Dr. Leong Si Man

1. Acute abdomen in pregnancy (AAP)
O&G IC: Leong Si Man
Tutor: Dr. Ng Wai Lon
Date of presentation: 2021/09/17

2. Acute Abdominal Pain in Pregnancy
• a unique diagnostic and therapeutic challenge
• include cause of pregnancy related and unrelated.
• Diagnosis is difficultly due to:
1) anatomical and physiological changes
2) radiological expose.
• Delay in diagnosis and treatment → adverse outcomes for both the
mother and fetus

3. DDX of Abdominal Pain in Pregnancy
Related pregnancy Unrelated by pregnancy
• Early pregnancy
(< 24 weeks)
• Later pregnancy
(> 24 weeks)
• Gynecological causes
• Surgical disorders
• Medical causes
• Musculoskeletal cause

4. Abdominal pain- caused of obstetric condition(1)
• Early pregnancy (< 24 weeks)
1) Ectopic pregnancy
2) Miscarriage
3) Mole pregnancy
4) Acute urinary retention due to retroverted gravid uterus.
5) Ligament stretching

5. Abdominal pain- caused of obstetric condition(2)
• Later pregnancy (> 24 weeks)
1) Braxton-Hicks Contraction.
2) Round Ligament Pain.
3) Placental abruption.
4) Pre-eclampsia .
5) Acute Polyhydramnios.
6) labour.
7) uterine rupture.
8) HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome.

6. Abdominal pain-unrelated of pregnancy conditions
• Gynecological causes
1) Torsion of ovary or fallopian tube.
2) Ovarian cyst : Torsion, Hemorrhage or Rupture
3) degeneration of fibroids
4) Ovarian hyperstimulation syndrome
5) salpingitis

7. Abdominal pain-unrelated of pregnancy conditions
• Surgical cause
1) Acute appendicitis
2) Cholecystitis and gallstones
3) Urinary tract: urinary tract obstruction, Renal calculi.
4) Intestinal obstruction or perforation
5) Gastric/duodenal ulcer
6) Mesenteric adenitis
7) Meckel’s diverticulitis
8) Inflammatory bowel disease
9) Acute pancreatitis
10) Rarely: hernia, Mesenteric venous thrombosis, rupture of visceral artery aneurysm.

8. Abdominal pain-unrelated of pregnancy conditions
• Medical causes
1) Urinary tract infection and acute pyelonephritis
2) Diabetic ketoacidosis
3) Pneumonia (especially lower lobe)
4) Sickle cell disease (abdominal crisis)
5) Venous thromboembolism
6) Gastroenteritis
7) Irritable bowel syndrome
8) Myocardial infarction

9. • Musculoskeletal cause
1) Round ligament pain.
2) General aches.
3) Rectus muscle hematoma.
4) Pelvic girdle pain.
5) Osteomalacia
Abdominal pain-unrelated of pregnancy conditions

10. How to Assessment???

11. Medical History taking
• History is MOST essential to diagnosis:
1) Pain history.
2) Other abdominal symptoms.
3) Fetal movements.
4) Obstetric history.
5) Past medical and gynaecological history, medication, allergies, last
meal.

12. physiological changes in pregnancy

13. Anatomical changes in pregnancy
• enlarging uterus, maximum reaches
the costal margin.
• As pregnancy progresses, the bowel
gets displaced laterally and upward.
• displaced omentum might fail to wall
off peritonitis.
• relaxed and stretched abdominal wall
can mask guarding
• change of anatomical can make the
diagnosis difficultly of acute abdomen.

14. Common causes of acute abdomen in pregnancy
Gezginç K, Korkmaz T. Gebelik döneminde gebelikle ilişkili olmayan akut karın nedenleri ve tedavileri. Selçuk Tıp Dergisi 2013;29(4):192-9.
cause and incidence of non-obstetric abdominal
pain in pregnancy varies little by gestational age
of the fetus.
• Appendicitis (1/1500)
• Cholecystitis (1-6/10000)
• Nephrolithiasis (1/3000)
• Pancreatitis (1/3000)
• Small bowel obstruction (1/1500-16000)

15. Acute appendicitis in pregnancy(1)
• The most common non-obstetric surgical emergency during
pregnancy.
• Incidence rale: 1/1,000–2,000.
• Accounting for 25% of the non-obstetric surgical interventions
done during pregnancy.
• the highest incidence found in the second trimester.
• Appendicular perforation more frequent in the third trimester.

