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Image Presentation

Acute Abdomen in Pregnancy


Role of Sonography
Phyllis Glanc, MD, FRCP(C), Cynthia Maxwell, MD, FRCSC, RDMS

Objective. The purpose of this presentation is to review the role of sonography in evaluation of acute abdomen during pregnancy. Methods. Illustrative cases were collected from gravid patients who presented with signs and symptoms suspicious for acute abdomen and subsequently underwent sonography. Results. This presentation shows sonographic findings of various maternal complications that can present with acute abdominal pain in pregnant patients. Conclusions. Sonography remains the first line of imaging in pregnant patients presenting with acute abdomen. Patient triage or additional imaging may be obtained on the basis of the sonographic findings. Key words: acute abdomen; complications of pregnancy; pregnancy; sonography.

S
Abbreviations CDS, color Doppler sonography; GB, gallbladder; MRI, magnetic resonance imaging

Received April 6, 2010, from the University of Toronto, Sunnybrook Health Sciences Center (P.G.), Toronto, Ontario, Canada; and University of Toronto, Mount Sinai Hospital (C.M.), Toronto, Ontario, Canada. Revision requested April 21, 2010. Revised manuscript accepted for publication May 26, 2010. Address correspondence to Phyllis Glanc, MD, FRCP(C), Obstetric Ultrasound Center, Department of Medical Imaging, Sunnybrook Health Sciences Center, Bayview Campus, 2075 Bayview Ave, MG104, Toronto, ON M4N 3M5, Canada E-mail: phyllis.glanc@sunnybrook.ca

onography remains the initial imaging study of choice in the evaluation of the pregnant woman presenting with acute abdomen. It is a safe, relatively inexpensive, and versatile technique that is readily available. The traditional definition of acute abdomen is any serious intra-abdominal condition for which emergency surgery must be considered. In pregnancy, this definition may be expanded to include conditions that may result in preterm labor or emergency cesarean delivery for fetal well-being. Prompt clinical diagnosis and intervention may minimize maternal and fetal morbidity and mortality. The evaluation of acute abdomen in pregnancy is complicated by both physiologic and anatomic changes that occur during pregnancy. Generalized symptoms of nausea, vomiting, constipation, increased frequency of urination, and abdominal and pelvic discomfort may be normal accompaniments of pregnancy. Localization of disease may be limited because of the enlarging gravid uterus, which both displaces and compresses structures. Peritoneal signs may be absent secondary to the lifting and stretching of the anterior abdominal wall. Some commonly used laboratory tests have altered reference ranges for pregnancy, limiting their utility. For example, pregnancy alone can produce white blood cell counts as high as 16,000/mm3 in second and third trimester and up to 30,000/mm3 in labor.1 Similarly, anemia is common and thus not predictive of blood loss. Coincidental asymptomatic pyuria can occur in 10% to 20% of gravid

2010 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2010; 29:14571468 0278-4297/10/$3.50

Acute Abdomen in Pregnancy

women with appendicitis.1 The use of conventional imaging algorithms is constrained by the potential risk of harm to the fetus from ionizing radiation. All of the usual medical and surgical conditions must be considered within the context of two patients: the mother and her fetus. To further complicate the evaluation, there are a number of medical conditions that are specific to pregnancy that must be added to the differential diagnosis. In summary, the physical and clinical examination is limited; laboratory values can be misleading; and the usual imaging algorithms are altered to minimize exposure to ionizing radiation. Nonetheless, as in the nongravid patient, the two most common abdominal surgical emergencies remain acute cholecystitis and acute appendicitis.

