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Acute Abdomen in Pregnancy

Kate Pettit, MS III


June 18, 2007
The Most Important Equation

+ +

=
How old are your prospective
pregnant patients?

45-54 yrs

40-44 yrs Avg Age


35-39 yrs
at First
Birth in
30-34 yrs US:
c
25-29 yrs 25.1 yrs
20-24 yrs

15-19 yrs

10-14 yrs

0 20
Live Births
40
per
60
1,000 Women
80 100 120 140

CDC 2004
DDx of Abdominal Pain in
Pregnancy
 Divided
into three categories:
1) Conditions incidental to pregnancy
2) Conditions associated with
pregnancy
3) Conditions due to pregnancy
Conditions Incidental to Pregnancy
 Acute appendicitis  Rupture of renal pelvis
 Acute pancreatitis  Ureteral obstruction
 Peptic ulcer  SMA syndrome
 Gastroenteritis  Thrombosis/infarction
 Hepatitis  Ruptured visceral artery
 Bowel obstruction aneurysm
 Bowel Perforation  Pneumonia
 Herniation  Pulmonary embolus
 Meckel’s Diverticulitis  Intraperitoneal hemorrhage
 Toxic megacolon  Splenic rupture
 Pancreatic pseudocyst  Abdominal trauma
 Ovarian cyst rupture  Acute intermittent porphyria
 Adnexal torsion  Diabetic ketoacidosis
 Ureteral calculus  Sickle Cell Disease
Conditions Associated with
Pregnancy
 Acute pyelonephritis
 Acute cystitis
 Acute cholecystitis
 Acute fatty liver of pregnancy
 Rupture of rectus abdominus muscle
 Torsion of pregnant uterus
Conditions Due to Pregnancy
 Ectopic pregnancy
 Septic abortion with peritonitis
 Acute urinary retention due to retroverted uterus
 Round ligament pain
 Torsion of pedunculated myoma
 Placental abruption
 Placenta percreta
 HELLP Syndrome
 Acute Fatty Liver of Pregnancy
 Uterine rupture
 Chorioamionitis
Ectopic Pregnancy
 Classic Symptoms
 Abdominal pain
 Amennorrhea
 Vaginal Bleeding
 Diagnosis
 Transvaginal U/S (TVS)
 Presence of a true  Management
gestational sac at 4.5 to 5  Option of medical vs surgical
management if pt is hemodynamically
wks is the 1st sign of IUP. stable and no rupture has occurred.
 Cardiac activity is first  Emergent surgical management if
detected at 5.5 to 6 weeks. rupture has occurred and/or patient is
 Serum quantitative HCG hemodynamically unstable
 Absence of an intrauterine  Prognosis
gestational sac at hCG  Ruptured ectopic pregnancies account
concentrations >1500-2000 for 4- 10 percent of all pregnancy
related deaths.
IU/L suggests an ectopic or
nonviable intrauterine
pregnancy
HELLP Syndrome
Hemolysis – Elevated Liver Enzymes – Low Platelets

 Incidence: 1 in 1K pregnancies
 Timing: Majority diagnosed at
28-36 wks Sign/Sx Frequency
 Labs: Plts, AST/ALT,
indirect bili, haptoglobin, Proteinuria 87
schistocytes on peripheral
Smear HTN (>140/90) 85
 Management: RUQ/Epigastric pain 40-90
 Emergent delivery for
pregnancies > 34 weeks, Nausea/Vomiting 29-84
nonreassuring fetal status, Headache 33-60
severe maternal disease
(multiorgan dysfunction, DIC, Visual changes 10-20
liver infarction or hemorrhage,
ARF, or abruptio placenta) Jaundice 5
 Delayed delivery in stable
pregnancies <34 wks after
administration of
corticosteroids
Acute Fatty Liver of Pregnancy
 Incidence: Rare (1 in 7K – 16K deliveries)
 Timing: 2nd half of pregnancy (usually 3rd tri)
Sxs: N/V (75%), epigastric abdominal pain
(50%), anorexia, jaundice +/- signs of pre-
eclampsia
 Labs: PT, PTT, AST/ALT, Cr,
glucose, +/- WBC, +/- Plts
 Tx: Maternal stabilization (glucose infusion,
reversal of coagulopathy) and emergent
delivery
Definition of Acute Abdomen

 Stedman's Medical Dictionary, 27th


Edition defines acute abdomen as "any
serious acute intra-abdominal condition
attended by pain, tenderness, and
muscular rigidity, and for which
emergency surgery must be
considered.”
Epidemiology
 Incidenceof acute abdomen during
pregnancy is 1 in 500-635

