Acute Abdominal Emergencies Associated with Pregnancy

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Acute Abdominal Emergencies Associated with
Pregnancy

• STONE, KEITH MD
• Clinical obstetrisc and gynecology
• Volume 45(2)  ,June 2002 , pp 553-561
• Command ???
• Report ???

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Maternal Physiology

• Cardiac output
• in pregnancy increases 3050, peaking late in
  the second trimester, with output directed
  primarily to the uterus , KIDNEY, skin
• BP
• 5- to 10-mm Hg decrease in systolic pressure
• 10- to 20-mm Hg decrease in diastolic pressure
• HR
• increase in the resting pulse 10 to 15 beats per
  minute over baseline.

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• Position
• avoid the supine position, especially after 20
  weeks' gestation, left side tilt is prefered.
• physiologic hypervolemia
• makes the pregnant patient much less likely to
  show signs of hypovolemia until perhaps 3050 of
  blood volume has been lost
• Anemia, hypercoagulate state

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• Respiratory
• hyperventilation, maternal Pco2 is decreased and
  maternal Pco2 is increased
• Digestive changes
• gastroesophageal reflux , constipation
• appendicitis is no more common in pregnancy, the
  death and complication rates of this condition
  are increased due to delay
• increases the risk of cholecystitis (due to
  progesterone)

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Fetal Physiology/Development

• first trimester
• avoid exposure to potentially teratogenic agents
• maxim that indicated elective surgery be
  postponed until the second trimester
• regional anesthesia is preferred
• decision to obtain radiographic studies should be
  based on whether they are indicated
• Most common radiographic studies involve fetal
  irradiation doses of 1 cGy or less. Direct
  irradiation to the fetus of 10 cGy or more is
  associated with adverse effects

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• Antibiotics following should be avoided
• Gentamicin , (risk small)
• Tetracyclines ,( bone, teeth)
• fluoroquinolones (cartilage)
• Fetal heart rate
• Monitor is important, 120160 beats per minute

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Surgical Conditions

• APPENDICITIS
• cephalad repositioning from the region of
  McBurney's point at 12 weeks
• appendicitis is confirmed in 3650 of cases
• more than 40 of patients who undergo
  appendectomy in the second and third trimester
  have a normal appendix
• A fetal loss rate of 35 is observed with an
  unruptured appendix this rate increases up to
  20 if the appendix is ruptured
• R/O APN, UTI, ovarian tumor

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CHOLECYSTITIS/CHOLELITHIASIS

• Symptoms commonly associated with gallbladder
  disease include nausea, vomiting, and epigastric
  or right upper quadrant pain.
• Sonography is 9698 sensitive and specific for
  cholelithiasis
• elevated conjugated bilirubin, alkaline
  phosphatase, and/or transaminase level
• OP indication
• recurrent attacks of biliary colic, acute
  cholecystitis, and obstructive cholelithiasis
  should be managed with cholecystectomy,
  preferably laparoscopically and preferably in the
  second trimester

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BOWEL OBSTRUCTION

• Most commonly caused by adhesions, bowel
  obstruction in pregnancy may also be a
  consequence of volvulus.
• OP indication
• tachycardia, and progressing leukocytosis, in
  association with abdominal pain and tenderness,
  warrant early surgical exploration.
• Indications for cesarean section fetal distress
  or inability

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Gastrointestinal surgical conditions during
pregnancy
Sharp HT.. Clin Obstet Gynecol. 1994 37306315

• 66 pregnant patients undergoing exploration for
  bowel obstruction
• 23 required bowel resection and the fetal death
  rate was 26
• four maternal deaths were recorded

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TRAUMA

• primary cause
• motor vehicle accidents
• Unrestrained women
• maternal death rates of 33 and fetal death rates
  of 47 and higher
• Anatomic alterations
• displace the bowel into the upper abdomen
• increases the risk of retroperitoneal hemorrhage
  in the pelvis

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• placenta (abruptio placentae)
• in 4050 of life-threatening injuries
• uterine rupture.
• in 0.6 of all injuries during pregnancy
• Direct fetal injury
• fetal skull and brain when pelvic fracture occurs
  in association with an engaged cephalic
  presentation.
• penetrating trauma
• perinatal death rate is 4771
• rarely associated with maternal death

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survey

• Ultrasonography
• fetal gestational age, fetal heart activity,
  fetal activity, and amniotic fluid volume
• maternal intraperitoneal fluid, suggesting
  intraperitoneal hemorrhage
• suspicion for abruptio placentae
• The presence of uterine contractions
• fetal monitoring may be performed for at least 4
  hours and then can be discontinued

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• peritoneal lavage indication
• altered sensorium, unexplained shock, multiple
  thoracic injuries, or major orthopedic injuries
• laparotomy is advised for gunshot wounds to the
  abdomen in pregnancy.
• Rarely, selective observation may be entertained
  in a pregnant patient with a gunshot wound to the
  anterior abdomen in a subfundal location, with
  imaging studies showing the bullet has not
  crossed the posterior uterine wall.
• Laparotomy for maternal indications is not an
  indication for a cesarean section

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Kleihauer-Betke test

• assess the level of fetal-maternal hemorrhage in
  Rh-negative mothers, allowing a more accurate
  determination of the amount of Rh immunoglobulin
  to administer
• One ampule of 300 mg D-immunoglobulin protects
  against hemorrhage of less than 30 mL
• D-immunoglobulin to all sensitized D-negative
  pregnant patients evaluated for abdominal trauma
• tetanus toxoid (0.5 mL) if there has been no
  booster in 5 years

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Perimortem cesarean

• 75 of surviving infants had been delivered
  within 5 minutes and were neurologically intact
• Four minutes of resuscitation and one minute to
  deliver the infant results in the 5-minute
  rule.

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Uterine Emergencies

• UTERINE ATONY
• postpartum hemorrhage are due to uterine atony
• multiple gestation, polyhydramnios, and
  macrosomia
• diagnosis is easily made by palpating a boggy
  uterus in association with steady, usually
  significant blood loss

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• Management
• medical
• 20 to 60 units oxytocin in lactated Ringer's at
  200 to 500 mL per hour.
• If bleeding persists, methylergonovine
  (Methergine) may be given intramuscularly at a
  dose of 0.2 mg
• 15-methyl prostaglandin F2-alpha (PGF2a) as 0.25
  mg intramuscularly or intramyometrially every 15
  to 60 minutes (maximum 8 doses). Watch out for
  asthma.
• Surgical
• selective ligation of the ascending uterine
  arteries

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UTERINE RUPTURE

• association with
• automobile accident in which the pregnant
  patient is not restrained and results in fetal
  death rates approaching 100 and maternal death
  rates approaching 10
• C/S indication
• Fetal bradycardia or severe decelerations if
  fetus (23 weeks or beyond).