How should I manage a postpartum woman with massive hemorrhage‑induced coagulopathy, oliguria, pulmonary edema, and pancytopenia who now has air‑fluid levels on an abdominal X‑ray indicating a small‑bowel obstruction?

Management of Air-Fluid Levels in a Critically Ill Postpartum Patient

Immediate Surgical Consultation is Mandatory

In a postpartum patient with massive hemorrhage-induced coagulopathy, oliguria, pulmonary edema, pancytopenia, and now air-fluid levels on abdominal X-ray indicating small-bowel obstruction, immediate surgical consultation is required because this constellation of findings—particularly in the setting of ongoing critical illness—carries high risk for bowel ischemia, strangulation, or perforation that will not resolve with conservative management alone. 1

Why Conservative Management is Contraindicated in This Patient

• The standard 72-hour trial of non-operative management (nasogastric decompression, IV fluids, NPO status, water-soluble contrast) that successfully resolves 70-90% of adhesive small-bowel obstructions applies only to hemodynamically stable patients without systemic complications. 1, 2

• This patient's oliguria indicates acute kidney injury from massive hemorrhage, which represents hemodynamic instability and end-organ hypoperfusion—an absolute contraindication to conservative management. 1

• Pulmonary edema in the setting of massive transfusion suggests fluid overload and potential right ventricular dysfunction, which is characteristic of amniotic fluid embolism and requires intensive hemodynamic monitoring, not delayed surgical decision-making. 1

• Pancytopenia with ongoing coagulopathy (DIC occurs in >80% of amniotic fluid embolism cases) means this patient has consumptive coagulopathy that will worsen with any bowel ischemia or necrosis. 1

Critical Diagnostic Considerations

Obtain Urgent CT Abdomen/Pelvis with IV Contrast

• CT scan has approximately 90% accuracy in predicting strangulation and the need for urgent surgery and should be obtained immediately if the patient is stable enough for transport. 1

• CT findings that mandate immediate surgery include: closed-loop obstruction, mesenteric edema, free intraperitoneal fluid with peritoneal enhancement, bowel wall thickening >3mm, absent or decreased bowel wall enhancement, pneumatosis intestinalis, or mesenteric venous gas. 1, 2

• Plain abdominal X-rays have only 70% sensitivity for small-bowel obstruction and cannot detect early signs of peritonitis or strangulation. 1

Monitor for Evolving Ischemia

• Rising serum lactate >2.0 mmol/L, progressive metabolic acidosis, persistent fever, or worsening leukocytosis indicate bowel ischemia and require immediate laparotomy. 1, 2

• Physical examination has only 48% sensitivity for detecting strangulation, so clinical assessment alone is unreliable. 1

Surgical Approach

Open Laparotomy is Mandatory

• Open laparotomy is the only appropriate surgical approach for this critically ill patient; laparoscopy is absolutely contraindicated given her hemodynamic instability, coagulopathy, and high likelihood of bowel compromise. 1, 2

• Laparoscopic adhesiolysis carries a 6.3-26.9% risk of iatrogenic bowel injury even in stable patients and requires hemodynamic stability, absence of peritonitis, and minimal bowel distension—none of which apply here. 1, 2

Intraoperative Priorities

• Resect all non-viable bowel with margins extending to clearly viable tissue (normal color, peristalsis, pulsatile mesenteric vessels). 2

• If severe sepsis or hemodynamic instability persists, consider damage control surgery with resection, stapled intestinal ends, and temporary abdominal closure (laparostomy) rather than attempting primary anastomosis. 1

Critical Pitfalls to Avoid

• Do not delay surgery to "optimize" the patient medically—each hour of delay when ischemia is present increases morbidity, and mortality can reach 25% with ischemic bowel. 2

• Do not administer water-soluble contrast in this setting; it delays definitive treatment and offers no benefit when ischemia or strangulation is suspected. 2

• Do not rely on nasogastric decompression and observation—conservative management is contraindicated when any concern for ischemia exists in a hemodynamically compromised patient. 1, 2

• Avoid fluid overload during resuscitation; use blood products rather than crystalloid or colloid to minimize worsening pulmonary edema in the setting of right ventricular dysfunction. 1

Multidisciplinary Coordination

• Maintain close communication between obstetrics, surgery, anesthesia, and critical care teams—this patient requires intensive care unit-level monitoring postoperatively. 1

• Correct coagulopathy aggressively before surgery if time permits: target fibrinogen >1.5 g/L, platelets >75×10⁹/L, and consider cryoprecipitate over fresh frozen plasma to minimize volume overload. 1

• Active warming is essential—many clotting factors function poorly if body temperature is <36°C. 1