# 1 Acute Appendicitis
# 2 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 (10-20K) and anemia are common in
normal pregnancies and thus, not as predictive of
infection or blood loss.
Which conditions require urgent
surgical management in pregnancy?
 Trauma
 Acute appendicitis
 Intestinal obstruction
 Perforated duodenal ulcer
 Spontaneous visceral rupture
 Ectopic pregnancy
 Ovarian or uterine torsion
Timing of Surgery

 1st trimester (wks 1-12)


 12% SAb rate
 2nd trimester (wks 13-26)
0 - 5.6% SAb rate
 5% rate of preterm labor

 3rd trimester (wks 27-40)


 30-40% rate of preterm labor
Imaging Options

 U/S: No known adverse effects.


 X-ray: Presence of adverse effects
depends on total radiation dose.
 CT: Presence of adverse effects
depends on total radiation dose.
 MRI: No known adverse effects.
 ERCP: Only recommended for
therapeutic use, not for routine imaging.
Radiation during pregnancy
Use of ERCP in Pregnancy
American Society for Gastrointestinal Endoscopy Guidelines

 ERCP should only be used when therapeutic intervention is intended


(usually for biliary pancreatitis, choledocholithiasis, or cholangitis).

 Several studies have confirmed the safety of ERCP in pregnancy.

 With precautions, fetal exposure is well below the 5- to 10-rad level.


 Kahaleh et al. reported an estimated fetal radiation exposure of 40 mrads
(range 1-180 mrad).

 Precautions for reducing radiation exposure:


 Lead shields placed under the pelvis and lower abdomen, remembering that
the x-ray beam originates from beneath the pt.
 Use of brief ''snapshots'' of fluoroscopy to confirm cannula position and CBD.
 Minimize total fluoroscopy time.
Reducing Radiation in Pregnancy
 X-ray: PA exposures lowers
the radiation dose by 2 to 4
mrad compared with the
traditional AP exposures
because the uterus is located
in an anterior pelvic position.
 CT: Narrow collimation and
wide pitch (the patient moves
through the scanner at a
faster rate) results in a
slightly reduced image
quality, but provides a large
reduction in radiation
exposure.
Sequelae of Radiation in Pregnancy

 May cause failure of implantation,


malformation, growth retardation,
CNS abnormalities, or fetal loss.
 Exposure <10 rads (100 mGy)
does not  the risk of fetal death,
malformation, or developmental
delay.*
 Highest risk of radiation damage
during embryonic period of
organogenesis (weeks 3-9).

*International Commission on
Radiological Protection.
Childhood Leukemia and Radiation

 The background rate of leukemia in


children is about 3.6 per 10,000.
 Exposure to one or two rad increases
this rate to 5 per 10,000.
Use of contrast in pregnancy
 Iodinated contrast:
 Crosses the placenta
 Can produce transient effects on the developing fetal thyroid
gland, although clinical sequelae from brief exposures have
not been reported.
 May be used when indicated.
 Gadolinium:
 Crosses the placenta.
 Because of limited experience with this agent, gadolinium is
currently not recommended for use in the pregnant patient
unless the potential benefit justifies the potential risk to the
fetus.
 Animal studies have shown an  risk of spontaneous
abortion and skeletal and visceral anomalies.
MRI as an imaging modality

 Mechanism
 Electromagnetic field induced changes in
proton spin
 Theoretical risks to fetus
 Induction of local electric fields and currents
 Radiofrequency radiation results in heating
of tissue
American College of Radiology
Paper on MRI Safety
MRI should only be used in pregnancy when:
 The information requested from the study
cannot be obtained from nonionizing
means.
 The information is needed to care for the pt
and fetus during pregnancy.
 The ordering MD does not feel it is prudent
to delay diagnosis until after pregnancy.
MRI in Pregnancy
 No studies have shown adverse effects on the
fetus or the outcome of the pregnancy.
 However, arbitrarily MRI is NOT usually
performed in the 1st trimester 2/2 to this being
the period of organogenesis.
 When MRI is used, informed consent must
include the possibility that a previously
undiagnosed fetal abnormality may be found.
"No single diagnostic
procedure results in a
radiation dose that threatens
the well-being of the
developing embryo and fetus."
-- American College of
Radiology
Appendicitis
#1 Cause of Acute Abdomen
Appendicitis

