Acute abdomen obstetrics gynaecology

1. The acute abdomen in obstetric and
gynaecologic patients
JT Nel lvIBChB, MMed (O & G), FCOG (SA), MRCOG, FRCS (Ed), Senior specialist and Senior lecturer, Department of
Obstetrics and Gynaecology, University of the Orange Free State, Bloemfbntein
III
IV
V
The acute abdomen in obstetric and gynaecologic patients can
be classified lnto five broad categories:
I Obstetric causes of an acute abdomen
II Gynaecologic causes of an acute abdomen in the pregnant
patlent.
Gynaecologic causes of an acute abdomen in the non-
pregnant patient.
Surgical and medical causes of an actlte abdomen in the
pregnant patient.
Surgical and medical causes of an acute abdomen in the
non-pregnant female.
I OBSTETRIC CAUSES OF AN ACUTE ABDOMEN
Abruptio placentae
Abruptio placentae is defined as the premature separation of a
normally situated placenta. The incidence is about I in 80 to 1
in 200 pregnancies.l It is a serious condition which results in
loss of the fetus in 30 - 600/o of casesr and occasionaily in the
death of the mother, especially if not expeditiously treated' The
clinical f'eatures of a classical case are:
a. Acute abdominal pain with or without vaginal bleeding. The
pain is sudden in onset and continuous in character'
b. A rigid tender uterus - the fetal pafis are therefore difficult
to feel.
c. Signs of f'etal distress or absent fetai hearl sounds.
d. Hypovolaemic shock of varying degree - if the patient had
previously been hypertensive, ar-terial blood pressure may
be misieading.l
e. Anaemia.
The clinical features may be atypicai in the case of abruption
of a posteriorly inserred placenta when the patient may only
complain of backache and vaginal bleeding'r'a
The principles of treatment of abruptio placentae are:
a. The replacement of blood volume mainly by whole blood
transtusion. Blood loss is nezdy always more than can be
seen externally. Central venous pressure should be used to
monitor transfusion.3
b. The doing of clotting tests on the first specimen of blood
taken for cross-matching and if a clotting def'ect is found, the
institution of appropriate treatment. Fresh frozen plasrna
transfusion is an imporlant first aid measure.:l
c. The expedition of delivery.
n If the fetus is still alive an emergency caesarean section
should be cione. The retroplacental bloodclot may make
it dilficult to hear the fetal heart with a Pinard fetal
stethoscope. If the fetal heart cannot be heard, ultrasound
should be used to confim the presence or absence of the
f'etal heartbeat.
n If the fetus is dead an amniotomy is indicated, followed
by vaginal delivery. Syntocinon should be used with
caution as it may not be possible to monitor uterine
contractions accurately.3
d. The monitoring of urine outputby an inrJwelling transurethral
catheter. Serum urea shouid be estimated and if urinary
output is not adequate treatment for ollguria should be
stafted.
e. Preparedness to treat atonic postpartum haemorrhage. Intra-
myometrial injection of prostaglandin F']-alpha (1,0 - 5,0 mg
diluted in 10 ml sterile water) may be necessary.
Ectopic pregnancy
The incidence ofectopic pregnancy is itrcreasings and rnaternal
deaths due to ectopic pregnancy have increased from 7,87o ot
all maternal deaths to 11,57o between 1970 and 1978.6 The
clinical features of ruptured ectopic pregnancy are:
a. The sudden onset of acute abdominal pain, sometimes
accompanied by shoulder-tip pain.
b. Hypovolaemic shock and anaemia.
c. With abdominal palpation a full, doughy feeling. When the
intra-abdominal blood starts to clot with the resultant fbrma-
tion of fibrin bands attached to the peritoneum, rebound
tendemess becomes marked.
cl. During vaginal examination acute tendemess is elicited by
moving the cervix frorn side to side"
The clinical features of unruptured ectopic pregnancy, chronic
ectopic pregnancy and advanced extra-uterine pregnancy ffe
non-specific and may consist of:
a. Chronic abdominal discomfbrt.
b. Oceasional faiuting.
c. Metrorrhagia or bloodstained vaginai discharge.
d. In the case ofadvanced extra-uterine pregnancy easily pal-
pable f'etal pafls and/or abnotmal 1ie of the fetus.
If the diagnosis is uncerlain, the following diagnostic aids
rnay help:
a. Laparoscopy: This is the most valuable of a1l the diagnostic
aids. If blood is seen in the peritoneal cavity an emergency
456 Trauma and Emergency Medicine, November/December 1991

2. laparotomy shouid be performed.
r. A pregnancy test: Radioimmuno-assay of the beta sub-unit
of human chorionic gonadotrophin is of value, butit does not
differentiate between ectopic and intra-uterine pregnancy.
:. Ultrasound: Transvaginal ultrasound is of value in the early
detection of an unruptured tubal pregnancy. Transabdominal
ultrasound may be of value as a complementary investiga-
tion to a positive pregnancy test, by demonstrating the
presence or absence of intra-uterine pregnancy. The pres-
ence of intra-uterine pregnancy makes the diagnosis of
ectopic pregnancy extremely unlikely, since a combined
intra-uterine and extra-uterine pregnancy is very rare.
