1. CasAcute Abdomen in Pregnancy
Hale T., O & G Resident,
Mekelle University,
College of Health Sciences, Dep't of OB-GYN
October 27, 2016

2. • Contents
– Abdominal Pain
• Pregnancy Related Abdominal Pain
– First half of pregnancy– First half of pregnancy
– Second half of pregnancy
– Abdominal Pain
• Incidental Surgical Causes
Hale T., M.D., Resident Physician 2

3. • Objectives
– To identify those who have a serious or life
threatening etiology for their symptoms and
require urgent intervention
– To discuss the diagnostic uncertainities– To discuss the diagnostic uncertainities
related with pain in pregnancy
– To discuss concerns about fetal safety with
diagnosis and management of pain
Hale T., M.D., Resident Physician 3

4. • Introduction
– Mild to moderate pain
•Enlarging uterus, fetal position or movement,
Braxton-Hicks contraction, round ligamentBraxton-Hicks contraction, round ligament
pain
– Severe pain with associated symptoms
•Never normal in pregnancy
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5. • Why is it diffuclt to evaluate pain in
pregnancy?
– Enlarged Uterus
•Impedes physical exam•Impedes physical exam
•Affect location of pelvic and abdominal
organs
•Mask or delay peritoneal signs
•May cause hydroureter and hydronephrosis
•May cause aortocaval compression
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6. – Progesterone
•Decreases lower esophageal sphincter tone,
small bowel and colonic motility, gallbladder
emptying, and ureteral tone
•These physiologic changes are important in•These physiologic changes are important in
the pathogenesis and diagnosis of conditions
such as gastroesophageal reflux, constipation,
cholelithiasis, and nephrolithiasis, all of which
may be associated with abdominal pain
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7. – WBC counts increase to a normal range
of 10,000 to 14,000 cells/mm 3 during
pregnancy, and in labor the white blood
cell count may be as high as 20,000 to
30,000 cells/mm 3 ,30,000 cells/mm 3 ,
– However, bandemia is not a normal
variant of pregnancy and its presence
suggests infection until proven otherwise
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8. – Decrease in hemoglobin concentration
(normal hemoglobin ≥10.5 to 11.0 g/dL)
coupled with the normal modest increase
in heart rate (by 10 to 15 beats per
minute) can be mistaken for signs of mildminute) can be mistaken for signs of mild
hemorrhage
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9. – Uterine tenderness or rigidity is abnormal,
and may be due to
•Labor,
•Abruptio placenta,
•Uterine rupture, or
•Intrauterine infection
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10. • Lab
– Complete blood count with differential
– Urinalysis
– Liver and pancreatic function tests– Liver and pancreatic function tests
(aminotransferases, bilirubin, amylase,
lipase)
– Blood and urine cultures
– Serum electrolytes
– Coagulation studies
– Blood group and RhHale T., M.D., Resident Physician 10