 Accounts for 25% of the operative


indications for non-obstetric surgery
antepartum.
 Appendicitis is NOT more common
during pregnancy.
 Incidence is approximately equal in all
three trimesters.
Signs and Symptoms
 RLQ pain: Most reliable sx
 Anorexia and vomiting: Not sensitive
nor specific.
 Direct RLQ tenderness: ~100%
 Rebound tenderness: 55-75% of pts
 Abdominal muscle rigidity: 50-65% of
pts
 Psoas sign: Observed less frequently.
 All findings are less common in 3rd
trimester due to laxity of abdominal wall
muscles.
Adler Sign

 Ifthe point of maximal tenderness shifts


medially with repositioning on the left
lateral side, the etiology is generally
adnexal or uterine (vs appendiceal).
Appendiceal Location
 Historically, many references
have reported appendiceal
displacement.
 In 2003, a study by Hodjati et
al showed that pregnancy did
NOT change appendiceal
location.
 Degree of displacement, if
any, is likely due to different
extents of cecal fixation.
Laboratory Evaluation

 WBC: Absolute number not reliable


given leukocytosis of pregnancy.
 Differential:  levels of band cells can
be reliable indication of infection.
 U/A: Caution as 20% of pts have pyuria
or hematuria with appendicitis due to
extraluminal irritation of the ureter (rather
than due to a UTI).
1st Line Imaging for Appendicitis
 Graded compression U/S
 80% sensitive: non-perforating appendicitis

 28% sensitive: perforated appendicitis

 3rd trimester accuracy is lower due to


technical difficulties.

* Doris et al (meta-analysis).
2nd Line Imaging for Appendicitis

CT MRI
 94% sensitivity  Up to 100%
 94% specificity sensitivity*
 96% specificity*
 No known adverse
effects on fetus, but
cost and availability
may be prohibitive.

*Values are from small study of 45 pregnant pts. Fielding and Chin (2006).
Risks for Mother and Fetus
 66% risk of perforation if surgery delayed by >24 hrs
from presentation.
 Negative laparotomy rates of up to 35% are
considered acceptable in the pregnant population (vs
15% in non-pregnant population).
 Non-perforated appendix
 Fetal mortality of 1.5%
 Perforated appendix
 Fetal mortality of 20-35%
 Maternal mortality of 1%
 83% risk of preterm contractions due to localized peritonitis.
 In all cases, the rate of premature delivery is highest
in the 1st week post-op.

Augustin and Majerovic


(2006).
Recommendations for Diffuse
Peritonitis
1) IV Cefuroxime, ampicillin, metronidazole,
and oxygen pre-operatively.
2) Immediate C-section can be considered,
depending on gestational age of fetus.
3) Preoperative intubation and ventilation in
cases of fetal hypoxia.

Augustin and Majerovic


(2006).
Acute Cholecystitis

# 2 Cause of Acute Abdomen


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 and  GB contraction in
response to CCK
Epidemiology

 Cholelithiasis is the cause of


cholecystitis in pregnant pts in 90% of
cases
 Incidence of cholelithiasis in pregnancy
is 3.5-10%
 Only 30-40% of pregnant pts with
gallstones are symptomatic

Augustin and Majerovic


(2006).
Presentation and Diagnosis

 Symptoms: Basically identical in


pregnant and non-pregnant pts
 Labs: Bilirubin, +/- Transaminases,
 Alkaline phosphatase is non-specific
as it is  normally in pregnancy
 Imaging: U/S has an accuracy of 95-
98% of detecting acute cholecystitis and
choledocolithiasis
Initial Management of Cholecystitis

 IVhydration
 Bowel rest
 Pain control
 Antibiotics
 Fetal monitoring
 Nasogastric decompression if necessary
Surgical Management of
Cholecystitis
 Cholecystectomy is now recommended as the
primary treatment for cholecystitis because of:
 Recurrence rate during pregnancy of 44-92%,
depending on date of 1st presentation
 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

Augustin and Majerovic


(2006).
Other Indications for Cholecystectomy
During pregnancy
 Choledocolithiasis
(after ERCP)
 Gallstone Pancreatitis
 Recurrent symptomatic cholelithiasis
 Several studies have found the incidence of SAb, preterm
labor, or premature delivery to be higher in pts treated non-
operatively than in those undergoing cholecystectomy.
 However, no prospective trial has been done to determine the
best management for recurrent biliary colic.

