Acute Abdomen in Pregnancy 2

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Acute Abdomen in Pregnancy

Kate Pettit, MS III

June 18, 2007


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The Most Important Equation

+ +

=


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10-14 yrs

15-19 yrs

20-24 yrs

25-29 yrs

30-34 yrs

35-39 yrs

40-44 yrs

45-54 yrs

0 20 40 60 80 100 120 140

c

How old are your prospective

pregnant patients?

CDC 2004

Live Births per 1,000 Women

Avg Age

at First

Birth inUS:

25.1 yrs


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DDx of Abdominal Pain in

Pregnancy

Divided into three categories:

1) Conditions incidental to pregnancy

2) Conditions associated withpregnancy

3) Conditions due to pregnancy


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Conditions Incidental to Pregnancy

Acute appendicitis

Acute pancreatitis

Peptic ulcer

Gastroenteritis

Hepatitis

Bowel obstruction Bowel Perforation

Herniation

Meckels 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


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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


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Ectopic Pregnancy

Classic Symptoms Abdominal pain Amennorrhea Vaginal Bleeding

Diagnosis Transvaginal U/S (TVS)

Presence of a truegestational sac at 4.5 to 5wks is the 1st sign of IUP.

Cardiac activity is firstdetected at 5.5 to 6 weeks.

Serum quantitative HCG Absence of an intrauterine

gestational sac at hCGconcentrations >1500-2000IU/L suggests an ectopic ornonviable intrauterinepregnancy

Management Option of medical vs surgical

management if pt is hemodynamicallystable and no rupture has occurred.

Emergent surgical management ifrupture has occurred and/or patient ishemodynamically unstable

Prognosis

Ruptured ectopic pregnancies accountfor 4- 10 percent of all pregnancyrelated deaths.


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HELLP SyndromeHemolysis Elevated Liver Enzymes Low Platelets

Incidence: 1 in 1K pregnancies Timing: Majority diagnosed at

28-36 wks Labs:Plts,AST/ALT,indirect bili,haptoglobin,schistocytes on peripheral

Smear Management:

Emergent delivery forpregnancies > 34 weeks,nonreassuring fetal status,severe maternal disease(multiorgan dysfunction, DIC,

liver infarction or hemorrhage,ARF, or abruptio placenta) Delayed delivery in stable

pregnancies 140/90) 85

RUQ/Epigastric pain 40-90

Nausea/Vomiting 29-84

Headache 33-60

Visual changes 10-20

Jaundice 5


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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-eclampsiaLabs:PT,PTT,AST/ALT,Cr,glucose, +/-WBC, +/-Plts

Tx: Maternal stabilization (glucose infusion,reversal of coagulopathy) and emergentdelivery


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Definition of Acute Abdomen

Stedman's Medical Dictionary, 27th

Edition defines acute abdomen as "any

serious acute intra-abdominal condition

attended by pain, tenderness, andmuscular rigidity, and for which

emergency surgery must be

considered.


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Epidemiology

Incidence of acute abdomen duringpregnancy is 1 in 500-635

# 1 Acute Appendicitis

# 2 Acute Cholecystitis


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Challenges of Diagnosis

Symptoms Nausea, vomiting, and abdominal pain are common

in the normal obstetric population. N/V are mostcommon 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 ofinfection or blood loss.


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Which conditions require urgent

surgical management in pregnancy?

Trauma

Acute appendicitis

Intestinal obstructionPerforated duodenal ulcer

Spontaneous visceral rupture

Ectopic pregnancyOvarian or uterine torsion


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Timing of Surgery

1st trimester (wks 1-12)12% SAb rate

2

nd

trimester (wks 13-26)0 - 5.6% SAb rate5% rate of preterm labor

3

rd

trimester (wks 27-40)30-40% rate of preterm labor


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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.


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Radiation during pregnancy


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Use of ERCP in PregnancyAmerican 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.


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Reducing Radiation in Pregnancy

X-ray: PA exposures lowersthe radiation dose by 2 to 4mrad compared with thetraditional AP exposuresbecause the uterus is located

in an anterior pelvic position. CT: Narrow collimation and

wide pitch (the patient movesthrough the scanner at afaster rate) results in aslightly reduced image

quality, but provides a largereduction in radiationexposure.


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Sequelae of Radiation in Pregnancy

May cause failure of implantation,malformation, growth retardation,CNS abnormalities, or fetal loss.

Exposure


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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.


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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 havenot 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 patientunless the potential benefit justifies the potential risk to thefetus.

Animal studies have shown an risk of spontaneousabortion and skeletal and visceral anomalies.


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MRI as an imaging modality

MechanismElectromagnetic field induced changes in

proton spin

Theoretical risks to fetus Induction of local electric fields and currents

Radiofrequency radiation results in heating

of tissue


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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 prudentto delay diagnosis until after pregnancy.


