This is a case presentation on acute abdomen in pregnancy.

1. Case Presentation:
on Acute Abdomen in Pregnancy
Hale T., O & G Yr-2 Resident,
Mekelle University,
College of Health Sciences, Dep't of OB-GYN
October 27, 2016

2. • Contents
– Summary of the case
– Abdominal Pain
• Pregnancy Related Abdominal Pain
– 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
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. • HPP
– W/ro: FA
– 27 year old, G3P2 (both via SVD, both
alive)
– Presented with history of
•Fall down accident of 1 month duration
– At that time: Minimal vaginal bleeding, abdominal
pain
– Vaginal bleeding stopped within 3 days
•Lower abdominal pain since then, worsened
over the last 3 days
•Vaginal bleeding of 3 days duration
Hale T., M.D., Resident Physician 4

5. • Physical Exam (at admission)
– GA: ASL (in pain, crying)
– Vitals
•BP: 100/60 mmHg
•PR: 104 bpm
•RR: 24 resp/min
•Temp: 36.6
Hale T., M.D., Resident Physician 5

6. – HEENT: Pink conjunctiva, nonicteric sclera
– Abdomen
•16 weeks sized gravid uterus
•Psoas sign positive
•Mild RLQ direct tenderness
•Otherwise unremarkable
Hale T., M.D., Resident Physician 6

7. • GUS:
– Mild right CVA tenderness
– No active vaginal bleeding
– DVEx
•Closed,
•No blood in the examining finger
•Adnexa are free
•No cervical motion or adnexal tenderness
Hale T., M.D., Resident Physician 7

8. Lab
Hale T., M.D., Resident Physician 8
R. No. Investigations
1. Hemoglobin 10.5, 11. 2
2. WBC/Gr % 10.5 / 69.9%
3. Plt 272
4. S/E No O/P seen
5. BG and Rh A positive
6. RBS 106
7. Urinalysis Few bac, otherwise unremarkable
8. HBsAg Not done
9. VDRL Nonreactive
10. Obst U/S Second TM Preg. (15 wks +4 days)
11. Abd. U/S Normal abd ultrasound

9. • Admitted on 26/01/09 with the Dx of
– 2nd TM pregnancy
– Acute abdomen Secondary to ? Acute
Appendicitis
Hale T., M.D., Resident Physician 9

10. • In-patient course
– Evaluated by surgical side (R2, R3, R4) with
senior consultation
•Observed as in-patient
•Discharged on 07/02/09 with appointment to
the SRC for follow up after 1 week
– Came on her follow up a week latter
» Scanned: Normal 2nd TM Preg + Normal
abdominal scan
Hale T., M.D., Resident Physician 10

11. • Introduction
– Mild to moderate pain
•Enlarging uterus, fetal position or movement,
Braxton-Hicks contraction, round ligament
pain
– Severe pain with associated symptoms
•Never normal in pregnancy
Hale T., M.D., Resident Physician 11

12. • Why is it diffuclt to evaluate pain in
pregnancy?
– Enlarged Uterus
•Impedes physical exam
•Affect location of pelvic and abdominal
organs
•Mask or delay peritoneal signs
•May cause hydroureter and hydronephrosis
•May cause aortocaval compression
Hale T., M.D., Resident Physician 12

13. – Progesterone
•Decreases lower esophageal sphincter tone,
small bowel and colonic motility, gallbladder
emptying, and ureteral tone
•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
Hale T., M.D., Resident Physician 13

14. – 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 ,
– However, bandemia is not a normal
variant of pregnancy and its presence
suggests infection until proven otherwise
Hale T., M.D., Resident Physician 14

15. – 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 mild
hemorrhage
Hale T., M.D., Resident Physician 15

16. – Uterine tenderness or rigidity is abnormal,
and may be due to
•Labor,
•Abruptio placenta,
•Uterine rupture, or
•Intrauterine infection
Hale T., M.D., Resident Physician 16

17. • Lab
– Complete blood count with differential
– Urinalysis
– 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 17

18. • Imaging
– Ultrasound is first-line
•Widely available
•Portable
•Nonionizing
•Adequate diagnostic performance
Hale T., M.D., Resident Physician 18

19. • 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
Hale T., M.D., Resident Physician 19

20. • Laparascopy
– As safe as laparatomy
– Indicated in
•Potentially life-threatening or organ-
threatening disorders
•Diagnosis not clear after less invasive tools
Hale T., M.D., Resident Physician 20

21. • Pregnancy related abdominal pain
– First half of Pregnancy
•Miscarriage
•Ectopic Pregnancy
– Second Half of Pregnancy
•Labor
•Placental abruption
•Uterine rupture
Hale T., M.D., Resident Physician 21

