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Case Presentation
o Approach  of pregnant lady
  with abdominal pain
o Proper Disposal
o Case discussion
o Pitfalls
 25years old pregnant lady,G1P0
, 12 weeks of gestation with
 severe lower abdominal pain
 since 1 day
o/e :
                           Abd pain since 1 day
A : patent                                            pale , in pain
B : 18/min , sat 98% in RA                           chest : clear
                           Getting worse with time
 Bilateral Air entry                                 CVS : s1,s2
                           Associated with
C : BP 110//70 mmhg                                  normal
                           vomiting
Pr: 83/min /min , regular                            p/a: tenderness
D : reflo 7 mmol                                     all over
                           -No PV bleeding
                                                     PV exam : Os is
                           -No urinary symptoms
   GCS : 15/15                                       closed , no
                           -No diarrhea
    UPT:+ve                                          bleeding
                           -No previous illnesses
                           -No previous scan
                          Action :
                          = no Ultrasound facility
                          =Buscopan Inj given
      DDX                  = referred to Obe/Gyne
                          oncall
                           = Gyne scan : SLF ,
                          BPD 13 weeks , FHR +,
                          placenta Upper posterior

                          Advise :
                          Nill Gyne
                          Surgical Referral
Physiological changes in vitals in 12 weeks
pregnant lady
   BP:Diastolic and systolic blood pressure tend to fall during
    mid pregnancy and then return to normal by week 36
   Diastolic pressure decreases more than systolic
    ◦ Heart rate: +10 beats/min (5%)
    ◦ Respiratory rate: no change
Patient came back from Gyne clinic
still c/o severe abdominal pain
A : patent
B : 18/min                                   o/e :
  Bilateral Air entry   Pain                  in severe pain
C : BP 110//70          progressively        p/a : Tenderness all
mmhg                    getting worse        over , Guarding++,
Pr : 120/min                                 Rigidity++
, regular                                    BS absent

   GCS : 15/15



                        Action :             Surgical Opinion :
                         =Pain killer
                          Buscopan Inj       = Admittion
                        , Morphine 5 mg IV   =NPO , IV fluid
DDx                     = NPO , IV fluid     = US abdomen
                          still in pain
                         US Vs Surgical
                        referral
    CBC : HGB 10.4 ( Micocytic , Hypochromic) , WBC 11.7 ,
    Platlate 222

   U&E : HCO3 19 , Urea 2.2 , Na135 , K 3.6 , Creatinie 42

   LFT : Bilirubin 5.2 , AST 27,ALT 19 , ALP51

   PT ,APTT : WNR
 Dilutional anaemia is caused by the rise in plasma
  volume.
 Serum alkaline phosphatase increases during
  pregnancy - due to placental production.
 Serum albumin decreases.
 A modest leukocytosis is observed
 Fibrinogen: 300 mg/dl  450 mg/dl
 D-dimer increase
 Platelet decrease due to hemodilution
 Define thrombocytopenia: < 116,000
  Limited study due to gravid uterus
 appendix could not be visualized
 RIF cyst like mass the origin of this
 mass could be ?? Appendicular
?? Ovarian
Small amount of free fluid seen in RIF &
 Morison pouch
   Abdomen was opened by McBurneys incision , on
    Opening the cavity , appendex found normal . Dirty
    fluid in the cavity with flakes of old hemorrhage
   Gyne called intraoperativly : rt sided ovary
    enlarged 6 cm , old chocolate coloured materia
    over the uterus , omentum & abdominal wall
   Appendicectomy done , rt ovarian chocolate cyst
    aspirated , Peritonial lavage done
   Pt admitted to ICU postoperativly , remain
    stable , remain in the hospital for 5 days
    then dischrged
Case Presentation
   Incidence of acute abdomen during
    pregnancy is 1 in 500


         # 1 Acute Appendicitis
         # 2 Acute Cholecystitis
   Symptoms
    ◦ Nausea, vomiting, and abdominal pain are
      common in the normal obstetric population. N/V
      are most common in weeks 4-16.
   Physical Exam
    ◦ Expanding uterus dislocates other
      intraabdominal organs.
   Labs
    ◦ Leukocytosis and anemia are common in normal
      pregnancies and thus, not as predictive of
      infection or blood loss.
 Trauma
 Acute appendicitis
 Intestinal obstruction
 Perforated duodenal ulcer
 Spontaneous visceral rupture
 Ectopic pregnancy
 Ovarian or uterine torsion
   Divided into three categories:
    1) Conditions incidental to pregnancy
    2) Conditions associated with
    pregnancy
    3) Conditions due to pregnancy
   Acute appendicitis           Rupture of renal pelvis
   Acute pancreatitis           Ureteral obstruction
   Peptic ulcer                 SMA syndrome
   Gastroenteritis              Thrombosis/infarction
   Hepatitis                    Ruptured visceral artery
   Bowel obstruction             aneurysm
   Bowel Perforation            Pneumonia
   Herniation                   Pulmonary embolus
   Meckel’s Diverticulitis      Intraperitoneal hemorrhage
   Toxic megacolon              Splenic rupture
   Pancreatic pseudocyst        Abdominal trauma
   Ovarian cyst rupture         Acute intermittent porphyria
   Adnexal torsion              Diabetic ketoacidosis
   Ureteral calculus            Sickle Cell Disease
 Acute pyelonephritis
 Acute cystitis
 Acute cholecystitis
 Acute fatty liver of pregnancy
 Rupture of rectus abdominus muscle
 Torsion of pregnant uterus
 Ectopic pregnancy
 Septic abortion with peritonitis
 Acute urinary retention due to retroverted uterus
 Round ligament pain
 Torsion of pedunculated myoma
 Placental abruption
 Placenta percreta
 HELLP Syndrome
 Acute Fatty Liver of Pregnancy
 Uterine rupture
 Chorioamionitis
Case Presentation
   It affects 1 in 1500 pregnancies, less common
    than in non-pregnant women , mortality is higher
    (esp. from 20 weeks), Perforation is commoner
    (15%-20%), Fetal mortality is ~1.5% for simple
    appendicitis , ~30% if perforation.

