Acute Abdominal Pain in Pregnancy:

Diagnosis and Management

Dr. I WAYAN PERIADIJAYA SpBK(Trauma)

SUB DIVISI BEDAH TRAUMATOLOGI & EMERGENCY
SMF BEDAH UMUM RS SANGLAH
DENPASAR
 Objectives
1. History, Physical, Investigations:
How they differ in pregnancy

2. Differential Diagnosis of acute abdominal pain

3. Diagnostic Imaging: US/ CT/ MRI

4. A review of some of the more common causes of acute

abdomen in pregnancy

5. In the Operating Room

Laparoscopy vs. Laparotomy
Issues specific to pregnancy
 Scope of the Problem
Definition of Acute Abdomen:
S&S of intra-peritoneal disease best treated surgically

~1/500 women need non-obstetrical abdominal

surgery during pregnancy

Most common non-obstetrical surgical emergencies:

1. Acute appendicitis
2. Cholecystitis
3. Intestinal Obstruction
4. Pancreatitis
5. Trauma
 Earlier diagnosis means better prognosis
Sir Zachary Cope 1921

Weigh risks and benefits of diagnostic

modalities and therapies for both mother
and fetus
 History
P Pain: onset, duration, intensity, character
Q - Quality
R Radiates
S Severity
T - Time

Gestational age

Associated symptoms All frequent in normal pregnancy :

Nausea & vomiting
Constipation
Increased frequency of urination
Pelvic / Abdominal discomfort
 Physical
Peritoneal signs are often absent in pregnancy
lifting and stretching of the anterior abdominal wall
underlying inflammation has no direct contact with the parietal
peritoneum
precludes muscular response or guarding that is expected

The uterus can obstruct and inhibit the movement of the omentum to
an area of inflammation

< 24 weeks document FHR

>24 weeks - A reassuring tracing allows the evaluation to continue

at an appropriate pace

Monitoring for contractions:

Throughout the evaluation period
After definitive treatment
 Investigations
Labs:
WBC (T2 <16, T3 <20-30 in early labour)

Ultrasound
CT
MRI
 Ultrasound
Safe

Relatively high sensitivity and specificity

Test of choice for most ob/gyn causes of abdo

pain

Also useful first line test for many non-gyne

conditions
 Risk of Ionizing Radiation
Risk based on gestational age and radiation dose
1 rad = 1 cGy

First trimester: all or nothing phenomenon

Most sensitive time for CNS teratogenesis is 10-17 wks

In T2 and T3 risk is childhood haematologic

malignancy
Background risk is 0.2-0.3% of childhood cancer and leukemia
Increased risk by 0.06% per rad of exposure

No single study should exceed 5 rads

Accepted cumulative dose of ionizing radiation in

pregnancy is 5-10 rads
 Fetal
Procedure Exposure

Chest radiograph (2 views) 0.02-0.07 mrad

Estimated Fetal Exposure from Some Common Radiologic Procedures

Abdominal film (single view) 100 mrad

Intravenous pyelography >1 rad*
Hip film (single view) 200 mrad
Mammography 7-20 mrad
Barium enema or small bowel series 2-4 rad
CT scan head or chest
CT scan abdomen and pelvis 3.5 rad
CT pelvimetry 250 mrad
 MRI
Safe in pregnancy for mother or fetus

Becoming standard of care for investigation of

placental implantation abnormalities, and further
delineation of fetal anomalies

Issue is contrast media

 Differential Diagnosis

Acute Abdomen
in
Pregnancy

Pregnancy
Gyne Non-Gyne
Related

Adnexal
Accident,
GI GU Vascular
fibroid
Degeneration
 Difficult Diagnosis
Expanding uterus dislocates other intra-
abdominal organs

High prevalence of nausea, vomiting and

abdominal pain in pregnancy

General reluctance to operate in

pregnancy
 Treatment
Conservative

Surgical
Laparoscopy
Laparotomy

Obstetrical issues:
Preterm labour
Intra-op monitoring
Tocolysis
Paeds
Delivery
Appendicitis
 Appendicitis
Most common non-obstetric cause of surgical emergency in
pregnancy

Incidence: 1 in 500-2000

Pregnancy does not affect the overall incidence of

appendicitis, but severity may be increased in pregnancy

Appendicitis more common in T2 (40% of cases)

Majority present with classic RLQ pain

25% of pregnant women will perforate

Dont delay O.R. >24 hrs, perforation rate from 0% to 66%
Perforation occurs 2x more often in the T3 than T1,2
 History
Most reliable symptom is RLQ pain

