ACUTE ABDOMEN

AND
PREGNANCY
Dr. Muhammad Noman
PG, Surgical Unit II
JPMC
Objective
• Approach to acute abdomen in pregnant patients.

•Management of acute abdomen in pregnant pts.

• Up to 2% of pregnancies complicated by non-obstetric surgical
problems

• Diagnostic and therapeutic dilemmas

• Delay in diagnosis => increase in maternal and fetal morbidity and

mortality.
• For Approach to abdominal pain and the acute abdomen in
pregnancy & to prevent delay in diagnosis must understand:

• Physiologic/anatomic changes specific to pregnancy,

• Fetal well-being, gestational age and fetal development, and

• Causes of acute abdomen that may be more common due to the

pregnancy or related to obstetrical complication.

•Diagnostic modalities (risks and benefits of each)

• Risk of surgery
 Maternal Physiology
• Cardiovascular System
• Cardiac output 30-50
•  Resting HR 10-15 bpm
• Uterine blood flow 500ml/hr
•  Blood volume 30-50%
• Physiological anemia
• Delays signs of hypovolemia
Cont…

•  risk 4-6 of thromboembolism

• Venous stasis
• Hypercoagulability
•  Factors II, VII, VIII, IX and X
•  antithrombin III and protein S

• Leukocytosis: ^ 12000, Labour 20,000

Cont…
Effects of Gravid uterus:

• Expanding uterus dislocates other

intraabdominal organs.
• E.g. Appendix may be cephalad.
• Abdominal wall further away from
inflammatory processes .
• Prevents omental isolation of infection.
• Inflammatory process progresses more rapid
than in non-pregnant patients.
 Fetal Development
• 1st trimester: Organogenesis

–  susceptibility to teratogens
–  spontaneous abortions

– CNS most sensitive to insults 8-25 weeks

Cont…

• 2nd and 3rd Trimester

• Fetal growth/development
• Susceptible to IUGR
• Preterm delivery

• Fetal viability >24wks

Causes of Acute Abdomen /
Abdominal Pain During Pregnancy
Divided into three categories:

• Conditions NOT related to pregnancy

• Conditions associated with pregnancy

• Conditions due to pregnancy


Non Pregnancy related:
• Acute appendicitis
• Gallbladder disease
• Bowel obstruction
• Inflammatory bowel disease
• Pancreatitis
• Diverticulitis
• Perforated ulcer
• Bowel Perforation
• Nephrolithiasis
• Ureteral obstruction
• Trauma
• Pneumonia
• Gastroenteritis
• Hemoperitoneum
Cont…
• Rupture of renal pelvis
• Ureteral calculus
• Ureteral obstruction
• Thrombosis/infarction
• Pulmonary embolus
• Ruptured visceral artery aneurysm
• Splenic artery aneurysm
• Splenic rupture
• Intraperitoneal hemorrhage
• Sickle Cell Disease
 Cont…
Associated with Pregnancy:
• Acute pyelonephritis
• Acute cystitis
• Acute cholecystitis
• Acute fatty liver of pregnancy
• Rupture of rectus abdominus muscle
• Torsion of pregnant uterus
 Cont…
Due to Pregnancy:
• Ovarian torsion or cyst rupture
• Fibroid degeneration
• Pelvic inflammatory disease
• Placental abruption
• Uterine rupture
• Extrauterine pregnancy
• Severe preeclampsia and HELLP syndrome
• Intraamniotic infection
 Diagnostic Modalities
• Ultrasound
• sound waves

• X-ray / CT scans
• ionizing radiation

• MRI
• radiowaves within a magnetic field
• Safe in pregnancy
 Ultrasound
• Assess fetus, adnexa, GB, kidneys, ureters
• Often can distinguish GYN problems
• Sensitivities 39-98% for appendicitis in non-pregnant
• Maybe that sensitive in 1st and 2nd trimester
• Gravid uterus often interferes
• Safe
• Used without maternal/fetal risk
• Recommended as first line diagnostic tool.
Xray & CT Scan
Harmful effects:
• Cell death and teratogenesis
• High doses of radiation before implantation is likely lethal
• In humans, high dose  growth restriction, microcephaly,
mental retardation
• Effects are greatest at 8-15 wks gestation
• Risks are not increased until radiation exposure = 5 rad
 Surgical
Outcomes
• Maternal/fetal outcomes of non-obstetric
surgical patients from a literature review.