Pregnancy and the Gallbladder


Symptomatic gallstone disease is the second most common abdominal emergency in pregnant women, requiring hospitalization in 0.5% within the first postpartum year. Pregnancy is a high-risk period for formation of biliary sludge and stones due to increased estrogen and progesterone levels, which lead to biliary cholesterol hypersecretion and gallbladder (GB) stasis; 4.2% of women develop new sludge or gallstones during pregnancy (Figure 1).2,3 The most sensitive combination of findings for the diagnosis of acute cholecystitis is the presence of cholelithiasis with a positive sonographic Murphy sign, resulting in a positive predictive value of 92%.4 Sonography is approximately 95% sensitive in the detection of gallstones larger than 2 mm. Secondary findings include GB distension (>5 cm diameter), wall thickening (>3 mm), pericholecystic fluid, and wall hyperemia. The secondary signs are nonspecific and may be associated with a variety of other medical conditions (Figures 2 and 3). Gangrenous cholecystitis will result in a negative sonographic Murphy sign in two-thirds of patients, may show a loss of wall vascularity on color Doppler sonography (CDS), and may contain irregular linear echoes within the lumen, which represent fibrinous exudates and sloughing of the GB mucosa (Figure 4).5 If the GB is not distended but the wall is massively thickened, viral hepatitis, the most common cause of jaundice in pregnancy, should be considered. Acalculous acute cholecystitis may
Figure 2. Acute cholecystitis in the third trimester. Sagittal sonogram showing a single calculus impacted in the neck of the GB. The patient had a positive sonographic Murphy sign. Additional findings included a mildly distended GB and striated wall thickening.

Figure 1. Tumefactive sludge can mimic a solid GB lesion. Repositioning of the patient will cause the sludge to move and reform, thus enabling the diagnosis. A, Sagittal sonogram showing tumefactive or ball-like sludge. B, Repositioning of the patient permits the sludge to reform, confirming the diagnosis.

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Figure 3. Acute cholecystitis in the third trimester with perforation. Interrogation of the entire GB wall is important to identify small wall disruptions that may be associated with perforation. A, Transverse sonogram showing a markedly thickened, striated GB wall with a diameter of 1.2 cm. B, Transverse sonogram showing discontinuity in the wall (arrows). C, Transverse sonogram with CDS showing corresponding discontinuity in wall hyperemia (arrows). D, Transverse sonogram showing a corresponding wall pericholecystic collection, consistent with perforation (arrow).

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occur, most typically in the setting of intensive care units and hyperalimentation. The traditional management of acute cholecystitis in pregnancy has been initial conservative therapy in the first and third trimesters, with surgical intervention preferably occurring in either the second trimester or postpartum period. Although approximately 25% of pregnant patients fail to respond to conservative therapy, the results of conservative and surgical management are similar with respect to maternal and fetal morbidity and mortality. Laparoscopic cholecystectomy may have some advantages related to its less invasive nature.68
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Pregnancy and the Bowel


Acute appendicitis is the most common cause of acute abdomen in pregnancy, complicating approximately 1 per 1500 pregnancies.9 Although the actual incidence of acute appendicitis is not increased in pregnancy, an associated delay in diagnosis leads to increased perforation rates. Fetal loss rates are less than 2% in uncomplicated acute appendicitis, whereas they can be greater than 30% if perforation has occurred.9,10 Perforation rates rise from 30% in the first and second trimesters to as high as 70% in the third trimester. The same criteria of a noncompressB

Figure 4. Gangrenous cholecystitis in patient with poorly localized pain, fever, and poorly controlled insulin-dependent diabetes at 32 weeks gestation. The diagnosis is considered when a negative sonographic Murphy sign is present in combination with sonographic findings indicative of GB wall ischemia and denervation. A, The gallbladder contains small calculi, echogenic bile, and debris. The wall is thickened with abnormal structures consistent with sloughed membranes (arrow). B, A small localized perforation is shown at the medial aspect of the GB (arrows). C, Color Doppler sonogram showing the avascular GB wall.

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ible, nonperistaltic, tender, blind-ending tubular structure with a diameter of greater than 6 mm is used in the pregnant patient; however, compression sonography may be limited by the enlarging gravid uterus and displacement of the surrounding bowel as pregnancy progresses (Figures 5
Figure 5. Acute appendicitis presenting in the first trimester with acute right-sided pain. A, Oblique sonogram showing the entire length of the appendix arising from the cecum, blind ending, and mildly distended at 0.8 cm (calipers). B, Oblique sonogram with CDS showing hyperemia of the appendix wall. C, Transverse sonogram with CDS showing hyperemic adjacent fat, consistent with inflammation.