16. Acute appendicitis in pregnancy(2)
• Clinical presentation:
1) initial periumbilical
pain>shifts to the RLQ.
2) Fever.
3) RLQ Pain is the most
common.
• Physical examination :
1) maximal tenderness at the
McBurney’s point
2) guarding and even rebound
tenderness
****These classical clinical signs may be altered, especially in
advanced pregnancy.

17. Acute appendicitis in pregnancy(3)
• Comp. exam
1) Blood exam for the inflammatory marker, such as WBC,
CRP, PCT, ESR.
2) Urinalysis for rule out pyelonephritis or renal calculus.
3) Ultrasound is the diagnostic imaging procedure of first
choice by American College of Radiology.
4) MRI is the second line of imaging.

18. Acute appendicitis in pregnancy(4)
• Treatment:
1) Appendectomy.
2) Perioperative antibiotic treatment
3) Conservative management is considered in uncomplicated of appendicitis in
pregnant women.
4) antibiotic therapy alone in complicated case is not recommended.
5) Delay in treatment> perforation, peritonitis, and septicemia, adverse
maternal and fetal outcomes

19. Acute appendicitis in pregnancy(5)
• SURGICAL APPROACH
1) Open and laparoscopic appendectomy.
2) No trials to suggest that one technique is better than another.
3) Choice of technique is based on: clinical status, patient preferences,
gestational age, and the surgeon's experience level.
4) Difference between LA and OA with respect to preterm delivery was not
significant.
5) Laparoscopic : overall complication rates ↓ and hospital stays ↓.

20. Acute appendicitis in pregnancy(5)
• Open appendectomy
1) transverse incision at McBurney's point or point of
maximal tenderness.
2) If diagnosis is not sure, lower midline vertical incision
is recommend.

21. Acute appendicitis in pregnancy(6)

22. Acute appendicitis in pregnancy(7)
• Outcome
1) symptom onset> 24 hrs without surgical intervention, 14%-43% of patient occurs perforation.
2) When appear appendix perforates, the risk of fetal loss is increased 36%.
3) When appear peritonitis or a peritoneal abscess, the risk of early delivery increased to 11%,
the risk of fetal loss is increased 16%.
4) The only independent variable associated of postoperative complications: symptom duration
prior to surgery greater >/= 48 hours
5) The long-term prognosis for women who undergo appendectomy during pregnancy is
generally good.
Chwat C, Terres M, Duarte MR, Valli D, Alexandre F, Rosato G, Lemme G. Laparoscopic treatment for appendicitis during pregnancy: Retrospective cohort study. Ann Med Surg (Lond).
2021 Aug 5;68:102668. doi: 10.1016/j.amsu.2021.102668. PMID: 34408866; PMCID: PMC8361228.

23. Gallbladder disease in pregnancy(1)
• Introduction :
1) Gallstones are more common in pregnant compared with nonpregnant patients.
2) Elevated serum cholesterol and lipid levels in pregnancy coupled with decreased
gallbladder motility and delayed emptying can predispose the formation of gallstones.
3) Gallstone disease is classified into uncomplicated and complicated disease.
4) Pregnant patients with repeated attacks of biliary colic or with complicated gallstone
disease will require an invasive procedure.
5) cholecystectomy is one of the leading nonobstetrical indications for surgery in
pregnant patients.

24. Gallbladder disease in pregnancy(2)
• Physical examination:
1) Guarding maybe
2) Murphy's sign(+):
• Clinical presentation:
1) Recurrent pain attacks (biliary colic)
2) Acute cholecystitis: steady and
severe RUQ or epigastric pain,
prolonged (>4-6 hours), and
possibly radiating to the right
shoulder or back.
3) With fever, anorexia, nausea, and
vomiting.

25. Gallbladder disease in pregnancy(3)
• Comp. exam
1) Laboratory testing: CBC, AST/ALT, total bilirubin, alkaline phosphatase,
Serum amylase and lipase, CRP
, PCT, Urine protein.
2) Ultrasonography is recommend for identifying gallstones in pregnant
patients.
3) MRCP may be useful in some complicated cases.

