Management of acute abdomen in pregnancy: current perspectives

Sanoop Koshy Zachariah, Miriam Fenn, Kirthana Jacob, Sherin Alias Arthungal, Sudeeptha Anna Zachariah, Sanoop Koshy Zachariah, Miriam Fenn, Kirthana Jacob, Sherin Alias Arthungal, Sudeeptha Anna Zachariah

Abstract

Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.

Keywords: abdominal pain; acute abdomen; appendicitis; cholecystitis; ectopic pregnancy; pregnancy; rupture uterus.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Anatomical relations according to different abdominal quadrants. Note: As pregnancy progresses, the bowel gets displaced laterally and upward (eg, athe appendix can move into the right upper quadrant).
Figure 2
Figure 2
An intraoperative image of uterine rupture at 23 weeks of gestation in a primigravida, showing the fetus lying outside the uterus (A). The rupture at the fundus is clearly seen (B). Repair of the uterus in two layers with absorbable sutures (C).
Figure 3
Figure 3
An intraoperative image of adnexal torsion (torsion of fimbrial cyst) at 34 weeks of gestation.
Figure 4
Figure 4
Management algorithm for pregnant women presenting with acute abdominal pain. Notes: The first step would be to perform a detailed clinical evaluation (history and physical examination) and sample blood for routine and specific investigations. The initial assessment would be hemodynamic stability. Hemodynamically unstable patients with evidence of clinical deterioration, impending shock, and a high index of suspicion for or with definite evidence of peritonitis might require emergency surgical intervention. Urgent multidisciplinary consults should be sought. Those who are hemodynamically stable can be assessed according to the possible etiology based on the localization of pain to the different abdominal quadrants. These patients can be further categorized into urgent and nonurgent groups, with obstetric or non-obstetric etiologies based on clinical, laboratory, and radiological evaluation. Urgent cases may require emergency surgery. For nonurgent cases, an initial trial of conservative therapy (nonoperative management) with close monitoring of clinical status could be attempted. In case of improvement, elective surgery can be planned in the postpartum period. In some situations, emergency surgery may be warranted for relapse of the disease process. Abbreviations: LFT, liver function tests; RFT, renal function tests; RUQ, right upper quadrant; RLQ, right lower quadrant; LUQ, left upper quadrant; LLQ, left lower quadrant; CT, computed tomography; ECG, electrocardiography; GERD, gastroesophageal reflux disease; HELLP, hemolysis, elevated liver enzymes, and low platelet count; USG, ultrasonography.

References

    1. Stedman’s Medical Dictionary [Accessed July 7, 2018];Stedman’s Medical Dictionary, 27th Edition Deluxe. [online] Alibris. 2018 2 Available from: .
    1. Martin RF, Rossi RL. The acute abdomen. Surg Clin North Am. 1997;77(6):1227–1243.
    1. Malangoni MA. Gastrointestinal surgery and pregnancy. Gastroenterol Clin North Am. 2003;32(1):181–200.
    1. Augustin G, Majerovic M. Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2007;131(1):4–12.
    1. Pritchard JA, Baldwin RM, Dickey JC. Blood volume changes in pregnancy and the puerperium, II: red blood cell loss and changes in apparent blood volume during and following vaginal delivery, cesarean section, and cesarean section plus total hysterectomy. Am J Obstet Gynecol. 1962;84:1271.
    1. Campbell-Brown M, Hytten F. Nutrition. In: Chamberlain G, Broughton Pipkin F, editors. Clinical physiology in obstetrics. Oxford: Blackwell Science; 1998. pp. 165–191.
    1. Tan EK, Tan EL. Alterations in physiology and anatomy during pregnancy. Best Pract Res Clin Obstet Gynaecol. 2013;27(6):791–802.
    1. Soma-Pillay P, Nelson-Piercy C, Tolppanen H, Mebazaa A. Physiological changes in pregnancy. Cardiovasc J Afr. 2016;27(2):89–94.
    1. Conklin KA. Maternal physiology adaptations during gestation, labour, and the puerperium. Semin Anesth. 1991;X(4):221–234.