and 6). If sonography is inconclusive, then magnetic resonance imaging (MRI) may be appropriate to identify the normal appendix, thus potentially avoiding unnecessary delays in diagnosis, surgery, or use of ionizing radiation.11,12 In the gravid patient, sonography is often the first choice in the evaluation of other bowel conditions such as small-bowel obstruction, inflammatory bowel disease, diverticulitis, volvulus, and intussusception. One-third of women with inflammatory bowel disease will relapse during pregnancy, with the most commonly cited reason being cessation or reduction of medications (Figures 7 and 8).7 Bowel obstruction in pregnancy is fairly uncommon, occurring in 1 per 2500 to 1 per 3500 deliveries. Adhesions are responsible for most cases (60%70%), followed by volvulus (25%).9 Maternal and fetal morbidity and mortality are often related to delays in diagnosis. The use of MRI in bowel conditions to other than appendicitis is less well validated in pregnancy but may be justifiable if it can provide information that would otherwise require ionizing radiation exposure.13

Figure 6. Distal tip appendicitis presenting in the first trimester as vague right-sided and periumbilical pain. Sonogram showing the mildly distended (0.7 cm) distal tip of the appendix (arrow) surrounded by echogenic fat, indicating adjacent inflammation.

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Pregnancy and the Kidney


Physiologic hydronephrosis of pregnancy occurs in 70% to 90% of pregnant women by the third trimester, thus representing the most common cause of hydronephrosis in pregnancy, typically asymmetric and more prominent on the right. It is due to a combination of mechanical obstruction from an enlarged uterus and relaxation of the smooth muscle of the urinary collecting system under the influence of progesterone. A smooth tapering of the ureter as it passes between the uterus and the iliopsoas muscle at the level of the sacral promontory suggests the diagnosis (Figures 9 and 10).

Approximately 1 per 1500 pregnancies are complicated by urinary calculi, similar to the nongravid woman.1 Most pregnant women with renal colic present in the second half of pregnancy with flank pain or hematuria. A urinary stone can be diagnosed on sonography when there is distinct focal echogenicity with discrete acoustic shadowing. In equivocal cases, the presence of the twinkling artifact with the application of CDS may improve confidence. The twinkling artifact occurs behind a strongly reflecting granular interface and appears as a fluctuating mixture of CDS signals that imitate turbulent flow, but the Doppler spectrum is flat. This sign is present in 86% of urinary calculi (Figure 11).14 Nonetheless the diagnosis of renal colic remains challenging,
Figure 8. Images from a 30-year-old patient with known Crohn disease who presented acutely in the first trimester with vague right-sided abdominal pain and diarrhea. A, Oblique sonogram showing the transition point between the thickened and nonthickened bowel wall. (arrow). B, Transverse sonogram showing several midabdominal distended fluid-filled loops with active peristalsis in real time, consistent with small-bowel obstruction.

Figure 7. Images from a 32-year-old patient who presented at 12 weeks gestation with acute right-sided pain. The patient had postpartum confirmation of new onset of Crohn disease. A, Transverse sonogram showing a normal appendix (arrow). B, Sonogram showing a markedly thickened terminal ileum wall at 1.2 cm (calipers).

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Figure 9. Physiologic hydronephrosis of pregnancy in the third trimester. Sagittal sonogram showing moderate hydronephrosis in the right kidney.

Figure 10. Physiologic hydronephrosis of pregnancy is associated with tapering of the right ureter as it passes over the sacral promontory/pelvic brim. A, Sagittal sonogram showing the classic smooth tapering of the ureter. B, Sagittal sonogram with CDS confirming that the tapering tubular structure is the ureter.

with almost one-third of cases incorrectly diagnosed.15,16 The distinction of a mechanical obstruction from physiologic hydronephrosis is crucial in directing appropriate management (Figure 12). If direct visualization of an obstructing calculus is not possible, then secondary signs such as a disparity in resistive indices of greater than 0.1 between the kidneys may be helpful.17 Before diagnosing a unilateral absent ureteric jet, this should be confirmed by reevaluation with the patient in a contralateral decubitus position to ensure that the absent jet is not secondary to compression by the gravid uterus. The transvaginal approach is helpful for visualization of distal ureteral calculi and urinary bladder jets (Figures 13 and 14). Forniceal rupture with formation of a perinephric urinoma is rare in pregnancy, whereas distended perFigure 11. Images from a 26-year-old patient who presented at 25 weeks gestation with acute right flank pain. A small proximal obstructing calculus was identified. A, Sagittal sonogram showing minimal hydronephrosis secondary to a small proximal ureteric calculus (arrow). B, Sagittal sonogram with CDS showing the twinkling sign (arrow).

