Sigmoid and cecal volvulus in pregnancy and puerperium: A systematic review

Abstract

BACKGROUND

Cecal and sigmoid volvulus during pregnancy are extremely rare. Symptoms of intestinal obstruction in pregnancy make accurate clinical diagnosis challenging.

AIM

To identify predictive factors for early diagnosis and successful treatment and an association between the diagnosis and maternal/neonatal outcomes.

METHODS

A systematic review of human studies (PubMed, PubMedCentral, Google Scholar) up to October 2024 was conducted per PRISMA guidelines. Data on demographics, clinical features, diagnostics, treatment, and outcomes were analyzed.

RESULTS

Antepartum and postpartum volvulus occurred in 75.5% and 24.5% of cases, respectively, most commonly in the third trimester (70.3%). Nausea was less frequent and obstipation was more common in sigmoid volvulus (P = 0.0004). Endoscopic detorsion was successful in 23.9% of sigmoid cases, with a mean gestational age of 33.5 ± 3.5 weeks. Maternal mortality was 12.5% for cecal and 5.5% for sigmoid volvulus (P = 0.103). While maternal mortality was unaffected by the timing of delivery relative to surgery, fetal mortality was significantly higher when the interval was < 24 hours (52.9% vs 10.4%, P < 0.001). Both maternal and fetal mortality declined over time.

CONCLUSION

Constipation was a risk factor for sigmoid volvulus and prior open appendectomy for cecal volvulus. Endoscopy was more often used in sigmoid cases. Gestational age and maternal age did not affect fetal outcomes. Earlier imaging and appropriate surgery were linked to lower mortality. Delay > 24 hours between intervention and delivery increased fetal, but not maternal mortality. Successful endoscopic detorsion eliminated maternal mortality and significantly lowered fetal mortality.

Key Words: Sigmoid volvulus; Cecal volvulus; Pregnancy; Puerperium; Outcomes; Systematic review

Core Tip: Cecal and sigmoid volvulus in pregnancy and puerperium are extremely rare. Constipation is a risk factor for sigmoid volvulus and open appendectomy for cecal volvulus. Endoscopic detorsion was successful through all trimesters and only performed for sigmoid volvulus. Neither gestational week nor maternal age influenced fetal outcome. Maternal and fetal mortality depended on the diagnostic imaging and the type of surgical procedure. Successful endoscopic detorsion eliminated maternal mortality and significantly lowered fetal mortality. Over the course of the century, maternal and fetal mortality have declined continuously, with maternal mortality at a steeper rate.

INTRODUCTION

Colonic volvulus occurs when a portion of bowel twists around its mesentery, resulting in bowel obstruction and commonly ischemia[1]. Non-fixed colonic segments can undergo volvulus, with the sigmoid colon most frequently affected, followed in decreasing frequency by the cecum, transverse colon, and splenic flexure[2]. Sigmoid volvulus incidence has significant regional variations, with high rates observed in areas termed “volvulus belts”, such as Latin America, Africa, Eastern Europe, Scandinavia, Russia, the Middle East, Pakistan, and India, where it accounts for 20%-54% of acute intestinal obstructions, compared to only 3%-5% in lower-incidence regions like North America, Western Europe, and Australia[3]. A long sigmoid colon with a long and wide mesentery is a primary cause of volvulus, with its length elongation as a significant factor[4-6]. Following the sigmoid colon, the cecum is the second most frequent site of colonic volvulus due to torsion or hyperflexion of the poorly fixed and highly mobile cecum[7]. After diverticular disease and cancer, colonic volvulus is the third most common cause of large bowel obstruction. Its clinical manifestation is obstruction due to lumen blockage[8,9]. In both sigmoid and cecal volvulus, patients experience lower abdomen pain, bloating, constipation, difficulty passing gas, and occasionally nausea and vomiting for one or more days[10,11]. A tympanitic and distended abdomen, usually in the upper abdomen, are common physical signs[12,13].

