ACUTE ABDOMEN DURING

PREGNANCY
BY:Dr. Belayneh.
Dr. Tsion
Dr. Merdiya
 Content
Introduction
General principle
Challenges
 Differential diagnosis
Specific disorders and their managment
 Introduction
Definition: Acute Abdomen is a term used
synonymously for a condition that needs
immediate surgical intervention
It means the presence of acute abdominal
symptoms (pain) and or signs suggesting a
disease which definitely or possibly life
threatening and may or may not demand
immediate operative interference.
Sudden, severe abdominal pain of unclear
etiologies < 7 days( <24-48 hrs) requiring rapid
intervention.
 Introduction…
 The approach to abdominal pain and the acute
abdomen in pregnancy is similar to that in the
nonpregnant state, with some additional challenges.
For example, the clinician needs to consider
physiologic/anatomic alterations related to pregnancy,
gestational age and fetal well-being, and causes of
acute abdomen that may be more common due to the
pregnant state or related to obstetrical complications.
 Indicated diagnostic imaging and interventions should
be performed since delay in diagnosis and treatment
can increase maternal and fetal/newborn morbidity
and mortality
When evaluating the pregnant women with abdominal pain
and acute abdomen, the following principles should
beconsidered :
Mild to moderate abdominal discomfort is a
common
Nausea & vomiting is a common feature of
early pregnancy, and usually abates by 20 wks
of gestation. Nausea and vomiting is not a
normal manifestation of pregnancy when it
occurs with abdominal pain, fever, diarrhea,
headache, or localized abdominal findings
 Principle……
 The uterus becomes an abdominal organ, enlarging beyond
the pelvis by 12 weeks of gestation. This enlargement may
make it difficult to localize pain as it can impede physical
examination, affect the normal location of pelvic and
abdominal organs, and mask or delay peritoneal signs
(rebound, guarding) . The laxity of the abdominal wall may
also diminish peritoneal signs (guarding, rebound).
 The enlarged uterus may compress the urinary tract,
leading to hydroureter and hydronephrosis or cause
aortocaval compression, resulting in dizziness or syncope
when the pregnant woman is in a supine position. These
physiological changes mimic some of the signs of
nephrolithiasis and cardiac arrhythmia
 Principle…..
Accurate knowledge of gestational age is
required - fetal viability, differentiate normal
pregnancy changes from the acute events
Peritoneal signs are often absent in pregnancy
Distinguish extra uterine tenderness from
uterine tenderness – performing the
examination with the patient in the right or left
decubitus position, thus displacing the gravid
uterus to one side.
 Principle……
 The high progesterone concentration during pregnancy
decreases lower Esophageal sphincter tone, small
bowel and colonic motility, gallbladder emptying, and
ureteral tone . These physiologic changes are
important in the pathogenesis and diagnosis of
conditions such as:
• GERD
• constipation,
• Cholelithiasis
• nephrolithiasis
 Physiologic changes in hematologic parameters may
mimic infection and occult hemorrhage, making
diagnosis of these disorders more difficult:
 Principle related to Surgery
Elective nonobstetric surgery is avoided during
pregnancy because of additional risks to the
mother and child in this setting
The risk of preterm labor and delivery is lower in
the second trimester compared to the third
The risk of spontaneous loss and risks due to
medications such as anesthetic agents are lower
in the second trimester compared to the first.
Preferably laparoscopic than open surgery
 Principle related surgery
Intraoperative management should include:
 left lateral uterine displacement,
 avoidance of uterine manipulation
 optimal maternal oxygenation
 external fetal monitoring if gestational age is in the
viable range
 Current data do not support intraoperatively the use of
tocolytic agents.
 Depending on gestational age, tocolytic agents may be
considered for postoperative PTL if there is no evidence
of uterine infection
 Principle related to imaging
 Ultrasound is typically the first-line modality for diagnostic
imaging of the abdomen in pregnant women since it is
widely available, portable, nonionizing, and its diagnostic
performance is often adequate.
 When US findings are equivocal or uncertain, then the
choice of the 2nd-line modality depends on the DDx and
should take into account availability, diagnostic
performance, and fetal radiation exposure.
 When indicated, use MRI is preferable to CTS because it
avoids ionizing radiation and, for diagnosis of many
disorders, performs as well as, or better than, CT
 Principle ……
Concerns about the possible fetal effects of
ionizing radiation should not prevent
medically indicated diagnostic procedures
during pregnancy using the best available
modality for the clinical situation.
A delay in diagnosis can increase the risk of
an adverse maternal and/or fetal outcome.
 Challenge of Abdominal Pain and acute
abdomen During Pregnancy

