Management of acute abdomen in pregnancy: current perspectives

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.

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

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

An intraoperative image of adnexal torsion (torsion of fimbrial cyst) at 34 weeks of gestation.

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.