Volvulus is usually diagnosed by plain abdominal radiography, followed by computed tomography or magnetic resonance imaging[14]. Emergency endoscopic reduction is an initial treatment in patients without bowel ischemia. It is a temporary measure, with definitive elective surgery recommended afterward[14]. Any decline in the patient’s condition should prompt concern for a possible perforation or gangrene, and urgent surgical exploration should be considered[4]. Ischemic or necrotic bowel should be resected[15]. Provoking factors for sigmoid volvulus are congenital, advanced age, a high-fiber diet, neurological conditions or drugs affecting intestinal motility, excessive body motions, and overeating following prolonged starvation[16,17]. Constipation is a risk factor for sigmoid volvulus recurrence because prolonged fecal overload causes the sigmoid colon to dilate, elongate, and rotate[18]. Furthermore, the anatomical changes resulting from previous surgeries, including cesarean section, lead to adhesion formation, which may contribute to the development of volvulus[19-21].

MATERIALS AND METHODS

We searched PubMed, PubMedCentral, and Google Scholar and analyzed the collected case reports and case series, following PRISMA. The search items included: ‘volvulus’, ‘colon’, ‘pregnancy’, ‘puerperium’, ‘postpartum’, ‘gravid’, ‘labor’, ‘sigmoid volvulus’, ‘bowel obstruction’, ‘cecal volvulus’. Additional studies were extracted by reviewing reference lists of retrieved studies. We included all available full-text cases and case series. We excluded cases with duplicated and overlapped data, insufficient data, spontaneous volvulus, volvulus of other parts of the colon, and patients who are not pregnant or not in the puerperium. The search was limited to human studies published until October 2024, without language or country restrictions. Non-English articles were translated and analyzed with the help of medical scientists proficient in the languages mentioned above. We aimed to summarize all reported cases of sigmoid or cecal volvulus in pregnancy and puerperium and identify predictive factors for early diagnosis and treatment of sigmoid and cecal volvulus during pregnancy and puerperium. Our second objective was to identify an association between the diagnosis and maternal/neonatal outcomes between the two types of volvuli. The study is exempt from ethics approval because we collected data from published cases.

Data extraction

Two authors independently reviewed the extracted data from the included articles. Pre-defined criteria were established to ensure the maximum reliability of the collected data. Obstetric data included maternal age, gestational age, parity, and previous labor - vaginal or cesarean. Clinical patient characteristic data included previous abdominal surgery, previous medical history, and predisposing factors such as constipation or recurrent volvulus. Diagnostic data included signs at clinical presentation and radiology findings. Other collected parameters were differential diagnosis, mother and child outcomes, type of delivery, type of surgery performed, time from delivery to operation or vice versa, intraabdominal access, location of volvulus, preoperative endoscopic diagnostic findings, and endoscopic treatment, summarized in Supplementary Table 1.

Statistical analysis

Categorical variables (prevalence) are expressed in absolute numbers and percentages, expressed as numbers in the total population, and presented descriptively as a percentage with a 95% confidence interval. The normality of the distribution was tested with the Kolmogorov-Smirnov test. Comparative analysis for continuous non-parametric variables was performed with the Mann-Whitney U test, and parametric variables were performed using the Student’s t-test. The comparison of categorical variables was performed with the χ²-test. In all tests, values of P < 0.05 were considered statistically significant, and for the necessary power of the tests, we set a minimum level of 80%. JASP Team (2024) JASP (Version 0.18.3) was used for statistical analysis.

RESULTS

A total of 195 cases were identified, with 18 cases excluded before screening due to duplicate records. After screening, 35 of 178 records were removed for various reasons, primarily due to the inaccessibility of full text, ectopic pregnancy as the primary diagnosis, overlapping data, cecal or sigmoid volvulus in fetuses, and volvulus in other parts of the colon. Finally, 143 studies were included, comprising 161 cases (Figure 1).

Figure 1  PRISMA flow diagram.

