1) A 25-year-old pregnant woman presented with severe lower abdominal pain for 1 day. On examination, she had tenderness all over her abdomen. 2) An ultrasound showed a right ovarian cyst. She underwent surgery where they found an enlarged right ovary with old blood. 3) She was diagnosed with a ruptured ovarian cyst and hospitalized. She recovered well and was discharged after 5 days.

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