11. • Imaging
– Ultrasound is first-line
•Widely available
•Portable•Portable
•Nonionizing
•Adequate diagnostic performance
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12. • Use the best available modality
regardless of concerns on fetal safety
– Chest X-Ray: 0.001 rad
– Abdominal X-Ray: 0.1 – 0.42 rad– Abdominal X-Ray: 0.1 – 0.42 rad
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13. • Laparascopy
– As safe as laparatomy
– Indicated in
•Potentially life-threatening or organ-•Potentially life-threatening or organ-
threatening disorders
•Diagnosis not clear after less invasive tools
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14. • Pregnancy related abdominal pain
– First half of Pregnancy
•Miscarriage
•Ectopic Pregnancy•Ectopic Pregnancy
– Second Half of Pregnancy
•Labor
•Placental abruption
•Uterine rupture
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15. – Second half of pregnancy cont’d
•Pregnancy related liver disease
– Severe preeclampsia
– HELLP Syndrome
– Acute Fatty Liver of Pregnancy– Acute Fatty Liver of Pregnancy
•Acute hepatitis
•Pneumonia
•Intraamniotic infection
•Spontaneous hemoperitoneum
•Uterine incarceration
•Arterial disection and rupture
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16. – Gynecologic Causes
•Ovarian torsion
•Ruptured or hemorrhagic ovarian cyst
•Fibroid degeneration or torsion
•PID
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17. Obstetric Causes of Acute Abdomen
• Miscarriage
– Signs and Symptoms
•Mild to moderate midline crampy pelvic pain
•Mild to moderate vaginal bleeding•Mild to moderate vaginal bleeding
– Speculum and pelvic exams
– HSG and Ultrasound
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18. • Ectopic Pregnancy
– Pain, ammenorrhea, vaginal bleeding,
nausea, vomiting, chest pain, fainting and
LOCLOC
– Ultrasound
•Extrauterine pregnancy
•Free blood in the peritoneum
– Heterotopic pregnancy
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19. – Heterotopic pregnancy
•Incidence: 1 in 10,000-30,000
•After IVF: 1%
•Average time for diagnosis: 7.5 weeks
•Diagnosis delays as late as 20 weeks are
possible
•Management
– Non-surgical
– Surgical
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20. • Labor
– Uterine contractions of increasing
frequency, intensity, and duration that
cause cervical dilation and/orcause cervical dilation and/or
effacement
– Light vaginal bleeding and/or rupture of
membranes increase diagnostic certainty
in women with mild cervical dilation or
effacement
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21. • Placental abruption
– Classically presents with
•Vaginal bleeding,
•Abdominal and/or back pain,•Abdominal and/or back pain,
•Uterine tenderness,
•Uterine rigidity, and
•Uterine contractions;
•DIC
•The fetal heart rate pattern may be
nonreassuring
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22. • Uterine Rapture
– Signs and symptoms include
•Nonreassuring fetal heart rate tracing or fetal
death,death,
•Uterine tenderness,
•Peritoneal irritation,
•Vaginal bleeding,
• Loss of fetal station, and
• Shock
– Can It occur before labor?
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23. • Uterine rupture before labor
– Scared uterus
– Cornual pregnancy
– Abdominal trauma– Abdominal trauma
– Pregnancy in rudimentary uterine horn
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24. • Abdominal trauma
– Pregnant mothers more likely to sustain
trauma
– Enlarged uterus renders protection of the– Enlarged uterus renders protection of the
viscera
– Shields the retroperitoneal structures
– Rebound tenderness and guarding less
prominent
– Direct fetal trauma and indirect
consequencesHale T., M.D., Resident Physician 24

25. • Perimorteum Cesarean Delivery
– The Five Minute Rule
•Normal neonatal neurological outcome was
most likely when delivery occurred within fivemost likely when delivery occurred within five
minutes of maternal cardiac arrest
– Indications
•Maternal resuscitative efforts have not been
successful within four minutes
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26. • Severe Preeclampsia
– Proteinuric hypertension after 20 weeks of
gestation
– Clinical manifestations– Clinical manifestations
•RUQ or epigastric pain
•Elivated liver enzymes
•Subcupsular hemorrhage or hepatic rupture
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27. • HELLP Syndrome
– Most common clinical presentation is
abdominal pain and tenderness in the
midepigastrium, right upper quadrant, ormidepigastrium, right upper quadrant, or
below the sternum
– HBP and proteinuria: Only in 85% of cases
– Hepatic rupture rare
– Ultrasound, MRI, CT Scan
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28. • Acute Fatty Liver
– Common in 3rd trimester
– Diagnosis is clinical
– Common symptoms– Common symptoms
•N & V – 75% of patients
•Abdominal pain – 50%
•Anorexia
•Jaundice
– Lab
– Ultrasound, CT, MRI (Infarct or hematoma)
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29. • Intraamniotic Infection
– Signs and symptos
•Fever
•Abdominal pain•Abdominal pain
•Uterine tenderness
•Leukocytosis
•Maternal and fetal tachycardia
•Uterine contractions
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30. • Spontaneous Hemoperitoneum
– 25 cases reported in the past 2 decades
– Sing and symptom
•Suden onset of abdominal pain in the second•Suden onset of abdominal pain in the second
half of pregnancy with hypovolemic shock
and/or abnormal fetal heart rate
•Exploratory laparatomy: 500-4000 mL of blood
•Risk facotrs: nulliparity and history of
endometriosis
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31. – Source of bleeding
•Superficial veins/Varicosities on the superior
surface of uterus or the parametrium
– Biopsy in 5 of 25 cases
•Endometriosis
– Outcome
•50% continued pregnancy
•50 % Still birth or neonatal death
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32. • Uterine incarceration
– Rare: 1/3000 pregnancies
– Present at 14-16 weeks of gestation
– Symptoms– Symptoms
•Related to adjacent anatomic structures to
the entraped enlarging uterus
•Pain and progressive difficulty voiding
•Frequency, dysuria, sensation of incompelete
emptying, voiding small volume, urinary
retention
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33. – Risk Factors
•Retroverted uterus
•Previous pelvic Surgery
•PID
•Endometriosis
•Leiomyoma
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34. • Arterial dissection and rupture
– Rupture of arterial aneurysms (splenic,
renal, uterine, ovarian, aorta)
– Related to the physiologic and– Related to the physiologic and
hemodynamic changes of pregnancy
– At risk population
•Marfan syndrome
•Ehler’s Danlos syndrome
•Turner syndrome
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35. – Presenting complaints
•Suden onset abdominal pain
•Free peritoneal fluid
•Sudden hemodynamic collapse
•Failure to identify the cause prior to
laparatomy
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36. Hale T., M.D., Resident Physician 36