Incidence and risk factors

The mean maternal age was 29.1 (95% confidence interval: 28.1-30 years); 45.3% were multiparous, 19.3% were primiparous, and 35.3% were nulliparous with a mean maternal age of 31.7, 27.3 and 26.3, respectively with a statistically significant age difference (analysis of variance, P = 0.004). Antepartum and postpartum volvulus occurred in 75.5% and 24.5% of cases, respectively. All postpartum cases occurred within the first 10 days after childbirth. Trimester distribution was 70.3% in the third, 27% in the second, and 2.7% in the first trimester. Constipation was a chronic predisposing factor in 3.2% of cecal and 13.2% of sigmoid volvulus cases. The difference is significant (z = -2.1542, P = 0.031). Ten percent of sigmoid volvulus patients had previous abdominal surgery, most commonly gynecological and colonic. 17.5% of cecal volvulus patients had previous abdominal surgery, mainly for appendicitis (the last case was in 1993, and all were open, “classic” appendectomies, without other intraabdominal operations). There is no statistical difference between groups (χ², P = 0.911). Furthermore, 84% had no medical history that could be associated with the cecal or sigmoid volvulus. In 4.7% (8/169) of cases, patients had a gynecologic operation, and 4.1% had an episode of prior sigmoid volvulus. There was a positive intraoperative finding regarding a predisposing factor for volvulus in 13% of cases. The most common findings were highly mobile cecum, highly mobile sigmoid colon, dolichosigma, and one case of post-cesarean cecal strangulation. The difference in predisposing factor occurrence between cecal and sigmoidal volvulus is insignificant.

Symptomatology

The most common symptoms were abdominal pain (98.8%) and vomiting (61.5%). Interestingly, 77.4% of cecal and “only” 52.8% of sigmoid volvulus patients reported vomiting without a significant difference (P = 0.9681). Nausea (25.4%) and obstipation (30.4%) were the most common findings in patients with cecal volvulus. In contrast, nausea was significantly less common (6.4%) and obstipation significantly more common (74.3%) in sigmoid volvulus (P = 0.00044). Abdominal tenderness was reported in 59%, rigidity in 4.1%, and abdominal distension in 89.4%. Both abdominal tenderness and distension were reported in 53.5%. Vaginal or rectal examinations were not performed in 48%. In the rest of the cases, vaginal or rectal examination was normal with the exception of three cases of ballooned rectum, one case of rectal wall tear, one case of perineal tear.

Diagnosis

A plain abdominal X-ray was performed in 63.1% (94/149) cases, abdominal ultrasound in 35.4% (51/144), computed tomography in 21.5% (31/144), magnetic resonance imaging in 11.1% (16/144), and chest X-ray in 5.6% (8/144) cases. Maternal mortality depended on the diagnostic imaging method used for both volvulus locations and antepartum or postpartum presentations (Table 1). Fetal mortality depended on the diagnostic imaging method used for antepartum volvulus cases in both locations (Table 2). In 51.5% of cases, differential diagnoses were mentioned. Intestinal obstruction was the most common (47.4%), and intestinal volvulus was mentioned as a differential diagnosis in 4.1%. Endoscopic examination was performed in 6/64 (9.3%) of cecal volvulus and 28/109 (25.7%) of sigmoid volvulus cases. The difference is statistically significant (z = -2.6, P = 0.009).

Table 1 Diagnostic imaging and maternal mortality.

Diagnostic imaging	Maternal mortality with imaging	Maternal mortality without imaging	The difference in mortality related to imaging type
Abdominal X-ray	6/82	1/41	χ2, P = 0.271
Abdominal ultrasound	1/49	6/71	χ2, P = 0.155
Chest X-ray	0/8	7/15	χ2, P = 0.472
CT	1/26	6/97	χ2, P = 0.647

CT: Computed tomography.

Table 2 Diagnostic imaging and fetal mortality.

Diagnostic imaging	Fetal mortality with imaging	Fetal mortality without imaging	The difference in mortality related to imaging type
Abdominal X-ray	20/50	3/37	χ2, P < 0.01
Abdominal ultrasound	11/43	12/44	χ2, P = 0.858
Chest X-ray	3/6	20/81	χ2, P = 0.175
CT	2/15	21/72	χ2, P = 0.206
MRI	2/12	21/75	χ2, P = 0.408

CT: Computed tomography; MRI: Magnetic resonance imaging.