Ultrasound is also of value in the diagnosis of advanced
extra-uterine pregnancy, by demonstrating the fetus outside
the uterus. An alterrative investigation in these cases is a
lateral abdominal X-ray, which may show the fetal bones
overlapping the matemal vertebral column.
l. Culdocentesis or abdominal paracentesis: These two inves-
tigations are seldom of value in the diagnosis of ectopic
pregnancy. Ifblood originating from an ectopic pregnancy
is aspirated, the typical appearance is that of mainly unclotted
blood with small clots which can be seen if the blood is
filtered through gauze.
The treatment of ectopic pregnancy consists of the follow-
.lg:
. Ruptured tubal pregnancy: Treatment of hypovolaemic
shock, laparotomy and blood transfusion. Resuscitation
should be simultaneous with surgery as there is no point in
delaying operation while blood is pouring into the abdo-
men.3 A partial or total salpingectomy is performed, depend-
ing on the degree of tubal destruction.
r. Unruptured tubal pregnancy: Laparotomy and partial
salpingectomy or salpingotomy. Conservative surgery has
the advantage that microsurgical re-anastompsis of the
uterine tube can be performed at a later stage.
OR
Laparoscopic salpingotomy (this should only be done by a
gynaecologic surgeon properly trained in endoscopic sur-
gery).
OR
Parenteral methotrexate and citrovorum factor provided the
ectopic pregnancy is smaller than 3 cm.7
OR
Transvaginal salpingocentesis with potassium chlorides or
methotrexate.e
:. Ruptured comual pregnancy: Treatment of hypovolaemic
shock, laparotomy, blood transfusion and partial
salpingectomy withexcision andrepairof the cornu. In some
cases ahysterectomy may be necessary because of extensive
uterine damage.
[. Ovarian pregnancy: The classic criteria of Spiegelberg
needed for the diagnosis of an ovarian pregnancy are:
i The fetal sac must occupy a portion of the ovary.
ii The ovary and sac must be connected to the uterus by the
ovarian ligament.
iii Ovarian tissue must be identified in the sac.
Acute abdomen
iv The uterine tube must be normal and intact on the affected
side of the pelvis.
Treatment consists of resection of the trophoblast fiom the
ovary, preserving as much ovarian tissue as possible. To
decrease the risk for postoperative peri-ovarian adhesions
the ovarian capsule should be meticulously repaired, prefer-
ably with PDS 6/0 on a micro-cutting needle, using an
inversion technique. 1o
e. Advanced extra-uterine pregnancy: Laparotomy with re-
moval of the fetus andplacenta. Ifthe location of the placenta
is such that removal would be dangerous, it should be left in
situ. Rh negative women can become sensitized by Rh
positive blood from an ectopic pregnancy and should be
treated with 300 pg Rh immunoglobulin.rr
Rupture of the uterus
Rupture of the uterus is a serious condition which occurs fairly
rarely. Mokgokong and Marivate report an incidence of 1 in 545
in a very large series of more than 180 000 deliveries.r2
Uterine rupture mostly occurs secondary to obstructed la-
bour or trauma to the uterus. Spontaneous t'rrpture of the uterus
may occur if there is a scar in the uterus and in exceptional cases
with an intact uterus. Spontaneous rupture of the intact uterus
mostly occurs in grand multiparae, but in exceptional cases it
may also be seen rn a primigravida.13
Threatening uterine rupture is clinically characterised by
continuous pain between contractions, tenderness over the
utems and haematuria. After the uterus has ruptured the classic
ciinical picture is that of shock, vaginal bleeding, an acute
abdomen, absent uterine contractions or a fibrillary pattern of
uterine contractions, easily palpable fetal parls and fetal distress
or death. However, the classic clinical picture is not always
present.ra
The treatnent of uterine rupture consists of resuscitating the
patient (oxygen and intravenous administration of fluid, includ-
ing blood, according to the central venous pressure) and an
emergency laparotomy. A total abdominal hysterectomy (or a
subtotal hysterectomy if the practitioner has not been trained in
the technique of atotalhysterectomy) is mostly necessary. Ifthe
patient desires furlher children the area of rupture can some-
times be repaired, provided it is small or it is a lower segment
scar which has ruptured.
The matemal mortality of uterine rupture varies between 5
and25c/o and the perinatal mortality between 13 and 7007o.
Torsion of the uterus
Dextrorotation of the uterus is a normal physiological phenom-
enon which occurs in more than 80Vo of pregnancies. The
rotation is normally not more than 30"to 40., but in exceptional
cases it may be more than 90" with a resultant acute torsion of
the uterus. The last-mentioned condition clinically presents
with abdominal pain, retention of urine and even shock. The
diagnosis is usually made at laparotomy. Treatment consists of
turning the uterus back to its normal position, followed by
caesarean section. An altemativetreatmentis to dothe caesarean
section through the posterior wall of the uterus, after which the
Trauma and Emergency Medicine, November/December 1991 457

3. Acute abdomen
torsion is corrected.
