Acute Abdomen in Pregnancy

Medical Causes
Dr. Chandrashekar S.
Professor of Medicine
1.1.M. Medical College
Davangere.
ACU1E ABDOMEA
W "any serious acute intra-abdominal condition"
W "pain, tenderness, and muscular rigidity"
W "emergency surgery must be considered."
DDx of Abdominal Pain in
Pregnancy
W Divided into three categories:
1) Conditions incidental to pregnancy
2) Conditions associated with pregnancy
3) Conditions due to pregnancy
Conditions Due to Pregnancy
W Ectopic pregnancy
W Septic abortion with peritonitis
W Acute urinary retention due to retroverted uterus
W Round ligament pain
W 1orsion of pedunculated myoma
W Placental abruption
W HELLP Syndrome
W Acute Fatty Liver of Pregnancy
W Uterine rupture
W Chorioamionitis
Conditions Associated with Pregnancy
W Acute pyelonephritis
W Acute cystitis
W Acute cholecystitis
W Acute fatty liver of pregnancy
W Rupture of rectus abdominus muscle
W 1orsion of pregnant uterus
Conditions Incidental to Pregnancy
W Acute appendicitis
W Acute pancreatitis
W Peptic ulcer
W Castroenteritis
W Hepatitis
W Bowel obstruction
W Bowel Perforation
W Herniation
W Meckel's Diverticulitis
W 1oxic megacolon
W Pancreatic pseudocyst
W Ovarian cyst rupture
W Adnexal torsion
W Ureteric calculus
W Acute pyelonephritis
W Ureteral obstruction
W SMA syndrome
W 1hrombosis/infarction
W Ruptured visceral artery
aneurysm
W Pneumonia
W Acute Coronary Syndrome
W Intraperitoneal hemorrhage
W Splenic rupture
W Abdominal trauma
W Acute intermittent porphyria
W Diabetic ketoacidosis
W Sickle Cell Disease
Conditions Due to Pregnancy
W Ectopic pregnancy
W Septic abortion with peritonitis
W Acute urinary retention due to retroverted uterus
W Round ligament pain
W 1orsion of pedunculated myoma
W Placental abruption
W HELLP Syndrome
W Acute Fatty Liver of Pregnancy
W Uterine rupture
W Chorioamionitis
HELLP Syndrome
W W HHemolysis, emolysis, EElevated levated LLiver enzyme levels and iver enzyme levels and
LLow ow PPlatelet count latelet count,
W Frequently misdiagnosed at initial presentation.
HELLP Syndrome
Etiology and Pathogenesis .
W icroangiopathic hemolytic anemia.
RBCs become fragmented as they pass through small blood vessels
with endothelial damage and fibrin deposits.
The peripheral smear reveals spherocytes, schistocytes,
triangular cells and burr cells
W Bilirubinemia & raised lactic dehydrogenase levels.
Secondary to obstruction of hepatic blood flow by fibrin
deposits in the sinusoids which leads to periportal necrosis
and, in severe cases, intrahepatic hemorrhage.
W Thrombocytopenia
Increased consumption &/or destruction of platelets.
HELLP Syndrome -Management
W Delivery
W Corticosteroids
W Magnesium sulphate
W Antihypertensive drugs
W Blood products
Conditions Due to Pregnancy
W Ectopic pregnancy
W Septic abortion with peritonitis
W Acute urinary retention due to retroverted uterus
W Round ligament pain
W 1orsion of pedunculated myoma
W Placental abruption
W HELLP Syndrome
W Acute Fatty Liver of Pregnancy
W Uterine rupture
W Chorioamionitis
Acute Fatty Liver of Pregnancy
W Incidence: Rare (1 in 7K 16K deliveries)
W 1iming:
nd
half of pregnancy (usually 3
rd
tri)
W bnormal mitochondrial fatty acid oxidation
W LCH ( Long Chain Hydroxyacyl Co
ehydrogenase) defects are implicated.
Acute Fatty Liver of Pregnancy
W Sxs. N/J (75), epigastric abdominal pain (50),
anorexia, faundice
W Signs. Hypertension, Edema, Icterus
W Labs. PT, PTT, ST/LT, Cr, glucose, /-
WBC, /- Plts
W 1x. aternal stabili:ation (glucose infusion,
reversal of coagulopathy) and emergent delivery
Acute pyelonephritis in pregnancy
W Pyelonephritis is important cause of RF during pregnancy
W In pregnancy the urinary collecting system is prone to
dilatation and stasis
W Incidence is approximately
W Common cause of sepsis during pregnancy
W Sx. Fever, Flank pain, urinary frequency, ysuria and urgency
W Common organisms. E coli (75) , Proteus, Klebsiella, etc.