Treatment

Colonic resection with terminal stoma was performed in 46% (69/150), detorsion in 38% (57/150), intestinal resection with primary anastomosis in 28% (42/150), and colon fixation (such as sigmoidopexy and cecopexy) in 14% (21/150) of cases. Laparotomy was the intraabdominal access in 93.8% (two cases of postpartum laparoscopy). In 52.3% (46/88) of sigmoid volvulus cases, intestinal resection with terminal stoma was performed, detorsion in 27.3% (24/88), intestinal resection with primary anastomosis in 12.5% (11/88), and sigmoidopexy in 8% (7/88). Successful endoscopic detorsion was performed in 23.9% (21/88) of sigmoid volvulus cases: One case in the first trimester, five cases in the second, and fifteen cases in the third (mean gestational age in the third trimester, 33.5 ± 3.5 weeks). Among these, recurrent detorsion was performed in 19.0% (4/21). Intestinal resection with primary anastomosis was performed in 50% (31/62), intestinal resection with terminal stoma in 37.1% (23/62), detorsion in 4.8% (3/62), and cecopexy in 8.1% (5/62) of cecal volvulus cases. Endoscopic detorsion was not performed for the cecal volvulus cases. Maternal mortality depended on the type of surgical procedure for both volvulus locations and both antepartum and postpartum cases (Table 3). Fetal mortality depended on surgical procedures for both volvulus locations and only for antepartum cases (Table 4).

Table 3 Surgical procedure-related maternal mortality.

Surgical procedure	Maternal mortality related to surgical procedure	Maternal mortality related to other surgical procedures	The difference in mortality related to surgical procedure
Detorsion	2.9% (1/35)	8.7% (10/115)	χ2, P = 0.349
Intestinal resection with anastomosis	2.4% (1/42)	9.2% (10/108)	χ2, P = 0.247
Intestinal resection with terminal stoma	8.7% (9/69)	2.6% (2/81)	χ2, P = 0.039
Sigmoidopexy/cecopexy	0% (0/21)	8.5% (11/129)	χ2, P = 0.267

Table 4 Surgical procedure-related fetal mortality.

Surgical procedure	Fetal mortality in cases with specific surgical procedure	Fetal death rate without a specific surgical procedure	The difference in mortality related to surgical procedure
Detorsion	20% (5/25)	31.8% (27/85)	χ2, P = 0.102
Intestinal resection with anastomosis	15.6% (5/32)	31.2% (27/79)	χ2, P = 0.111
Intestinal resection with terminal stoma	44.9% (22/49)	16.3% (10/61)	χ2, P = 0.003
Sigmoidopexy/cecopexy	9% (1/11)	31.3% (31/99)	χ2, P = 0.286

Maternal and fetal outcome

The mean maternal age was 29.1 ± 6.3 years for patients who survived and 29.7 ± 6.7 years for patients who died, without a statistically significant difference (Mann-Whitney U test, P = 0.706). The mean maternal age was 30.3 ± 6.9 years with cecal volvulus and 28.4 ± 5.8 years with sigmoid volvulus, without a statistically significant difference (Mann-Whitney U test, P = 0.09). The mean gestational week was 29.2 for surviving mothers and 29.8 for deceased mothers, without a statistically significant difference (Mann-Whitney U test, P = 0.948). The mean gestational week was 28.1 with cecal volvulus and 29.6 with sigmoidal volvulus, without a statistically significant difference (Mann-Whitney U test, P = 0.306). The mean maternal age was 29.6 ± 6.2 with fetal survival and 27.5 ± 6.7 with fetal death outcome, without a statistical difference (U test, P = 0.097). The mean gestational week with fetal survival was 29.6 ± 7.3 and 27.9 ± 5.3 with fetal death outcome; no statistically significant difference (Mann-Whitney U test, P = 0.948).

Fetal mortality with maternal cecal and sigmoid volvulus was 19.7% and 21.8%, respectively, without a statistically significant difference (χ² = 0.102, P = 0.749). Fetal mortality of complicated (perforated or gangrenous bowel) and uncomplicated volvulus was 26.5% and 24.3%, respectively, without a statistical difference (χ² = 0.780; P = 0.377). Maternal mortality with cecal and sigmoid volvulus was 12.5% and 5.5%, respectively, without a statistically significant difference (P = 0.1031). Maternal mortality with complicated volvulus (perforated or gangrenous bowel) and uncomplicated volvulus was 17.7% and 5.5%, respectively. The difference is statistically significant (χ² = 5.4, P = 0.02). Out of 134 cases with a known type of delivery, 67 were by Cesarean section, and 75 were vaginal deliveries; maternal mortality was 3% for Cesarean section and 8.0% for vaginal delivery, without a statistical difference (χ² = 1.674, P = 0.196). Fetal mortality was 14.9% for Cesarean section and 21.3% for vaginal delivery, without a statistical difference (χ² = 0.971, P = 0.324).