• Maternal death = 0.006%

• Miscarriage = 5.8% (10.5% first trimester)
• Preterm labor =3.5% (4.6% for appendectomies)
• Fetal loss = 2.5% (10.9% perforated appendectomies)
• Prematurity = 8.2%
• No increase risk of major birth defects
• No differences noted between risks of laparoscopic surgery vs. open

Ref: Am J Surg. 2005 Sep;190(3):467-73

 Timing of Surgery
•1st trimester (wks 1-12)
• 12% Spontaneous Abortion rate
•2nd trimester (wks 13-26)
• 0 - 5.6% Spontaneous Abortion rate
• 5% rate of preterm labor
•3rd trimester (wks 27-40)
• 30-40% rate of preterm labor

• Best Period: 2nd trimester

• Risk of preterm labor and delivery is lower.
• Risk of spontaneous loss & risks due to medications such as anesthetic
agents are lower.
Anesthetic Concrens:

• Inhalational/local anesthetics, narcotic agents,

benzodiazepines, paralytics all shown to be safe in
pregnancy.
 Antibiotics
• Safely use during Pregnancy

Metronidazole (Flagyl)

Penicillin

Cephalosporin (2nd, 3rd)

Macrolides
Cont…

• Antibiotics - Contraindicated

Drugs Teratogenic Adverse effects

effects on Mother
Aminoglycosides Nephrotoxicity, Nephrotoxicity,
Ototoxicity Ototoxicity
Floroquinolones Arthropathies, Dysplasia
of Cartilage
Tetracycline Growth stunting , teeth Acute fatty necrosis of
discoloration liver, pancreatitis, renal
damage.
 Acute Abdomen & Pregnancy
• Acute Appendicitis

• Acute Cholecystitis
 Challenges of Diagnosis
• Symptoms
• Nausea, vomiting, and abdominal pain are common in the
normal obstetric population. N/V are most common in weeks 4-
16.
• Physical Exam
• Expanding uterus dislocates other intraabdominal organs.
• Labs
• Leukocytosis and anemia are common in normal pregnancies
and thus, not as predictive of infection or blood loss.
 Appendicitis and Pregnancy
• Most common nonobstetric cause of surgical emergency in pregnancy.
• More common in the second trimester.
• Not affect the overall incidence but increase the severity of appendicitis.

• Symptoms:
• Abdominal pain is almost always present.
•1st trimester: Right lower quadrant
• 2nd trimester: Rt side of umblicus
• 3rd trimester: Diffuse or right upper quadrant
• Nausea - nearly all cases.
• Vomiting – 2/3 of pts.
• Anorexia - 1/3 to 2/3 of pts
 Cont…

• Signs:
• Direct Right lower quadrant tenderness: ~100
• 1st trimester: well localized in the right lower quadrant.
• Later in pregnancy: right periumbilical area, in the right upper quadrant, or diffuse.

• May be rebound tenderness & abdominal muscle rigidity.

• Rovsing sign – frequent

• Psoas irritation - less frequent.

• Rectal tenderness is usually present, particularly in the first trimester.

• Fever and tachycardia - not sensitive.

• Adler sign:
•If the point of maximal tenderness shifts medially with repositioning
on the left lateral side, the etiology is generally adnexal or uterine (vs
appendiceal)
 Investigation
• Blood CP: Leucocytosis
• Urinalysis: Pyuria or hematuria – 10-20% (extraluminal irritation of the
ureter )
• Ultrasound:
•80% sensitive: non-perforating appendicitis
• 28% sensitive: perforated appendicitis
• 3rd trimester accuracy is lower due to technical difficulties.
•
 Treatment

• Surgery: Appendicectomy within 24 hrs of presentation.

• Position: Tilt the operating table 30° to the patient's left.

• Incision: Centre of incision over the point of maximum tenderness.