26. Gallbladder disease in pregnancy(4)
• Treatment:
1) fasting
2) pain control
3) intravenous fluid therapy
4) antibiotic therapy when clinically indicated
5) early surgical or endoscopic intervention
6) Laparoscopic cholecystectomy

27. Gallbladder disease in pregnancy(5)
• Antibiotic choice during pregnancy:
1) Ampicillin-sulbactam 3 g IV Q6H
2) Piperacillin-tazobactam 3.375 g IV Q6H
3) An acceptable alternative is a third-generation cephalosporin, such as ceftriaxone 1 g IV q24H +
metronidazole 500 mg IV Q8H.
4) In patients who cannot take a penicillin or cephalosporin:
vancomycin 15 to 20 mg/kg/dose IV Q8-12H initially (adjust based on therapeutic monitoring)+ aztreonam 1
to 2 g IV Q8h (maximum 8 g/day) + metronidazole.
***Aminoglycosides are relatively safe but carry a risk of fetal (and maternal) ototoxicity and nephrotoxicity, so drug
levels should be monitored.

28. Gallbladder disease in pregnancy(6)
gallbladder surgery and ERCP can be safely performed during any trimester.
• ERCP with sphincterotomy:
For patients who are near term, perform ERCP >relieve the common bile duct
obstruction> delivery> gallbladder surgery.
• Gallbladder surgery:
Laparoscopic cholecystectomy is also the preferred in pregnant patient.

29. Gallbladder disease in pregnancy(7)
• ERCP
1) ERCP in pregnancy can be done safely and successfully.
2) Lead shielding should be used to minimize radiation exposure to the
uterus.
3) During the later pregnancy, the left lateral decubitus position is
required .
4) Procedure time should be minimized and Minimize fluoroscopy time.
5) The fetal dose of concern for teratogenesis is considered over 5 rad,
Fetal radiation exposure during ERCP is generally much lower than 5
rad.

30. Gallbladder disease in pregnancy(8)
• During Laparoscopy:
1) placed slightly head-up and tilted to
their left.
2) Use the open (Hasson) technique
• Open cholecystectomy:
1) A subcostal incision is preferred

31. Gallbladder disease in pregnancy(9)
• Outcome:
1) laparoscopic cholecystectomy for acute cholecystitis was delayed was associated with
increased risk of fetal complications .
2) early cholecystectomy with reduced preterm delivery rate and readmission rate
3) Pregnancy alone does not appear to increase postoperative surgical morbidity for
cholecystectomy in pregnant.
4) For pregnancy with complicated gallstone diseases we suggest early intervention
(gallbladder surgery or ERCP).
5) Delaying gallbladder surgery until after delivery is a reasonable alternative for some
patients near term

32. Intestinal obstruction in pregnancy(1)
• Adhesive obstruction occurs more commonly in advanced pregnancy.
• Risk of bowel obstruction during pregnancy increases as the uterus
enlarges.
• Rate of fetal loss was 17% and the maternal mortality rate was 2%.
• Adhesions and volvulus are the most common causes of the obstruction.

33. Intestinal obstruction in pregnancy(2)
• Symptoms:
include nausea, vomiting (82%), abdominal pain (98%), and absolute constipation
(30%)
• Physical exam:
1) Fever
2) Abdominal distension, tenderness, rebound, and guarding
3) Bowel sounds : hyperperistaltic> hypoperistaltic

34. Intestinal obstruction in pregnancy(3)
• Comp. exam
1) Blood exam: leukocytosis, CRP and PCT ↑
2) Ultrasound may show dilated loops of bowel with air-fluid levels
3) flat and upright AXR have been reported to be positive in 82%–100%
4) MRI helps to characterize the site and degree of obstruction.

35. Intestinal obstruction in pregnancy(4)
• Treatment:
1. Fasting
2. Fluid therapy
3. Gastrointestinal decompression
4. Antibiotics : with uncomplicated SBO, antibiotic isn’t recommend
5. Surgery: Indications same as for nonpregnant patients: suspected bowel
compromise (ie, perforation, necrosis, or ischemia).
6. Gastrografin challenge should not be administered to pregnant patients.

36. Intestinal obstruction in pregnancy(5)
• Surgery intervention:
1) Should be performed if failure to conservative therapy or symptoms of
fetal distress.
2) laparoscopy cannot be recommended.
3) Laparotomy is best done through a midline incision.