Spontaneous rupture of a subcapsular haematoma of the
liver
Spontaneous rupture of a subcapsular haematoma of the liver
is a rare complication of severe pre-eclampsia or eclampsia.
The maternal and fetal mortality is high.
II GYNAECOLOGIC CAUSES OF AN ACUTE
ABDOMEN IN THE PREGNANT PATIENT
Red degeneration of a leiomyoma
Red degeneration of a leiomyoma occurs because of thrombo-
sis in the leiomyoma's bloodvessels with resultant venous
congestion and a local inflammatory reaction. It especially
tends to occur in the second half of pregnancy or in the
puerperium. Clinically it is characterised by acute localised
abdominal pain, vomiting, low grade fever, tachycardia, 1o-
calisedperitoneal tenderness overthe surface of the leiomyoma
and a raised white cell count. Treatment consists of bedrest,
sedation and pain relief. The condition usually resolves spon-
taneously within a few days.
Torsion of a pedunculated leiomyoma
Torsion of a pedunculated leiomyoma presents with acute
abdominal pain and vomiting. Ultrasound is of value in con-
firming the diagnosis of a pedunculated leiomyoma. A lapa-
rotomy and a myomectomy are indicated. The only other
indication for a myomectomy during pregnancy is the excep-
tional case where a leiomyoma is so large that it has to be
removed to enable suturing of the uterus after a caesa-rean
section.l5 In all other circumstances leiomyomata are left
during pregnancy because of the greater danger of haemor-
rhage if a myomectomy is done during pregnancy.
Torsion of an ovarian tumour
The incidence of ovarian tumours in pregnancy is approxi-
mately 1 in 938 pregnancies of which only 2,4Vo are malig-
nant. 16
The commonest type is a benign cystic teratoma (dermoid
cyst).
Figure 1: If the adnexa is gangrenous a unilateral salpingo'
oophorectomy must be done.
The incidence of torsion of ovarian tumours is increased
during early pregnancy and the puerperium.
Clinically the patient presents with acute lower abdominal
pain, nausea and vomiting. Signs of shock may develop.
Tenderness may make it impossible to palpate the adnexal
mass. Ultrasound may be of value to demonstrate the ovarian
tumour. An emergency laparotomy is indicated.
In the case of a benign tumour which has undergone torsion,
the adnexa should be unwinded since normal blood supply
sometimes returns, especially if the torsionhad notbeenpresent
for a long time. The tumour is then removed with preservation
of as much ovarian tissue as possible. Ifthe adnexa is gangre-
nous a unilateral salpingo-oophorectomy must be done (Figure
1). If doubt exists during laparotomy whether a tumour is
benign or malignant, it is managed like a benign tumour so that
histological confirmation of the diagnosis can firstbe obtained.
This prevents unnecessary radical surgery, as the surgeon can
always operate again should the histology show malignancy.
Treatment of a malignant ovarian tumour consists of:
n Aspiration of ascites or rinsing the pouch of Douglas for
cytologic examination. A heparinised syringe should be
used.
n If the fetus is viable a caesarean section, followed by total
abdominal hysterectomy, bilateral salpingo-oophorectomy
and infracolic omentectomy.
n Chemotherapy if indicated.
Salpingitis
Salpingitis occurs very ra-rely during pregnancy. It is especially
rare after the first trimester when the chorion has fused with the
decidua, thus completely sealing off the uterine cavity.
Rupture of uterine or ovarian veins
A number of cases of rupture of veins on the surface of the
uterus or rupture of the ovarian veins during pregnancy have
been described. This may happen spontaneously or secondary
to trauma. The increased venous pressure during pregnancy is
a precipitating factor. Clinically the patient presents with
symptoms and signs of intra-abdominal haemorrhage. Because
of the rarity of the condition the diagnosis is usually made trate,
with a resultant high maternal and fetal mortality.
III. GYNAECOLOGIC CAUSES OF AN ACUTE
ABDOMEN IN THE NON.PREGNANT PATIENT
Acute pelvic inflammatory disease
Pelvic inflammatory disease is common and it is estimated that
15% of women in the United States have had salpingitis by the
age of 30 years.rT
The Gainesville classification of acute pelvic inflammatory
diseasels is of practical value in the management of these
patients (Table 1).
The main clinical features of acute pelvic inflammatory
disease are acute pelvic pain, fever higher than 38"C, a foul-
smelling vaginal discharge, an elevated white cell count, an
elevated erythrocyte sedimentation rate and in the case of a
tubo-ovarian complex or abscess a palpable mass.