    1. Broussard CN, Richter JE. Nausea and vomiting of pregnancy. Gastroenterol Clin North Am. 1998;27(1):123–151.
    1. Lawson M, Kern F, Everson GT. Gastrointestinal transit time in human pregnancy: prolongation in the second and third trimesters followed by postpartum normalization. Gastroenterology. 1985;89(5):996–999.
    1. Hancock H. Disease of the appendix cæci cured by operation. Boston Med Surg J. 1848;39(17):331–334.
    1. Choi JJ, Mustafa R, Lynn ET, Divino CM. Appendectomy during pregnancy: follow-up of progeny. J Am Coll Surg. 2011;213(5):627–632.
    1. Andersson RE, Lambe M. Incidence of appendicitis during pregnancy. Int J Epidemiol. 2001;30(6):1281–1285.
    1. Angelini DJ. Obstetric triage revisited: update on non-obstetric surgical conditions in pregnancy. J Midwifery Womens Health. 2003;48(2):111–118.
    1. Mourad J, Elliott JP, Erickson L, Lisboa L. Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. Am J Obstet Gynecol. 2000;182(5):1027–1029.
    1. Baer JL, Reis RA, Arens RA. Appendicitis in pregnancy: with changes in position and axis of the normal appendix in pregnancy. J Am Med Assoc. 1932;98(16):1359–1364.
    1. Hodjati H, Kazerooni T. Location of the appendix in the gravid patient: a re-evaluation of the established concept. Int J Gynaecol Obstet. 2003;81(3):245–247.
    1. Alders N. A sign for differentiating uterine from extrauterine complications of pregnancy and puerperium. Br Med J. 1951;2(4741):1194–1195.
    1. Wallace CA, Petrov MS, Soybel DI, Ferzoco SJ, Ashley SW, Tavakkolizadeh A. Influence of imaging on the negative appendectomy rate in pregnancy. J Gastrointest Surg. 2008;12(1):46–50.
    1. Williams R, Shaw J. Ultrasound scanning in the diagnosis of acute appendicitis in pregnancy. Emerg Med J. 2007;24(5):359–360.
    1. Rosen MP, Ding A, Blake MA, et al. ACR Appropriateness Criteria® right lower quadrant pain – suspected appendicitis. J Am Coll Radiol. 2011;8(11):749–755.
    1. Doberneck RC. Appendectomy during pregnancy. Am Surg. 1985;51(5):265–268.
    1. Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet. 2011;377(9777):1573–1579.
    1. Wilms IMHA, de Hoog DENM, de Visser DC, Janzing HMJ, Cochrane Colorectal Cancer Group Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev. 2011;82(2):CD008359.
    1. Ansaloni L, Catena F, Coccolini F, et al. Surgery versus conservative antibiotic treatment in acute appendicitis: a systematic review and meta-analysis of randomized controlled trials. Dig Surg. 2011;28(3):210–221.
    1. Young BC, Hamar BD, Levine D, Roqué H. Medical management of ruptured appendicitis in pregnancy. Obstet Gynecol. 2009;114(2 Pt 2):453–456.
    1. Walsh CA, Tang T, Walsh SR. Laparoscopic versus open appendicectomy in pregnancy: a systematic review. Int J Surg. 2008;6(4):339–344.
    1. Mcgory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM. Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg. 2007;205(4):534–540.
    1. Weston P, Moroz P. Appendicitis in pregnancy: how to manage and whether to deliver. Obstet Gynaecol. 2015;17(2):105–110.
    1. Mohammed JA, Oxorn H. Appendicitis in pregnancy. Can Med Assoc J. 1975;112(10):1187–1188.
    1. Ramin KD, Ramsey PS. Disease of the gallbladder and pancreas in pregnancy. Obstet Gynecol Clin North Am. 2001;28(3):571–580.
    1. Affleck DG, Handrahan DL, Egger MJ, Price RR. The laparoscopic management of appendicitis and cholelithiasis during pregnancy. Am J Surg. 1999;178(6):523–528.