   Diagnosis is complicated by change in position of
    appendix as it migrates upwards, outwards and
    posteriorly as pregnancy progresses, so pain is
    less well localized (often paraumbilical or
    subcostal but right lower quadrant still
    commonest) and tenderness, rebound, and
    guarding less obvious. Peritonitis can make the
    uterus tense and woody-hard.
   Leucocytosis is suggestive..
   < 10,000 leucocyte may be
    reassuring

   Operative delay is dangerous.
 Appendicitis is not diagnosed
in 1 in 5 cases in pregnant
women until the appendix has
ruptured causing peritonitis,
which can cause premature
labour or abortion.
   Graded compression ultrasonography
    accurate in 1st and 2nd trimesters
    , difficult in 3rd.

   98% ACCURATE.
   Adnexal disorders requiring surgical intervention
    occur in approximately one in 1000 pregnancies.

    Ovarian masses may be problematic during
    pregnancy because of their risk for
    torsion, rupture, or hemorrhage.

    large ovarian lesions may also become impacted in
    the pelvis and even obstruct labor. While most
    adnexal masses in pregnancy are functional cysts
    that resolve by 18 weeks' gestation,
   ultrasound. Simple cysts smaller than 6 cm are more likely
    to be functional, but extremely large functional cysts may
    sometimes be seen., also be used when adnexal torsion is
    suspected.

    Masses greater than 6 cm that persist should generally be
    removed in the early second trimester to reduce the risk of
    complications such as rupture, torsion, or hemorrhage.

    Large masses that are symptomatic may sometimes
    require earlier intervention
   Conclusion