458 Trauma and Emergency Medicine, November/December 1991

4. Acute abdomen
TABLE 1: THE GAINESVILLE CLASSIFICATION OF
ACUTE PELVIC INFLAMMATORY
DISEASE
Stage 1: Acuteendometritis-salpingitiswithoutperitonitis
Stage 2: Acute salpingitis with peritonitis
Stage 3: Acute salpingitis with superimposed tubal occlu-
sion or tubo-ovarian comPlex
Stage 4: Ruptured tubo-ovarian abscess
Stage 5: Respiratory complications, e.g. tuberculosis
citation, appropriate triple antimicrobial therapy and an emer-
gency laparotomy is indicated as the mortality is high. The
peritoneal cavity should be thoroughly explored, including the
subphrenic and paracolic spaces. If free pus is found in the
upper abdomen, the smaller peritoneal sac should be opened,
explored and irrigated.2o
At the end of the operation the abdominal and peritoneal
cavity should be thoroughly rinsed with 37"C saline (or with
diluted hydrogen peroxide followed by saline) to remove as
much of the pus and organisms as possible. Saline should notbe
warmer than 37"C as this may cause postoperative adhesions.23
In cases where multiple abscesses are found between loops
of bowel, the abdomen should be temporarily closed after
draining the abscesses and rinsing. The technique of tempora'ry
closure consists ofusing an open abdominal swab, overlayedby
silastic sheet on both sides, to cover loops of bowel thus
preventing herniation into the abdominal wound. With through-
and-through sutures the wound edges are pulled over the swab
and the sutures tied. After 24 hours the abdomen is explored and
irrigated again. Depending on the degree of sepsis found the
abdomen can eitherbe closed permanently or again temporarily
closed to enable another re-exploration after 24 hours. The
wound should only be closed permanently when no remaining
locules ofpus are found.
Septic abortion
The diagnosis of a septic abortion is made when an abortion is
accompanied by fever and symptoms and signs of pelvic or
general abdominal peritonitis. With speculum examination a
TABLE 2: CLINICAL SIGNS OF SEPTIC SHOCK
1. The early or warm hypotensive phase
(a) Fever
(b) A hot, clammY skin
(c) Blushing
(d) Tachycardia
(e) Rigors
(f) Hypotension of 85-95 mm Hg systolic
(g) A fully conscious Patient
(h) Urine output more than 30 mVh
2. The late or cold hypotensive phase
(a) A cold, clammy skin
(b) Hypotension of 70 mm Hg systolic or less
(ct Peripheral cyanosis
(d) A lowered temPerature
(e) A fast thready Pulse
(l) Impeded consciousness
(g) Oliguria
3. Irreversible shock or the final phase
(a) Severe metabolic acidosis
(b) Anuria
(c) Heart failure
(d) Respiratory disfress
(e) Coma
Laparoscopy is of value to confitm the diagnosis,re as the
possibility that the initial diagnosis is correct is only 657o'20
However, laparoscopy is contra-indicated in patients with large
adnexal masses or adhesions due to previous operations for
pelvic inflammatory disease.2o Ultrasound is of value to distin-
guish between an adnexal mass consisting of inflammatory
tissue and adherent bowel, and a tubo-ovarian abscess.
Stage I patients (see Table 1) can be treated as ambulatory
patients but all other patients need to be hospitalized. Aerobic
and anaerobic swabs should be taken from the endocervix for
culture and sensitivity testing. This should include an
endocervical culture for Chlamydia trachomatis and Neisseria
gonorrhoeae. A gram stain of endocervical discharge may also
be of value in the diagnosis of Neisseria gonorrhoeae' For
chlamydial infection, two methods of antigen detection are
available, namely the direct chlamydia enzyme immunoassay
and fluorescent antibody examination of a direct smear'20'21
These techniques are more accurate than the results obtained by
culture.22
Proper treatment of acute pelvic inflammatory disease is
essential to prevent permanent tubal damage, which will cause
infertility. Pelvic infl ammatory disease is usually amultibacterial
infection and single antibiotic therapy is therefore seldomly
indicated. The only indication for single drug therapy is where
Neisseria gonorrhoeae has been excluded with certainty or if
the patient is from an area where there are no known strains of
pencillinase-producing Neisseria gonorrhoeae.20 The drug of
choice for single therapy is doxycycline or tetracycline.'o Many
different antibiotic regimens exist, but the spectrum of activity
of the antimicrobial agents should cover Neisseria gonorrhoeae,
Chlamydia trachomatis, aerobic and anaerobic organisms'
Triple therapy should be used for stage 3 (e.g. penicillin 5
million units every 6 hours intravenously, clindamycin 600 mg
every 6 hours intravenously and tobramycin).20 An altemative
regimen consists of intravenous penicillin, intravenous
metronidazole and gentamicin.
An abscess should be surgically drained either via lapa-
rotomy, or by posterior colpotomy. Prerequisites for the latter
procedure are that the abscess fluctuates in the midline of the
posterior vaginal fornix and does not extend above the pelvic
inlet. In older patients with a completed family a total abdomi-
nal hysterectomy and bilateral salpingo-oophorectomy may be
indicated.
