This document discusses the evaluation and management of acute abdomen during pregnancy. It outlines common etiologies including appendicitis, bowel obstruction, and pregnancy-related causes. The evaluation involves history, physical exam focusing on signs of peritonitis, and lab tests. Imaging options like ultrasound and MRI are discussed. Laparoscopy is generally safe in pregnancy with precautions. Acute appendicitis is the most common non-obstetric surgical emergency. It can be more severe in pregnancy and risks increase with delayed treatment.

1. Acute Abdomen In
Pregnancy
Alaa Mohammad AbuZaineh

2. Topic Presentation
• Etiologies
• Approach
–History
–Examination
–Blood Investigations
–Imaging controversy
–Laparoscoscopy in pregnancy
• Acute Appendicitis in pregnancy

3. Etiologies
• Gastrointestinal
– Acute appendicitis
– Bowel obstruction
– Bowel perforation
• Causes associated with pregnancy
– Early
• Ruptured ectopic pregnancy
• Septic abortion with peritonitis
– Late
• Red degeneration of myoma
• Placental abruption
• Uterine rupture
• Chorioamnionitis
• Others :
– Ovarian cyst rupture , Diabetic ketoacidosiss , Sickle cell disease , Abdominal
trauma

4. History
• SOCRATES
• Associated Symptoms
– Normal in pregnancy.
– Ask the patient to differentiate these normal
pregnancy changes from the acute event
• GESTATIONAL AGE!

5. Pain
• stretching of the round ligament
• Braxton-Hicks contractions
• severe, associated with other
symptoms or confined to the
upper abdomen
• The presence of peritoneal signs
is never normal in pregnancy .
• common feature of early
pregnancy, and usually abates by
20 weeks of gestation
• Association with
abdominal/pelvic pain, fever,
diarrhea, headache, or
localized abdominal/pelvic findin
gs on physical examination.
• second half of pregnancy
Nausea and Vomiting

6. • Decreased lower esophageal
sphincter tone, small bowel
and colonic motility,
gallbladder emptying, and
ureteral tone .
• aortocaval compression
lightheadedness or syncope

7. Physical Examination
• Vitals : Increased HR , by 15 to 20 bpm
• Findings may be less prominent
• Peritoneal signs are often absent
– The underlying inflammation has no direct contact with the
parietal peritoneum
– The uterus can also obstruct and inhibit the movement of the
omentum to an area of inflammation
– The normal laxity of the abdominal wall in pregnancy may also
diminish peritoneal signs.
• To help distinguish extrauterine tenderness from uterine
tenderness, performing the examination with the patient
in the right or left decubitus position

8. • changing positions of the intra-abdominal
contents at different gestational ages.

9. Fetal considerations : evaluate two
patients at the same time
• Monitor the fetal heart rate and uterine tone
continuously throughout the period of
evaluation.
• A nonreassuring tracing or evidence of fetal
distress may suggest an obstetric etiology for
the acute abdomen (eg, placental abruption
or uterine rupture ).

10. Lab Investigations
– WBC
• 10,000 to 14,000 cells per mm3 during pregnancy
• 20,000 to 30,000 cells per mm3) In Labor
• returning to normal prepregnancy levels at approximately one week
postpartum
– bandemia is not a normal variant of pregnancy and its
presence suggests infection until proven otherwise.
– physiologic anemia.

11. -Non
Pregnant
1st Trimester 2nd
Trimester
3rd Trimester
Hemoglobin 12 to 15.8 11.6 to 13.9 9.7 to 14.8 9.5 to 15.0 
CRP 0.2 to 3.0 Not reported 0.4 to 20.3 0.4 to 8.1 
ESR 0 to 20 4 to 57 7 to 47 13 to 70 
WBC 3.5 to 9.1 5.7 to 13.6 5.6 to 14.8 5.9 to 16.9 
ALT 7 to 41 3 to 30 2 to 33 2 to 25 
ALP 33 to 96 17 to 88 25 to 126 38 to 229 
Amylase 20 to 96 24 to 83 16 to 73 15 to 81 
Lipase 3 to 43 21 to 76 26 to 100 41 to 112 

12. Diagnostic Imaging In Pregnancy
• Ultrasound VS MRI
– US : most frequently used modality (gallbladder, pancreas, and kidneys can
be evaluated easily). Limitations  body habitus in the later stages of
gestation
– In a series of 33 pregnant patients, the sensitivity of MRI for acute appendicitis
was 80%, compared with 20% for US.
– MRI to date has shown high sensitivity and specificity for appendicitis
– useful in the diagnosis of acute appendicitis when US was inconclusive
– In a 2017 committee opinion, the American College of Obstetricians and
Gynecologists (ACOG) stated that MRI, is preferable to US in the diagnosis of
appendicitis (lower non visualization rates)
– MRI contrast agents ?
• Intravenous gadolinium crosses the placenta, category C drug