37. Anesthesia in pregnancy
• Effects of anesthetics on the fetus and the pregnancy:
1) No evidence that any specific anesthetic agent is teratogenic in humans.
2) A single short anesthetic exposure does not adversely affect Fetal brain
development .
3) Pregnant patients may be more sensitive to anesthetic medications

38. Anesthesia in pregnancy
• Pre-anesthesia evaluation and anesthesia management:
1) evaluated preoperatively in the same manner as nonpregnant patients.
2) regional anesthesia is preferred, most non- obstetric procedures are performed under
general anesthesia due to the nature of the procedure and/or patient factors.
3) pregnant patients increased risk of aspiration during general anesthesia .
4) fetal heart rate (FHR) should be documented pre- and postoperatively.
5) If the patient more then 18 weeks of gestation, patients should be positioned with a
15-degree left lateral tilt when supine( left uterine displacement).

39. Take home message
1) AAP can be due to obstetric as well as non-obstetric causes.
2) complicates the diagnosis of AAP due to physiologic changes by pregnancy.
3) Initial imaging in evaluating AAP patients should begin with ultrasound.
4) Appendicitis remains the most common cause of non- obstetric AAP, that delay in diagnosis increases fetal
mortality.
5) Laparoscopic surgery is feasible and safe in selected patients.
6) Both the FDA and ACOG advise that necessary surgery should not be avoided or delayed during pregnancy.
7) multidisciplinary approach are indispensable for timely diagnosis and treatment of AAP patient .

40. REFERENCES
• Acute Abdomen During Pregnancy. Authors: Augustin, Goran. 2018, ISBN 978-3-319-72995-4
• Joo JI, Park HC, Kim MJ, Lee BH. Outcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy. Am J Med. 2017 Dec;130(12):1467-1469. doi:
10.1016/j.amjmed.2017.04.046. Epub 2017 Jun 9. PMID: 28602871.
• Chwat C, Terres M, Duarte MR, Valli D, Alexandre F, Rosato G, Lemme G. Laparoscopic treatment for appendicitis during pregnancy: Retrospective cohort study. Ann Med Surg
(Lond). 2021 Aug 5;68:102668. doi: 10.1016/j.amsu.2021.102668. PMID: 34408866; PMCID: PMC8361228.
• Masayuki Nakashima, Masato Takeuchi, Koji Kawakami, Clinical Outcomes of Acute Appendicitis During Pregnancy: Conservative Management and Appendectomy, World Journal
of Surgery, 10.1007/s00268-021-06010-w, (2021).
• Parangi S, Levine D, Henry A, et al. Surgical gastrointestinal disorders during pregnancy. Am J Surg 2007; 193:223.
• Stedman’s Medical Dictionary, 2. (2018). Stedman’s Medical Dictionary, 27th Edition Deluxe. [online] Alibris. Available from: https://www.alibris.com/Stedmans-Medical-
Dictionary-27th-Edition-Deluxe-Stedmans/book/30000738. Accessed July 7, 2018.
• Borzellino G, Massimiliano Motton AP, Minniti F, Montemezzi S, Tomezzoli A, Genna M. Sonographic diagnosis of acute cholecystitis in patients with symptomatic gallstones. J Clin
Ultrasound. 2016;44(3):152–158
• Choi JJ, Mustafa R, Lynn ET, Divino CM. Appendectomy during pregnancy: follow-up of progeny. J Am Coll Surg. 2011;213(5):627–632.
• Augustin G, Majerovic M. Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2007;131(1):4–12.
• Webster PJ, Bailey MA, Wilson J, Burke DA. Small bowel obstruction in pregnancy is a complex surgical problem with a high risk of fetal loss. Ann R Coll Surg Engl. 2015;97(5):339–
344.
• Committee Opinion No. 696: Nonobstetric Surgery During Pregnancy. Obstet Gynecol 2017; 129:777.
• Practice Advisory: FDA warnings regarding use of general anesthetics and sedation drugs in young children and pregnant women. The American College of Obstetricians and
Gynecologists. December 21, 2016 http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/FDA-Warnings-Regarding-Use-of-General-Anesthetics-and-Sedation-Drugs
(Accessed on December 22, 2016).
• ACOG Committee Opinion No. 775: Nonobstetric Surgery During Pregnancy. Obstet Gynecol 2019; 133:e285.