Remember that acute abdomen in
 pregnant ady might be sillent
Case Presentation

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Case Presentation

  • 2. o Approach of pregnant lady with abdominal pain o Proper Disposal o Case discussion o Pitfalls
  • 3.  25years old pregnant lady,G1P0 , 12 weeks of gestation with severe lower abdominal pain since 1 day
  • 4. o/e : Abd pain since 1 day A : patent pale , in pain B : 18/min , sat 98% in RA chest : clear Getting worse with time Bilateral Air entry CVS : s1,s2 Associated with C : BP 110//70 mmhg normal vomiting Pr: 83/min /min , regular p/a: tenderness D : reflo 7 mmol all over -No PV bleeding PV exam : Os is -No urinary symptoms GCS : 15/15 closed , no -No diarrhea UPT:+ve bleeding -No previous illnesses -No previous scan Action : = no Ultrasound facility =Buscopan Inj given DDX = referred to Obe/Gyne oncall = Gyne scan : SLF , BPD 13 weeks , FHR +, placenta Upper posterior Advise : Nill Gyne Surgical Referral
  • 5. Physiological changes in vitals in 12 weeks pregnant lady  BP:Diastolic and systolic blood pressure tend to fall during mid pregnancy and then return to normal by week 36  Diastolic pressure decreases more than systolic ◦ Heart rate: +10 beats/min (5%) ◦ Respiratory rate: no change
  • 6. Patient came back from Gyne clinic still c/o severe abdominal pain
  • 7. A : patent B : 18/min o/e : Bilateral Air entry Pain in severe pain C : BP 110//70 progressively p/a : Tenderness all mmhg getting worse over , Guarding++, Pr : 120/min Rigidity++ , regular BS absent GCS : 15/15 Action : Surgical Opinion : =Pain killer Buscopan Inj = Admittion , Morphine 5 mg IV =NPO , IV fluid DDx = NPO , IV fluid = US abdomen still in pain US Vs Surgical referral
  • 8. CBC : HGB 10.4 ( Micocytic , Hypochromic) , WBC 11.7 , Platlate 222  U&E : HCO3 19 , Urea 2.2 , Na135 , K 3.6 , Creatinie 42  LFT : Bilirubin 5.2 , AST 27,ALT 19 , ALP51  PT ,APTT : WNR
  • 9.  Dilutional anaemia is caused by the rise in plasma volume.  Serum alkaline phosphatase increases during pregnancy - due to placental production.  Serum albumin decreases.  A modest leukocytosis is observed  Fibrinogen: 300 mg/dl  450 mg/dl  D-dimer increase  Platelet decrease due to hemodilution  Define thrombocytopenia: < 116,000
  • 10.  Limited study due to gravid uterus appendix could not be visualized RIF cyst like mass the origin of this mass could be ?? Appendicular ?? Ovarian Small amount of free fluid seen in RIF & Morison pouch
  • 11. Abdomen was opened by McBurneys incision , on Opening the cavity , appendex found normal . Dirty fluid in the cavity with flakes of old hemorrhage  Gyne called intraoperativly : rt sided ovary enlarged 6 cm , old chocolate coloured materia over the uterus , omentum & abdominal wall  Appendicectomy done , rt ovarian chocolate cyst aspirated , Peritonial lavage done
  • 12. Pt admitted to ICU postoperativly , remain stable , remain in the hospital for 5 days then dischrged
  • 14. Incidence of acute abdomen during pregnancy is 1 in 500 # 1 Acute Appendicitis # 2 Acute Cholecystitis
  • 15. Symptoms ◦ Nausea, vomiting, and abdominal pain are common in the normal obstetric population. N/V are most common in weeks 4-16.  Physical Exam ◦ Expanding uterus dislocates other intraabdominal organs.  Labs ◦ Leukocytosis and anemia are common in normal pregnancies and thus, not as predictive of infection or blood loss.
  • 16.  Trauma  Acute appendicitis  Intestinal obstruction  Perforated duodenal ulcer  Spontaneous visceral rupture  Ectopic pregnancy  Ovarian or uterine torsion
  • 17. Divided into three categories: 1) Conditions incidental to pregnancy 2) Conditions associated with pregnancy 3) Conditions due to pregnancy
  • 18. Acute appendicitis  Rupture of renal pelvis  Acute pancreatitis  Ureteral obstruction  Peptic ulcer  SMA syndrome  Gastroenteritis  Thrombosis/infarction  Hepatitis  Ruptured visceral artery  Bowel obstruction aneurysm  Bowel Perforation  Pneumonia  Herniation  Pulmonary embolus  Meckel’s Diverticulitis  Intraperitoneal hemorrhage  Toxic megacolon  Splenic rupture  Pancreatic pseudocyst  Abdominal trauma  Ovarian cyst rupture  Acute intermittent porphyria  Adnexal torsion  Diabetic ketoacidosis  Ureteral calculus  Sickle Cell Disease
  • 19.  Acute pyelonephritis  Acute cystitis  Acute cholecystitis  Acute fatty liver of pregnancy  Rupture of rectus abdominus muscle  Torsion of pregnant uterus
  • 20.  Ectopic pregnancy  Septic abortion with peritonitis  Acute urinary retention due to retroverted uterus  Round ligament pain  Torsion of pedunculated myoma  Placental abruption  Placenta percreta  HELLP Syndrome  Acute Fatty Liver of Pregnancy  Uterine rupture  Chorioamionitis
  • 22. It affects 1 in 1500 pregnancies, less common than in non-pregnant women , mortality is higher (esp. from 20 weeks), Perforation is commoner (15%-20%), Fetal mortality is ~1.5% for simple appendicitis , ~30% if perforation.  Diagnosis is complicated by change in position of appendix as it migrates upwards, outwards and posteriorly as pregnancy progresses, so pain is less well localized (often paraumbilical or subcostal but right lower quadrant still commonest) and tenderness, rebound, and guarding less obvious. Peritonitis can make the uterus tense and woody-hard.
  • 23. Leucocytosis is suggestive..  < 10,000 leucocyte may be reassuring  Operative delay is dangerous.  Appendicitis is not diagnosed in 1 in 5 cases in pregnant women until the appendix has ruptured causing peritonitis, which can cause premature labour or abortion.
  • 24. Graded compression ultrasonography accurate in 1st and 2nd trimesters , difficult in 3rd.  98% ACCURATE.
  • 25. Adnexal disorders requiring surgical intervention occur in approximately one in 1000 pregnancies.  Ovarian masses may be problematic during pregnancy because of their risk for torsion, rupture, or hemorrhage.  large ovarian lesions may also become impacted in the pelvis and even obstruct labor. While most adnexal masses in pregnancy are functional cysts that resolve by 18 weeks' gestation,
  • 26. ultrasound. Simple cysts smaller than 6 cm are more likely to be functional, but extremely large functional cysts may sometimes be seen., also be used when adnexal torsion is suspected.  Masses greater than 6 cm that persist should generally be removed in the early second trimester to reduce the risk of complications such as rupture, torsion, or hemorrhage.  Large masses that are symptomatic may sometimes require earlier intervention
  • 27. Conclusion Remember that acute abdomen in pregnant ady might be sillent