Approach to non obstetrical abdominal emergancies during pregnancy

Case presentation

Patient: 30yG3l1ab1(c/s) Lmp 34w Sono(16w) 33w+2 CC: abdominal pain and vomiting from 2 days ago PMH: hypothyroidism PSH: c/s & appendectomy PDH: fersulin & multivitamine & levothyroxine

Vital sign: Bp:100/7o PR:90 T:37.1 oral Heart: NL Abdominal exam:distended abdomen without peritoineal sign FHR: ok FH: 34w Other examination: NL

Lab data 18000(86%) 20500(90%) A+ 10/4 9/4 289000 174000 Coagulation test:NI/331 LFT: NL Cr: 0/6 uric acid:3.6 LDH:353 Bs:90 Electrolyte: NL Amylase: 44 Lipase: 15 ESR:52 TSH:NL CRP:7 Troponin: 0/01 U/A:NL

Sonography 33+2 Sono:S/Bx/Ant/NL 33+1 33+5

management Corticostreoid Mgso4 NST Hydration observation

Because of consistant of abdominal pain and non-reactive NST

Surgery counsult: VBG Abdomino pelvic sonography:moderate free fluide of intestinal interloop CXR, abdominal X ray observation Increasing of abdominal pain Metabolic acidosis Addition the generalized Abdominal tenderness in serial abdominal exam

Acute abdomen laparatomy

Whate was Diagnosis?

diferentioal diagnosis: Acute appendicitis Acute cholecystitis GI obstraction Acute pancreatitis

Acute appendicitis Appendectomy for presumed appendicitis is the most common surgical emergency during pregnancy The incidence is approximately 1 in 766 births. Acute appendicitis can occur at any time during pregnancy but is rare in the third trimester. The overall negative appendectomy rate during pregnancy is approximately 25% and appears to be higher than the rate seen in nonpregnant women. A higher rate of negative appendectomy is seen in the second trimester, whereas the lowest rate is in the third trimester.

during pregnancy, there are anatomic changes in the appendix and increased abdominal laxity that may further complicate clinical evaluation. The most consistent sign encountered in acute appendicitis during pregnancy is pain in the right side of the abdomen. Only 57% of patients present with the classic history of diffuse periumbilical pain migrating to the right lower quadrant.

Laboratory evaluation is not helpful in establishing the diagnosis of acute appendicitis during pregnancy. only 38% of patients with appendicitis had a white blood cell count of more than 16,000 cells/ incidence of perforated or complex appendicitis is not increased in pregnant patients When the diagnosis is in doubt, abdominal ultrasound may be beneficial. Another option is magnetic resonance imaging,

Laparoscopy has been advocated in equivocal cases, especially early in pregnancy; Laparoscopic appendectomy may be associated with an increase in pregnancy related complications. in California using administrative databases, laparoscopy was found to be associated with a 2.31 times increased risk of fetal loss compared with open surgery. The overall incidence of fetal loss after appendectomy is 4%, and the risk of early delivery is 7%.

Removing a normal appendix is associated with a 4% risk of fetal loss and 10% risk of early delivery. Maternal mortality after appendectomy is extremely rare (0.03%).

Despite the predilection toward biliary sludge and stone formation in pregnancy, acute cholecystitis does not occur more frequently during pregnancy; data suggest that cholecystitis only affects 0.1% of pregnant women. Most patients with symptomatic gallstones complain of biliary colic (recurrent pain characteristically exacerbated by heavy fatty meals) likely resulting from gallbladder contractions and increased pressure and luminal expansion.

Common signs and symptoms include right upper quadrant pain, fever, tachycardia, leukocytosis, and inflammation of the gallbladder wall; additional symptoms include anorexia, nausea, vomiting, intolerance to fatty foods, and right upper quadrant pain. Physical examinationmay reveal Murphy’s sign, but this depends largely on gestational age and body habitus. Sepsis and jaundice also may be seen.

Sonography is the most useful and sensitive test for detecting gallstones, whereas x-ray and CT scanning may not be useful in symptomatic patients. For the pregnant patient with symptoms of biliary disease, the differential diagnosis includes appendicitis, pancreatitis, peptic ulcer disease, pyelonephritis, HELLP syndrome (syndrome of hemolysis, elevate liver enzymes, and low platelets), acute fatty liver, and hepatitis.

