Essentialities of knowledge of whys and whats of acute abdomen during pregnancy

Shakuntala Chhabra; Pradeep Borkar

doi:10.4103/0971-9903.117791

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Year : 2013 | Volume : 18 | Issue : 2 | Page : 97-102

Essentialities of knowledge of whys and whats of acute abdomen during pregnancy

Shakuntala Chhabra, Pradeep Borkar
Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Aakanksha Shishu Kalyan Kendra, Sevagram, Wardha, Maharashtra, India

Date of Web Publication

6-Sep-2013

Correspondence Address:
Shakuntala Chhabra
Department of Obstetrics and Gynaecology, Aakanksha Shishu Kalyan Kendra, OSD, Melghat Project, Mahatma Gandhi Institute of Medical Sciences, Sevagram - 442 102, Wardha, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0971-9903.117791

Abstract

Acute abdomen accounts for 5-10% of emergency department visits. It designates symptoms, signs of intraperitoneal disease with sudden onset, can persist for hours to days, and is associated with wide variety of clinical features which may not be, specific to underlying disease. Pregnant state complicates the issue because of anatomic, physiologic changes during pregnancy. Its causes are many, obstetric, gynecological, many others which encompass a wide spectrum of surgical and medical conditions from aortic dissection to psychogenic pain, almost anything in between, a trivial to life-threatening condition, which requires immediate therapy.
Diagnosis is challenging, requires careful history, thorough evaluation of symptoms, examination, and judicious use of investigations to specify disease and management which many times could be surgery only. Individualized approach is the best with basics known.

Keywords: Acute abdomen, pregnancy, adnexal torsion, ovarian tumor

How to cite this article:
Chhabra S, Borkar P. Essentialities of knowledge of whys and whats of acute abdomen during pregnancy. J Mahatma Gandhi Inst Med Sci 2013;18:97-102

How to cite this URL:
Chhabra S, Borkar P. Essentialities of knowledge of whys and whats of acute abdomen during pregnancy. J Mahatma Gandhi Inst Med Sci [serial online] 2013 [cited 2023 Mar 29];18:97-102. Available from: https://www.jmgims.co.in/text.asp?2013/18/2/97/117791

Introduction

Acute abdomen means abdominal conditions that cause pain and tenderness over abdomen for which emergency surgery may be needed. It designates symptoms and signs of intraperitoneal disease with sudden onset, can persist for hours to days, and is associated with wide variety of clinical features which may not be, specific to the underlying disease. Pregnant state complicates the issue because of anatomic and physiologic changes during pregnancy. Its causes are many, obstetric, gynecological, and many others which encompass a wide spectrum of surgical and medical conditions from aortic dissection to psychogenic pain, almost anything in between, a trivial to life-threatening condition, which requires immediate therapy.

Acute abdomen accounts for 5-10% of all emergency department visits and is leading cause of hospital admissions even in the US. ^[1] The clinical picture of two patients with the same underlying pathology may look totally different or similar with the disease entities very distinct. Diagnosis of acute abdomen is challenging, requires careful history, thorough evaluation of symptoms, examination, and judicious use of investigations to specify the disease and management ^[2] which many times could be surgery only. ^[3] The anatomical and physiological alterations because of pregnancy change the clinical picture. Physical findings are less prominent compared to those in the nonpregnant state with the same disorder. Accurate knowledge is essential for appropriate and timely decision. Conditions like septic abortion, ectopic pregnancy, invasive mole, torsion of gravid uterus, placental abruption, rupture uterus are all specific to pregnancy, similarly gynecological conditions like torsion, rupture of ovarian tumor, or hydrosalphinx, leiomyoma with red degeneration are also known. Quite a few medical, surgical conditions are commonly diagnosed; however, diagnostic dilemmas continue and it is essential to be aware. Some examples are as follows.

