Acute Abdomen During Pregnancy appe.pptx

Surgical note

1. Seminar on Acute Abdomen During Pregnancy Presenter: Nurhusien A. ( Year III Surgical Resident) May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 1

2. Objective of the Seminar To know the principles of management of acute abdomen in pregnant patients. To differentiate obstetrics emergencies from the surgical emergencies during early pregnancy . May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 2

3. General Considerations Same surgical diseases as nonpregnant patients of similar age P hysiologic changes and the enlarging uterus may result in atypical presentation of surgical disease Symptoms may be attributed to normal pregnancy A delay in diagnosis and treatment of surgical illnesses in pregnancy poses a greater risk to maternal and fetal well-being If there is any doubt then immediate referral is required Prevention of preterm labor should be individualized based on the patient’s gestational age and underlying disease process May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 3

4. Surgery in Pregnancy Surgical interventions other than cesarean section are performed in 1.5–2% of all pregnancies Some increased risks are associated with surgery and anesthesia during pregnancy, and purely elective surgical procedures should be postponed until after pregnancy The interests of mother and fetus are best served by the obstetrician's active participation throughout the mother's course of diagnosis and management of a non-obstetric surgical disorder May 10, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 4

5. Surgical techniques usually are not altered because of the pregnancy At operation, the least extensive procedure necessary should be performed Unless an obstetric indication is present or the uterus interferes with the procedure , cesarean delivery shouldn't be performed during an abdominal operation Spontaneous abortion is most likely to occur if surgery is performed before 14 weeks' gestation or when peritonitis is present May 10, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 5

6. Acute Abdomen Acute abdominal diseases accompanied primarily by sudden abdominal pain for which a decision to perform emergency surgery must be made in a very short time A sudden, severe abdominal pain of unclear etiology that is less than 24 hours in duration May 10, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 6

7. Acute Abdomen in Pregnancy Incidence of acute abdomen in pregnancy: 1 in 500-635 pregnancies Acute abdomen in pregnancy presents a unique diagnostic and therapeutic challenge May 10, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 7

8. Prevalence, E tiology , and Clinical Profile of Acute Abdomen in Pregnancy in Southwest Cameroon : A 5-Year Retrospective Study May 10, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 8

9. Abdominal emergencies specific to pregnancy are either; 1. Pregnancy Related Pain Ectopic pregnancy Abortion Braxton-Hicks contractions Round ligament pain Cholestasis of pregnancy Acute fatty liver Red degeneration of a fibroid Abruptio placenta Rupture of uterus Pre-eclampsia Chorioamionitis Preterm labor May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 9

10. 2. Conditions associated with pregnancy Rupture of rectus abdominis muscle Torsion of the pregnant uterus Adnexal torsion Ovarian cyst rupture AUR due to retroverted gravid uterus May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 10

11. 3. Non-pregnancy related pain Acute Appendicitis Acute Cholecystitis Intestinal Obstruction Acute pancreatitis Gastrointestinal perforation Hernia Nephrolithiasis Pyelonephritis Rupture of visceral aneurysm May 10, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 11

12. I. Acute Appendicitis Acute appendicitis is the most common nonobstetric operative emergency during pregnancy Affects 1/1,500 pregnancies, less common than in non-pregnant Fetal mortality is 1.5% and 30% , for the simple and perforated respectively It accounts to 25% of operative indications for the acute abdomen during pregnancy and puerperium Ninety percent of pregnant women are <30 years of age More common in the second trimester with the incidence of 35–50% In patients with chronic appendicitis, the pregnancy may light up another attack May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 12

13. Clinical Presentation Medical History Constant abdominal pain and pain in the RLQ Pain localized in the RUQ Abdominal pain aggravated by fetal movements Nausea Anorexia May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 13

14. Physical Examination Abdominal guarding and rigidity , do not occur No single reliable sign Rebound tenderness - 55–93% Abdominal muscle rigidity - 50–65 % Rovsing’s sign - 50–60% Psoas sign (Obraztsova’s sign ) - 5–50% Rectal or pelvic tenderness Alder’s sign May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 14

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16. Aaron’s sign Bryan’s sign Differential Diagnosis Round Ligament Pain/Syndrome Stump Appendicitis Meckel’s Diverticulitis Crohn’s Disease Urolithiasis/Urinary Tract Infection May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 16