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icapsular veins are not uncommon. The application of CDS can help distinguish between these two entities. The incidence of asymptomatic bacteriuria is similar in both the gravid and nongravid populations; however, the incidence of acute pyelonephritis is substantially increased in pregnancy. Acute pyelonephritis occurs in 1% to 2% of pregnancies and is associated with preterm labor.18,19 This may be related to the relative decreased peristalsis of the ureters and urinary stasis under the influence of progesterone. Although sonographic findings are typically negative in the setting of acute pyelonephritis,
Figure 12. Images from a patient with twin pregnancy who presented at 27 weeks gestation with right flank pain. Surgical laparoscopic resection revealed ovarian torsion with a necrotic right ovary. A, Sagittal sonogram showing an abnormally enlarged right ovary (5 7 cm), which was tender and avascular, consistent with ovarian torsion. A small amount of free fluid is present (arrow). B, Transverse sonogram showing the normal left ovary (calipers).

A B
Figure 13. Images from a patient with twin pregnancy who presented at 33 weeks gestation with right-sided pain. No point of mechanical obstruction was identified. Only a unilateral left ureteric jet could be identified. The sonographic findings were consistent with right-sided obstruction. A, Sagittal sonogram showing moderate right hydronephrosis with perinephric fluid, consistent with a urinoma (arrow). B, Absent right ureteric jet. The left ureteric jet present. Figure 14. Transvaginal sonogram from a third-trimester patient with left-sided flank pain. A cephalic presentation obscured transabdominal visualization of the ureterovesical junction. The sonogram shows a 2-mm calculus (arrow) in the ureterovesical junction, which is located in the anterior left aspect of the image.

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findings such as renal enlargement, focal hyperechogenicity, and perinephric fluid may be present (Figure 15).

pregnancy as well as in conditions such as intestinal obstruction, infarction, and perforation.21

Pregnancy and Cancer Pregnancy and the Pancreas


Acute pancreatitis complicating pregnancy is rare, affecting approximately 1 per 3333 gestations.20 Gallstones are the most common etiology. Serum amylase testing is useful for diagnosis, but levels may be mildly elevated during normal
Figure 15. Images from a patient with twin pregnancy who presented at 29 weeks gestation with left-sided flank tenderness. Right hydronephrosis was thought to be physiologic. Milder left hydronephrosis was associated with a thickened uroepithelium and perinephric fluid indicative of inflammation, likely secondary to an ascending infection. The patient underwent left ureteric stenting. A, Sagittal sonogram showing mild left hydronephrosis, but closer inspection shows layering debris in the renal pelvis (arrow) and thickened ureter wall with periureteric fluid, consistent with an edematous inflamed ureter (perforated arrow). B, Cross section through the lower pole of the left kidney showing perinephric fluid (arrow) and a thickwalled ureter with periureteric fluid (perforated arrow).

Cancer complicating pregnancy is rare, affecting approximately 1% of gestations.22,23 As the average age of the gravid population increases, malignancy becomes a more important consideration. Appropriate imaging evaluation will depend on the organ involved (Figures 16 and 17).

Pregnancy and the Liver


Hepatic diseases complicate approximately 3% of pregnancies; however, hepatic diseases that are specific to pregnancy are rare.2427 The key role of sonography in hepatic diseases specific to pregnancy is to rule out alternate hepatic or bile duct conditions.