Treatment Conservative treatment may be an option at least initially in an attempt to avoid surgery during pregnancy. Conservative therapy, including intravenous hydration, opioid analgesia, and bowel rest, is appropriate in patients with few symptoms or with an incidental finding of gallstones. Broad spectrum antibiotic use is recommended with systemic symptoms and for the patients in whom there is no improvement in 12 to 24 hours.

Nonsteroidal antiinflammatory drugs should be used with caution as high doses or prolonged administration, particularly after 32 weeks’ gestation, can be associated with pregnancy complications, including oligohydramnios and narrowing of the fetal ductus arteriosus.

Definitive surgical therapy is required for pregnant patients with signs of sepsis, ileus, or perforation. An alternative to surgical intervention includes percutaneous cholecystostomy,

GI obstruction

symptoms: neusa & vomiting abdominal pain Metabolic acidosis

Bowel Obstruction Intestinal obstruction is the failure of normal proximal to distal movement of intestinal contents. mechanical obstruction, characterized by intestinal contractions against a fixed obstruction, and paralytic ileus, characterized by the absence of functional intestinal myoelectric activity.

Patients complain of constipation and absent flatus and then nausea, vomiting, and abdominal pain. Some patients continue to pass flatus in the presence of partial intestinal obstruction. If intestinal obstruction causes strangulation and/or perforation, abdominal pain can be more severe, constant, and/or localized.

Intestinal obstruction associated with pregnancy is relatively rare. Intestinal obstruction during the first trimester of pregnancy is an extremely rare event. Diffuse abdominal pain and tenderness can be differentiated from uterine contractions by manual palpation of the uterus or by use of a fetal monitor during an episode of pain. Localized tenderness is more suggestive of an acute surgical abdomen unrelated to pregnancy. Again, one must stress the importance of differentiating paralytic ileus from mechanical intestinal obstruction.

The causes of mechanical intestinal obstruction during pregnancy are the same as for the non-pregnant patient, but the order of frequency is different.

The possible operative approaches includel4: 1. Laparotomy and cesarean section followed by surgical relief of the obstruction. 2. Laparotomy and relief of the obstruction without disturbing the pregnancy. 3. Induction of labor and vaginal delivery with spontaneous resolution of the intestinal obstruction. 4. Induction of labor and vaginal delivered followed by laparotomy and surgical relief of the obstruction. The actual approach depends on the estimated gestational age and whether or not strangulation is suspected. The most recent review reporting mortality figures in the treatment of mechanical obstruction during pregnancy showed a maternal mortality of 8% and a fetal loss rate of 23%

Paralytic ileus during pregnancy most commonly presents as pseudoobstruction of the large intestine. Patients present after normal vaginal delivery or cesarean section with nausea, vomiting, constipation, and abdominal distention. Patients are usually afebrile and minimally minimally tender unless cecal perforation has occurred. Bowel sounds are absent to minimal. There is marked colonic gaseous distention detected by plain radiography. Sigmoidoscopy and barium enema are normal. The pathophysiology is not understood but may involve disruption of parasympathetic impulses to the colon in the early postpartum period. Treatment is initially nonoperative and consists of nasogastric suction and intravenous hydration.

Pancreatitis Acute pancreatitis (AP) is a rare event in pregnancy, occurring in approximately 3 in 10 000 pregnancies. The spectrum of AP in pregnancy ranges from mild pancreatitis to serious pancreatitis associated with necrosis, abscesses, pseudocysts, and multiple organ dysfunction syndromes. Pregnancy related hematological and biochemical alterations influence the interpretation of diagnostic tests and assessment of severity of AP.

Diagnostic studies such as endoscopic ultrasound, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography and therapeutic modalities that include endoscopic sphincterotomy, biliary stenting, common bile duct (CBD) stone extraction, and laparoscopic cholecystectomy are major milestones in gastroenterology. When properly managed AP in pregnancy does not carry a dismal prognosis as in the past.

Signs and symptoms of acute pancreatitis usually include midepigastric pain, left upper quadrant pain radiating to the left flank, anorexia, nausea, vomiting, decreased bowel sounds, low-grade fever, and associated pulmonary findings 10% of the time (unknown cause). The general management of AP in pregnancy is supportive. Laparoscopic cholecystectomy is ideally performed in the second trimester when the risk to fetus is the least and only limited technical problems exist as a result of an enlarging uterus.