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How old are your prospective
pregnant patients?
45-54 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
# 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
*International Commission on
Radiological Protection.
Childhood Leukemia and Radiation
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
* 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.
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
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
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.