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Acute Abdominal Pain in Pregnancy: Diagnosis and Management Conservative vs. Surgical Andrea Lausman MD, FRCSC Maternal Fetal Medicine Specialist St. Michael’s Hospital University of Toronto - Assistant Professor March 19, 2013 Objectives 1. History, Physical, Investigations: • How they differ in pregnancy 2. Differential Diagnosis of acute abdominal pain 3. Diagnostic Imaging: US/ CT/ MRI 4. A review of some of the more common causes of acute abdomen in pregnancy 5. In the Operating Room • • Laparoscopy vs. Laparotomy Issues specific to pregnancy Scope of the Problem • Definition of Acute Abdomen: – S&S of intra-peritoneal disease best treated surgically • ~1/500 women need non-obstetrical abdominal surgery during pregnancy • Most common non-obstetrical surgical emergencies: 1. 2. 3. 4. 5. Acute appendicitis Cholecystitis Intestinal Obstruction Pancreatitis Trauma • “Earlier diagnosis means better prognosis” Sir Zachary Cope 1921 • Weigh risks and benefits of diagnostic modalities and therapies for both mother and fetus History • • • • • P – Pain: onset, duration, intensity, character Q - Quality R – Radiates S – Severity T - Time • Gestational age • Associated symptoms – All frequent in normal pregnancy : – – – – Nausea & vomiting Constipation Increased frequency of urination Pelvic / Abdominal discomfort Physical • Peritoneal signs are often absent in pregnancy – lifting and stretching of the anterior abdominal wall – underlying inflammation has no direct contact with the parietal peritoneum – precludes muscular response or guarding that is expected • The uterus can obstruct and inhibit the movement of the omentum to an area of inflammation • < 24 weeks – document FHR • >24 weeks - A reassuring tracing allows the evaluation to continue at an appropriate pace • Monitoring for contractions: – Throughout the evaluation period – After definitive treatment Investigations • Labs: – ↑WBC (T2 <16, T3 <20-30 in early labour) • Ultrasound • CT • MRI Ultrasound • Safe • Relatively high sensitivity and specificity • Test of choice for most ob/gyn causes of abdo pain • Also useful first line test for many non-gyne conditions Risk of Ionizing Radiation • Risk based on gestational age and radiation dose – 1 rad = 1 cGy • First trimester: all or nothing phenomenon • Most sensitive time for CNS teratogenesis is 10-17 wks • In T2 and T3 – risk is childhood haematologic malignancy – Background risk is 0.2-0.3% of childhood cancer and leukemia – Increased risk by 0.06% per rad of exposure • No single study should exceed 5 rads • Accepted cumulative dose of ionizing radiation in pregnancy is 5-10 rads Procedure Chest radiograph (2 views) Fetal Exposure 0.02-0.07 mrad Estimated Fetal Exposure from Some Common Radiologic Procedures Abdominal film (single view) 100 mrad Intravenous pyelography >1 rad* Hip film (single view) 200 mrad Mammography 7-20 mrad Barium enema or small bowel series 2-4 rad CT scan head or chest CT scan abdomen and pelvis 3.5 rad CT pelvimetry 250 mrad MRI • Safe in pregnancy for mother or fetus • Becoming standard of care for investigation of placental implantation abnormalities, and further delineation of fetal anomalies • Issue is contrast media CLINICAL PRACTICE – March 2006 • Canadian Family Physician; Motherisk Update • Safety of gadolinium during pregnancy Garcia-Bournissen F, Shrim A, Koren G There is no evidence that points to Gadolinium being unsafe in pregnancy although no centres in Canada use Gd in pregnancy Differential Diagnosis Acute Abdomen in Pregnancy Pregnancy Related Gyne Adnexal Accident, fibroid Degeneration… Non-Gyne GI GU Vascular Difficult Diagnosis • Expanding uterus dislocates other intraabdominal organs • High prevalence of nausea, vomiting and abdominal pain in pregnancy • General reluctance to operate in pregnancy Treatment • Conservative… • Surgical – Laparoscopy – Laparotomy • Obstetrical issues: – – – – – Preterm labour Intra-op monitoring Tocolysis Paeds Delivery Appendicitis Appendicitis • Most common non-obstetric cause of surgical emergency in pregnancy • Incidence: 1 in 500-2000 • Pregnancy does not affect the overall incidence of appendicitis, but severity may be increased in pregnancy • Appendicitis more common in T2 (40% of cases) • Majority present with classic RLQ pain • 25% of pregnant women will perforate – Don’t delay O.R. >24 hrs, ↑ perforation rate from 0% to 