Maternal death caused by midgut volvulus after bariatric surgery Paul V. Loar, III, MD, a, * Luis Sanchez-Ramos, MD, a Andrew M. Kaunitz, MD, a Andrew J. Kerwin, MD, b Jesus Diaz, MD c Departments of Obstetrics and Gynecology, a Surgery, b and Medicine, c The University of Florida Health Science Center Jacksonville, FL Received for publication January 23, 2005; revised March 31, 2005 KEY WORDS Pregnancy Gastric bypass Maternal mortality Counseling A 31-year-old woman with a history of laparoscopic Roux-en-Y gastric bypass surgery presented at 25 6/7 weeks’ gestation with complaints of abdominal pain. Maternal death followed midgut volvulus, perforation, and septic shock. Ó 2005 Mosby, Inc. All rights reserved. More than 100,000 gastric bypass surgeries were performed in the United States in 2003 alone, with up to 73% involving women. As a result, pregnancy after gastric bypass is becoming much more common. Case report A 31-year-old G4P2012 woman with a singleton preg- nancy at 25 6/7 weeks and a history of laparoscopic Roux-en-Y gastric bypass was transferred to the Uni- versity of Florida Health Science Center at Shands Jacksonville because of nonspecific abdominal pain and possible small bowel obstruction. On arrival, her examination was nonacute and she was maintained on bowel rest with nasogastric decom- pression. A computed tomography (CT) found disten- sion of the entire small bowel with air fluid levels and a distended colon from cecum to sigmoid. Ultrasound revealed a 784 g fetus in cephalic presentation and normal amniotic fluid. After several days with some clinical improvement, she began to complain of dark, black emesis and copious melanotic diarrhea. Tests for Clostridium difficile (C diff ) toxin were positive and treatment was begun. At the recommendation of the consultant general surgeon, flexible sigmoidoscopy was performed to exclude colon obstruction. There was no evidence of obstruction and the colon appeared normal. Symptom resolution after this procedure was attributed to therapeutic decompression. She continued to improve but later at 26 5/7 weeks’ gestation experienced preterm premature rupture of membranes with a prolapsed umbilical cord. An emergent cesarean delivery was performed via a Pfannensteil incision, during which healthy loops of small bowel were visualized with no evidence of intra-abdominal infection. The infant’s Apgar scores were 1 at 1 minute, 6 at 5 minutes, and 8 at transfer to the neonatal intensive care unit (NICU). On postoperative day 3 the patient was noted to be tachycardic, tachypneic, and hypotensive. She became increasingly unstable and was intubated after transfer to * Reprint requests: Paul V. Loar, III, MD, 655 W. 8th St, Jacksonville, FL 32209. E-mail: paul.loar@jax.ufl.edu 0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.04.041 American Journal of Obstetrics and Gynecology (2005) 193, 1748–9 www.ajog.org