Adnexal Torsion

Adnexal torsion during pregnancy is known, if not dealt with quickly ends up in the loss of the ovary. ^[4] The case births ratio is approximately 1:1600. Actually, pregnancy predisposes to adnexal torsion and one in five adnexal torsions occur during pregnancy, ^[5] no wonder adnexal torsion occurs predominantly in teenagers and young women. The condition is associated with an ovarian mass in 50-60% of patients, and the mass is most often dermoid. Adnexal torsion occurs more frequently on the right than on the left side, by a ratio of 3:2, more frequently in the first, occasionally in the second, and rarely in the third trimester. ^[5] Pregnancy outcome associated with adnexal torsion generally is good; however, nearly 3% masses are malignant. ^[6]

Ovarian tumor

Ovarian tumor occurs in pregnancy with a frequency ranging from 1 in 80 to 1 in 1000. ^[7] Rupture of ovarian cyst is rare. Patients typically present with a lateralized lower quadrant pain, often sudden in onset. Nausea, vomiting, fever, and leukocytosis may be present, but none of these are reliable during pregnancy. Ultrasonography is particularly helpful in diagnosis. Furthermore, Doppler studies may assist in documenting the presence or absence of ovarian blood flow. If adnexal torsion is suspected, surgery should not be delayed, as the viability of the ovary may be compromised. Color Doppler can help document absent ovarian flow, which may make it difficult to localize the pain and may also mask or delay peritoneal signs. ^[8] The laxity of the anterior abdominal wall may also delay peritoneal signs. Alterations in the gastrointestinal function are thought to be mediated by elevated levels of sex steroids. Progesterone decreases lower esophageal sphincter pressure and small bowel motility. ^[9]

Red degeneration

Red degeneration occurs in 5-10% of leiomyomas in the pregnant women, often between 12 and 20 weeks gestation.

In addition to gynecological disorders, 2% pregnancies may be complicated by surgical disorders, ^[10] and many a times there are diagnostic problems.

Appendicitis

Appendicitis is the most common surgical cause of the acute abdomen in pregnancy, 1 in 2000 to 1 in 6000 pregnancies, ^[11] most common indication of nonobstetric surgery during pregnancy, 1 in 1500 deliveries representing more than 25% of the indications of surgery, mostly in the second trimester. The incidence is same for pregnant and nonpregnant women, but diagnosis is delayed due to alterations in pregnancy which could lead to perforation of the appendix and increase in morbidity. The diagnostic challenge is due to the blunting of signs and symptoms along with the changing appendiceal location as pregnancy advances. Located at the McBurney point in early pregnancy, the appendix is progressively displaced upward toward the gall bladder in late pregnancy. Peritoneal signs are often absent in pregnancy as the underlying inflammation has no direct contact with the parietal peritoneum, to produce any muscular response or guarding that would otherwise be expected because of the lifting of the abdominal wall. To help distinguish extrauterine tenderness from uterine tenderness, the exact right or left decubitus position may prove helpful. Diagnosis is difficult as many conditions mimic acute appendicitis.

Pregnancy itself can produce white blood cell counts ranging from 20,000-30,000/mm ³ in second, third trimesters and, early labor. Polymorphonuclear leucocytes are often greater than 80% when appendicitis is present. ^[12] Leukocytosis, C-reactive protein help in the diagnosis of appendicitis in first trimester and rule out other pelvic conditions but are not useful as pregnancy progresses. ^[13] A single diagnostic radiograph does not result in any harmful effect, even multiple procedures with exposure of less than 0.05 Gy have not been shown to cause fetal anomalies or pregnancy loss. ^[14] One retrospective review found tomography to be 100% sensitive in diagnosis of appendicitis; however, clinical judgment rather than laboratory findings remain the gold standard and the pregnant women presenting with abdominal pain should be assessed and treated as any nonpregnant woman with the same complaints. Unnecessary delay should be avoided as it directly affects maternal fetal morbidity mortality.

A strong correlation is observed between intraabdominal infection and preterm pains and delivery. Although there is delay in diagnosing, but misdiagnosis of appendicitis is comparable to that in the general female population, and appendicectomy should not be delayed to avoid complications. Balance of the delayed surgery and the effects of surgery on the mother and fetus are essential. Fetal mortality is minimal with surgery before perforation. It is essential to tailor the surgical approach to the clinical situation and remember to tilt the operating table to bring the uterus away from the surgical site and to improve maternal venous return.

The second most common surgical condition associated with pregnancy is cholecystitis, approximately 1 in 1600 to 1 in 10,000 pregnancies. Case-to-delivery ratio varies between 1:1130 and 1:12,890. Asymptomatic gall bladder disease is more common, 3-4% in hemolytic diseases, such as sickle cell disease, which increases the risk for gallstone formation and cholelithiasis is the cause of cholecystitis in pregnancy in over 90-95% of cases. Detection of cholelithiasis in pregnant women undergoing routine obstetric ultrasound examination is around 3-4%. Whether pregnancy predisposes to cholecystitis is not clear; however, much less cholecystectomies are performed on pregnant women than on nonpregnant women, may be due to reluctance to operate.