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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 beingthe period of organogenesis.

When MRI is used, informed consent must

include the possibility that a previously

undiagnosed fetal abnormality may be found.


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"No single diagnosticprocedure results in a

radiation dose that threatens

the well-being of the

developing embryo and fetus."

-- American College ofRadiology


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Appendicitis

#1 Cause of Acute Abdomen


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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.


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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 3rdtrimester due to laxity of abdominal wall

muscles.


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Adler Sign

If the point of maximal tenderness shifts

medially with repositioning on the left

lateral side, the etiology is generally

adnexal or uterine (vs appendiceal).


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Appendiceal Location

Historically, many referenceshave reported appendicealdisplacement.

In 2003, a study by Hodjati et

al showed that pregnancy didNOT change appendiceallocation.

Degree of displacement, ifany, is likely due to different

extents of cecal fixation.


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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).


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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).


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2nd Line Imaging for Appendicitis

CT

94% sensitivity

94% specificity

MRI

Up to 100%

sensitivity*

96% specificity*No known adverse

effects on fetus, but

cost and availabilitymay be prohibitive.

Fielding and Chin (2006).*Values are from small study of 45 pregnant pts.


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Risks for Mother and Fetus

66% risk of perforation if surgery delayed by >24 hrsfrom presentation.

Negative laparotomy rates of up to 35% areconsidered acceptable in the pregnant population (vs15% 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 highestin the 1st week post-op.

Augustin and Majerovic

(2006).

R d ti f Diff


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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).


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Acute Cholecystitis

# 2 Cause of Acute Abdomen

P th h i l


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Pathophysiology:

Hormones and biliary disease

Estrogen in pregnancy

cholesterol synthesis,hepatic

cholesterol uptake,catabolism of

cholesterol to bile acidsBile supersaturation & cholesterol stones

Progesterone in pregnancy

bile stasis and GB contraction inresponse to CCK


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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).


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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 andcholedocolithiasis


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Initial Management of Cholecystitis

IV hydration

Bowel rest

Pain controlAntibiotics

Fetal monitoring

Nasogastric decompression if necessary

S rgical Management of


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Surgical Management of

Cholecystitis

Cholecystectomy is now recommended as theprimary 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


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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, noprospective trial has been done to determine thebest management for recurrent biliary colic.

Curet (2000).


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Laparotomy vs Laparoscopy?


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Choosing Surgical Technique

Laparotomy Currently considered 1st

line approach. Always preferred

approach when diffuseperitonitis is present, asit is associated with alower complication ratethan laparoscopy in thissetting.

Laparoscopy First offered in 1991 for

pregnant patients forappendectomy andcholecystectomy.

Many new studies showthis technique to be safein pregnancy for routineappendicitis, especiallyduring the 2nd trimester.

Can help r/o salpingitis,adnexal mass, orectopic pregnancy whendx is uncertain.

ecommen a ons o mprove


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ecommen a ons o mprovesafety of laparoscopy during

pregnancy1) 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 lateraldecubitus position and degree of reverse Trendelenburgshould be minimized.

4) Open Hasson technique should be used to prevent puncture ofuterus.

5) Pneumoperitoneum pressures should be minimized to 8-12mm Hg with maximum 15 mm Hg.

6) Administration of tocolytic agents and perioperative monitoringof fetal heart tones should be considered.

7) Pneumatic compression devices should always be used asboth pneumoperitoneum and the condition of pregnancy are arisk for venous stasis.

Halkik et al (2006).


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Optimizing Delivery

*Understanding what the consulting

obstetrician is doing for your patients*


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Use of Tocolytics for Preterm Labor

PurposeDelay 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


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Types of Tocolytics I

Terbutaline (Beta-2 agonist)Mechanism: Agonist at myometrium causing

relaxationMeta-analysis showed # of births within

subsequent 48 hrs but no change in # of birthswithin subsequent 7 days

Magnesium sulfateMechanism: Unknown, likely competes with

calcium reducing myometrial contractility

Cochrane review concluded that this drug did notsignificantly reduce the proportion of womendelivering within 48 hrs.


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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 birthswithin subsequent 7 days.

Indomethacin (Cyclooxygenase inhibitor)Mechanism: Blocks production of prostaglandins

Small studies indicate effectiveness for prolongingtime to delivery

Use of corticosteroids to improve


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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 thefirst dose.

Benefits include reduction in the incidence of: Neonatal respiratory distress syndrome

Intraventricular hemorrhage Necrotizing enterocolitisMortality


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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 theanimal mortality rate.

Modzelewski et al (2002).


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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.


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Acute Abdomen in Pregnancy 2

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