    1. Landers D, Carmona R, Crombleholme W, Lim R. Acute cholecystitis in pregnancy. Obstet Gynecol. 1987;69(1):131.
    1. Dietrich CS, Hill CC, Hueman M. Surgical diseases presenting in pregnancy. Surg Clin North Am. 2008;88(2):403–419.
    1. Borzellino G, Massimiliano Motton AP, Minniti F, Montemezzi S, Tomezzoli A, Genna M. Sonographic diagnosis of acute cholecystitis in patients with symptomatic gallstones. J Clin Ultrasound. 2016;44(3):152–158.
    1. Swisher SG, Schmit PJ, Hunt KK, et al. Biliary disease during pregnancy. Am J Surg. 1994;168(6):576–581.
    1. Jelin EB, Smink DS, Vernon AH, Brooks DC. Management of biliary tract disease during pregnancy: a decision analysis. Surg Endosc. 2008;22(1):54–60.
    1. Tham TC, Vandervoort J, Wong RC, et al. Safety of ERCP during pregnancy. Am J Gastroenterol. 2003;98(2):308–311.
    1. Pitchumoni CS, Yegneswaran B. Acute pancreatitis in pregnancy. World J Gastroenterol. 2009;15:5641–5646.
    1. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. Philadelphia: Lippincott Williams & Wilkins; 2005. Meperidine; pp. 999–1000.
    1. Webster PJ, Bailey MA, Wilson J, Burke DA. Small bowel obstruction in pregnancy is a complex surgical problem with a high risk of fetal loss. Ann R Coll Surg Engl. 2015;97(5):339–344.
    1. Augustin G, Majerovic M. Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2007;131(1):4–12.
    1. American College of Obstetricians and Gynecologists . ACOG Committee Opinion 158. Washington, DC: ACOG; 1995. Guidelines for diagnostic imaging during pregnancy.
    1. Zachariah SK, Fenn MG. Acute intestinal obstruction complicating pregnancy: diagnosis and surgical management. BMJ Case Rep. 2014;2014:bcr2013203235.
    1. Chiedozi LC, Ajabor LN, Iweze FI. Small intestinal obstruction in pregnancy and puerperium. Saudi J Gastroenterol. 1999;5(3):134–139.
    1. Essilfie P, Hussain M, Bolaji I. Perforated duodenal ulcer in pregnancy – a rare cause of acute abdominal pain in pregnancy: a case report and literature review. Case Rep Obstet Gynecol. 2011;2011:263016.
    1. Amdeslasie F, Berhe Y, Gebremariam TT. Perforated duodenal ulcer in the third trimester of pregnancy. Saudi J Med Med Sci. 2015;3:164–166.
    1. Drago JR, Rohner TJ, Chez RA. Management of urinary calculi in pregnancy. Urology. 1982;20(6):578–581.
    1. Sadat U, Dar O, Walsh S, Varty K. Splenic artery aneurysms in pregnancy – a systematic review. Int J Surg. 2008;6(3):261–265.
    1. Trimble WK, Hill JH. Congestive splenomegaly (Banti’s disease) due to portal stenosis without hepatic cirrhosis; aneurysms of the splenic artery. Arch Pathol Lab Med. 1942;34:423.
    1. Caillouette JC, Merchant EB. Ruptured splenic artery aneurysm in pregnancy. Twelfth reported case with maternal and fetal survival. Am J Obstet Gynecol. 1993;168(6 Pt 1):18101811–18111813.
    1. Nincheri Kunz M, Pantalone D, Borri A, et al. Management of true splenic artery aneurysms. Two case reports and review of the literature. Minerva Chir. 2003;58(2):247–256.
    1. Castro LP, de Paula Castro L. Reflux esophagitis as the cause of heartburn in pregnancy. Am J Obstet Gynecol. 1967;98(1):1–10.
    1. Figueiredo P, Almeida N, Lopes S, et al. Small-bowel capsule endoscopy in patients with suspected Crohn’s disease – diagnostic value and complications. Diagn Ther Endosc. 2010;2010(9):1–7.
    1. Matok I, Gorodischer R, Koren G. The safety of H2-blockers use during pregnancy. J Clin Pharmacol. 2013;50(1):81–87.
    1. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol. 2010;116(6):1302–1309.