Signs and symptoms are different during pregnancy; Murphy's sign (tenderness under the right costal margin on deep inspiration) is less common. Fever, tachycardia, and tachypnea may be present. Jaundice is rare, but if present may be associated with common bile duct stones. Ultrasound helps in diagnosis with speed and accuracy, can usually yield good view of the gall bladder without fasting. Serum alkaline phosphatase levels are normally elevated in pregnancy. Aspartate transferase and alanine transferase levels may help distinguish cholecystitis.

The traditional management of cholecystitis in pregnancy is medical, especially in the third trimester. It consists of supportive intravenous hydration, enteric rest with nasogastric suction, antibiotics, and judicious use of narcotics. Surgery is typically reserved for those in whom medical treatment fails or with repeated attacks of biliary colic or with suspicion of perforation, sepsis, or peritonitis. Acute symptoms last for approximately 6 days. The maternal mortality ranges from 0-37%, while the perinatal mortality is around 10-12%, the risk of perinatal death increases with the severity of the disease. ^[15]

Pancreatitis

Pancreatitis during pregnancy is not common and occurs in approximately 1 in 1000 to 1 in 10,000 births, usually late in the third trimester or in the early postpartum period, caused by increased intraabdominal pressure on biliary duct.

Cholelithiasis

Cholelithiasis is the most common cause of pancreatitis in pregnancy, ^[16] others are alcohol ingestion, abdominal surgery, blunt abdominal trauma, infection, medications like diuretics, antihypertensives, and antibiotics, perforative duodenal ulcer, connective tissue diseases, hyperlipidemia, and hyperparathyroidism. ^[17]

Acute pancreatitis

Acute pancreatitis presents essentially in the same way during pregnancy as in the nonpregnant state. Symptoms include sudden and severe epigastric pain radiating to the back, postprandial nausea, vomiting, and fever. Acute symptoms last for approximately 6 days. The patient often appears acutely ill and is found lying in the "fetal position" with flexed knees, hips, and trunk. Bowel sounds are usually hypoactive, secondary to ileus, diffusely tender abdomen. Several other disease states can mimic pancreatitis like duodenal ulcer perforation, cholecystitis, hepatitis, bowel obstruction, diabetic ketoacidosis, and preeclampsia.

Serum amylase and lipase levels should be measured serially to confirm the clinical diagnosis. It is important to realize that these levels tend to increase spontaneously as gestation progresses, transiently in up to a third of women, a marked increase suggests pancreatitis. However, there are several conditions that may result in elevation of serum amylase and lipase, cholecystitis, bowel obstruction, hepatic trauma, and perforative duodenal ulcer; therefore, amylase to creatinine clearance ratio may be useful in pregnancy. This ratio is generally low in pregnant women, is elevated in pregnant women with pancreatitis. Hypocalcaemia may also result from fat saponification.

Ultrasound is useful for ruling out cholelithiasis, pancreatic pseudo cyst, and abscess. Computerized tomography (CT) is rarely needed but can be used. The classic triad of medical management consists of bowel rest, fluid/electrolyte balance, and pain relief. Bowel rest may be achieved by the use of nasogastric suction which may not be necessary. Electrolyte abnormalities correction especially hyperglycemia and severe hypoglycemia, intravascular fluid loss is usually underestimated. Meperidine is the drug of choice for pain control, because it is less likely to produce spasm of the Sphincter of Oddi ^{More Details} (morphine, may cause a spasm). When managing a severely ill patient, care must be taken to monitor in intensive care setting with watch for poor prognostic signs, including respiratory insufficiency, hypotension, hypocalcemia, and the need for massive fluid replacement. If fever persists and sepsis is suspected, broad-spectrum antibiotics should be started. Surgery may be necessary and is in fact life-saving in cases refractory to medical management to remove toxic pancreatic tissue or drain a pancreatic abscess. The maternal mortality ranges from

0 to 35%. The risk of perinatal death increases with the severity of disease. Mortality and morbidity can be reduced if the diagnosis is made early with prompt treatment.