22. – Second half of pregnancy cont’d
•Pregnancy related liver disease
– Severe preeclampsia
– HELLP Syndrome
– Acute Fatty Liver of Pregnancy
•Acute hepatitis
•Pneumonia
•Intraamniotic infection
•Spontaneous hemoperitoneum
•Uterine incarceration
•Arterial disection and rupture
Hale T., M.D., Resident Physician 22

23. – Gynecologic Causes
•Ovarian torsion
•Ruptured or hemorrhagic ovarian cyst
•Fibroid degeneration or torsion
•PID
Hale T., M.D., Resident Physician 23

24. Obstetric Causes of Acute Abdomen
• Miscarriage
– Signs and Symptoms
•Mild to moderate midline crampy pelvic pain
•Mild to moderate vaginal bleeding
– Speculum and pelvic exams
– HSG and Ultrasound
Hale T., M.D., Resident Physician 24

25. • Ectopic Pregnancy
– Pain, ammenorrhea, vaginal bleeding,
nausea, vomiting, chest pain, fainting and
LOC
– Ultrasound
•Extrauterine pregnancy
•Free blood in the peritoneum
– Heterotopic pregnancy
Hale T., M.D., Resident Physician 25

26. – 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
Hale T., M.D., Resident Physician 26

27. • Labor
– Uterine contractions of increasing
frequency, intensity, and duration that
cause cervical dilation and/or
effacement
– Light vaginal bleeding and/or rupture of
membranes increase diagnostic certainty
in women with mild cervical dilation or
effacement
Hale T., M.D., Resident Physician 27

28. • Placental abruption
– Classically presents with
•Vaginal bleeding,
•Abdominal and/or back pain,
•Uterine tenderness,
•Uterine rigidity, and
•Uterine contractions;
•DIC
•The fetal heart rate pattern may be
nonreassuring
Hale T., M.D., Resident Physician 28

29. • Uterine Rapture
– Signs and symptoms include
•Nonreassuring fetal heart rate tracing or fetal
death,
•Uterine tenderness,
•Peritoneal irritation,
•Vaginal bleeding,
• Loss of fetal station, and
• Shock
– Can It occur before labor?
Hale T., M.D., Resident Physician 29

30. • Uterine rupture before labor
– Scared uterus
– Cornual pregnancy
– Abdominal trauma
– Pregnancy in rudimentary uterine horn
Hale T., M.D., Resident Physician 30

31. • Abdominal trauma
– Pregnant mothers more likely to sustain
trauma
– 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 31

32. • Perimorteum Cesarean Delivery
– The Five Minute Rule
•Normal neonatal neurological outcome was
most likely when delivery occurred within five
minutes of maternal cardiac arrest
– Indications
•Maternal resuscitative efforts have not been
successful within four minutes
Hale T., M.D., Resident Physician 32

33. • Severe Preeclampsia
– Proteinuric hypertension after 20 weeks of
gestation
– Clinical manifestations
•RUQ or epigastric pain
•Elivated liver enzymes
•Subcupsular hemorrhage or hepatic rupture
Hale T., M.D., Resident Physician 33

34. • HELLP Syndrome
– Most common clinical presentation is
abdominal pain and tenderness in the
midepigastrium, right upper quadrant, or
below the sternum
– HBP and proteinuria: Only in 85% of cases
– Hepatic rupture rare
– Ultrasound, MRI, CT Scan
Hale T., M.D., Resident Physician 34

35. • Acute Fatty Liver
– Common in 3rd trimester
– Diagnosis is clinical
– Common symptoms
•N & V – 75% of patients
•Abdominal pain – 50%
•Anorexia
•Jaundice
– Lab
– Ultrasound, CT, MRI (Infarct or hematoma)
Hale T., M.D., Resident Physician 35

36. • Intraamniotic Infection
– Signs and symptos
•Fever
•Abdominal pain
•Uterine tenderness
•Leukocytosis
•Maternal and fetal tachycardia
•Uterine contractions
Hale T., M.D., Resident Physician 36

37. • Spontaneous Hemoperitoneum
– 25 cases reported in the past 2 decades
– Sing and symptom
•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
Hale T., M.D., Resident Physician 37

38. – 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
Hale T., M.D., Resident Physician 38

39. • Uterine incarceration
– Rare: 1/3000 pregnancies
– Present at 14-16 weeks of gestation
– 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
Hale T., M.D., Resident Physician 39

40. – Risk Factors
•Retroverted uterus
•Previous pelvic Surgery
•PID
•Endometriosis
•Leiomyoma
Hale T., M.D., Resident Physician 40