W Prompt and appropriate antibiotic use is very effective
W Urosepsis is the only indication for intervention in pregnancy.
(PCN / Stent)
Conditions Incidental to Pregnancy
W Peptic ulcer
W Castroenteritis
W Hepatitis
W Acute appendicitis
W Acute pancreatitis
W Bowel obstruction
W Bowel Perforation
W Herniation
W Meckel's Diverticulitis
W 1oxic megacolon
W Pancreatic pseudocyst
W Ovarian cyst rupture
W Adnexal torsion
W Ureteric calculus
W Rupture of renal pelvis
W Ureteral obstruction
W SMA syndrome
W 1hrombosis/infarction
W Ruptured visceral artery
aneurysm
W Pneumonia
W Acute Coronary Syndrome
W Intraperitoneal hemorrhage
W Splenic rupture
W Abdominal trauma
W Acute intermittent porphyria
W Diabetic ketoacidosis
W Sickle Cell Disease
Peptic ulcer disease in pregnancy
W PU is uncommon during pregnancy
W Risk factors for PU in pregnancy include smoking,
alcoholism, stress, & Helicobacter pylori gastritis.
W Symptoms include dyspepsia, epigastric pain, nausea,
vomiting, and heartburn. GI bleeding and perforation are rare
W First treat with dietary and lifestyle changes, together with
antacids or sucralfate.
W When symptoms persist, H receptor-antagonists are
recommended.
W If symptoms continue and are severe , proceed with EG or
proton pump inhibitor therapy during the
nd
/3
rd
trimester.
W Treatment for Helicobacter pylori gastritis should be initiated
after the pregnancy and breastfeeding periods are complete
Castroenteritis in pregnancy
W cute gastroenteritis is the rapid onset of diarrhea less than 14 days
W Infections and also by non-infectious toxins in food.
W Pregnant women are more vulnerable to complications.
W stool sample is usually advisable.
W Infections which may affect the fetus.
Listeria spp. (direct infection of the placenta and chorioamnionitis)
Salmonellosis in pregnancy . (reports of intrauterine death, premature
delivery and neonatal infection. Early diagnosis and treatment)
W Infections which carry a higher risk of causing severe illness in the mother.
E. coli O157
Shigellosis (bacillary dysentery)
Clostridium difficile
Cholera
Castroenteritis in pregnancy
Assessment & Management
W Symptoms . blood/mucus in stool, fever, vomiting, abdominal pain, oliguria.
W h/o Travel, contact with animals, contaminated food or water.
W ssess whether systemically unwell or dehydrated.
W Stool sample
W Blood tests.
Renal function and electrolytes if dehydrated.
Platelet count useful if suspected HUS (e.g. from E. coli O157)
Blood cultures if systemically unwell or Listeria spp. Suspected
ost GI infections in pregnancy only require rehydration.
Specific antibiotics are rarely required.
Acute colitis in pregnancy
W cute inflammation of colon.
Jiral acute GE
Travelers diarrhea
moebic colitis
cute Bacillary ysentery
Inflammatory bowel disease
W Stool culture reveals organism
W Colonoscopy best avoided during acute phase
W Conservative and supportive treatment.
Acute colitis in pregnancy
W Inflammatory bowel disease
Ulcerative colitis.
Bloody diarrhea with mucus
ore common than crohns
ainly disorder of rectum & distal colon
Tx. edical with sulfasala:ine, and steroids.
Crohns disease.
ll layers of the bowel are involved mainly ileum.
Not common in India
Pregnancy per se does not exaggerate the IBs
iagnostic evaluation should not be postponed if needed
Acute Hepatitis in pregnancy
Etiology
W ost commonly Jiral
Hepatitis Jirus
Hepatitis B Jirus
Hepatitis C Jirus
Hepatitis Jirus
Hepatitis E Jirus
W Rarely Bacteria / Proto:oa
Acute Hepatitis in pregnancy
W The course of acute hepatitis is about -4 months
generally.