Bowel obstruction

Bowel obstruction in pregnancy occurs in 1 in 2500 to 1 in 3500 deliveries. ^[18] The cause is adhesions in 60-70% of cases, usually occurring in first pregnancies in second and third trimesters and puerperium, rarely during the first trimester. Volvulus is the second most common cause of bowel obstruction in pregnancy, occurring in approximately 25% cases. Other causes (intussusception, hernia, and cancer) are rare. While hyperemesis gravidarum in the second and third trimesters is rare, this is a common misdiagnosis. An upright plain film of the abdomen is the best initial study for diagnosis. ^[19] Significant morbidity and mortality can occur as a result of bowel obstruction due to delay in the diagnosis and management. Maternal mortality ranges from 0 to 6%, fetal mortality from 25 to 40% [Table 1]. ^[20]

Table 1: Disorders causing acute abdomen

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Diagnostic Modalities and Dilemmas

In a study by Ratnapalan, ^[21] obstetrician's perception of potential fetal harm by CT scan and conventional radiograph was unrealistically high. Usually, it is unnecessary delay in diagnosis that leads to untoward outcomes. Magnetic resonance imaging (MRI) uses magnets rather than ionizing radiation to alter the energy state of hydrogen present in the evolution of the maternal abdomen and of the fetus. Although no adverse effects are documented, advice is against the use of MRI in the first trimester. While ionizing radiation exposure can lead to cell death, carcinogenesis, and genetic effects or mutation in germ cells, no single diagnostic radiograph procedure results in radiation exposure to a degree that would threaten the well-being of the developing preembryo, embryo, or fetus, according to the American College of Radiology. Information gained from atomic bomb survivors shows that the greatest risk to fetus is at 8 to 15 weeks gestation, with radiation-induced mental retardation, the highest potential danger. Risk increases linearly as exposure rises above 20 rad. ^[22]

Laparoscopy During Pregnancy

Operative laparoscopy has become increasingly common in pregnant women in many situations, especially in the diagnosis and management of heterotopic pregnancy. ^[23] Heterotopic pregnancy rates are increasing with in vitro fertilization, so the need of laparoscopy in today's era. If laparoscopic surgery is to be performed during pregnancy, the Hasson technique, an open approach to entering the abdomen, has been suggested, Trocar or Veress needle injury to the uterus is prevented. The use of a uterine manipulator is absolutely contraindicated in pregnancy. Preterm labor and delivery is the most significant complication. Complications are related to the cardiopulmonary pneumoperitoneum, carbondioxide absorption, extraperitoneal gas insufflation, inadvertent injuries to intraabdominal organs. Pneumoperitoneum enhances lower extremity venous stasis already present and pregnancy induces a hypercoagulable state. Therefore, persufflator devices should be utilized whenever possible. The prophylactic effect of tocolytics remains unproven in these patients.

The most common laparoscopic surgery during pregnancy is cholecystectomy, more during the first and second trimesters. Although most series report favorable short-term outcomes for mother and the fetus, like low-preterm delivery rates and normal Apgar scores, there are still unresolved issues, the potential for decreased uterine blood flow due to increased intraabdominal pressure from insufflation and possible fetal carbon dioxide absorption and so on.

Anesthesia during pregnancy

If possible elective, nonobstetric surgery should be avoided during pregnancy. Surgery is safe between end of the first to the second trimester as it avoids the period of organogenesis and highest pregnancy loss. When possible, regional analgesia is favored over general anesthesia as the maternal mortality is 16 times higher with general anesthesia. The effects of anesthesia on the fetus remain unclear without good evidence to suggest a clear relationship between outcome and type of anesthesia. There is little evidence that any drug used during general anesthesia is a proven teratogen in humans. There is an increased chance of pulmonary aspiration and all pregnant women should be treated as though they have a full stomach. Premedication with citrate and histamine-2 receptor blockers is warranted. The rate of preterm labor after nonobstetric surgery during pregnancy tends to increase with increasing gestational age and depends on the type and duration of the procedure. Use of thromboembolism deterrent and sequential compression devices should be considered in all pregnant women undergoing nonobstetric surgery during pregnancy.