Multiple causes including essentially all non

pregnancy causes plus obstetric causes
Clinical presentation & natural history often
altered with pregnancy
Diagnostic evaluation and treatment plans
altered & limited
Fetal wellbeing to be considered
Diagnostic imaging limitations
Anesthesia issues
 Obstetric/Gynecologic Etiologies
 Ruptured Ectopic
 Pre-eclampsia/Eclampsia
 Placental Abruption
 Uterine Rupture
 Ovarian Cyst Rupture
 PID
 Tubo-Ovarian Abscess
 Uterine Leiomyomas
 Abortion
 Salpingitis
 Endometriosis
 Cancer of Cervix or Ovary
 Common Non OB Etiologies
Appendicitis
GERD/other bowel c/o
Intestinal Obstruction
Cholelithiasis/Cholecystitis
Pancreatitis
Pyelonephritis
Nephrolithiasis
 HISTORY
• As with most things, history essential
to diagnosis:
-Location
-Character
-Radiation
-Aggravating/Relieving Factors
 PHYSICAL EXAM
• Uterus displaces abdominal organs
• Moving omentum does not wall off infection
as well
• Late pregnancy abdominal wall laxity may
mask rigid abdomen of peritonitis
Appendicitis:
The most common surgical condition
of the abdomen
Lifetime occurrence of 7%
Peak incidence 10-30y

The most common nonobstetric

surgical intervention during pregnancy
 Acute appendicitis
 75% of all cases of an
acute abdomen during
pregnancy (if ectopic
excluded)
 Acute appendicitis occurs
more often during the
second trimester (50%)
than during the first
(10%) or third trimester
(35%). 5% occur during
labor or in puerperium
 Appendicitis cont …
Up to 25% develop appendiceal perforation
Fetal complications mostly secondary to
preterm labor (1-2% in uncomplicated
appendicitis and 30-40% with peritonitis)
RLQ in the first trimester,
at the level of the umbilicus in the second
trimester,
in the RUQ in the third trimester.
 Clinical manifestation
• The most common symptom of appendicitis,
ie, right lower quadrant pain, occurs close to
McBurney's point in the majority of pregnant
women
• in T3, pain may localize to the mid or even the
upper right side of the abdomen
• there is less rebound tenderness or guarding
• Rectal tenderness is usually present
 Clinical manifestation…
• Nausea is present in nearly all cases
• Vomiting present in two thirds of patients
• Anorexia is present in only 1/3 – 2/3 of pregnant patients
• Direct abdominal tenderness most common
– T1: Tenderness well localized in RLQ
– T2, T3: tenderness may change location: right periumbilical
area, RUQ, diffuse
• Classic Signs:
– Rebound present in 55-75% of patients
– Abdominal muscle rigidity in 50-65%
– Psoas sign observed less frequently in pregnancy
– The Rovsig sign as frequent in pregnancy as non-pregnancy
state
 Appendicitis cont …
• Investigations:
-Leukocytosis normal in pregnancy
-U/S nonspecific but may show
-appendiceal mural thickening &
periappendiceal fluid (mostly to help r/o other
etiologies)
Graded compression ultrasound:
• Normal appendix (<6mm) rules out appendicitis.
• Nonpregnant – Sensitivity 85%
specificity 92%
• Pregnant – cecal displacement & uterine imposition makes
precise examination difficult (Williams,21 edition)
-CT better but exposes fetus to radiation
 Appendicitis Management
APPENDICITIS REQUIRES SURGERY
IV hydration & lytes correction
Abx (Penicillin, Cephalosporins, Clinda, Gent)
Laparoscopy in T1 & ? T2 for nonperforated
Laparotomy incision over pt of focal
tenderness
Appendectomy even if no appendicitis
Concomitant c/s not done
“The mortality of appendicitis
complicating pregnancy is the
mortality of delay “

