Information about acute abdomen in pregnancy. Gastrointestinal surgery in pregnancy. Presentation on acute abdomen in pregnancy, physiology of pregnancy, upper abdominal pain, lower abdomen pain, diffuse abdominal pain, lonizing radiation etc. https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Dr Dhaval Mangukiya
Surgical Gastroenerologist
Dept of GI-HPB & Cancer Surgery
SIDS Hospital & Research Centre

2. Physiology of pregnancy
Abdominal pain

3. Upper abdominal pain
Life-threatening causes
 Bowel obstruction
 Perforated ulcer
 Splenic rupture
 Hepatic rupture

4. Upper abdominal pain
Common causes
 Gastroesophageal reflux
 Gallbladder disease
 Pneumonia

5. Upper abdominal pain
Uncommon causes
 Acute hepatitis
 Pancreatic disease
 Rectus sheath hematoma
 Adrenal hemorrhage
 Hiatal hernia
 Wandering spleen syndrome

6. Pain in the lower abdomen
Common causes
 Acute appendicitis
 Appendicitis is the most common cause of the acute
surgical abdomen during pregnancy [Tamir IL, Bongard FS, Klein SR. Acute
appendicitis in the pregnant patient. Am J Surg 1990; 160:571.].
 Nephrolithiasis

7. Uncommon causes
 Inflammatory bowel disease
 Diverticulitis
Pain in the lower abdomen

8. Diffuse abdominal pain or pain in
variable locations
Life-threatening causes
 Trauma
 Spontaneous hemoperitoneum
 Aneurysm
 Mesenteric venous thrombosis

9. Common causes
 Gastroenteritis
 Sickle cell crisis
 Hereditary angioedema
Diffuse abdominal pain or pain in
variable locations

10. Uncommon causes
 Iliopsoas abscess
 Cutaneous nerve entrapment
 Abdominal wall hernia
 Spontaneous rupture of the urinary tract
Diffuse abdominal pain or pain in
variable locations

11. Ionizing Radiation
 Preconceptional ovarian exposure to diagnostic levels
of ionizing radiation has no measurable effect on
future pregnancies.
 The ideal time to schedule radiologic procedures in
women of reproductive age is during the first 10 days
of the menstrual cycle

12. Surgery in pregnancy
 Open
 Laparoscopic

13. Laparoscopic surgery in pregnancy
 Decrease utero-placental blood flow and result in fetal
hypoxia
 Fetal acidosis could develop from absorption of carbon
dioxide (CO2)
 Directly or indirect injury by a trocar or Veress needle.
 Preterm premature rupture of the membranes and
preterm delivery.

14.  In a retrospective study of nearly 2000 pregnant
women that compared open and laparoscopic
appendectomy and cholecystectomy, laparoscopic
surgery was associated with shorter operative times,
shorter length of stay, and fewer complications
compared with open surgery
Cox TC, Huntington CR, Blair LJ, et al. Laparoscopic appendectomy and cholecystectomy
versus open: a study in 1999 pregnant patients. Surg Endosc 2016; 30:593.
Laparoscopic surgery in pregnancy

15.  In a cohort study of nearly 20,000 women undergoing
appendectomy or cholecystectomy during pregnancy,
open surgery was associated with a threefold increased
risk of postoperative obstetric complications,
including preterm delivery, preterm labor without
preterm delivery, and miscarriage, when compared to
laparoscopy
 Sachs A, Guglielminotti J, Miller R, et al. Risk Factors and Risk Stratification for
Adverse Obstetrical Outcomes After Appendectomy or Cholecystectomy
During Pregnancy. JAMA Surg 2017.
Laparoscopic surgery in pregnancy

16.  A report from Swedish health registries compared the
outcome of 2181 laparoscopies performed on pregnant
patients prior to 20 weeks of gestation with the
outcome of 1522 laparotomies performed in a similar
population. There were no significant differences
between groups in any measured outcome: birth
weight, gestational duration, intrauterine growth
restriction, congenital malformations, stillbirths, or
neonatal deaths.
 Reedy MB, Källén B, Kuehl TJ. Laparoscopy during pregnancy: a study of five fetal
outcome parameters with use of the Swedish Health Registry. Am J Obstet Gynecol
1997; 177:673.
Laparoscopic surgery in pregnancy

17.  TIMING
 The optimal time to operate is the early second trimester
 In third trimester if it is technically possible and
clinically appropriate.
 In first trimester introducing a potential teratogen
during organogenesis is a concern
Laparoscopic surgery in pregnancy

18. Thromboprophylaxis
 For laparoscopic procedure (gynecologic or general
surgical) likely to take >45 minutes, use of low
molecular weight heparin is suggested
 Mechanical thromboprophylaxis is a reasonable
alternative for shorter procedures.
Laparoscopic surgery in pregnancy