With rupture of a tubo-ovarian abscess pre-operative resus-
460 Trauma and Emergency Medicine, November/December 1991

5. Figure 2: Hysterectomy specimen in a case of postpartum
sepsis with early gangrenous changes in the uterus. (Note
areas of green discolouration and also pus plaques on the
surface of the uterus).
foul-smelling, frequently purulent discharge though the cervi-
cal os, can usually be seen. Gas-bubbles and dark-blue disco-
louration of the cervix is a serious sign and indicative of
Clostridium welchii infection.2a
If the diagnosis of a septic aborlion is made, it is very
important to examine the patient for clinical signs of septic
shock (Table 2).24
The principles of treatment of a septic abortion are:
a. The control of infection with antimicrobial drugs.
b. The treatment of bloodloss.
c. Removal of the focus of infection; and
d. The prevention and early diagnosis of complications.
The focus of infection is removed by curettage, or by
medical induction followed by curettage (if the uterus is larger
than 14 weeks) or by hysterectomy. Absolute indications for a
hysterectomy are:
a. The patient does not respond in a satisfactory way to medical
treatment and curettage.
b. Longstanding uterine infection with associated oliguria is
presenl. in a normovolemic patient: or
c. Gangrene of the uterus is present (Figure 2).
In patients older than 40 years and patients whose families
are completed, the following are also absolute indications for
hysterectomy'.
a. Septic shock
b. Perforation of the uterus caused by criminal intervention.
c. The presence of a pelvic abscess.
d. Failed medicaI induction.
In young patients who desire more children, one can some-
times be more conservative in the above-mentioned cases, but
each patient should be individually assessed and it should be
remembered that conservative treatment is always associated
with an element of risk.2a
Torsion of an ovarian tumour
This has already been discussed. The.management is as in the
pregnant patient. Il*Ipr" cases a normal ovary may undergo
Acute abdomen
torsion. A laparotomy should be performed and if the ovary is
gangrenous a unilateral oophorectomy is indicated. Ifthe ovary
is not gangrenous the torsion should be unwound and if blood
supply to the ovary is satisfactory it should be fixed to the lateral
peritoneal wall to prevent arecurrence. Non-absorbable suture
material with minimal tissue reactivity effect should be used
e.g. Prolene@ O.
Haemorrhage in an ovarian tumour
Intemal haemorrhage in a cystic or solid ovarian tumour causes
sudden distension of the ovary accompanied by a boring,
throbbing pain of increasing severity. On examination the
ovarian lesion has a tense consistency and is very tender to
gentle compression. Rapid surgical exploration is indicated
before rupture and spillage can occur.2s
Rupture of an ovarian cyst
The clinical picture associated with rupture of an ovarian cyst
is largely dependent on the character ofthe cyst's contents and
associated bleeding from the rupture site. Rupture of a follicle
cyst is frequently painless or may cause only a temporary acute
reaction that rapidly resolves. Corpus luteum cyst rupture is
usually associated with some degree of intra-peritoneal bleed-
ing and is therefore frequently accompanied by complaints of
pain. Rupture usually follows a period of amenorrhoea and the
clinical picture may therefore simulate that of an ectopic
pregnancy.25 The diagnosis is usually made at laparoscopy or
laparotomy. If significant bleeding is found the cyst should be
removed and the ovarian capsule repaired as already described.
Rupture of a benign cystic teratoma releases a highly irritat-
ing material into the pelvic cavity with rapid development of
chemical peritonitis and persistent spreading pelvic pain. Early
in this course fever, ileus and abdominal distension develop.25
An emergency laparotomy is indicated, with removal of the
teratoma followed by thorough rinsing of the abdominal and
pelvic cavities with 37"C physiological saline.
Torsion of a pendunculated leiomyoma
Treatment is as in the pregnant patient. A hysterectomy may be
indicated in the older patient with a completed family, espe-
Figure j: A hydatid cyst of Morgagni (arrow).
Trauma and Emergency Medicine, November/December 1991 461

6. Acute abdomen
cially if multiple leiomyomas are present.
Torsion of a hydatid cyst of Morgagni
A hydatid cyst of Morgagni is a congenital remnant of the
cranial end of the paramesonephric duct. It can be seen as a
cystic appendix to the Fallopian tube and it is fairly frequently
incidentally discovered at operation (Figure 3).
A Morgagni hydatid is usually asymptomatic and no specific
treatment is needed. In rare cases it may undergo torsion and
cause the symptoms and signs of peritoneal irritation.26 The
diagnosis can be confirmed by laparoscopy and the peduncu-
lated cyst is easily removed by laparoscopic surgery.
Traumatic perforation of the uterus during a dilatation and
curettage
In the case of a small perforation the patient must be carefully
observed for symptoms and signs of intra-peritoneal bleeding.
In most cases the myometrium will spontaneously contract
around the area of perforation and no further intervention will
be necessary. An immediate laparoscopy may be of value to
assess the damage to the uterus and the degree of bleeding.
If symptoms and signs of intra-peritoneal bleeding develop
or if the uterine damage is extensive, a laparotomy should be
done. A small perforation can be sutured but a hysterectomy
may be necessa.ry in cases of extensive uterine damage.