    1. Clayton HB, Schieve LA, Peterson HB, Jamieson DJ, Reynolds MA, Wright VC. Ectopic pregnancy risk with assisted reproductive technology procedures. Obstet Gynecol. 2006;107(3):595–604.
    1. Jabeen K, Karuppaswamy J. Non-surgical management of cesarean scar ectopic pregnancy – a five-year experience. J Obstet Gynaecol. 2018;8:1–7.
    1. Chang YL, Chang SD, Cheng PJ. Perinatal outcome in patients with placental abruption with and without antepartum hemorrhage. Int J Gynaecol Obstet. 2001;75(2):193–194.
    1. Salihu HM, Bekan B, Aliyu MH, Rouse DJ, Kirby RS, Alexander GR. Perinatal mortality associated with abruptio placenta in singletons and multiples. Am J Obstet Gynecol. 2005;193(1):198–203.
    1. Dusse LM, Alpoim PN, Silva JT, Rios DR, Brandão AH, Cabral AC. Revisiting HELLP syndrome. Clin Chim Acta. 2015;451(Pt B):117–120.
    1. Haddad B, Barton JR, Livingston JC, Chahine R, Sibai BM. Risk factors for adverse maternal outcomes among women with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Am J Obstet Gynecol. 2000;183(2):444–448.
    1. Vigil-de Gracia P, Ortega-Paz L. Pre-eclampsia/eclampsia and hepatic rupture. Int J Gynaecol Obstet. 2012;118(3):186–189.
    1. Porreco RP, Clark SL, Belfort MA, Dildy GA, Meyers JA. The changing specter of uterine rupture. Am J Obstet Gynecol. 2009;200(3):269:269.e1–269.e4.
    1. Gupta S, Manyonda IT. Acute complications of fibroids. Best Pract Res Clin Obstet Gynaecol. 2009;23(5):609–617.
    1. Bassi A, Czuzoj-Shulman N, Abenhaim HA. Effect of pregnancy on the management and outcomes of ovarian torsion: a population-based matched cohort study. J Minim Invasive Gynecol. 2018;25(7):1260–1265.
    1. Cappell MS, Friedel D. Abdominal pain during pregnancy. Gastroenterol Clin North Am. 2003;32(1):1–58.
    1. Ahmed FU, Ambreen A, Zubair S, Kiran N. Torsion of a term uterus. J Coll Physicians Surg Pak. 2016;26(6 Suppl):S50–S51.
    1. Daykan Y, Bogin R, Sharvit M, et al. Adnexal torsion during pregnancy: pregnancy outcomes after surgical intervention – a retrospective case–control study. J Minim Invasive Gynecol. 2019;26(1):117–121.
    1. Dahab AA, Aburass R, Shawkat W, Babgi R, Essa O, Mujallid RH. Full-term extrauterine abdominal pregnancy: a case report. J Med Case Rep. 2011;5(1):531.
    1. Matovelo D, Ng’walida N. Hemoperitoneum in advanced abdominal pregnancy with a live baby: a case report. BMC Res Notes. 2014;7(1):106.
    1. Brenner DJ, Hall EJ. Computed tomography – an increasing source of radiation exposure. N Engl J Med Overseas Ed. 2007;357(22):2277–2284.
    1. 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(5):1107–1109.
    1. Woodfield CA, Lazarus E, Chen KC, Mayo-Smith WW. Abdominal pain in pregnancy: diagnoses and imaging unique to pregnancy – review. AJR Am J Roentgenol. 2010;194(6 Suppl):WS14–WS30.
    1. Masselli G, Brunelli R, Monti R, et al. Imaging for acute pelvic pain in pregnancy. Insights Imaging. 2014;5(2):165–181.
    1. Mccollough CH, Schueler BA, Atwell TD, et al. Radiation exposure and pregnancy: when should we be concerned? Radiographics. 2007;27(4):909–917.
    1. Sadro C, Bernstein MP, Kanal KM. Imaging of trauma: part 2, abdominal trauma and pregnancy – a radiologist’s guide to doing what is best for the mother and baby. AJR Am J Roentgenol. 2012;199(6):1207–1219.