17. Diagnosis Negative appendectomy rates of up to 50% in pregnant women Appendicitis is not diagnosed in 20 % in pregnant women until the appendix has ruptured Leukocytosis Raised C-reactive protein (CRP ) Leukocyturia – 57% Bacteriuria - 41% Modified Alvarado score for pregnant patients Transabdominal Ultrasound Transvaginal Ultrasound Abdominal MRI - S n and S p are 80–100% and 93–98 % respectively Abdominal CT May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 17

18. May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 18

19. Treatment May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 19

20. Conservative Treatment Confirmed - management is always surgical If the patient is in active labor and delivery is imminent Open Appendectomy Should be completed with minimal or no uterine manipulation Most experienced abdominal surgeon available should perform the procedure Laparoscopic Appendectomy May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 20

21. May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 21

22. Clinical Outcomes of Acute Appendicitis During Pregnancy: Conservative Management and Appendectomy, Retrospective study in Japan May 10, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 22

23. II. Acute Biliary Tract Disease Most common causes of the gallbladder disease - gallstones and biliary sludge Incidence of gallbladder disease in pregnancy is 0.05–0.3% Asymptomatic gallstones occur in 3.5–10% of all pregnancies 40% of symptomatic patients require cholecystectomy 1/1200 pregnancies are complicated by CBD stones CBD stones account for 7% of cases of jaundice in pregnancy May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 23

24. 1. Acute Cholecystitis/Biliary Colic Cholecystitis is second only to appendicitis as an indication for surgery in pregnant women Risk Factors Biliary Sludge Multiparity Obesity and Diabetes Mellitus Oral Contraceptives Age Gallbladder Volume and Function May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 24

25. Clinical Presentation Biliary colic Nausea and vomiting Fever chills (rigors) Persistent jaundice Physical Examination Direct abdominal tenderness Murphy’s sign Abdominal muscle rigidity Fever and tachycardia May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 25

26. Differential Diagnosis Hyperemesis Gravidarum Perihepatitis ( Fitz-Hugh-Curtis Syndrome) Costal Margin Pain Appendicitis May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 26

27. Diagnosis Typical Symptoms Laboratory Findings Leukocytosis C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR) Serum bilirubin and transaminases Serum alkaline phosphatase Serum amylase Imaging Transabdominal Ultrasound - 95–98 % MRCP Endoscopic Ultrasound ERCP May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 27

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29. Treatment Conservative management Total Parenteral Nutrition-effective alternative to surgical treatment of chronic cholecystitis Diet Pain Management Antibiotics Ursodeoxycholic Acid Surgical treatment Percutaneous Biliary Drainage-first or third trimester or high-risk patients May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 29

30. Operative Treatment Most common indication for biliary surgery; Repeated biliary colic-37–70 % Acute cholecystitis-20–40% CBD stones-7% Biliary AP-3% Conservative medical management of symptomatic cholelithiasis in pregnant women often leads to suboptimal clinical outcomes Recurrence rate during pregnancy is 31–38 % for symptomatic cholelithiasis Open Versus Laparoscopic Cholecystectomy May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 30

31. 2. Common Bile Duct Stones and Acute Cholangitis Clinical Presentation Abdominal pain Jaundice Nausea Vomiting Itching Differential Diagnosis Intrahepatic cholestasis of pregnancy Acute fatty liver of pregnancy May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 31

32. Diagnosis Laboratory Findings Liver tests-increased metabolism of maternal transaminases Transabdominal Ultrasound-limited in the evaluation of the CBD and the pancreas MRCP-best imaging option ERCP Endoscopic Ultrasound May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 32

33. Treatment ERCP Laparoscopic Cholecystectomy After ERCP Common Bile Duct Exploration May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 33

34. 3. Acute Pancreatitis The most common cause of acute pancreatitis is gall stones , but alcoholism and drug reaction should be included in the differential Incidence 1/3000 pregnancies Clinical features Nausea Vomiting Burning type epigastric pain – radiating to the back Corner stone of the diagnosis depends on serum amylase and lipase Treatment is conservative- NPO + Hydration + Analgesics + Strict follow up May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 34

35. III. Gastrointestinal Perforation Perforations of the upper gastrointestinal tract are extremely Perforations of the lower intestinal tract are more common Most common are post instrumental perforations for termination of pregnancy May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 35