13. Xray and CT scan
• radiation exposure from a single diagnostic
procedure does not result in harmful fetal
effects.
• perform medically indicated diagnostic
radiographic procedures when needed; when
possible
• minimize exposure when possible without
compromising patient care

14. Surgical Consideration
• Indications for emergency surgery are the same
for patients who are pregnant as for any other
patients.
• If surgery is required but is considered elective,
waiting until after the pregnancy is completed .
• If surgery is deemed necessary during
pregnancy, it should be performed in the second
trimester if possible
– Risk of preterm labor is lower than in the third
– Risk of spontaneous loss and risks due to medications
such as anesthetic agents are lower than in the first.

16. Laparoscopy During pregnancy
• pregnancy was considered a contraindication for laparoscopy
• no strong evidence of increased risk of miscarriage or teratogenesis
from anesthetic agents used during early pregnancy.
• minimize manipulation of the uterus.
• Fetal heart rate monitoring
• The surgeon must work closely with the obstetrician.
• Trocar location should be adjusted on the basis of uterine size.

17. CO2 Insufflation pressure : 10-15 mm Hg is safe

18. • Thromboprophylaxis —
– pneumatic compression devices on all pregnant
women undergoing surgery.
– pharmacologic prophylaxis (LMWH)
• length of the procedure :
– >45 mins laparoscopic
• risk factors for venous thrombosis in addition to the
pregnancy (eg, thrombophilia, prolonged
immobilization, past history of venous thrombosis,
malignancy, diabetes mellitus, varicose veins, paralysis
or obesity).
• Post Op thromboprophylaxis is continued until
the patient is fully mobile.

19. Appendicitis in Pregnancy
• Key Facts
– the most common non obstetric cause of surgical
emergency in pregnancy.
– more common in the second trimester.
– No effect on incidence
– Increased severity
– The incidence of perforation is 25% in pregnancy.
If surgery is delayed for more than 24 hours, the
incidence of perforation increases to 66%.

20. History and physical examination
• Abdominal pain
– 1st trimester : RLQ
– 2nd trimester: level of
umbilicus
– 3rd trimester : diffused or RUQ
• Nausea - Present in nearly
all cases
• Vomiting
• Anorexia

21. Examination :
• Direct abdominal tenderness - Observed most commonly and
only rarely absent
– 1st Trimester - Well localized in the RLQ
– 2nd and 3rd trimesters - right periumbilical area, in the RUQ, or diffuse
• Rebound tenderness - Present in 55-75% of patients
• Abdominal muscle rigidity - Observed in 50-65% of patients
• Rovsing sign - as frequently in pregnant as in nonpregnant
• Psoas irritation – less frequent in pregnancy than nonpregnancy
• Rectal tenderness - Usually present, particularly 1st trimester
• Fever and tachycardia – insensitive

22. Workup
• Leukocytes
– Limited usefulness
– severe disease can occur with a normal count.
– PMNs are often greater than 80% when appendicitis is present.
• Urinalysis - Pyuria is observed in 10-20% of patients with appendicitis
• In some centers, US has been used to help diagnose appendicitis
• Upright abdominal radiography - In severe disease, a right-side mass
or free air may be visualized
• MRI and CT - These have been used in difficult cases

23. Management
• Surgical
• Appendectomy
• either open or laparoscopic, as soon as the diagnosis is seriously
considered.
• Laparoscopic appendectomy is the method preferred by most
surgeons.
• Even if the appendix appears normal, there are two reasons to
remove it.
– early disease may be present despite the grossly normal appearance
– diagnostic confusion can be avoided if the condition recurs.
• Remember to tilt the operating table 30º to the patient's left to
help bring the uterus away from the surgical site and to improve
maternal venous return and cardiac output.

24. Prognosis
• Perforation and abscess formation are more likely
to occur in pregnant patients with appendicitis
than in nonpregnant patients with appendicitis.
• increasing severity in the third trimester , may be
due to a delay in diagnosis.
• The rate of generalized peritonitis relates directly
to the interval of time from symptom onset to
diagnosis.
• Maternal and fetal morbidity and mortality
increase once perforation occurs.

25. Thank You
References
• MedScape
• Up to date