Gupta AS
Pregnant women can be affected by acute conditions related
to the abdominal viscus. Acute abdomen is an emergency in all patients and a
decision regarding surgical management is usually needed. Acute abdomen in
pregnancy can be due to conditions specific, associated or incidental to
pregnancy. Pregnant women with acute abdomen many times are seen primarily by
the obstetrician. The obstetrician should be aware about the incidental causes
while evaluating such patients so as not to delay diagnosis and appropriate
treatment. A need for multidisciplinary consultation should always be
considered and sought. Cause of acute abdomen in pregnancy may be difficult to
elicit due to altered anatomy, physiology and altered laboratory parameters.
Many of the incidental causes like acute appendicitis, cholecystitis,
pancreatitis may mimic the normal symptoms of pregnancy like nausea and
vomiting. Leucocytosis that is an important investigation of infectious and
inflammatory pathology is also seen in normal pregnancy thus diluting its
importance. Abdominal signs of tenderness, guarding and rigidity are also not
very prominent as the enlarged gravid uterus has already stretched the
peritoneum in advanced pregnancy thus limiting the occurrence of overt
peritoneal signs. Examining the woman in the right or the left lateral position
and displacing the gravid uterus may help in identifying the organ causing the
pain.
A detailed history of onset, duration and progress of the
symptoms chiefly pain, period of gestational age, detailed obstetric history, a
meticulous general, systemic and local examination with specific attention to
the altered anatomy at different gestational ages should be done. This is best
illustrated by studying the changing location of the appendix. It is located at
McBurney point in the 1st trimester, umblical in the 2nd
trimester and right hypochondrium in the 3rd trimester. Acute
appendicitis can mimic acute cholecystitis, pancreatitis or even a perforated
duodenal ulcer. Precise diagnosis is required especially as some conditions
like acute pancreatitis requires conservative management whereas conditions
like appendicitis, duodenal ulcer perforation need prompt surgical management.
Diagnosis needs to be established by imaging techniques. Ulltrasonography is the
main diagnostic technique used in pregnant women. It not only evaluates the
extrauterine, the uterine structures but also provides detailed information of
the fetus. Risk of exposure to the fetus by ionizing radiation from radiology
and CT scan restricts their use. Contrast drugs like gadolinium that cross the
placenta also cannot be used. MRI with lower magnetic fields can be used
without contrast in the 2nd and the 3rd trimester. Use of
MRI in the 1st trimester, even though considered safe is not
recommended by the National Radiological Protection Board. Precise diagnosis
helps in planning and choosing between conservative and surgical treatment and
also the timing of the surgery. In acute conditions when surgery is the
treatment of choice and cannot be deferred it should be performed irrespective
of the gestational age or else it is best performed in the 2nd
trimester when the uterus is quiet and chances of teratogenesis due to the
anesthetic agents are absent. Incidence of preterm labor and spontaneous loss
is higher in the other two trimesters. Laparoscopy or laparotomy are both safe
in expert, trained hands. Even in the 3rd trimester laparoscopy has
been performed with good results for both diagnostic and therapeutic
indications. Prophylactic, tocolytic administration has no proven benefits
though they are still administered. Administration of glucocorticoids for lung
maturity can be considered when the risk of preterm labor is significant though
the flaring up of infection in the mother can be a real morbid occurrence, and
its use should be weighed accordingly. Acute abdomen due to incidental causes
is usually not an indication for termination of pregnancy or delivery and many
a times it can be dealt with without disturbing the pregnancy. However, if that
is not possible then the route of delivery should be decided by obstetric
indication only.
We hope our readers will enjoy reading this issue which
besides having direct obstetric cases also presents a case of acute abdomen due
to splenic torsion.