36. Perforated Peptic Ulcer in Pregnancy Incidence of perforated duodenal ulcer was 1/70,000 pregnancies , and of perforated gastric ulcer was 1/350,000 pregnancies Risk Factors Helicobacter pylori Infection Medications Lifestyle Factors Severe Physiological Stress Hypersecretory States May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 36

37. Perforated duodenal ulcer in the third trimester of pregnancy, with survival of both the mother and neonate, in Ethiopia: a case report May 10, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 37

38. Perforated Duodenal Ulcer in the Third Trimester of Pregnancy,Case Report from Mekelle May 10, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 38

39. Clinical Presentation Acute and severe abdominal pain Vomiting Pyrexia History of previous PUD Spontaneous abortion Preterm labor Diagnosis Chest radiograph- Lateral Erect CXR is better than the AP May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 39

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41. Treatment Surgical intervention Omental patch repair with H. pylori eradication Pharmacological gastric acid suppression Histamine2 Receptor Antagonists (H2RA ) Proton-Pump Inhibitors (PPIs) May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 41

42. IV. Intestinal Obstruction 1. Small Bowel Obstruction Incidence varies from 1/1500 to 1/3,000 SBO is the third most common causes of nonobstetric acute abdominal conditions during pregnancy More common in the third trimester, least common in the first Large bowel obstruction is less common than small bowel obstruction Conservative therapy is rarely successful Major causes of intestinal obstruction in the pregnant Adhesions Volvulus Intussusceptions Hernias May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 42

43. Clinical Presentation Depend upon: Location of the obstruction • The degree of obstruction • The rate of progression of obstruction • Intestinal perforation • Underlying malignancy Includes: Colicky abdominal pain Constipation Vomiting Abdominal distension May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 43

44. Diagnosis Serial examination Plain abdominal radiograph Treatment Nasogastric decompression and intravenous fluid-not more than 6 to 8 hours Operative management Maternal mortality - 6 % to 20% May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 44

45. 2. Sigmoid Volvulus Sigmoid volvulus in pregnancy is a rare occurrence Potentially serious condition and should be recognized as a surgical emergency First trimester-nonoperative (colonoscopic detorsion and rectal tube decompression) Second trimester-sigmoid resection is performed for recurrent cases Third trimester-nonoperative until fetal maturity and delivery May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 45

46. V. Abdominal Trauma Penetrating trauma most commonly includes growing uterus and the fetus which act as a shield for maternal intra-abdominal organs Blunt trauma is more difficult to diagnose and treat 0.3–0.4% of pregnant women require hospital admission because of trauma Motor vehicle accidents ( MVAs ) followed by falls Trauma is the leading nonobstetric cause of maternal mortality May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 46

47. Risk Factors Maternal Risk Factors Young age (<25 years) Illicit drugs, alcohol, or smoking Domestic violence Noncompliance with proper seat belt use Epilepsy or other seizures Overweight and obesity Work outside the home Low socioeconomic status May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 47

48. Investigations BG and Rh X-match Radiologic Investigations ( Abdominal Ultrasound, X-ray, Abdominal CT Scan) May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 48

49. Management Fetal outcomes are directly related and correlate with the state of maternal resuscitation Initial evaluation and treatment of an injured pregnant patient is identical to that of a nonpregnant patient Most common cause of fetal death after blunt injury is abruptio placentae Primary survey Airway Breathing Circulation-left lateral decubitus position May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 49

50. Early and rapid fluid resuscitation should be administered even in a pregnant patient who is normotensive If an emergent blood transfusion is warranted, Rh-negative blood should be administered Secondary survey Abdominal examination Pelvic examination May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 50

51. Treatment Resuscitation Fetal monitoring (Cardiotocographic Monitoring) All Rh-negative pregnant trauma patients should be considered for Rh immunoglobulin (RhoGAM) therapy May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 51

52. Summary Acute abdomen in pregnancy can be due to obstetric as well as non-obstetric causes Acute abdomen in pregnancy is a surgical and obstetric emergency Early diagnosis and intervention is of paramount importance Delay in diagnosis and performance of surgery is the factor primarily responsible for increased maternal morbidity rates and perinatal loss Altered anatomy and physiology Delay in presentation Misdiagnosis Multidisciplinary approach May 10, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 52

53. References: May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 53

54. May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 54 Thanks for your attention!

55. Questions and Comments ??? May 9, 2023 Acute Abdomen During Pregnancy, Nurhusien A. 55