    1. van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker J, Boermeester MA. Acute appendicitis: meta-analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology. 2008;249(1):97–106.
    1. Dewhurst C, Beddy P, Pedrosa I. MRI evaluation of acute appendicitis in pregnancy. J Magn Reson Imaging. 2013;37(3):566–575.
    1. Ross JT, Matthay MA, Harris HW. Secondary peritonitis: principles of diagnosis and intervention. BMJ. 2018;361:k1407.
    1. Goldberg-Stein SA, Liu B, Hahn PF, Lee SI. Radiation dose management: part 2, estimating fetal radiation risk from CT during pregnancy. AJR Am J Roentgenol. 2012;198(4):W352–W356.
    1. Groen RS, Bae JY, Lim KJ. Fear of the unknown: ionizing radiation exposure during pregnancy. Am J Obstet Gynecol. 2012;206(6):456–462.
    1. National Council on Radiation Protection and Measurements . Medical radiation exposure of pregnant and potentially pregnant women. NCRP report no 54. Bethesda, MD: National Council on Radiation Protection and Measurements; 1977.
    1. ACOG Committee Opinion Number 299, September 2004 (replaces No. 158, September 1995). Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104:647–651.
    1. Andreotti RF, Lee SI, Choy G, et al. ACR Appropriateness Criteria on acute pelvic pain in the reproductive age group. J Am Coll Radiol. 2009;6(4):235–241.
    1. Brent R, Mettler F, Wagner L. Pregnancy and medical radiation: ICRP publication 84. International Commission on Radiological Protection Website; [Accessed July 17, 2012]. Available from: .
    1. Chen MM, Coakley FV, Kaimal A, Laros RK. Guidelines for computed tomography and magnetic resonance imaging use during pregnancy and lactation. Obstet Gynecol. 2008;112(2 Pt 1):333–340.
    1. Ciet P, Litmanovich DE. MR safety issues particular to women. Magn Reson Imaging Clin N Am. 2015;23(1):59–67.
    1. Kilpatrick CC, Orejuela FJ. Management of the acute abdomen in pregnancy: a review. Curr Opin Obstet Gynecol. 2008;20(6):534–539.
    1. Barber-Millet BL, Castro G, Gavara G, Pla B, Domínguez G. Update on the management of non-obstetric acute abdomen in pregnant patients. Cir Esp. 2016;9494(5):257257–265265.
    1. Palanivelu C, Rangarajan M, Senthilkumaran S, Parthasarathi R. Safety and efficacy of laparoscopic surgery in pregnancy: experience of a single institution. J Laparoendosc Adv Surg Tech A. 2007;17(2):186–190.
    1. Gurbuz AT, Peetz ME. The acute abdomen in the pregnant patient. Is there a role for laparoscopy? Surg Endosc. 1997;11(2):98–102.
    1. Rollins MD, Chan KJ, Price RR. Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new standard of care. Surg Endosc. 2004;18(2):237–241.
    1. Upadhyay A, Stanten S, Kazantsev G, et al. Laparoscopic management of a nonobstetric emergency in the third trimester of pregnancy. Surg Endosc. 2007;21(8):1344–1348.
    1. Chung JC, Cho GS, Shin EJ, Kim HC, Song OP. Clinical outcomes compared between laparoscopic and open appendectomy in pregnant women. Can J Surg. 2013;56(5):341–346.
    1. Pearl JP, Price RR, Tonkin AE, Richardson WS, Stefanidis D. Guidelines for the use of laparoscopy during pregnancy. Available from:
    1. Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol. 2013;209(1):1–10.
    1. El Kady D. Perinatal outcomes of traumatic injuries during pregnancy. Clin Obstet Gynecol. 2007;50(3):582–591.
    1. El-Kady D, Gilbert WM, Anderson J, Danielsen B, Towner D, Smith LH. Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population. Am J Obstet Gynecol. 2004;190(6):1661–1668.
    1. Muench MV, Baschat AA, Reddy UM, et al. Kleihauer–Betke testing is important in all cases of maternal trauma. J Trauma. 2004;57(5):1094–1098.

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