There was no maternal mortality from sigmoid volvulus when endoscopic detorsion was performed (21 cases of sigmoid volvulus). In comparison, the rate was 7.1% when endoscopic detorsion was not performed (85 cases of sigmoid volvulus) (χ² = 1.571, P = 0.21). No fetal mortality was reported with endoscopic detorsion (21 cases of sigmoid volvulus), while fetal mortality was 27.1% when endoscopic detorsion was not performed (85 cases of sigmoid volvulus) (χ² = 7.257, P = 0.07). The difference is statistically significant (cases of preintervention fetal deaths have been excluded). In 67.1% (106/158) of cases, more than 24 hours have passed between procedure and delivery (or vice versa), but it did not affect maternal mortality (6.6% for > 24 hours vs 7.7% for < 24 hours, χ² = 0.064, P = 0.801). A duration of more than 24 hours between procedures is associated with increased fetal mortality (10.4% for > 24 hours vs 52.9% for < 24 hours, χ² = 13.676, P < 0.001). The linear graph in Figure 2 shows that the frequency of specific operative procedures remained constant regardless of the time interval between the procedure and delivery. Table 5 shows that the type of surgery performed depended on the time between the surgical procedure and delivery (and vice versa). Fetal mortality did not depend on the gestational trimester (χ², P = 0.299) (Table 6). According to the linear regression test (analysis of variance), gestational week (P = 0.586) and maternal age (P = 0.107) did not influence fetal outcome.

Figure 2 Surgical procedure related to the timing of surgery and delivery. The frequency of specific surgical procedures depends on the time between the surgery procedure and delivery (and vice versa).

Table 5 Duration between surgery and delivery and its relation to surgical procedure.

Surgical procedure	The period between surgery and delivery < 24 hours	The period between surgery and delivery > 24 hours	P value
Detorsion	33.3% (30/90)	44.9% (22/49)	0.188
Intestinal resection with anastomosis	32.2% (29/90)	22.4% (11/49)	0.224
Intestinal resection with terminal stoma	45.6% (41/90)	42.9% (21/49)	0.760
Sigmoidopexy/cecopexy	17.8% (16/90)	10.2% (5/49)	0.234

Table 6 Trimester-related fetal outcomes.

Gestational trimester	Alive	Stillborn	Total
1st trimester	3	0	3
2nd trimester	26	13	39
3rd trimester	56	17	73

For cases from 1975 to 2023, maternal mortality was 7.8%, and for cases older than the year 1975, maternal mortality was 30.8% for patients with cecal volvulus. The difference is statistically significant (χ², P = 0.026). Fetal mortality rates between 1975 and 2023 were 15.7%, compared to 33.3% before 1975. The difference is statistically insignificant (χ², P = 0.161) for patients with cecal volvulus, although a declining trend is evident. Between 1975 and 2023, maternal mortality was 5.3%, and before 1975, maternal mortality was 7.1% for patients with sigmoidal volvulus. The difference is statistically insignificant (χ², P = 0.773). Fetal mortality rates between 1975 and 2025 were 20.4%, compared to 30.8% before 1975. The difference is statistically insignificant (χ², P = 0.397) for patients with sigmoidal volvulus.

The linear regression analysis indicates a declining trend in maternal deaths, with older publications showing higher rates than those published more recently, such as those closer to 2024. The regression analysis reveals a statistically significant relationship between maternal deaths and the publication year (P = 0.003) (Table 7). The declining trend is evident across four periods over a century (Figure 3A). The regression analysis reveals a statistically insignificant relationship between antepartum fetal deaths and the publication year (P = 0.276) (Table 8). The declining trend of fetal mortality is evident, but it is insignificant due to a small number of cases (Figure 3B).

Figure 3 Maternal and fetal mortality trends. A: Maternal mortality across four publication periods shows a declining trend in maternal deaths over the century; B: Fetal mortality across four publication periods shows a declining trend in antepartum fetal deaths over the century.

Table 7 Mother mortality depending on publication period, linear regression.