66% – Perforation occurs 2x more often in the T3 than T1,2 History • Most reliable symptom is RLQ pain • Nausea is present in nearly all cases • Vomiting present in two thirds of patients • Anorexia is present in only 1/3 – 2/3 of pregnant patients, while it is present almost universally in Non-pregnant patients Physical • Direct abdominal tenderness most common – T1: Tenderness well localized in RLQ – T2, T3: tenderness may change location: right periumbilical area, RUQ, diffuse • Classic Signs: – – – – Rebound present in 55-75% of patients Abdominal muscle rigidity in 50-65% Psoas sign observed less frequently in pregnancy The Rovsig sign as frequent in pregnancy as non-pregnancy state • Rectal tenderness is usually present, particularly in the first trimester • Fever and tachycardia are variably present; not sensitive signs • Uterine activity due to localized peritonitis is common Investigations • US is imaging of choice – Accuracy is greatest in T1; in T2 and T3 up to 40% normal appendix rate • General Laboratory Investigations: – Elevated WBC – Neutrophils often >80% – Urinalysis: Pyuria is observed in 10-20% Treatment • Surgical: Laparotomy or laparoscopy • If the appendix appears normal remove it because: (1) Early disease may be present despite its grossly normal appearance (2) Diagnostic confusion can be avoided if the condition recurs Laparotomy Incision – Right mid-transverse incision directly over the point of maximal tenderness vs. Lower abdominal midline incision to accommodate unexpected surgical findings and the possibility of the need for cesarean delivery • Tilt the operating table 30° to the patient's left Acute appendicitis and Diffuse Peritonitis (Perforation) • Cefuroxime, ampicillin, metronidazole, oxygen pre-op • Depending on G.A. consider CS as fetal loss rate up to 20-36% • Pre-op intubation and ventilation in cases of hypovolemia • Copious irrigation and use of intra-peritoneal drain Morbidity • Perforation and abscess formation are more likely to occur in pregnant patients • The rate of generalized peritonitis relates directly to the interval of time from symptom onset to diagnosis • Maternal and fetal morbidity and mortality rates increase once perforation occurs • Fetal mortality is dependant on if perforation is present: 20-35% vs. 1.5% is no perf • PTL/PTD is common – 5-14%, up to 50% in T3 • Maternal mortality should be <1% Acute Cholecystitis Acute Cholecystitis • Incidence in pregnancy is 1:600-1:10,000 • Second most common cause of acute abdomen in pregnancy • Cholelithiasis is the cause in 90% of cases • Incidence of cholelithiasis in pregnant women having routine OB scans is 3.5-10% History and physical examination • Previous history; dyspepsia, intolerance of fatty foods • RUQ/ mid-epigastrium pain; may radiate to the back • Nausea & Vomiting ~ 50% of cases • Fever occasionally • Direct tenderness usually present in RUQ, Rebound tenderness is rare • Cholecystitis can mimic appendicitis in the third trimester Investigations • Blood tests are of limited value – ↑ WBC, ↑ ALP – normal in pregnancy – AST/ALT may help distinguish cholecystitis from hepatitis – Amylase elevated transiently ~1/3; high amylase suggests pancreatitis – Lytes: if persistent vomiting Investigations • Ultrasound is diagnostic – Gall bladder calculi: present in> 95% with acute cholecystitis – Wall thickening >3mm – Pericholecystic fluid – Sonographic Murphy’s sign – Dilation of intra and extra-hepatic ducts in common bile duct obstruction • If a radionucleotide scan of the gallbladder is needed, the radiation dose is not prohibitive Treatment • Supportive: Intravenous fluids, Nasogastric suction Non-surgical Management increases risk of: • Recurrence in pregnancy if episode occurs: – T1 92% – T2 64% – T3 44% • Gallstone pancreatitis ~13% (Fetal loss rate 10-60%) • ↑ SA, ↑PTL, ↑PTD • A percutaneous drainage procedure may be indicated in select patients in order to defer definitive surgery Surgical Management • Has been source of much controversy • Recently immediate surgical management is used more widely because: 1. Reduced use of medications 2. Recurrence rate in pregnancy is 44-92%, depending on trimester 3. Shorter hospital stay 4. ↓ risk of developing life-threatening complication: perforation, sepsis, peritonitis • “Laparoscopy or laparotomy – depends on GA and surgeon skill” Choledocholithiasis • 1/1200 patients require intervention • ERCP uses 2-12 rads… ERCP: • Risk of bleeding = 1.3% • Risk of pancreatitis = 3.5% • Options are common bile duct exploration at time of laproscopic cholecystectomy or ERCP followed by cholecystectomy – no studies comparing the two Bowel Obstruction Bowel Obstruction • Third most common cause of acute abdomen in pregnancy: 1:1500 – 1:16,000 • Etiology: 1. Adhesions – 60-70% of cases 2. Volvulus ~25% of cases (much higher than non-pregnant) • Risk of cecal volvulus is highest at times of rapid changes in uterine size (16-20 wks, and 32-36 wks) • Any redundant or abnormally mobile cecum is raised out of the pelvis and allows for rotation around a fixed point • Small bowel volvulus is more common in T3 and PP 3. <5% of time: Intussusception, incarcerated hernia, cancer, diverticulosis etc. History • Crampy abdominal pain ~90% – Constant or periodic, mimicking labor – Pain may radiate to the flank, imitating pyelonephritis – The severity of pain may not reflect the severity of disease • Vomiting • Obstipation Physical findings • Classic distended tender abdomen with high-pitched bowel sounds is the exception in pregnancy • Uterus/cervix/adnexa share the same visceral innervation as the lower ileum, sigmoid colon and rectum - separating GI and Gyn sources of pain is often difficult • Abdominal tenderness may be absent • Bowel sounds are often normal upon presentation • A tender cystic mass can sometimes be palpated • Rebound tenderness, fever, and tachycardia occur late in the course Laboratory Studies • • • • Leukocytosis may be present Electrolyte abnormalities Hemoconcentration Elevated serum amylase levels • X-Ray – Abdominal Plain film - best initial study – Sequential films may be needed – Air-fluid levels, progressive bowel dilation Treatment Conservative • Fluid and electrolyte replacement • NG suction • Enema Surgical • Midline abdominal incision • Decompress the bowel • Relieve obstruction • Resect nonviable tissue Prognosis • Maternal Mortality ~6% • Fetal mortality ~26% • Bowel strangulation requiring resection ~23% Pancreatitis Pancreatitis • 1:1000 – 1:3000 pregnancies • Usually late in T3, or PP – may be due to increased intra-abdominal pressure on the biliary ducts • Etiology – – – – – – – Cholelithiasis – 67-100% of cases Abdominal surgery Blunt abdominal trauma Infection Penetrating duodenal ulcer Hyperparathyroidism Hyperlipidemic pancreatitis • Associated with pregnancy – Preeclampsia – damage to microvasculature – AFLP History • Sudden, severe epigastric pain radiating to the back • Postprandial nausea and vomiting • Fever Physical • Patient in the ‘fetal position’ – due to severe pain • Hypoactive bowel sounds (paralytic ileus) • Jaundice • Epigastric tenderness is the most reliable physical finding • Peritoneal signs are minimal or absent • Pulmonary findings in ~10% - can lead to ARDS Laboratory Studies • Amylase – During normal pregnancy, amylase levels are slightly elevated • Lipase – better predictor than amylase • Hyperglycemia • Hyperbilirubinemia • Hypocalcemia • Hemoconcentration • Electrolyte abnormalities • Ultrasound of the upper abdomen Ranson’s Criteria On Admission: At 48 hours After Admission: • • • • • • • • • • • Age > 55 WBC > 16 Glucose > 10 LDH > 350 AST > 250 Hct drop > 10% BUN increase > 1.79 Ca < 2 Arterial pO2 < 60 Base deficit (24 - HCO3) > 4 Fluid needs > 6L Prediction of Mortality • <5 – 15% • 5-9 40% • >9 100% Treatment • Bowel rest – npo, NG suction, IV fluids • Fluid/electrolyte resuscitation • Analgesics: – demerol doesn’t cause spasm of sphincter of Oddi • Anti-spasmodics • Antibiotics if fever or sepsis is present • ERCP, endoscpic sphincterotomy can be used to treat gallstone pancreatitis • Surgery for refractory cases Prognosis • Acute symptoms last for ~6 days • Maternal mortality rate ranges from 0-37% • Perinatal mortality rate is ~ 10% • The risk of perinatal death increases with the severity of disease Trauma in Pregnancy Trauma in Pregnancy • Occurs in 6-7% of pregnancies • Penetrating – Gunshot wounds – Stab wounds • Blunt trauma – MVA – Physical abuse, Sexual Abuse – Accidental Falls Maternal Injury • Gravid uterus changes the location of abdominal organs • 25% of pregnant women with blunt trauma will have hemodynamically significant hepatic or splenic injuries due to increased vascularity • In penetrating trauma maternal death rate is lower than non-pregnant (~3.9% vs 12%) because the uterus ‘protects’ intra-abdominal organs • Uterine