Ovarian vein rupture as a result of blunt abdominal trauma
Ovarian vein rupture secondary to blunt abdominal trauma is
extremely rare in the non-pregnant patient. Blumenthal and
Burgin repofied a case resulting from a motor vehicle acci-
dent.27 An emergency laparotomy is necessary in order to
secure haemostasis.
IV. SURGICAL AND MEDICAL CAUSES OF AN
ACUTE ABDOMEN IN THE PREGNANT PATTENT
Appendicitis
Appendicitis is the most common general surgical emergency
during pregnancy. In the first half of pregnancy the mortality is
4 to 5 times higher than in the non-pregnant patient and in the
second half of pregnancy 10 times higher . The reasons for this
are as follows:
i The diagnosis is frequently difficult because the appendix is
displaced posterolaterally, and sometimes also superiorly,
by the enlarging uterus. Maximal tenderness is therefore not
necessarily found at McBufirey's point and rebound tender-
ness may be absent.
The normal increase in the white cell count dunng preg-
nancy and the common occulrence of nausea during preg-
nancy further hamper the diagnosis.
ii Perforation of the appendix and diffuse peritonitis occur
more"commonly because of increased vascularity and de-
creased omental protection.
Early diagnosis and treatment of appendicitis during preg-
nancy is therefore of vital imporlance. With early diagnosis and
treatment the matemal and fetal mortality is not higher than in
the non-pregnant patient.
A diagnosis of appendicitis should always be considered if
unexplained abdominal symptoms occur during pregnancy.
The classic symptom of peri-umbilical pain shifting to the right
fossa iliaca is also the commonest way in which appendicitis
presents during pregnancy.
The sign of Alders can be used to distinguish between the
tenderness caused by appendicitis and that caused by
gynaecologic pathology - gentle pressure is exerted on the point
of maximal tenderness and the patient is then asked to turn on
her left side - in the case of gynaecologic pathology the'
tenderress will frequently disappear because the uterus and,
tubes move to the left under the influence of gravity, whereas
the tenderness caused by appendicitis will usually remain in the
same place, as the appendix is less mobile.
Treatment consists of a laparotomy and appendectomy. The
operation should be carried out with the patient tilted 30" to the
left, as this position helps the surgeon to avoid handling the
uteflrs. This is imporlant as handling of the uterus can cause
premature labour. A caesarean section is only carried out if
pregnancy duration is 38 weeks or more, as it is very uncomfort-
able to be in labour with a fresh abdominal wound.
Trauma
Blunt abdominal trauma occurs most frequently because of a
motorcar accident. Possible consequences include abruptio
placentae, uterine rupture, splenic rupture and liver rupture. A11
cases should be observed for at least 24 hours, including
monitoring of the fetal hearl rate, as retarded separation of the
placenta sometimes occurs. If signs of intra-abdominal haem-
orrhage are present or develop, a laparotomy must be done.
Penetrating abdominal trauma occurs most frequently be-
cause of a knife wound or a gunshot wound. In the second and
third trimesters the uterus is frequently injured with a subse-
quenl40Vo to70Vo perinatal mortality. A penetrating injury to
the upper abdomen can cause severe injury to the bowel, as the
loops of bowel are compressed by the enlarged pregnant uterus."
t
A laparotomy is indicated under the following circum- ,
SIANCCS: I
n A penetrating abdominal injury above the level of the uterihe
fundus
n Signs of intra-abdominal haemorrhage are present or de-'
velop
n Intra-abdominal sepsis
n Signs offetal distress.
Thermal injury'
Pregnancy as such does not influence the matemal prognosis
after thermal injury. However, thermal injury during preg-
nancy increases the risk for spontaneous aborlion and prema-
ture labour.
If thermal injury affects more than 507o of the total body
surface, the matemal and fetal mortality is high. Termination of
pregnancy is only indicated in the seriously ill patient where
complications like hypoxia, hypotension and sepsis endanger
the life of a viable fetus.28 A vaginal delivery is preferable to a
caesarean section.
464 Trauma and Emergency Medicine, November/December 1991

7. Cholecystitis
Next to appendectomy, cholecystectomy is the most frequent
non-gynaecological abdominal operation performed on preg-
nantwomen.2e Changes which occurin the composition of bile'
predispose the pregnant woman to an increase in the size of
existing stones and/or the formation of new cholesterol stones.
However, doubt exists as to whether there is a true increase in
the incidence of cholelithiasis and cholecystitis during preg-
nancy when compared to matched non-pregnant patients.
The clinical picture of cholecystitis during pregnancy is as
in the non-pregnant patient. However, jaundice occurs rarely
because dilatation ofthe bile ducts during pregnancy decreases
the risk for obstruction by a stone. Cholangiography should be
avoided during pregnancy because of radiation hazards to the
fetus. Ultrasound can be used to confirm the presence or
absence of gallstones.
The treatment of gallbladder disease during pregnancy is
usually medical (sedation, bedrest, intravenous fluid and naso-
gastric suction). Antibiotics are sometimes necessary. The
administration of chenodeoxycholic acid to dissolve gallstones
is contra-indicated, especially during early pregnancy as doubt
exists as to the safety of the drug for the developing fetus. A
laparotomy and cholecystectomy are indicated in the following
circumstances:
n Obstruction of the common bile duct
n Empyema of the gallbladder
n Cholangitis
n Pancreatitis
n The patient does not improve with conservative treatment.
