Prabath Sumanathissa1, Tharanga Wijethilake1

arterial thromboembolism and venous thrombosis accounts for less than 1% of explorative laparotomies for acute abdomen. Mesenteric vein thrombosis due to ...

A rare case report of small bowel gangrene due to hypercoagulable state of pregnancy Prabath Sumanathissa1, Tharanga Wijethilake1, Malith Perera1, Sardha Hemapriya1, Thirunavukkarasu Niruthan1 1 Department of obstetrics and gynaecology / Teaching hospital, Kandy / Sri Lanka

Introduction: Mesenteric ischemia due to arterial thromboembolism and venous thrombosis accounts for less than 1% of explorative laparotomies for acute abdomen. Mesenteric vein thrombosis due to pregnancy in the absence of a secondary coagulation error is extremely rare.

Clinical description: A 22 years old primi gravida presented at 22 weeks of period of amenorrhoea with one day history of abdominal pain and vomiting. She had opened her bowel for stools and flatus. She received routine obstetric care and her pregnancy was uncomplicated until admission. Her medical history did not reveal connective tissue disorders or pregnancy loses and she was not on prescription medication. The patient was haemodynamically stable on admission. The abdomen was soft and obstetric ultrasonography revealed a live foetus with parameters consistent with 19+5 maturity. There was no free peritoneal fluid. 12 hours after presentation patient became hemodynamically unstable and developed a rigid abdomen. Ultrasound abdomen revealed distended fluid filled bowel loops and free peritoneal fluid. Foetal heartbeat was absent. The patient urgently underwent explorative laparotomy which revealed gangrenous small bowel loops (duodenojejunal flexure to the distal ileum; length 235 cm) which was resected and anastomosed end-to-end. A diagnosis of mesenteric vein thrombosis was postulated (confirmed later with histopathology) and the patient was investigated for a primary thrombophilia state.

Clinical description: Full Blood Count showed normal Haemoglobin and Haematocrit. Screening with ESR, CRP and ANA was negative. Echocardiography did not reveal cardiac source for thrombo-embolism. Electrocardiogram was in sinus rhythm. Blood picture revealed moderate anaemia due to acute blood loss. Anti-Thrombin III, protein C, S and Ham’s test) was negative. Anti-Phospholipid Syndrome screening (Lupus anticoagulant screen, Anticardiolipin antibody Ig G) was negative. JAK2PV617F mutation screening by DNA extraction was negative. The patient was prescribed anticoagulation with warfarin for 3 months and thrombophilia screening was repeated and confirmed to be negative. Thus primary cause for bowel gangrene was ascertained to be due to the hypercoagulable state due to pregnancy.

Discussion & Conclusion: Pregnancy is a hypercoagulable state; with elevation of Factors VII, VIII and fibrinogen and the reduction of fibrinolytic activity. The presentation is with nonspecific signs, symptoms and laboratory results making early diagnosis a challenge. The microscopic features of mesenteric vein thrombosis help in histopathological diagnosis. This case signposts that pregnancy is a pro-thrombotic state warranting consideration of bowel ischaemia due to mesenteric vein thrombosis in the differential diagnosis of a pregnant lady presenting with acute abdomen.

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