Concluding Comments

Diagnosis and treatment of acute abdomen in pregnancy depends on the specific situations. Indications for surgery are same for pregnant and nonpregnant woman. If surgery is elective, waiting until after the pregnancy is completed is prudent. If surgery is deemed necessary, it is performed in early second trimester; the risk of preterm labor and delivery is less compared to the third, and the risk of spontaneous loss and risks due to medications are lower compared to the first. All said "Don't penalize her for being pregnant woman!" never is this phrase truer than when evaluating a pregnant woman who may require surgical intervention with a diagnostic dilemma and individualized approach is the best with basics known.

References

1.	Majumdar S, Prasad M, Fraser D, Roberts P. Endometriosis of the appendix presenting as acute abdomen following emergency caesarean section. J Obstet Gynaecol 2006;26:692-3.
2.	Sutton CD, White SA, Marshall LJ, Dennison AR, Thomas WM. Idiopathic chronic ulcerative enteritis - the role of radical surgical resection. Dig Surg 2002;19:406-8.
3.	Lowe Scott DT. Nitric oxide dysfunction in the pathophysiology of preeclampsia. Nitric Oxide 2000;4:441-58.
4.	Toure B, Dao B, Sano D, Akotionga M, Lankoande J, Kone B. Adnexal torsion during pregnancy. Diagnostic and therapeutic problems in Burkina Faso. Rev Med Brux 1997;18:379-80.
5.	Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985;152:456-61.
6.	Mashiach S, Bider D, Moran O, Goldenberg M, Ben-Rafael Z. Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Fertil Steril 1990;53:76-80.
7.	Hopkins M, Malviya VK, Nunez C. Meigs's syndrome and ovarian thecoma in pregnancy. A case report. J Reprod Med 1986;31:198-202.
8.	Albayram F, Hamper UM. Ovarian and adnexal torsion: Spectrum of sonographic findings with pathologic correlation. J Ultrasound Med 2001;20:1083-9.
9.	Parangi S, Levine D, Henry A, Isakovich N, Pories S. Surgical gastrointestinal disorders during pregnancy. Am J Surg 2007;193:223-32.
10.	Radman HM. Pregnancy complicated by nonobstetric surgical disease. Arch Surg 1964;88:279-86.
11.	Gabbay M. Preface. Occas Pap R Coll Gen Pract 2002:6.
12.	Yang HR, Wang YC, Chung PK, Chen WK, Jeng LB, Chen RJ. Role of leukocyte count, neutrophil percentage, and C-reactive protein in the diagnosis of acute appendicitis in the elderly. Am Surg 2005;71:344-7.
13.	Gronroos JM. Is there a role for leukocyte and CRP measurements in the diagnosis of acute appendicitis in the elderly? Maturitas 1999;31:255-8.
14.	Brent RL. The effect of embryonic and fetal exposure to x-ray, microwaves, and ultrasound: Counseling the pregnant and nonpregnant patient about these risks. Semin Oncol 1989;16:347-68.
15.	Schirmer BD, Winters KL, Edlich RF. Cholelithiasis and cholecystitis. J Long Term Eff Med Implants 2005;15:329-38.
16.	Ros E, Navarro S, Bru C, Garcia-Pugés A, Valderrama R. Occult microlithiasis in 'idiopathic' acute pancreatitis: Prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Gastroenterology 1991;101:1701-9.
17.	Crisan LS, Steidl ET, Rivera-Alsina ME. Acute hyperlipidemic pancreatitis in pregnancy. Am J Obstet Gynecol 2008;198:e57-9.
18.	Hill LM, Symmonds RE. Small bowel obstruction in pregnancy. A review and report of four cases. Obstet Gynecol 1977;49:170-3.
19.	Davis MR, Bohon CJ. Intestinal obstruction in pregnancy. Clin Obstet Gynecol 1983;26:832-42.
20.	Connolly MM, Unti JA, Nora PF. Bowel obstruction in pregnancy. Surg Clin North Am 1995;75:101-13.
21.	Ratnapalan S, Bona N, Chandra K, Koren G. Physicians' perceptions of teratogenic risk associated with radiography and CT during early pregnancy. AJR Am J Roentgenol 2004;182:1107-9.
22.	Shaw P, Duncan A, Vouyouka A, Ozsvath K. Radiation exposure and pregnancy. J Vasc Surg 2011;53(1 Suppl):28-34S.
23.	Remorgida V, Carrer C, Ferraiolo A, Natucci M, Anserini P. Laparoscopic surgery in pregnancy. A case report with a brief review of the topic. Surg Endosc 1995;9:195-6.