Madam, I read the article  "acute colonic pseudo-obstruction (ACPO) after normal vaginal delivery" by Hafeez Bhatti et al with great interest published in February 2010.However I would like to mention that it would have been more helpful if authors would have mentioned about the history of previous abdominal or pelvis surgeries undertaken in the past. Because adhesions are the important aetiological factor in intestinal obstruction cases both in pregnant and non-pregnant patients.
For the interest of readers I would also like to discuss possible mechanism involved other than ACPO. In broad terms gestational intestinal obstruction tends to occur during periods of rapid uterine size changes.  The three key periods are as follows: weeks 16-20, as the uterus becomes an intra-abdominal organ, weeks 32-36, as the foetus moves into the pelvis and during the puerperium, when the rapid decrease in uterine size leads to sudden changes in the position of the bowel.^1,2 In this patient, obstruction occurred at a known risk period. Therefore the possibility of simple mechanical obstruction due to gravid uterus (Increased size of uterus as mentioned in report) can not be ruled out. It is thought that in advanced pregnancy, the enlarged uterus displaces the mobile caecum out of the pelvis into the right upper quadrant, where the small bowel mesentry and superior mesenteric vessels become the points of rotation and torsion. However, spontaneous detorsion is restricted by the position of the gravid uterus^3-5 but again in this case gravid uterus could have caused the partial obstruction relieved on its own once size of uterus significantly reduced after delivery which exactly correlates with the events of this case.Also in ACPO symptoms typically develops slowly over several days (2-12 days after caesarean section).⁶
I appreciate that establishing diagnosis between large bowel obstruction and ACPO is difficult but this is an effort to highlight another possible mechanism, open for discussion and positive criticism.
 
Junaid Rafi
Obstetrics and Gynaecology, 56 Tassel Road, Bury St Edmunds, UK.

1.Singla SL, Kadian YS, Goyal A, Sharma U, Kadian N. Caecal volvulus in pregnancy: is delay in diagnosis avoidable? Asian J Surg 2005; 28 : 52-4.
2.Wheeler JMD, Woodward A, Williams R. Small bowel volvulus and pregnancy. J of Obstet and Gynaecol 1997; 17: 482.
3.Ventura-Braswell AM, Satin AJ, Higby K. Delayed diagnosis of bowel infarction secondary to maternal midgut volvulus at term. Obstet Gynecol 1998; 91: 808-10.
4.Anifowoshe SO, Al Hakeem M, Noureldin OH. Case report: Sigmoid volvulus complicating advanced pregnancy. Saudi J Obstet & Gynecol 2005; 5: 89-92.
5.Kantor HM. Midgut volvulus in pregnancy. The J of Reproductive Medicine 1990; 35: 577-80.
6.Kakarla A, Posnett H, Jain A,George M, Ash A. Review:Acute colonic pseudo obstruction after cesarean section. The Obstetrician & Gynaecologist. 8: 207-213.