Acute Abdominal Pain in Pregnancy: Diagnosis and Management Conservative vs.

Surgical
Andrea Lausman MD, FRCSC Maternal Fetal Medicine Specialist St. Michaels 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)

Estimated Fetal Exposure from Some Common Radiologic Procedures

Fetal Exposure 0.02-0.07 mrad 100 mrad

Abdominal film (single view)

Intravenous pyelography
Hip film (single view) Mammography Barium enema or small bowel series CT scan head or chest CT scan abdomen and pelvis CT pelvimetry

>1 rad*
200 mrad 7-20 mrad 2-4 rad 3.5 rad 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

Non-Gyne

Adnexal Accident, fibroid Degeneration

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
Dont 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 Murphys 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

Ransons Criteria
On Admission: Age > 55 WBC > 16 Glucose > 10 LDH > 350 AST > 250 At 48 hours After Admission: 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 doesnt 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 MVAs 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
ABCs 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