1. Dr. M.Mokhtari Zahedan University of Medical sciences

2. Case Presentation A 22- year-old woman G1 32 weeks of gestation C.C. : Abdominal pain Past history:Gastritis Prenatal care : POS

3. BP : 120/70 mmHg PR : 85/min RR: 19/min T: 37.3 Chest Abdomen

4. laboratory findings WBC : 12400/mm Hb:10.6mg/dL PLT:154000/mm AST,ALT,LDH : Normal U/A: Normal Creat : 0.7 BS: 102 mgr/100 Sonography: 31+4 w fetus, AF Normal Abdominal and sonography NL

5. OBSERVATION

6. Principles of Ab. pain in pregnancy Mild to moderate abdominal discomfort (usually transient) is common in normal pregnancy. Pain related to enlarging uterus is more common in early pregnancy. Fetal position or movement,Braxton-Hicks uterine contractions are more common later in pregnancy, especially in the third trimester.

7. Pain that is severe, sudden, constant, associated with other symptoms (eg, nausea, vomiting, vaginal bleeding), or in the upper abdomen suggests a disease process. The presence of peritoneal signs (rebound tenderness, abdominal guarding) is never normal in pregnancy. Prompt maternal-fetal evaluation.

8. 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 Monitoring for contractions: Throughout the evaluation period After definitive treatment

9. Challanges Normal location of pelvic and abdominal organs The laxity of the abdominal wall may also diminish peritoneal signs (guarding, rebound). Hydroureter and hydronephrosis aortocaval compression

10. Hematologic parameters White blood cell counts during pregnancy : 10,000 to 14,000 cells/mm 3 In labor :20,000 to 30,000 cells/mm 3 Returning to normal prepregnancy levels at about one week postpartum

11. History and physical examination The fetal heart rate should be documented. Continuous fetal heart rate monitoring is usually appropriate in pregnancies that have reached 23 to 24 weeks of gestation. Past and current obstetrical history Laboratory: Complete blood count Urinalysis Liver and pancreatic function tests (aminotransferases, bilirubin, amylase, lipase)

12. In the presence of fever or unstable vital signs, blood and urine cultures should be performed. Electrolytes and renal function tests can be useful in women who are vomiting or anorectic Imaging Ultrasound is typically the first-line modality When ultrasound findings are equivocal or uncertain, then the choice of the second-line modality depends on the differential diagnosis and should take into account availability, diagnostic performance, and fetal radiation exposure. When indicated, use of magnetic resonance (MR) imaging is preferable

13. 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

14. Delay in diagnosis and treatment can increase maternal and fetal/newborn morbidity and mortality.

15. Differential Diagnosis Uterine conditions Adnexal disease Nongynecological

16. Pregnancy-related causes 1)First half of pregnancy Miscarriage Ectopic pregnancy 2)Second half of pregnancy Labor Placental abruption Uterine rupture Pregnancy-related liver disease (Severe preeclampsia,HELLP, acute fatty liver of pregnancy) Intraamniotic infection

17. Nonpregnancy-related causes Rupture of spleen often occurs during pregnancy, usually in the third trimester, and is typically a catastrophic event. Presenting symptoms include diffuse abdominal pain centered in the midline or left upper quadrant and radiating to the shoulder, anorexia, nausea, vomiting, syncope, and diarrhea or constipation. If the patient is in hemorrhagic shock, immediate laparotomy should be performed with ligation of the splenic artery and splenectomy.

18. Most common non-obstetrical surgical emergencies: 1. Acute appendicitis 2. Cholecystitis 3. Intestinal Obstruction 4. Pancreatitis 5. Trauma

19. Observation After 6-7 hours : Epigasteric pain Gradually increase in BP in 2-3 h No other severity sign

20. U/A: Normal AST:350 ALT:450 LDH :840IU/L Creat : 0.7 PLT:90,000/mm PBS

22. Diagnosis: HELLP syndrome Magnesium sulfate and termination of pregnancy Repeated U/A: Neg for proteinuria

23. Preeclampsia Syndrome New-onset HTN+ new-onset proteinuria 0r new-onset thrombocytopenia < 100,000 creat>1.1 0r doubling creat Transaminase: twice NL Pulmonary edema Headache, visual disturbances, covulsions Proteinuria is not absolutely required