Figure 16. Bowel carcinoma resembling acute complicated appendicitis in a 47-year-old primigravida who presented at 12 weeks gestation with right lower quadrant pain and fever. Sonogram showing a complex 5 4 2.7-cm hypoechoic mass (calipers) surrounded by echogenic fat, consistent with bowel perforation and an abscess, suspected to be appendiceal in origin. In view of a long infertility history, the patient requested conservative therapy. She underwent percutaneous drainage and received antibiotic therapy. She returned in 1 week with increasing pain and underwent surgery. The pathologic diagnosis was perforated aggressive adenocarcinoma arising from the base at the junction of the appendix and cecum.

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Pregnancy and Trauma


Trauma occurs in 5% of pregnancies and is the leading nonobstetric cause of maternal death.28 Even minor maternal trauma may result in fetal death, typically due to placental abruption.28,29

Placental abruption occurs as a shear injury between the relatively nonelastic placenta and the uterine wall; thus, trauma protocols are amended for the pregnant patient to include a 24-hour observation period in the labor and delivery unit for fetal monitoring and potential delivery.

Figure 17. Images from a 43-year-old infertility patient with twin pregnancy who presented at 33 weeks gestation with acute rightsided pain that had progressed for 2 days. Her clinical history revealed appendectomy and low-grade right-sided pain for 2 to 3 months. Her pregnancy weight gain was only 13 pounds, less than anticipated for a third-trimester twin gestation, indicating weight loss. Sonography revealed serosal uterine and liver metastases from right colon primary carcinoma. Per the patients request, presurgical MRI was performed to confirm the diagnosis. Primary resection and anastomosis were performed at the time of cesarean delivery, and chemotherapy was begun 4 weeks after surgery. A, Transverse sonogram showing uterine serosal surface drop metastases (arrow) and ascites. B, Sagittal sonogram of the right flank showing an abnormally thickened segment of the colon (arrows) of concern for primary colon cancer. C, Coronal T2-weighted MRI showing hepatic lesions and incidental physiologic right hydronephrosis. D, Coronal T2weighted MRI showing an abnormal thickened loop of the right colon (arrows), consistent with primary colon carcinoma.

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The size of the placental abruption or degree of intrauterine hemorrhage is related to morbidity and mortality. Blunt abdominal trauma is typically evaluated by screening abdominal computed tomography; however, the 90% negative rate suggests that this is hard to justify in the pregnant population. Sonography is only moderately sensitive for detection of intra-abdominal injury in the pregnant patient (60%) but is highly specific.30 This permits a rapid triage of a group of patients who require additional evaluation. Sonography is most sensitive in the first trimester. Placental abruption is the most common injury, followed by splenic, liver, and then bowel injury.

Table 1. Can We Rely on Positive or Negative Sonographic Findings?


Sonographic Finding Positive Negative

Acute cholecystitis Bile duct stones Acute appendicitis Hydronephrosis due to calculus Pyelonephritis Hepatic disease specific to pregnancy Trauma

Excellent Excellent Very good Excellent Rarely Occasionally Good

Excellent Limited value Limited value Limited value None None Limited value

Conclusions
Sonography is the first-line screening tool in acute abdomen during pregnancy (Table 1). Pregnancy increases the technical challenge of the examination. If the sonographic results are inconclusive or inadequate, additional imaging such as
Figure 18. Images from a 23-year-old patient who presented at 19 weeks gestation with severe diffuse abdominal pain. Sonography showed large amounts of complex fluid, indicative of high-risk findings, although nondiagnostic. Computed tomography was performed and suggested possible gastric perforation. The surgical diagnosis was gastric volvulus with perforation and contamination of the intrathoracic and intra-abdominal contents. Intrauterine fetal death occurred. A, Sonogram of the pelvis showing the gravid uterus surrounded by complex free fluid. Note the fluid-debris level anterior to the uterus (arrow). B, Sagittal computed tomogram showing large amounts of free air (arrows) and complex fluid with layering in the posterior cul de sac (perforated arrow). The stomach (S) is intrathoracic.

MRI may be indicated. Computed tomographic examinations are reserved for cases in which MRI is unavailable or inconclusive or when rapid imaging is indicated. At times, surgery may be required without a diagnosis (Figure 18).
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