W Symptoms . fever, malaise, N / J, RUQ pain &
faundice
W Signs . Tender hepatomegaly, Icterus
W LFT . arked elevation of LT & ST (1000 000)
/-Bilirubin & lkaline phosphatase elevation
W USG
W Jiral arkers
Management of Acute Jiral Hepatitis
in Pregnancy
W Establish type by serologic test
W Institute appropriate isolation and precautions
W etermine need for contact prophylaxis with serum globulin
W preparation and/or vaccine
W iet. High carbohydrate Low fat, pareneteral if necessary
W ntiemetics. phenothia:ines may be used
W Corticostcroids. not indicated
W Immunoprophylaxis of infant. if hepatitis B is present
W Interferon (F category C), & Ribavirin (category X). Both
drugs are contraindicated in pregnancy.
Pneumonia in Pregnancy
W Unusually pain may be referred to abdomen
mimicking acute abdomen.
W Pain due to overlying inflammation of pleura.
W Pain in the left/right Upper quadrants.
W Typical symptoms of pneumonia include cough
(N90), sputum production (66), dyspnea (66),
and pleuritic chest pain (50).
W Signs include fever, crackles, and abnormal breath
sounds.
Pneumonia in Pregnancy
W Etiology
Bacterial
Streptococcus pneumoniae ( most common ),
Hemophilus influen:ae, Chlamydia pneumoniae,
ycoplasma pneumoniae & Legionella pneumophila
Pregnant infected with HIJ, Pneumocystis carinii pneumonia
(PCP) is the leading cause of IS-related death
Jiral
H. influen:a and varicella-:oster virus (JZJ)
Fungal
Histoplasmosis, blastomycosis, cryptococcal pneumonia
Pneumonia in Pregnancy - Management
W The chest radiograph will confirm pneumonia, rule out other
diagnoses suggest a possible etiology, and aid in determining
the severity of illness.
W Grams stain and culture of sputum can be helpful in
focusing therapy
W PCR, ELIS, and indirect fluorescent antibody (IF) for viral
pneumonia.
W Broad-spectrum antibiotics should be started empirically
before identification of the etiologic agent.
W Erythromycin is an acceptable initial choice for treatment,
because it is considered safe in pregnancy.
W Ceftriaxone or mpicillin are other drugs initiated commonly.
Acute Coronary Syndrome in pregnancy
W nginal pain may be referred to upper abdomen mimicking
acute abdomen
W CS symptoms may be difficult to differentiate from those of
normal pregnancy
W ild dyspnea v/s Severe Progressive dyspnea
W Fatigability v/s Syncope on exertion
W ecreased exercise tolerance v/s chest pain with effort/emotion
W Treatment options for CS are thrombolysis, PCI or coronary
artery bypass grafting (CBG).
W uring pregnancy, decision-making not only depends on best
maternal results, but is also influenced by fetal safety
ACS in pregnancy - management
W 1hrombolytic therapy during pregnancy - no consensus
The complications include
maternal hemorrhage (.5), uterine hemorrhages with
emergency section (), preterm delivery (6), fetal loss (),
abruptio placenta (.5), spontaneous abortion (1.5).
W PCI is the first-line therapy for ACS in general population.
High doses of radiation place the fetus at risk of spontaneous
abortion, organ deformation, mental retardation and childhood
cancer.
W Coronary artery-bypass grafting can be performed during
pregnancy. aternal mortality equals mortality in nonpregnant
cardiac surgery, but fetal mortality risk is still high with an
incidence of 0
ACS in pregnancy - management
W The use of low-dose aspirin (150 mg/day) is considered safe during
pregnancy. Higher doses are associated with premature closure of the
ductus arteriosus, fetal congenital abnormalities and fetal and maternal
hemorrhage.
W There is no information available about clopidogrel during pregnancy.
W Treatment with (low molecular weight) heparins is safe during pregnancy.
It does not cross the placenta and it can be administered up to 1 h before
delivery
W In general, -blockers are relatively safe. However, severe bradycardia
should be avoided in order to prevent uteroplacental hypoperfusion
W High-dose nitrates may cause maternal hypotension and subsequent fetal
hypoperfusion. No other adverse effects of nitrates during pregnancy have
been reported
W CE-inhibitors are teratogenic in pregnancy, even during the first trimester
and, therefore, should not be given
Porphyrias in pregnancy
W Porphyria is a disruption in the heme pathway.