Model		Sum of squares	df	Mean square	F	P value
H1	Regression	5876.476	1	5876.476	9.400	0.003

H₁: Hypothesis; df: Degrees of freedom; F: F-statistic.

Table 8 Fetus mortality depending on publication period, linear regression.

Model		Sum of squares	df	Mean square	F	P value
H1	Regression	784.152	1	784.152	1.198	0.276

The statistical model is performed only for antepartum cases. H₁: Hypothesis; df: Degrees of freedom; F: F-statistic.

DISCUSSION

This systematic review summarizes the critical characteristics of sigmoid and cecal volvulus during pregnancy and the puerperium. Maternal and gestational age did not influence maternal or fetal mortality or volvulus location. Antepartum and postpartum volvulus occurred in 75.5% and 24.5% of cases, respectively. The highest incidence occurred in the third trimester (> 70%), and the incidence rose as the pregnancy advanced because the growing uterus displaced the sigmoid colon and cecum, the nearest organs. Also, advancing pregnancy, due to hormonal changes, intensifies constipation, a known risk factor for volvulus, especially sigmoid[22]. Chronic constipation was a predisposing factor (13.2% in sigmoid and 3.2% in cecal volvulus. Keeping in mind that all postpartum cases of intestinal volvulus occurred within the first 10 days after childbirth, changes in abdominal anatomy and abdominal pressure, constipation, and the use of laxatives could be risk factors. According to the Royal College of Obstetricians and Gynaecologists (United Kingdom), it is recommended to use osmotic laxatives, such as lactulose, to reduce the risk of wound dehiscence[23]. Laxatives are considered when lifestyle modifications are inadequate. Studies suggest an increased use of laxatives among pregnant women (up to 68.8% of mothers in labor)[24]. An effect of laxatives on colonic volvulus cannot be drawn due to the lack of data. Prepregnancy sigmoid volvulus was present in 4.1%. Approximately 10% of sigmoid volvulus patients had previous abdominal surgeries, especially cesarean sections, with resultant adhesions in the lower abdomen and pelvis. Interestingly, more patients with cecal than sigmoid volvulus had a history of previous abdominal operations, although the difference was not significant. Not surprisingly, most previous surgeries for cecal volvulus were open appendectomies. The volvulus could be explained by the mobilization and exteriorization of the cecum needed to complete an open appendectomy. Exteriorization refers to mobile cecum; if the cecum cannot be brought into the wound, it is mobilized. A mobilized cecum is prone to torsion (volvulus). The absence of laparoscopic appendectomy, which rarely requires mobilization of the cecum, was not done in any published case, so this additionally confirms this hypothesis. Additionally, intraoperative findings suggestive of underlying anatomical predispositions, including dolichosigma and/or a highly mobile cecum or sigmoid colon, identified in 13% of cases, confirm structural abnormalities as a risk factor.

Abdominal pain (98.8%) was followed by abdominal distension (89.4%) and vomiting (61.5%). Abdominal tenderness was present in > 50%. Symptom profiles significantly differed between sigmoid and cecal volvulus. Cecal volvulus more frequently presented with nausea and vomiting, while obstipation was predominant in sigmoid volvulus. Vaginal and rectal examinations were generally normal. The differential diagnosis was mentioned in 51.5%; intestinal obstruction was the most common (47.4%), while intestinal volvulus was in only 4.1%. In decreasing order, the diagnostic imaging methods were plain abdominal X-rays, abdominal ultrasound, computed tomography, magnetic resonance imaging, and chest X-rays. The application of multiple imaging modalities could improve diagnostic accuracy and ultimately facilitate timely intervention, which can positively impact outcomes. However, due to limitations in the primary data and variability in reporting, we were unable to examine the impact of combined imaging on maternal or fetal mortality. We recognize this as a valuable area for future research.