41. • Arterial dissection and rupture
– Rupture of arterial aneurysms (splenic,
renal, uterine, ovarian, aorta)
– Related to the physiologic and
hemodynamic changes of pregnancy
– At risk population
•Marfan syndrome
•Ehler’s Danlos syndrome
•Turner syndrome
Hale T., M.D., Resident Physician 41

42. – Presenting complaints
•Suden onset abdominal pain
•Free peritoneal fluid
•Sudden hemodynamic collapse
•Failure to identify the cause prior to
laparatomy
Hale T., M.D., Resident Physician 42

43. Hale T., M.D., Resident Physician 43

44. • Acute Hepatitis
– Hep E virus has severe clinical disease in
pregnancy
– CMV, EBV, Adenoviruses
– Anorexia, nausea, jaundice, RUQ
discomfort
Hale T., M.D., Resident Physician 44

45. Gynecologic Causes of Acute Abdomen
• Ovarian Torsion
– Similar in nonpregnant and pregnant
patients
– 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
Hale T., M.D., Resident Physician 45

46. Hale T., M.D., Resident Physician 46

47. – Presumptive Diagnosis
•Acute pelvic pain +
•Adnexal mass +
– Masses related to endometriosis, tuboovarian
abscess, 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
Hale T., M.D., Resident Physician 47

48. Hale T., M.D., Resident Physician 48

49. Hale T., M.D., Resident Physician 49

50. – Defintive diagnosis
•Direct visualization of rotated ovary at the
time of surgery
Hale T., M.D., Resident Physician 50

51. • Can ovarian torsion happen in normal
ovaries?
– In premenarchal girls
•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
Hale T., M.D., Resident Physician 51

52. • Checking viability of torsed ovary
– Inspection
•Blue or black – nonviable
– Ovarian bivalving
Hale T., M.D., Resident Physician 52

53. • Management
– Detorsion
– Surgical removal
•Cystoectomy
•Unilaterla salpingo-oophorectomy
Hale T., M.D., Resident Physician 53

54. • Ruptured or Hemorrhagic Ovarian Cyst
– Presenting complaints
•Sudden onset of unilateral lower abdominal
pain
•Pain begins during strenous physical activity or
sexual intercourse
•Hemodynamic instability and pelvic collection
– Bradycardia (paradoxically)
Hale T., M.D., Resident Physician 54

55. – Asymptomatic: Serous or mucinous fluid
– Severe pain: Spillage of sebaceous
material upon rupture of a dermoid cyst
•Granulomatous reaction
•Chemical peritonitis
Hale T., M.D., Resident Physician 55

56. – Ultrasound
•First-line imaging study for
– identification and characterization of the ovarian
mass or cyst
– to look for fluid in the cul-de-sac
Hale T., M.D., Resident Physician 56

57. – Management
•Uncomplicated
– Outpatient management with oral analgesia
•Complicated
– Inpatient,
– Fluid
– Follow vitals
– Surgery to control hemorrhage if hemodynamically
unstable or if dermoid cyst rupture is suspected
Hale T., M.D., Resident Physician 57

58. • Fibroid degeneration or torsion
– Most remain asymptomatic in pregnancy
•Degeneration: myomas > 5 cms in size
•Torsion: Pedunculated myomas
– Presenting complaints
•Localized pain
•Mild leucocytosis, fever, peritoneal signs, N & V
•Miscarriage
•Premature labor and delivery
•Abnormal fetal position
•Placental abruption
Hale T., M.D., Resident Physician 58

59. – Other rare complications
•DIC
•Spontaneous hemoperitoneum
•Uterine inversion
•Uterine incarceration
•ARF
•Urinary retention
•Pyomyoma
– Fever, leukocytosis, tachycardia, Pelvic pain
– Ultrasound: Heterogenous mass with gas
Hale T., M.D., Resident Physician 59

60. – Ultrasound
•To see the mass
•Pain after ballottement by the abdominal
ultrasound probe directly over the fibroid
supports the diagnosis
Hale T., M.D., Resident Physician 60

61. • Pelvic Inflammatory Disease
– Rare because of barrier formed by
•Cervical mucus plug
•Decidua
– Diagnosis
•Fever with lower abdominal pain
•Rule out other causes first
Hale T., M.D., Resident Physician 61

62. • Medical causes of abdominal pain in
pregnancy
– Mesentric venous thrombosis
– Pancreatitis
– Pneumonia
– Inflammatory bowel disease
– Gastroenteritis
– Sickle cell crisis
Hale T., M.D., Resident Physician 62

63. REFERENCES
Hale T., M.D., Resident Physician 63

64. Hale T., M.D., Resident Physician 64

65. Hale T., M.D., Resident Physician 65

66. Thank you for listening!
Hale T., M.D., Resident Physician 66