Acute Abdomen in Pregnancy

Acute Abdomen in Pregnancy
Presentation by:Kate Pettit, MS III

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
* Acute pancreatitis
* Peptic ulcer
* Gastroenteritis
* Hepatitis
* Bowel obstruction
* Bowel Perforation
* Herniation
* Meckel’s Diverticulitis
* Toxic megacolon
* Pancreatic pseudocyst
* Ovarian cyst rupture
* Adnexal torsion
* Ureteral calculus
* Rupture of renal pelvis
* Ureteral obstruction
* SMA syndrome
* Thrombosis/infarction
* Ruptured visceral artery aneurysm
* Pneumonia
* Pulmonary embolus
* Intraperitoneal hemorrhage
* Splenic rupture
* Abdominal trauma
* Acute intermittent porphyria
* Diabetic ketoacidosis
* 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
o Abdominal pain
o Amennorrhea
o Vaginal Bleeding
* Diagnosis
o Transvaginal U/S (TVS)
o Serum quantitative HCG
* Management
o Option of medical vs surgical management if pt is hemodynamically stable and no rupture has occurred.
o Emergent surgical management if rupture has occurred and/or patient is hemodynamically unstable
* Prognosis
o Ruptured ectopic pregnancies account for 4- 10 percent of all pregnancy related deaths.

HELLP Syndrome
Hemolysis – Elevated Liver Enzymes – Low Platelets
Acute Fatty Liver of Pregnancy
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
# 1 Acute Appendicitis
# 2 Acute Cholecystitis

Challenges of Diagnosis
* Symptoms
* Physical Exam
* Labs

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)
o 12% SAb rate
* 2nd trimester (wks 13-26)
o 0 - 5.6% SAb rate
o 5% rate of preterm labor
* 3rd trimester (wks 27-40)
o 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.
o Kahaleh et al. reported an estimated fetal radiation exposure of 40 mrads (range 1-180 mrad).
* Precautions for reducing radiation exposure:
o Lead shields placed under the pelvis an

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
Use of contrast in pregnancy
MRI as an imaging modality
American College of Radiology Paper on MRI Safety
MRI should only be used in pregnancy when:
o The information requested from the study cannot be obtained from nonionizing means.
o The information is needed to care for the pt and fetus during pregnancy.
o 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.

Appendicitis
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
Appendiceal Location
Laboratory Evaluation
1st Line Imaging for Appendicitis
2nd Line Imaging for Appendicitis
MRI
Risks for Mother and Fetus
Recommendations for Diffuse Peritonitis
Acute Cholecystitis
Pathophysiology:
Hormones and biliary disease
Epidemiology
Presentation and Diagnosis
Initial Management of Cholecystitis
* IV hydration
* 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:
o Recurrence rate during pregnancy of 44-92%, depending on date of 1st presentation
o Reduced use of medications
o Shorter hospital stay and fewer hospitalizations
o Elimination of risk of subsequent gallstone pancreatitis
o Minimizing development of potentially life-threatening complications such as perforation, sepsis, and peritonitis

Other Indications for Cholecystectomy During pregnancy
* Choledocolithiasis (after ERCP)
* Gallstone Pancreatitis
* Recurrent symptomatic cholelithiasis

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

Optimizing Delivery
Use of Tocolytics for Preterm Labor
Types of Tocolytics I
Types of Tocolytics II
Use of corticosteroids to improve fetal outcomes in premature delivery
Steroids and peritonitis?
References

Acute Abdomen in Pregnancy.ppt