Previously, it was claimed that endoscopic intervention would be impossible in late gestation[25,26]. Our systematic review found that colonoscopic detorsion is successful even in the third trimester. Endoscopic detorsion was a successful first-line treatment, particularly for sigmoid volvulus. Successful detorsion eliminated maternal mortality and significantly lowered fetal mortality compared to cases without endoscopic therapy. Endoscopic detorsion was successful even in recurrent sigmoid volvulus during the same pregnancy. All this means that surgery can be postponed after childbirth if viable mucosa is found on endoscopy. These results support the implementation of colonoscopy as a first-choice treatment. Laparotomy was the most common abdominal wall access (93.8%). Resection of the involved bowel with a terminal stoma was the most commonly performed surgical intervention, undertaken in 46% of patients, followed by detorsion (38%), resection with primary anastomosis (28%), and fixation procedures (e.g., sigmoidopexy and rectopexy) in 14%. The delivery method did not influence maternal and fetal mortality. Maternal mortality was higher in complicated cases with perforation or bowel gangrene (17.7%) than in uncomplicated cases (5.5%). Hence, early intervention prevents disease progression. The rate of maternal death is higher with cecal (12.5%) than with sigmoid volvulus (5.5%), indicating that cecal volvulus might have a more aggressive course or delayed intervention, though not statistically significant.

Fetal outcomes depended on multiple factors, notably the timing of intervention concerning delivery. Fetal mortality was substantially higher with surgery < 24 hours from delivery compared to > 24 hours. One could mistakenly conclude that delaying delivery yields better fetal outcomes. On the contrary, this indicates more severe bowel damage and, subsequently, fetal distress, mandating emergent delivery. Endoscopic detorsion significantly improved fetal survival, with no fetal mortality reported when endoscopic detorsion was performed. Interestingly, some maternal and fetal characteristics, including maternal and gestational age, did not affect outcomes. Results further indicate that early diagnosis and timing of intervention are more consequential prognostic variables than demographics. Improvements in diagnostic methods, increased endoscopic use, and enhanced neonatal care can reduce fetal and potentially eliminate maternal mortality.

This review highlights the importance of a multidisciplinary approach in treating volvulus during pregnancy. Obstetricians, surgeons, radiologists, and gastroenterologists must collaborate to ensure timely diagnosis and intervention. Volvulus should be considered in the differential diagnosis of abdominal pain and distension in pregnancy, especially in higher-risk populations, the third trimester, or early postpartum. This review demonstrates a steady decline in maternal deaths across four separate publication intervals, underscoring a substantial improvement in maternal health outcomes over the century. The primary limitation of this review is the reliance on case reports and series, which may be subject to selection and reporting biases. Similar challenges, including heterogeneity in reported outcomes and management strategies, have limited the generalizability of findings. Additionally, a period of almost a century was analyzed, although the majority of diagnostic modalities and treatment options remained relatively unchanged. Treatments for constipation during pregnancy are not described in detail, which is essential for understanding the impact of constipation on the incidence of volvulus. Multicenter prospective studies are warranted to confirm these findings and develop standardized approaches to diagnosing and managing volvulus during pregnancy. Further studies are also needed to assess the impact of advanced image modalities and minimally invasive techniques on outcome enhancement.

CONCLUSION

Cecal and sigmoid volvulus in pregnancy and puerperium are extremely rare. Constipation is a risk factor for sigmoid and open appendectomy for cecal volvulus in pregnancy. Endoscopy was more common for sigmoid volvulus. Volvulus should be considered in the differential diagnosis of abdominal pain and distension in pregnancy, especially in higher-risk populations, the third trimester, or early postpartum. Gestational week and maternal age did not influence the child’s outcome. Endoscopic detorsion can be achieved throughout pregnancy, allowing surgery to be postponed after childbirth if the mucosa is viable on endoscopy. Cecal volvulus in pregnancy carried a higher maternal mortality than sigmoid volvulus. Maternal mortality depended on whether diagnostic imaging was performed and on the type of surgical procedure for both volvulus locations and antepartum or postpartum presentations. Fetal mortality depended on whether diagnostic imaging and the type of surgical procedure were performed for both volvulus locations and only for antepartum cases. A delay > 24 hours between intervention and delivery influenced fetal but not maternal mortality. Complicated volvulus increased maternal but not fetal mortality. Obstetricians, surgeons, radiologists, and gastroenterologists must collaborate to ensure timely diagnosis and intervention. The results also encourage using endoscopic approaches as a first-line treatment when appropriate. This decreases maternal morbidity and leads to better fetal outcomes and fewer invasive procedures. Over the course of the century, maternal and fetal mortality have declined continuously, with maternal mortality at a steeper rate.