• If doubt, esp in 1st trimester: lower midline incision.
Risk to Mother and fetus

• If surgery delayed by >24 hrs from presentation – Complications:

• Perforation
• Fetal & maternal morbidity & mortility.
• Premature labour & threatened abortion
•Non-perforated appendix
• Fetal mortality of 1.5%
• Perforated appendix
• Fetal mortality - 20-35%
• Maternal mortality - 1%
• 83% risk of preterm contractions due to localized peritonitis.
• In all cases, the rate of premature delivery is highest in the 1 st week post-op.
 Acute Cholecystitis & Pregnancy
• Pt with chronic hemolytic conditions, increase the risk for gallstone formation.

• Epidemiology:
• Cholelithiasis - cause of cholecystitis in pregnant pts, 90% of cases
• Incidence of cholelithiasis in pregnancy - 3.5-10%
• Only 30-40% of pregnant pts with gallstones are symptomatic

• Pathophysiology: Hormones and biliary disease

• Estrogen in pregnancy   cholesterol synthesis,  hepatic cholesterol uptake,

catabolism of cholesterol to bile acids  Bile supersaturation & cholesterol stones.
• Progesterone in pregnancy bile stasis &  GB contraction in response to CCK
 Sign & Symptoms

• Basically identical in pregnant and non-pregnant pts.

• Cholecystitis can mimic appendicitis in the third trimester.

 Investigation

• Ultrasound: diagnostic and safe.

• Blood CP: Leukocytosis – in normal pregnancy.

•  Alkaline phosphatase is non-specific as it is  normally in

pregnancy.

• Amylase levels are elevated transiently in 1/3 pts.

MANAGEMENT
• INITIAL MANAGEMENT:

•IV hydration

• Bowel rest

• Pain control

• Antibiotics

• Fetal monitoring

• Nasogastric decompression if necessary

 Surgery
• Cholecystectomy is now recommended as the primary treatment for
cholecystitis because of:
• Recurrence rate during pregnancy of 44-92%

• Reduced use of medications

• Shorter hospital stay and fewer hospitalizations

• Elimination of risk of subsequent gallstone pancreatitis

• Minimizing development of potentially life-threatening complications such as perforation,

sepsis, and peritonitis
Other Indications of Cholecystectomy During pregnancy

• Choledocolithiasis (after ERCP)

• Gallstone Pancreatitis

• Recurrent symptomatic cholelithiasis

 BILIARY COLIC/ACUTE CHOLECYSTITIS IN
PREGNANCY PROTOCOL

BILIARY COLIC/ ACUTE CHOLECYSTITIS

2ND TRIMESTER 3RD TRIMESTER

1ST
TRIMESTER

Medical Management for Lap Chole Medical Management

RECURRENCE RESOLUTION RECURRENCE RESOLUTION

FAILURE FAILURE
Elective Lap Elective Lap
Chole in 2nd Chole Post
Repeat Medical Repeat Medical for Lap
for Lap Trimester Partum
Management Management Chole
Chole
CHOLEDOCHALITHIASIS IN PREGNANCY
PROTOCOL

CBD STONE

2ND TRIMESTER 3RD TRIMESTER

1ST TRIMESTER

ERCP
ERCP ERCP

ELECTIVE LAP OR FOR ELECTIVE LAP

CHOLE IN 2ND LAP CHOLE CHOLE POST
TRIMESTER PARTUM
Laparoscopy vs. open
• Benefits:
• Decreased post operative narcotic requirements (fetal
depression)
• Decreased wound complications
• Decreased post op maternal hypoventilation
• Faster maternal recovery
• Risks:
• Uterine injury
• Decreased uterine blood flow
• Premature labor due to increase intra-abd pressure
• Effects of CO2 pneumoperitoneum (fetal acidosis)
Which trimester period best for Surgery
a) 1st
b) 2nd
c) 3rd
d) All
Which diagostic tool is not safe in pregnancy
a) Xray
b) Ultrasound
c) MRI
d) All
Following conditions occur in normal
pregnency except
a) Leucocytosis
b) Nause & vomiting
c) Abdominal pain
d) Rectal tenderness.
THANK YOU