37. • Acute Hepatitis
– Hep E virus has severe clinical disease in
pregnancy
– CMV, EBV, Adenoviruses– CMV, EBV, Adenoviruses
– Anorexia, nausea, jaundice, RUQ
discomfort
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38. Gynecologic Causes of Acute Abdomen
• Ovarian Torsion
– Similar in nonpregnant and pregnant
patients
– Risk factors– Risk factors
•Ovarian cyst/Adnexal mass
•Induction ovulation
– Presenting complaints
•Lateralized lower abdominal pain
•N & V, low grade fever, leukocytosis
•Most common in the first trimester
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40. – Presumptive Diagnosis
•Acute pelvic pain +
•Adnexal mass +
– Masses related to endometriosis, tuboovarian
abscess, malignancy – less likely to torseabscess, malignancy – less likely to torse
– The larger the mass - torsion more frequent
» Till the mass becomes large enough to be fixed
in the pelvis
•Sonographic features consistent with torsion
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42. Hale T., M.D., Resident Physician 42

43. – Defintive diagnosis
•Direct visualization of rotated ovary at the
time of surgery
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44. • Can ovarian torsion happen in normal
ovaries?
– In premenarchal girls
•Elongated utero-ovarian ligament•Elongated utero-ovarian ligament
– Right ovary – more likely to torse
•More longer utero-ovarian ligament
•Presence of sigmoid colon in the left prevents
torsion of the left ovary
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45. • Checking viability of torsed ovary
– Inspection
•Blue or black – nonviable
– Ovarian bivalving– Ovarian bivalving
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46. • Management
– Detorsion
– Surgical removal
•Cystoectomy•Cystoectomy
•Unilaterla salpingo-oophorectomy
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47. • Ruptured or Hemorrhagic Ovarian Cyst
– Presenting complaints
•Sudden onset of unilateral lower abdominal
painpain
•Pain begins during strenous physical activity or
sexual intercourse
•Hemodynamic instability and pelvic collection
– Bradycardia (paradoxically)
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48. – Asymptomatic: Serous or mucinous fluid
– Severe pain: Spillage of sebaceous
material upon rupture of a dermoid cyst
•Granulomatous reaction•Granulomatous reaction
•Chemical peritonitis
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49. – Ultrasound
•First-line imaging study for
– identification and characterization of the ovarian
mass or cyst
– to look for fluid in the cul-de-sac– to look for fluid in the cul-de-sac
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50. – Management
•Uncomplicated
– Outpatient management with oral analgesia
•Complicated
– Inpatient,– Inpatient,
– Fluid
– Follow vitals
– Surgery to control hemorrhage if hemodynamically
unstable or if dermoid cyst rupture is suspected
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51. • Fibroid degeneration or torsion
– Most remain asymptomatic in pregnancy
•Degeneration: myomas > 5 cms in size
•Torsion: Pedunculated myomas
– Presenting complaints– Presenting complaints
•Localized pain
•Mild leucocytosis, fever, peritoneal signs, N & V
•Miscarriage
•Premature labor and delivery
•Abnormal fetal position
•Placental abruption
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52. – Other rare complications
•DIC
•Spontaneous hemoperitoneum
•Uterine inversion
•Uterine incarceration
•ARF
•Urinary retention
•Pyomyoma
– Fever, leukocytosis, tachycardia, Pelvic pain
– Ultrasound: Heterogenous mass with gas
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53. – Ultrasound
•To see the mass
•Pain after ballottement by the abdominal
ultrasound probe directly over the fibroid
supports the diagnosissupports the diagnosis
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54. • Pelvic Inflammatory Disease
– Rare because of barrier formed by
•Cervical mucus plug
•Decidua•Decidua
– Diagnosis
•Fever with lower abdominal pain
•Rule out other causes first
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55. • Medical causes of abdominal pain in
pregnancy
– Mesentric venous thrombosis
– Pancreatitis– Pancreatitis
– Pneumonia
– Inflammatory bowel disease
– Gastroenteritis
– Sickle cell crisis
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56. REFERENCES
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57. Hale T., M.D., Resident Physician 57

58. Thank you for listening!
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