Pancreatitis
Acute pancreatitis rarely occurs during pregnancy. It is a'
serious disease with a high morbidity and mortality. The
condition should always be considered in the differential diag-
nosis of upper abdominal pain in a pregnant patient. The use of
thiazide diuretics may be a precipitating factor.3o Grey-Turner's
sign (a blue discolouration in the loins) is sometimes present in
acute pancreatitis. The serum amylase increases slightly during
pregnancy, but not as much as in acute pancreatitis. Treatment
is conservative as in the non-pregnant patient.
Intestinal obstruction
Intestinal obstruction rarely occurs during pregnancy. The
condition is especially rare in early pregnancy and more than
507o of cases occur in the third trimester when the large uterus
compresses the bowels with resultant distortion and stretching
of pre-existing adhesions.
The diagnosis of intestinal obstruction during pregnancy
may be difficult as the classic symptoms of vomiting, abdomi-
nal pain and constipation also frequently occur during normal
pregnancy. Intestinal obstruction should especially be consid-
ered if the above symptoms and signs occur in a patient who has
had a previous abdominal operation, as the latter could have
caused adhesions.
Treatment consists of restoring fluid and electrolyte balance,
followed by a laparotomy with surgical correction of the
Acute abdomen
obstruction as in the non-pregnant patient. A caesarean section
should be avoided, but it may occasionally be necessary to
enable access to the site ofobstruction.
Rupture of a splenic artery aneurysm
A ruptured splenic artery aneurysm is very rare, but 207o of all
reported cases had occur:red during pregnancy, mainly in the
third trimester. The maternal and fetal mortality is high. Treat-
mentconsists of ligatingthe splenic artery andsplenectomy. As
most cases occur in the third trimester, a caesarean section is
usually necessary to make proper access to the upper abdomen
possible.
Peptic ulcer
Because of decreased gastric secretion an existing peptic ulcer
frequently improves during pregnancy. Treatment is as in the
non-pregnant patient.
Renal calculi
The incidence ofrenal calculi during pregnancy is as in the non-
pregnant population. Pain is usually less because ofphysiologi-
cal dilatation of the ureters during pregnancy' Treatment is as
in the non-pregnant patient.
Porphyria
Porphyria is an inherited abnormality of porphyrin metabolism
with resultant abnormal porphyrin synthesis. The condition can
be diagnosed antenatally by amniotic fluid analysis.
In Southern Africa there is a relatively high incidence of
variegate porphyria in the white population, especially amongst
Afrikaners. Porphyria cutanea tarda is les s common and mainly
prevalent in the black population. Acute intermittent porphyria
is the type which occurs most frequently during pregnancy. The
clinical picture can be confusing with symptoms and signs like
psychosis, acute abdominal pain and hypertension.
An acute attack of porphyria can be precipitated by preg-
nancy and also by certain drugs like harbiturates.
chloramphenicol, ergometrine, erythromycin, ethanol,
halothane, hydralazine, mercaptopurine, methyldopa' nalidixic
acid, oestrogen, progesterone, oral contraception.
phenobarbitone, phenytoin, sulphonamides, thiopentone, etc.
Before a drug is prescribed to a patient with porphyria it is
advisable to consult manuals like the " South African Medicines
Formulary" (see Holderness and Straughan 1991).31
The effect of pregnancy on porphyria varies depending on
the type of porphyria. Acute intermittent porphyria can deterio-
rate in lp to 757o of patients, whereas variegate porphyria is
frequently not influenced by pregnancy. A worsening of the
condition frequently occurs postpartum.
Specialised treatmentis necessary' Sunli ght mustbe avoided'
Termination of pregnancy is only indicated if conditions like
hypertension or psychosis warrant it.
Tlphoid
Typhoid is associated with a high morbidity and mortality, but
the course of the disease is not changed by pregnancy. Fever
Trauma and Emergency Medicine, Novernber/December 1991 465

8. episodes are assbciated with a high incidence of spontaneous
abortion. Treatment is as in the non-pregnant patient and a
therapeutic abortion is not indicated.
Acute retention of urine
Acute retention of urine may occur as a complication of
obstructed labour or severe urinary tract infection. The reten-
tion should be relieved by transurethral or rarely suprapubic
TABLE 3: SURGICAL AND MEDICAL CAUSES OF AN
ACUTE ABDOMEN IN THE NON.