19. Patient position
 Supine patients beyond 18 to 20 weeks of gestation
should be positioned with a 15 percent left lateral tilt,
to reduce aortocaval compression and cardiovascular
compromise.
 Alternatively, a wedge may be placed under her right
hip.
Laparoscopic surgery in pregnancy

20.  Trocar placement/insertion
 Orogastric tube placement
 Open technique
 Right hypochondrium for veress
Laparoscopic surgery in pregnancy

23. Pneumoperitoneum
 Intraabdominal pressure between 8 to 12 mm Hg and
not exceeding 15 mmHg
 Routine blood gas monitoring was unnecessary
Laparoscopic surgery in pregnancy

24.  Fetal assessment — Fetal heart rate should be
confirmed and documented before and after the
procedure
 If maternal acidosis is suspected and confirmed, it can
be reversed by immediately hyperventilating the
mother and decreasing intraabdominal pressure
Laparoscopic surgery in pregnancy

25. POSTOPERATIVE CARE
 Fetal heart rate and uterine activity should be
monitored
 Opioids and antiemetics can be used
 Nonsteroidal antiinflammatory drugs should be
avoided
Laparoscopic surgery in pregnancy

26. Antibiotics
 Cephalosporins
 Penicillins
 Erythromycin (except the estolate)
 Azithromycin
 clindamycin

27. GALL STONE DISEASE

28. INCIDENCE AND COURSE IN
PREGNANCY
 Incidence - 0.05 to 0.33 percent
 In the postpartum period, gallbladder sludge resolved in 61
percent of cases
 Approximately 30 percent of stones smaller than 10 mm
disappeared
 Serious complications of gallstones, such as acute
cholecystitis, choledocholithiasis, gangrenous gallbladder,
or pancreatitis, developed in <10 percent of symptomatic
patients
Ko CW, Beresford SA, Schulte SJ, et al. Incidence, natural history, and risk factors for biliary sludge and
stones during pregnancy. Hepatology 2005; 41:359.

29. Gall stone disease

30. Biliary colic
 Symptomatic treatment (Grade 2c)
 No Surgery
 Surgery for recuurent symptoms (Grade 2c)

31. Acute cholecystitis
 Surgery (Grade 2b)
 If biliary colic or acute cholecystitis occurs near term,
make every effort to avoid surgery
 Wait six weeks to perform cholecystectomy after
delivery

32. Choledocholithiasis/cholangitis
 ERC with sheild
 Surgery
 Urgent or emergent intervention when signs of sepsis,
gangrene or perforation, or for patients who develop
intractable pain or fever while being observed

33. Gallstone pancreatitis
 Conservative
 Followed by surgery

34. Conclusion
 Cholecystectomy can be performed safely and
effectively during any trimester of pregnancy
 Pregnancy alone does not appear to increase
postoperative morbidity for cholecystectomy
 Cholecystectomy can be technically challenging near
term

35. Acute Appendicitis
 Most common GI surgical problem encountered during pregnancy
 Right lower quadrant pain
 In late pregnancy, pain may be the right mid or upper quadrant.
 Rebound tenderness and guarding are less prominent in pregnant
women, especially in the third trimester
 Leukocytosis may or may not be a sign
 Strongly suspected in pregnant women with abdominal pain that
migrates to the right lower quadrant, right lower quadrant
tenderness, nausea/vomiting, fever, and leukocytosis with left shift.
 Imaging:
 USG
 Magnetic Resonance Imaging (MRI)
 Delaying intervention for more than 24 hours increases the risk of
perforation

37. Questions?

38. Question
Best investigation for gall stone disease?
1. USG
2. MRCP
3. HIDA
4. CT Scan

39. Question
Approach for Lap appendicectomy in third trimester
1. Right transverse incision
2. Mcburney’s incision
3. Laparoscopic

40. Question
Acute cholecystitis with CBD stone/cholangitis
1. Surgery f/b ERC
2. ERC f/b surgery
3. ERC f/b Antibiotics

41. Scenario 1
 29 year old female
 Primi 9 weeks
 Acute pain abdomen
 Fever
 Vomiting
 Investigations?

42.  CBC – 16000
 Bili – 2.6
 Direct- 2.1
 Amylase/Lipase – Normal
 SGOT/SGPT – Normal
 ALK PO4 – 580
Imaging?
Scenario 1

43.  USG – lower CBD stone with dilated proximal
dilatation, cholelithiasis
Plan?

44.  ERCP with stenting – frank pus drained with stone
removal
Surgery?

45. Thank you