Nausea is present in nearly all cases

Vomiting present in two thirds of patients

Anorexia is present in only 1/3 2/3 of pregnant

patients, while it is present almost universally in
Non-pregnant patients
 Physical
Direct abdominal tenderness most common
T1: Tenderness well localized in RLQ
T2, T3: tenderness may change location: right periumbilical area,
RUQ, diffuse

Classic Signs:
Rebound present in 55-75% of patients
Abdominal muscle rigidity in 50-65%
Psoas sign observed less frequently in pregnancy
The Rovsig sign as frequent in pregnancy as non-pregnancy
state

Rectal tenderness is usually present, particularly in the first trimester

Fever and tachycardia are variably present; not sensitive signs

Uterine activity due to localized peritonitis is common

 Investigations

US is imaging of choice
Accuracy is greatest in T1; in T2 and T3 up to
40% normal appendix rate

General Laboratory Investigations:

Elevated WBC
Neutrophils often >80%
Urinalysis: Pyuria is observed in 10-20%
 Treatment
Surgical: Laparotomy or laparoscopy

If the appendix appears normal remove it because:

(1) Early disease may be present despite its grossly
normal appearance
(2) Diagnostic confusion can be avoided if the condition
recurs

Laparotomy Incision
Right mid-transverse incision directly over the point of
maximal tenderness vs. Lower abdominal midline
incision to accommodate unexpected surgical findings
and the possibility of the need for cesarean delivery

Tilt the operating table 30 to the patient's left

 Acute appendicitis and Diffuse
Peritonitis (Perforation)
Cefuroxime, ampicillin, metronidazole, oxygen
pre-op

Depending on G.A. consider CS as fetal loss

rate up to 20-36%

Pre-op intubation and ventilation in cases of

hypovolemia

Copious irrigation and use of intra-peritoneal

drain
 Morbidity
Perforation and abscess formation are more likely to
occur in pregnant patients

The rate of generalized peritonitis relates directly to the

interval of time from symptom onset to diagnosis

Maternal and fetal morbidity and mortality rates increase

once perforation occurs

Fetal mortality is dependant on if perforation is present:

20-35% vs. 1.5% is no perf

Maternal mortality should be <1%

Acute Cholecystitis
 Acute Cholecystitis
Incidence in pregnancy is 1:600-1:10,000

Second most common cause of acute abdomen

in pregnancy

Cholelithiasis is the cause in 90% of cases

Incidence of cholelithiasis in pregnant women

having routine OB scans is 3.5-10%
 History and physical examination
Previous history; dyspepsia, intolerance of fatty foods

RUQ/ mid-epigastrium pain; may radiate to the back

Nausea & Vomiting ~ 50% of cases

Fever occasionally

Direct tenderness usually present in RUQ, Rebound

tenderness is rare

Cholecystitis can mimic appendicitis in the third trimester

 Investigations
Blood tests are of limited value

WBC, ALP normal in pregnancy

AST/ALT may help distinguish cholecystitis

from hepatitis

Amylase elevated transiently ~1/3; high

amylase suggests pancreatitis

Electrolytes: if persistent vomiting

 Investigations
Ultrasound is diagnostic

Gall bladder calculi: present in> 95% with

acute cholecystitis
Wall thickening >3mm
Pericholecystic fluid
Sonographic Murphys sign
Dilation of intra and extra-hepatic ducts in
common bile duct obstruction

If a radionucleotide scan of the gallbladder is

needed, the radiation dose is not prohibitive
 Treatment
Supportive: Intravenous fluids, Nasogastric suction

Non-surgical Management increases risk of:

Recurrence in pregnancy if episode occurs:

T1 92%
T2 64%
T3 44%

Gallstone pancreatitis ~13% (Fetal loss rate 10-60%)

SA, PTL, PTD

A percutaneous drainage procedure may be indicated in select

patients in order to defer definitive surgery
 Surgical Management
Has been source of much controversy

Recently immediate surgical management is used more

widely because:

1. Reduced use of medications

2. Recurrence rate in pregnancy is 44-92%, depending on
trimester
3. Shorter hospital stay
4. risk of developing life-threatening complication: perforation,
sepsis, peritonitis

Laparoscopy or laparotomy depends on GA and

surgeon skill
 Choledocholithiasis
1/1200 patients require intervention
ERCP uses 2-12 rads

ERCP:
Risk of bleeding = 1.3%
Risk of pancreatitis = 3.5%

Options are common bile duct exploration at time of

laproscopic cholecystectomy or ERCP followed by
cholecystectomy no studies comparing the two
Bowel Obstruction
 Bowel Obstruction
Third most common cause of acute abdomen in
pregnancy: 1:1500 1:16,000