PREGNANT FEMALE
L. Conditions requiring immediate surgery:
(a) Acute appendicitis
(b) Acute cholecystitis with perforation
(c) Intestinal obslruction
(d) Intra-abdominal abscess
(e) Strangulated hernia
(f) Rupture of sPleen
(g) Rupture ofbladder
(h) Perforated peptic ulcer
(i) Perforated bowel
0) lntussuscePtion
(k) Volvulus
(1) Gangrene of the intestine
(m) Trauma with visceral injury or haemorrhage
(n) Unresolved severeupper gastro-intestinalhaemorhage
(o) Ruptured abdominal aneurysm
2. Conditions not requiring immediate surgery
(a) Acute cholecYstitis
(b) Acute pancreatitis
(c) Chronic pancreatitis
(d) Pseudocyst of the Pancreas
(e) Responsive upper gastro-intestinal haemorrhage
(f) Sigmoiddiverticulitis
(g) Haematoma of the abdominal wall
3. Non-surgical conditions
(a) Pyelonephritis
(b) Renal colic
(c) Acute gastro-enteritis
1d) Regionalenteritis
(e) Non-pertbrated PePtic ulcer
(t) Ulcerative colitis
(g) Mesenteric adenitis
(h) Tuberculous Peritonitis
(i) Porphyria
(,) Acute retention of urine
(k) Periarteritis nodosa
(1) Henoch-Schonlein PurPura
(m) Abdominal crisis associated with syphilis, diabetes
mellitus, sickle cell disease, systemic lupus erythema-
tosus, acute lead poisoning and drug withdrawal'
(n) Miinchhausen sYndrome
Acute abdomen
drainage of urine.
Other surgical and medical conditions
Any of the surgical and medical conditions summarised in table
3 can also occur in the pregnant patient, but most are rare. Of
the non-surgical conditions pyelonephritis is most frequently
seen. It should be expeditiously treated with intravenous anti-
biotics, as septic shock may occur with advanced infection.
V. SURGICAL AND MEDICAL CAUSES OF AN
ACUTE ABDOMEN IN THE NON.PREGNANT
FEMALE
A full discussion ofthese conditions falls outside the scope of
this arlicle and they are therefore summarised in Table 3.
VI. CONCLUSION
Numerous conditions may present as an acute abdomen in the
female patient. Diagnostic acumen and expedient treatment is
usually required or the life of the patient may be endangered'
This is even more so in the pregnant patient, where two lives are
at stake.
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Puhlications Division: Medical Association of South Africa 1991.
Clinical trial shows absorbable barrier reduces
incidence and severity of postsurgical adhesions
Interceed Barrier is indicated as an adjuvant in gynaecologic
pelvic surgery for reducing the incidence of postoperative
pelvic adhesions after haemostasis is achieved consistent with
microsurgical principles. Adhesions are implicatedin 407o of
the curent 5 million cases of infertility'
Researchers involved in a multicentre clinical trial have
reported a "90Vo improvement" over controls in preventing
adhesion formation using an oxidized regenerated cellulose
fabric, according to an article publishedinFertility and Sterility.
Interceed (TC7) Absorbable Adhesion Barrier was usedduring
microsurgery on infertility patients forbilateral pelvic sidewall
adhesions.
Used with meticulous haemostasis, Interceed Barrier treat-
ment eliminated the formation of adhesions in nearly twice as
many pelvic sidewalls as state-of-the-art surgery alone (40
versus 2l),the study concluded. In addition, use oflnterceed
Barrier was associated with a 577o reduction of the extent of
adhesion formation over that obtained by meticulous surgical
techniques alone.
"Our study clearly proves that use of Interceed Barrier can
significantly reduce the occurrence and severity of adhesions,
overcoming a major obstacle to the success of these proce-
dures," said L Russell Malimak, MD, Department of Obstetrics
and Gynaecology, Baylor College of Medicine, and one of the
ten authors of the paper.
Adhesions (fibrous tissue that causes other tissues and,/or
organs to adhere abnormally to one another) are a major cause
of infertility and pain in women. The74 women participating
in the randomized trials consented to undergo a traditional
surgical procedure, adhesiolysis, to restore fertility through
excision of scars and adhesions resulting from endometriosis or
pelvic infl ammatory disease.
"The effectiveness of a cornmon procedure, adhesiolysis,
has been limited in the past; the same procedure intended to
remove adhesions may themselves cause additional scarring
and adhesions.
"After the removal of adhesions at laparotomy, the
deperitonealized (removal of the peritoneum, the membrane
lining the abdominal cavity) area of one pelvic sidewall was
completely covered with Interceed (TC7) Absorbable Adhe-
sion Barrier knitted fabric," explained Dr Malinak. Interceed
Barrier adheres to raw surfaces without the need for suturing,
he added.
The opposite pelvic sidewall, which was not treated with
Interceed Barrier, served as the control. "Each patient served
as her own control," he said. The assignment of the test sidewall
(either right or left) for each patient was made prior to the study
using a computerized algorithm to ensure randomness.
During surgery, drawings and photographs were taken and
a written evaluation was done to document the extent and
severity ofadhesions. These data were recorded on standard-
ized forms for computerized data entry. Ten days to 14 weeks
after the surgery, surgeons inserted a fibre-optic scope
(laparoscope) into the abdomen to record the incidence, extent
and severity of recurrent adhesions on the pelvic sidewalls.
Data were recorded in a manner similar to that used at the
original surgery.
Trauma and Emergency Medicine, November/December l99l 467