Porphyria is a disruption in the heme pathway
W Group of metabolic diseases resulting
from a partial deficiency of an en:yme
in the heme biosynthesis
W Seven en:ymes in the pathway
W Four of the porphyrias cause
acute attacks
W Increased demand for heme
can precipitate attacks
secondary to overproduction
of toxic heme precursors
(porphyrins, L)
W The porphyrins have no useful function
and act as highly reactive oxidants
damaging tissues
Key Clinical Features of porphyrias
W Castrointestinal symptoms - bdominal pain (most common
presenting complaint), nausea/vomiting, constipation, and
diarrhea.
W Dehydration
W Hyponatremia
W Cardiovascular symptoms - tachycardia, hypertension,
arrhythmias
W Aeurologic manifestations - motor neuropathy, sensory
neuropathy, mental symptoms, sei:ures.
Exacerbating Factors of Acute Attack
W rugs that increase demand for
hepatic heme (especially
cytochrome P450 en:ymes)
W Crash diets (decrease
carbohydrate intake)
W Endogenous hormones
(progesterone)
W Cigarette smoking (induces
cytochrome P450)
W etabolic stresses (infections,
surgery, psychological stress)
Management of Acute Porphyria
W Initial testing with rapid urinary PBG testing
PBC Qualitative - POSI1IJE
W Confirm with quantitative PBG and L testing (cute attacks. urinary
PBG 2-2 mg/d)
W treat acute symptoms.
Sei:ures Sei:ure precautions, medications?
bdominal Pain narcotic analgesics
Nausea/vomiting phenothia:ines
Tachycardia/hypertension Beta blockers
W ild attacks IJ 10 glucose at least 300 g per day
W Severe attacks Intravenous hemin (3-4 mg/kg daily for 4 days) SP
(can give IJ glucose while waiting for IJ hemin)
W Cimetidine for treatment of crisis and prevention of attacks
DKA in pregnancy
Symptoms
Polyuria.
Polydipsia.
Nausea.
Jomiting.
bdominal pain.
Weakness.
Weight loss.
Signs
Hyperventilation.
Ketotic breath.
Tachycardia.
Hypotension.
ry mucous membranes.
isorientation.
Coma.
DKA in pregnancy
W Pregnancy is a state of insulin resistance.
W Insulin sensitivity falls by as much as 56.
W HPL, prolactin and cortisol, contribute to this.
W The insulin requirement progressively rises during
pregnancy explaining the higher incidence of diabetic
ketoacidosis in the second & third trimesters.
Factors precipitating ketoacidosis in
diabetic pregnancies
W Emesis.
W Infection.
W Non-compliance.
W Insulin pump failure.
W -Sympathetomimetic drugs.
W Corticosteroids.
W Poor management.
Management of DKA in pregnancy
Fluid replacement
W 1 litres of isotonic saline in the first hour.
W 300500 ml/hour of 0.9 or 0.45 saline thereafter.
W dd 5 dextrose when serum glucose approaches 00md/dl
Insulin therapy
W Loading dose 0.4 U/kg regular insulin.
W Continuous infusion at 610 U/hour
W ouble infusion rate if no response in 1 hour.
W ecrease infusion to 1 U/hour as serum glucose drops to 00md/dl.
W Continue infusion 14 hours after resolution of ketosis.
Electrolyte replacement
W Potassium replacement.
W Check phosphorus, magnesium.
Search and treat precipitating factor like infection
Sickle cell crisis in pregnancy
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Sickle Cell Anemia Jaso-occlusive Events
(Pain Crisis)
W Precipitating factors
Hypoxia
cidosis
Fever
Infection
ehydration
Exposure to cold
W Perceived factors
Exposure to cold 34
Emotional stress 10
Physical exertion 7
Pregnancy 5
lcohol consumption 4
Not identified 40
Sickle cell vaso - occlusive crisis
W Serious complication of sickle cell anemia
W Risk of acute event (48 hours)
cute chest syndrome
Splenic sequestration
assive hemolysis
Risk of sudden death
Sickle Cell Anemia Painful Events:
Management Principles
W Correct fluid/electrolyte abnormalities, use hypotonic fluid
and limit volume to avoid overhydration
W Treat any underlying illness
W Opioid analgesics
W Blood transfusion is not indicated for an uncomplicated pain
episode
Acute abdomen in pregnancy
W cute abdomen in pregnant woman can be due to
vivid causes.
W Careful history & examination coupled with
knowledge of various causes helps in timely x
and appropriate management.
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