Etiology:
1. Adhesions 60-70% of cases

2. Volvulus ~25% of cases (much higher than non-pregnant)

Risk of cecal volvulus is highest at times of rapid changes in
uterine size (16-20 wks, and 32-36 wks)
Any redundant or abnormally mobile cecum is raised out of the
pelvis and allows for rotation around a fixed point
Small bowel volvulus is more common in T3 and PP

3. <5% of time: Intussusception, incarcerated hernia, cancer,

diverticulosis etc.
 History
Crampy abdominal pain ~90%
Constant or periodic, mimicking labor
Pain may radiate to the flank, imitating pyelonephritis
The severity of pain may not reflect the severity of
disease

Vomiting

Obstipation
 Physical findings
Classic distended tender abdomen with high-pitched
bowel sounds is the exception in pregnancy

Uterus/cervix/adnexa share the same visceral

innervation as the lower ileum, sigmoid colon and rectum
- separating GI and Gyn sources of pain is often difficult

Abdominal tenderness may be absent

Bowel sounds are often normal upon presentation

A tender cystic mass can sometimes be palpated

Rebound tenderness, fever, and tachycardia occur late

in the course
 Laboratory Studies
Leukocytosis may be present
Electrolyte abnormalities
Hemoconcentration
Elevated serum amylase levels

X-Ray
Abdominal Plain film - best initial study
Sequential films may be needed
Air-fluid levels, progressive bowel dilation
 Treatment
Conservative
Fluid and electrolyte replacement
NG suction
Enema

Surgical
Midline abdominal incision
Decompress the bowel
Relieve obstruction
Resect nonviable tissue

Prognosis
Maternal Mortality ~6%
Fetal mortality ~26%
Bowel strangulation requiring resection ~23%
Pancreatitis
 Pancreatitis
1:1000 1:3000 pregnancies
Usually late in T3, or PP may be due to increased
intra-abdominal pressure on the biliary ducts

Etiology
Cholelithiasis 67-100% of cases
Abdominal surgery
Blunt abdominal trauma
Infection
Penetrating duodenal ulcer
Hyperparathyroidism
Hyperlipidemic pancreatitis

Associated with pregnancy

Preeclampsia damage to microvasculature
AFLP
 History
Sudden, severe epigastric pain radiating to
the back

Postprandial nausea and vomiting

Fever
 Physical
Patient in the fetal position due to severe pain

Hypoactive bowel sounds (paralytic ileus)

Jaundice

Epigastric tenderness is the most reliable physical

finding

Peritoneal signs are minimal or absent

Pulmonary findings in ~10% - can lead to ARDS

 Laboratory Studies
Amylase
During normal pregnancy, amylase levels are slightly elevated

Lipase better predictor than amylase

Hyperglycemia

Hyperbilirubinemia

Hypocalcemia

Hemoconcentration

Electrolyte abnormalities

Ultrasound of the upper abdomen

 Ransons Criteria
On Admission: At 48 hours After Admission:

Age > 55 Hct drop > 10%

WBC > 16 BUN increase > 1.79
Glucose > 10 Ca < 2
LDH > 350 Arterial pO2 < 60
AST > 250 Base deficit (24 - HCO3) > 4
Fluid needs > 6L

Prediction of Mortality
<5 - 15%
5-9 - 40%
>9 - 100%
 Treatment
Bowel rest npo, NG suction, IV fluids

Fluid/electrolyte resuscitation

Analgesics:
demerol doesnt cause spasm of sphincter of Oddi

Anti-spasmodics

Antibiotics if fever or sepsis is present

ERCP, endoscpic sphincterotomy can be used to treat

gallstone pancreatitis

Surgery for refractory cases

 Prognosis
Acute symptoms last for ~6 days

Maternal mortality rate ranges from 0-37%

Perinatal mortality rate is ~ 10%

The risk of perinatal death increases with

the severity of disease
Trauma in Pregnancy
 Trauma in Pregnancy
Occurs in 6-7% of pregnancies

Penetrating
Gunshot wounds
Stab wounds

Blunt trauma
MVA
Physical abuse, Sexual Abuse
Accidental Falls
 Maternal Injury
Gravid uterus changes the location of abdominal
organs

25% of pregnant women with blunt trauma will

have hemodynamically significant hepatic or
splenic injuries due to increased vascularity

In penetrating trauma maternal death rate is

lower than non-pregnant (~3.9% vs 12%)
because the uterus protects intra-abdominal
organs

