis of a 26 weeks pregnancy with IUFD with a large
cervical fibroid or rectal mass was made.
On
ultrasonography (USG) a dead fetus in transverse lie with extensive flexion of
its body with spalding sign was seen. There was no free fluid in abdominal
cavity and uterine rupture was ruled out. Uterine part of cervix could not be
assessed on ultrasonography. CT scan was done. It showed a grossly distended
rectum,
descending and transeverse colon. Rectum and sigmoid colon were extensively
loaded with faeces which appeared to be compressing the lower part of the
uterus, cervix and vagina.
Figure 1
CT Image in Transverse Section. Showing the bladder stone (B.S.), fetal skeleton (F.S.) and fecolith (FL)
Figure 2
CT Image in Longitudinal Section: Showing the dilated bowel loops (D.B.L.), rectum (R), fetal head (F.H.) and fecolith (FL)
A 4.7 x
3.1 cm sized calculus was noted in the urinary bladder. Right kidney was 12.3 x
5.7cm and left kidney was 5.6 x 3.2 cm. There was bilateral hydronephrosis and
hydroureter.
Final
diagnosis on CT scan was IUFD with transverse lie, fecal impaction, urinary bladder
calculus, bilateral hydronephrosis and hydroureter .
Her Hb was
11.1gm%, WBC, platelet counts and DIC profile were
within normal limits. Enema
was given. There was incomplete evacuation of the bowel. Cervical
Os could now be reached with difficulty. On PV she was 2-3cm dilated,
60% effaced, station was high up, pelvis was adequate and an
indentable fecolith
was felt through the posterior vaginal wall.
We watched
for progress of labour. After 4 hours she developed signs of obstructed labour
with scar tenderness and impacted shoulder with hand prolapse.
Patient
was taken for emergency hysterotomy and anal dilation with manual removal of the
fecolith with suprapubic
cystolithotomy. A multidisciplinary team approach involving gynaecologist,
surgeons, and anesthesiologists was undertaken.
Abdomen was opened through an infra-umbilical midline incision. Intraoperatively bladder
was advanced and distended with a calculus of
5x4cm size. Sigmoid and transverse colon were loaded and
markedly distended with
stools. Lower uterine segment was thinned out. Female baby of
780 g was
delivered by breech extraction. Liquor was scanty and placenta
was foul
smelling. The uterus was sutured in a single layer.
Lithotomy
position was given and surgeons noted a fissure in ano at 7
o’clock position, stricture 2-3cm from anal verge and grossly dilated sigmoid
colon loaded with hard stools. Anal dilatation and manual removal of feces was
done. Colon was milked from descending colon up to rectum and feces were
evacuated
till colon completely collapsed. Bowel was inspected and there was
no evidence of any stricture, serosal tear or perforation.
The vesical
calculus of 5x4 cm was removed by a cystotomy. Midline suprapubic
catheter was placed and bladder was closed in two layers. Abdomen
was closed in layers. One
unit blood transfusion was given. Postoperatively patient was given
antibiotics, analgesics. Postoperative course was uneventful. Suprapubic
catheter was removed after three weeks.
Discussion
Prolonged
stasis of fecal matter causes impaction and a giant fecolith
forms. This
obstructs the colon necessitating surgery.
[1] Direct abdominal x-rays, ultrasosnography and CT
scans are the imaging modalities to diagnose intestinal obstruction
caused by fecal impaction. Emergent surgical intervention
and removal of fecolith is life saving.[5] Urolith causing
dystocia requires caesarean section with cystolithotomy .[3] In this case, fecolith
caused the malpresentation (transverse lie) and obstructed labor.
As the
urolith was not in the pelvis but suprapubically it did not
contribute to the obstructed labor. A timely emergency hysterotomy
with anal dilation, manual removal of feces, milking of descending,
sigmoid
colon and suprapubic cystolithotomy prevented a neglected
obstructed labor and its consequences.[1,2,3,4,5] In this case the
giant fecolith
leading to obstructed labour was not diagnosed by the
referral secondary care center. It was erroneously diagnosed as a large posterior
cervical fibroid. In
cases with obstructed labour with a mass felt per vaginum, large fecoliths
should be considered in the differential diagnosis. Multidisciplinary team
approach is essential for management of such cases.
Acknowledgements
We
acknowledge Mantri Nilima, Tiruke Raviraj and Chaturvedi Pritali for performing
emergency hysterotomy; Jadhav Sudhir and Patel Maitri for removal of fecolith;
and Gajingi Ajay and Sharma Anand for performing suprapubic cystolithotomy on
this patient
References
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Farshid AM.
Fecal Impaction. Clinics in colon and rectal surgery.
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2.
Colapinto MN,
Vowinckel EAM, Colapinto ND.
Complete Currarino syndrome in an adult, presenting as a fecolith obstruction:
report of a case. Can J Surg. 2003 Aug; 46(4):303-306.
3.
Ait Benkaddour Y, Aboulfalah A, Abbassi H. Bladder stone:
uncommon cause of mechanical dystocia. Gynecol Obstet. 2006 Aug; 274(5): 323-4.
4.
Holt WA,
Hendricks CH.
Dysfunctional labour due to fecal impation: report of a case. Gynecol
Obstet. 1969; 68: 502-504.
5.
Atahan
K, Cokmez A, Durak E, Gur S,
Tarcan E. Colonic Obstruction
Secondary to Giant Fecolith. J Colon Rectum disease. 2010; 20: 84-86.
Citation
Yadav P, Warke HS, Gupta AS. Obstructed labour due to a Giant
fecolith. JPGO Volume 1 Issue 3, March 2014, available at:http://www.jpgo.org/2014/03/obstructed-labour-due-to-giant-fecolith.html