Babler 1908
 Intestinal Obstruction
Third most common nonobstetrical
abdominal emergency (>1/1500)
Incidental or secondary to pregnancy
Large increase in #’s results from increased
#’s abdominal procedures, PID, & #
pregnancies in older women
Most common T3 b/c mechanical effects
large uterus, fetal head descent or
immediately PP because rapid change
uterine size
Adhesions (previous surgery) 60-70% SBO
 Intestinal Obstruction cont …
 AXR required to dx & monitor despite risk radiation
to fetus
 Surgery for complete/unremitting
 Medical tx for partial/intermittent
-IV fluid & lyte correction
-NGT to suction

-Morbidity/mortality related to delayed dx

-Maternal < 6%
-Fetal 20-30%
-Maternal 13% in colonic volvulus
 Cholelithiasis
Pregnancy increases bile lithogenicity &
sludge formation b/c estrogen increases
cholesterol synthesis and progesterone
impairs gallbladder motility
>12% pregnancy compared to 1-2% controls
Pregnancy does not increase severity of
complications
Most gallstones are asymptomatic
 Cholelithiasis
 Symptoms:
-Biliary colic in epigastrium/RUQ
-May radiate to back, flank, or shoulders
-pain often associated with post prandial states
(especially fatty foods)
-Pain typically lasts 1 to several hours
-Diaphoresis, nausea, & emesis common

Physical exam often unremarkable apart from

occasional RUQ tenderness
 Cholelithiasis
1/3 patients no additional episode X 2 yrs
Complications of cholelithiasis include
cholecystitis, choledocholithiasis, jaundice,
cholangitis, biliary stricture, sepsis, abscess,
empyema, gallbladder perforation, &
gallstone pancreatitis
 Cholecystitis
 Inflammation usually caused by cystic duct
obstruction & supersaturated bile
 2nd most common nonobstetric surgical emergency
 1-8/10,000
 Same symptoms but pain more prolonged
 Often get tachycardia, fever, R subcostal
tenderness, & Murphy’s sign
 Leukocytosis common
 Serum LFT’s may be slightly abnormal
 Jaundice may suggest choledocholithiasis
 Tx for Cholecystitis
 Cholecystectomy
 Pre-op NPO, IV fluid, abx
 Abdominal surgery best in T2
 T1 associated with fetal abortion & T3 with
premature labor
 Cholecystectomy may be deferred in appropriate
cases
 Lap chole safe in earlier pregnancy
 Intraoperative cholangiography only for strong
indications
 Maternal & fetal mortality < 5%
 Choledocholithiasis
Abdominal pressure & jaundice
Endoscopic u/s
Fever/chills, leukocytosis, n&v
ERCP & sphincterotomy with
cholecystectomy PP
 Pyelonephritis
• Renal alterations in 70-90%
• More pronounced T2 & T3 when risk
pyelonephritis is greatest
• Asymptomatic bacteriuria (ASB) in about 7%
• Acute cystitis 2%
• ASB treated to prevent pyelonephritis
(cephalosporins, nitrofurantoin …)
• 25-40% untreated ASB develop pyelo
• 30% retreatment
 Pyelonephritis
• Acute pyelo in 1-2% pregnancies
• Symptoms & Signs:
-Fever/chills
-N & V
-Flank pain
-CVA tenderness