Uterine rupture: most often at the fundus

 Fetal Injury
Direct fetal injury occurs in <1% of blunt trauma

Direct fetal injury occurs in up to 90% of blunt trauma

Fetal skull and brain injury more common in T3 when the

head is engaged in the pelvis

Deceleration injury to the fetal had can also occur

Most common cause of fetal death is maternal death

Fetal mortality 3-38%: abruption, shock, maternal death

 Placental Abruption
CTX > thAn 1 in 10 minutes is associated with 20% risk of
diagnosed placental abruption

Initiate CTG monitoring asap at >24 weeks; at least 4-6 hrs

Risk of abruption exists for several days post-trauma

Up to 40% of severe MVAs are associated with abruption

Minor trauma can result in abruption in 2-3%

10-30% of trauma victims have evidence of feto-maternal

hemorrhage
 Management
ABCs

Rapid maternal respiratory support

Evaluate the fetus once mother is stable: CTG

Left lateral decubitus

US

Fetal monitoring for at least 4 hrs,then prn

Surgical exploration prn +/- CS

ATLS in Pregnancy
 Surgical Management
Exploratory Laparotomy

Delivery of fetus if direct uterine injury

or fetal injury
 Prevention Techniques
Seat Belts
Airbags
 Gynecologic Causes of Acute
Abdomen: Adnexal Masses

Incidence in Pregnancy = 2%

Most are functional cysts

Expectant Mgmt for those <6cm

82-94% resolution

Torsion:
~4% of adnexal masses will tort
 Adnexal Torsion
Pregnancy predisposes to adnexal torsion

1 in 5 adnexal torsions occurring during

pregnancy

Associated with an ovarian mass in 50-60% -

most often a dermoid

Occurs on R > L, by a ratio of 3:2

Occurs most frequently in the first trimester

 Treatment
Surgical

Conserve as much ovarian tissue as possible

If the tissue is necrotic - unilateral salpingo-oophorectomy

Partial torsion:
Conservative management - Untwist the pedicle, remove the cyst,
and stabilize the ovary

If removal of the corpus luteum is necessary prior to 10

weeks of gestation needs progesterone supplementation
In the Operating Room
 Pre-Op Decision Making
Laparoscopy has the same indications as the
non-pregnant patient

Approach is based on skill of surgeon and

availability of staff/ equipment

Benefits of Laparoscopy:
post-op pain
post-op ileus
LOS
Faster return to work
 Concerns r.e. Laparoscopy
Trocar insertion
CO2 insufflation
Technical ability to get exposure
Altered physiology of pneumoperitoneum
Decreased venous return

Can be used in all trimesters

 With increasing experience with this technique, there are fewer barriers
Reports of successful appendectomy and cholecystectomy in the third
trimester
Benefits in the Pregnant Patient
fetal depression due to less narcotic use

risk of wound complications

post-op maternal hypoventilation

risk of VTE due to early mobilization

uterine irritability leads to less SA and PTL

 Technical Issues
Patient positioning
Left lateral decubitus

Initial Port Placement

Hassan/ Verres, Optical trocar adjust location to fundal height,
previous incisions and experience of surgeon

Place trocars under direct visualization according to

fundal height

Insufflation to 10-15mmHg
No evidence of long-term detrimental effects of CO2
pneumoperitoneum
 Intra-op CO2 monitoring should be used
Theoretical risk of fetal acidosis due to
pneumoperitoneum; has been seen in animal studies,
but not documented in the human fetus

VTE Prophylaxis (pneumoperitoneum increases

venous stasis)
Intra-op/ Post-op pneumatic compression stockings
Early post-op ambulation
 Peri-Operative Care
Obstetrical Consultation

Fetal Heart Rate Monitoring pre and

post-op documentation of FHR / NST

Tocolytics
No literature supports prophylactic use of tocolytics
Consider if S&S of PTL
Need OB consult for meds/ dosing etc
 Conclusions
Laparoscopy is safe in all trimesters of
pregnancy

The Veress needle can be used depends on

surgeon experience with alternate site entries

Pressure of 12-15mmHg less than uterine ctx.

Laparoscopy decreases maternal morbidity,

LOS, fetal depression (due to less narcotic use)
 Summary
The incidence of acute abdominal pain in
pregnancy which requires surgery is ~1/500

It is important to keep a broad differential

diagnosis as signs, symptoms and investigations
can all altered due to pregnancy

Diagnostic Imaging is safe in pregnancy

Surgical options include laparotomy and

laparoscopy