Curet (2000).
Laparotomy vs Laparoscopy?
Choosing Surgical Technique
Laparotomy Laparoscopy
 Currently considered 1st  First offered in 1991 for
line approach. pregnant patients for
 Always preferred appendectomy and
approach when diffuse cholecystectomy.
peritonitis is present, as  Many new studies show
it is associated with a this technique to be safe
lower complication rate in pregnancy for routine
than laparoscopy in this appendicitis, especially
setting. during the 2nd trimester.
 Can help r/o salpingitis,
adnexal mass, or
ectopic pregnancy when
dx is uncertain.
Recommendations to improve
safety of laparoscopy during
pregnancy
1) Obstetrical consultation should be obtained preoperatively.
2) When possible, operative intervention should be deferred until
2nd trimester.
3) Procedure should be performed with pt in supine, left lateral
decubitus position and degree of reverse Trendelenburg
should be minimized.
4) Open Hasson technique should be used to prevent puncture of
uterus.
5) Pneumoperitoneum pressures should be minimized to 8-12
mm Hg with maximum 15 mm Hg.
6) Administration of tocolytic agents and perioperative monitoring
of fetal heart tones should be considered.
7) Pneumatic compression devices should always be used as
both pneumoperitoneum and the condition of pregnancy are a
risk for venous stasis.

Halkik et al (2006).
Optimizing Delivery

*Understanding what the consulting


obstetrician is doing for your patients*
Use of Tocolytics for Preterm Labor

 Purpose
 Delay delivery so that corticosteroids can be
administered.
 Prolong pregnancy when there are underlying,
self-limited causes of labor, such as
pyelonephritis or abdominal surgery, that are
unlikely to cause recurrent PTL.
 Use is limited to <34 weeks gestation
Types of Tocolytics I
 Terbutaline (Beta-2 agonist)
 Mechanism: Agonist at myometrium causing
relaxation
 Meta-analysis showed  # of births within
subsequent 48 hrs but no change in # of births
within subsequent 7 days
 Magnesium sulfate
 Mechanism: Unknown, likely competes with
calcium reducing myometrial contractility
 Cochrane review concluded that this drug did not
significantly reduce the proportion of women
delivering within 48 hrs.
Types of Tocolytics II
 Nifedipine (Calcium channel blocker)
 Mechanism: Directly blocks influx of Ca ions
 Meta-analysis showed  # of births within 48 hrs
as compared to terbutaline as well as  # of births
within subsequent 7 days.
 Indomethacin (Cyclooxygenase inhibitor)
 Mechanism: Blocks production of prostaglandins
 Small studies indicate effectiveness for prolonging
time to delivery
Use of corticosteroids to improve
fetal outcomes in premature delivery
 Administration:
 Two doses of 12 mg betamethasone IM given 24
hrs apart.
 Benefit of therapy is initially observed 18 hrs after
the first dose with maximal benefit 48 hrs after the
first dose.
 Benefits include reduction in the incidence of:
 Neonatal respiratory distress syndrome
 Intraventricular hemorrhage
 Necrotizing enterocolitis
 Mortality
Steroids and peritonitis?
 “Glycocorticosteroids administered during the
initial phase of experimental diffuse peritonitis
display favorable action decreasing animal
mortality rate regardless of the dose. However,
glycocorticosteroids given in the developed
septic syndrome decrease the pro-
inflammatory cytokine serum concentration
regardless of the dose, still not affecting the
animal mortality rate.”

Modzelewski et al (2002).
References
 “Acute Fatty Liver of Pregnancy.” Up-to-date.
 Augustin, G and M Majerovic. Non-obstetrical acute abdomen during pregnancy. European
J of Obstetrics, Gynecology, and Reproductive Biology 2006; 131: 4-12.
 Brooks et al. The Pregnant Surgical Patient. ACS Surgery: Principles and Practice.
 Curet, MJ. Special problems in laparascopic surgery: previous abdominal surgery, obesity,
and pregnancy. Surg Clinic North Am 2000; 80: 1093-1110.
 “Ectopic Pregnancy.” Up-to-date.
 Fielding, JR and BM Chin. Magnetic Resonance Imaging of Abdominal Pain during
Pregnancy. Top Magn Resonance Imaging 2006; 17: 409-416.
 Halkic et al. Laparascopic management of appendicitis and symptomatic cholelithiasis during
pregnancy. Langenbacks Arch Surg 2006; 391: 467-471.
 “HELLP Syndrome.” Up-to-date.
 “Inhibition of preterm labor.” Up-to-date.
 Kahaleh et al. Safety and efficacy of ERCP in pregnancy. Gastrointestinal Endoscopy 2004;
60: 287-292.
 Modzelewski et al. Tests for the usefulness of glucocorticosteroids in treatment of
experimental peritonitis. Pol Merkur Lekarski 2002; 69: 228-231.
 Murray et al. Diagnosis and treatment of ectopic pregnancy. CMAJ 2005; 73: 905.
 Pedrosa et al. MR Imaging of Acute Right Lower Quadrant Pain in Pregnant and
Nonpregnant Patients. Radiographics 2007; 27: 721-753.