-Complications include sepsis, shock, ADRS,

Pulmonary edema, renal insufficiency/abscess,
& recurrent infection
 Pyelonephritis
• Tx is IV abx until patient clinically improves
and then PO abx
• Renal u/s if no improvement after 3 days
• Associated with preterm labor and delivery
 Nephrolithiasis
• Symptomatic < 5/1000 pregnancies but accounts for
the most nonobstetric hospitalizations
• About 50% causes by hypercalciuria
• Usually T2 or T3
• Symptoms & Signs :
-Abdominal/flank pain often radiating to
groin
-Gross hematuria, urgency, frequency
-N&V, diaphoresis, fever/chills
 Nephrolithiasis
• Fluoroscopy relatively contraindicated
• U/S initial test of choice

• Tx includes hydration, analgesia, & abx if

infection – most responds well
• Obstruction, sepsis requires ureteral stent
• Surgery in refractory cases
• Risk premature labor
 Acute Pancreatitis
• 0.1-1% pregnancies
• Most common T3 & PP
• Gallstones cause > 70%
• EtOH quite uncommon but other causes
include drugs, surgery, trauma, etc
• Pregnancy does not affect
• Epigastric pain most common complaint
• Pain may radiate to back, shoulders, or flanks
• Nausea, emesis, fever common
 Acute Pancreatitis cont …
• Signs:
-Midabdominal tenderness
-Occasional rebound
-Guarding
-Hypoactive BS
-Distension
-Tympany
 Acute Pancreatitis cont …
• Elevated Amylase & Lipase
• U/S for cholelithiasis & bile duct dilation
• Endoscopic u/s for choledocholithiasis

• Pancreatitis in pregnancy usually mild and responds

well to medical therapy
-NPO
-IV fluids
-Gastric acid suppression
-Analgesia (Meperidine)
-? NGT suction
 Acute Pancreatitis cont …
• Severe pancreatitis with abscess, sepsis,
phlegmon requires ICU, Abx, TPN, & possible
radiologic/surgical intervention
• Pregnancy should not delay CT or surgery in
these cases
• Endoscopic spincterotomy can be performed
during pregnancy with minimal fetal radiation
exposure
• Maternal mortality low with uncomplicated
but > 10% with complicated pancreatitis
• T1 – fetal abortion ; T3 – preterm labor
 APPENDICITIS
• Most common nonobstetric surgical
emergency (1/1000) in pregnancy
• Appendicitis in 1/1500 (65%)
• Slightly more likely during T2
• Maternal mortality (highest in T3) somewhat
higher secondary to delayed dx and decline of
laparotomy (0.1% without perforation & 4%
with perforation)
 Appendicitis cont …
• Up to 25% develop appendiceal perforation
• Fetal complications mostly secondary to
preterm labor (1-2% in uncomplicated
appendicitis and 30-40% with peritonitis)
 Appendicitis cont …
Symptoms:
-Periumbilical (early visceral obstructive)
-RLL/RUQ (late parietal secondary
inflammation) – very focal
-N & V, anorexia, urinary frequency

Signs:
-Focal tenderness/guarding /rebound/ ?
peritoneal signs (omental displacement)
 Appendicitis cont …
• Investigations:
-Leukocytosis normal in pregnancy
-U/S nonspecific but may show
appendiceal mural thickening &
periappendiceal fluid (mostly to help r/o other
etiologies)
-CT better but exposes fetus to radiation
-Often confused with right
pyelonephritis/cholecystitis
 Appendicitis Management
• APPENDICITIS REQUIRES SURGERY
• IV hydration & lytes correction
• Abx (Penicillin, Cephalosporins, Clinda, Gent)
• Laparoscopy in T1 & ? T2 for nonperforated
• Laparotomy incision over pt of focal
tenderness
• Appendectomy even if no appendicitis
• Concomitant c/s not done