Suad AL-Sulimani R3

Case Presentation

oApproach of pregnant lady with abdominal pain

oProper Disposal oCase discussionoPitfalls

Objectives

25 years old pregnant lady,G1P0

, 12 weeks of gestation with severe lower abdominal pain since 1 day

A : patent B : 18/min , sat 98% in RA Bilateral Air entry C : BP 110//70 mmhg Pr: 83/min /min , regular D : reflo 7 mmol GCS : 15/15 UPT:+ve

Abd pain since 1 day

Getting worse with time Associated with vomiting

-No PV bleeding -No urinary symptoms-No diarrhea -No previous illnesses-No previous scan

o/e : pale , in pain chest : clear CVS : s1,s2 normal p/a: tenderness all over PV exam : Os is closed , no bleeding

DDX

Action : = no Ultrasound facility =Buscopan Inj given = referred to Obe/Gyne oncall = Gyne scan : SLF , BPD 13 weeks , FHR +, placenta Upper posterior

Advise : Nill Gyne Surgical Referral

Physiological changes in vitals in 12 weeks pregnant lady

BP:Diastolic and systolic blood pressure tend to fall during mid pregnancy and then return to normal by week 36

Diastolic pressure decreases more than systolic◦ Heart rate: +10 beats/min (5%)◦ Respiratory rate: no change

Patient came back from Gyne clinic

still c/o severe abdominal pain

A : patent B : 18/min Bilateral Air entry C : BP 110//70 mmhg Pr : 120/min , regular GCS : 15/15

Pain progressively getting worse

o/e : in severe pain p/a : Tenderness all over , Guarding++, Rigidity++ BS absent

DDx

Action : =Pain killer Buscopan Inj , Morphine 5 mg IV = NPO , IV fluid still in pain US Vs Surgical referral

Surgical Opinion :

= Admittion =NPO , IV fluid = US abdomen

Investigations: CBC : HGB 10.4 ( Micocytic , Hypochromic) ,

WBC 11.7 , Platlate 222

U&E : HCO3 19 , Urea 2.2 , Na135 , K 3.6 , Creatinie 42

LFT : Bilirubin 5.2 , AST 27,ALT 19 , ALP51

PT ,APTT : WNR

Expected changes

Dilutional anaemia is caused by the rise in plasma volume.

Serum alkaline phosphatase increases during pregnancy - due to placental production.

Serum albumin decreases.A modest leukocytosis is observedFibrinogen: 300 mg/dl 450 mg/dlD-dimer increasePlatelet decrease due to hemodilutionDefine thrombocytopenia: < 116,000

Ultrasound

Limited study due to gravid uterus

appendix could not be visualized RIF cyst like mass the origin of

this mass could be ?? Appendicular

?? OvarianSmall amount of free fluid seen in

RIF & Morison pouch

Intraoperativly Abdomen was opened by McBurneys incision

, on Opening the cavity , appendex found normal . Dirty fluid in the cavity with flakes of old hemorrhage

Gyne called intraoperativly : rt sided ovary enlarged 6 cm , old chocolate coloured materia over the uterus , omentum & abdominal wall

Appendicectomy done , rt ovarian chocolate cyst aspirated , Peritonial lavage done

Pt admitted to ICU postoperativly , remain stable , remain in the hospital for 5 days then dischrged

Progress

Acute abdomen during pregnancy

Epidemiology

Incidence of acute abdomen during pregnancy is 1 in 500

# 1 Acute Appendicitis# 2 Acute Cholecystitis

Challenges of DiagnosisSymptoms

◦ 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 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?

TraumaAcute appendicitisIntestinal obstructionPerforated duodenal ulcerSpontaneous visceral ruptureEctopic pregnancyOvarian or uterine torsion

DDx of Abdominal Pain in PregnancyDivided into three categories:

1) Conditions incidental to pregnancy2) Conditions associated with pregnancy3) Conditions due 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 Incidental to Pregnancy

Acute pyelonephritisAcute cystitisAcute cholecystitisAcute fatty liver of pregnancyRupture of rectus abdominus

muscleTorsion of pregnant uterus

Conditions Associated with Pregnancy

Condition due to Pregnancy

Ectopic pregnancySeptic abortion with peritonitisAcute urinary retention due to retroverted

uterusRound ligament painTorsion of pedunculated myomaPlacental abruptionPlacenta percretaHELLP SyndromeAcute Fatty Liver of PregnancyUterine ruptureChorioamionitis

Acute Appendicitisduring pregnancy It affects 1 in 1500 pregnancies, less

common than in non-pregnant women , mortality is higher (esp. from 20 weeks), Perforation is commoner (15%-20%), Fetal mortality is ~1.5% for simple appendicitis , ~30% if perforation.

Diagnosis is complicated by change in position of appendix as it migrates upwards, outwards and posteriorly as pregnancy progresses, so pain is less well localized (often paraumbilical or subcostal but right lower quadrant still commonest) and tenderness, rebound, and guarding less obvious. Peritonitis can make the uterus tense and woody-hard.

Leucocytosis is suggestive..< 10,000 leucocyte may be

reassuring

Operative delay is dangerous.

Appendicitis is not diagnosed in 1 in 5 cases in pregnant women until the appendix has ruptured causing peritonitis, which can cause premature labour or abortion.

APPENDICITIS - DIAGNOSIS

Graded compression ultrasonographyaccurate in 1st and 2nd trimesters , difficult in 3rd.

98% ACCURATE.

Adnexal disorders requiring surgical intervention occur in approximately one in 1000 pregnancies.

Ovarian masses may be problematic during pregnancy because of their risk for torsion, rupture, or hemorrhage.

large ovarian lesions may also become impacted in the pelvis and even obstruct labor. While most adnexal masses in pregnancy are functional cysts that resolve by 18 weeks' gestation,

Adnexal And Ovarian complications

ultrasound. Simple cysts smaller than 6 cm are more likely to be functional, but extremely large functional cysts may sometimes be seen., also be used when adnexal torsion is suspected.

Masses greater than 6 cm that persist should generally be removed in the early second trimester to reduce the risk of complications such as rupture, torsion, or hemorrhage.

Large masses that are symptomatic may sometimes require earlier intervention

Conclusion

Remember that acute abdomen in pregnant ady might be sillent,,,

Thank you