rupture: most often at the fundus Fetal Injury • Direct fetal injury occurs in <1% of blunt trauma • Direct fetal injury occurs in up to 90% of blunt trauma • Fetal skull and brain injury more common in T3 when the head is engaged in the pelvis • Deceleration injury to the fetal had can also occur • Most common cause of fetal death is maternal death • Fetal mortality 3-38%: abruption, shock, maternal death Placental Abruption • CTX > thAn 1 in 10 minutes is associated with 20% risk of diagnosed placental abruption • Initiate CTG monitoring asap at >24 weeks; at least 4-6 hrs • Risk of abruption exists for several days post-trauma • Up to 40% of severe MVA’s are associated with abruption • Minor trauma can result in abruption in 2-3% • 10-30% of trauma victims have evidence of feto-maternal hemorrhage Management • ABC’s • Rapid maternal respiratory support • Evaluate the fetus once mother is stable: CTG • Left lateral decubitus • US • Fetal monitoring for at least 4 hrs,then prn • Surgical exploration prn +/- CS ATLS in Pregnancy Surgical Management • Exploratory Laparotomy • Delivery of fetus if direct uterine injury or fetal injury Prevention Techniques • Seat Belts • Airbags Gynecologic Causes of Acute Abdomen: Adnexal Masses • Incidence in Pregnancy = 2% • Most are functional cysts • Expectant Mgmt for those <6cm – 82-94% resolution • Torsion: – ~4% of adnexal masses will tort Adnexal Torsion • Pregnancy predisposes to adnexal torsion • 1 in 5 adnexal torsions occurring during pregnancy • Associated with an ovarian mass in 50-60% most often a dermoid • Occurs on R > L, by a ratio of 3:2 • Occurs most frequently in the first trimester Treatment • Surgical • Conserve as much ovarian tissue as possible • If the tissue is necrotic - unilateral salpingo-oophorectomy • Partial torsion: – Conservative management - Untwist the pedicle, remove the cyst, and stabilize the ovary • If removal of the corpus luteum is necessary prior to 10 weeks of gestation needs progesterone supplementation In the Operating Room Pre-Op Decision Making • Laparoscopy has the same indications as the non-pregnant patient • Approach is based on skill of surgeon and availability of staff/ equipment • Benefits of Laparoscopy: – – – – ↓ post-op pain ↓ post-op ileus ↓ LOS Faster return to work Concerns r.e. Laparoscopy • • • • • Trocar insertion CO2 insufflation Technical ability to get exposure Altered physiology of pneumoperitoneum Decreased venous return • Can be used in all trimesters • • With increasing experience with this technique, there are fewer barriers Reports of successful appendectomy and cholecystectomy in the third trimester Benefits in the Pregnant Patient • ↓ fetal depression due to less narcotic use • ↓ risk of wound complications • ↓ post-op maternal hypoventilation • ↓ risk of VTE due to early mobilization • ↓ uterine irritability leads to less SA and PTL Technical Issues • Patient positioning – Left lateral decubitus • Initial Port Placement – Hassan/ Verres, Optical trocar – adjust location to fundal height, previous incisions and experience of surgeon • Place trocars under direct visualization according to fundal height • Insufflation to 10-15mmHg – No evidence of long-term detrimental effects of CO2 pneumoperitoneum • Intra-op CO2 monitoring should be used – Theoretical risk of fetal acidosis due to pneumoperitoneum; has been seen in animal studies, but not documented in the human fetus • VTE Prophylaxis (pneumoperitoneum increases venous stasis) – Intra-op/ Post-op pneumatic compression stockings – Early post-op ambulation Peri-Operative Care • Obstetrical Consultation • Fetal Heart Rate Monitoring – pre and post-op documentation of FHR / NST • Tocolytics – No literature supports prophylactic use of tocolytics – Consider if S&S of PTL – Need OB consult for meds/ dosing etc Conclusions • Laparoscopy is safe in all trimesters of pregnancy • The Veress needle can be used – depends on surgeon experience with ‘alternate site’ entries • Pressure of 12-15mmHg – less than uterine ctx. • Laparoscopy decreases maternal morbidity, LOS, fetal depression (due to less narcotic use) Summary • The incidence of acute abdominal pain in pregnancy which requires surgery is ~1/500 • It is important to keep a broad differential diagnosis as signs, symptoms and investigations can all altered due to pregnancy • Diagnostic Imaging is safe in pregnancy • Surgical options include laparotomy and laparoscopy