1) A 25-year-old pregnant woman presented with severe lower abdominal pain for 1 day. On examination, she had tenderness all over her abdomen.
2) An ultrasound showed a right ovarian cyst. She underwent surgery where they found an enlarged right ovary with old blood.
3) She was diagnosed with a ruptured ovarian cyst and hospitalized. She recovered well and was discharged after 5 days.
2. o Approach of pregnant lady
with abdominal pain
o Proper Disposal
o Case discussion
o Pitfalls
3. 25years old pregnant lady,G1P0
, 12 weeks of gestation with
severe lower abdominal pain
since 1 day
4. o/e :
Abd pain since 1 day
A : patent pale , in pain
B : 18/min , sat 98% in RA chest : clear
Getting worse with time
Bilateral Air entry CVS : s1,s2
Associated with
C : BP 110//70 mmhg normal
vomiting
Pr: 83/min /min , regular p/a: tenderness
D : reflo 7 mmol all over
-No PV bleeding
PV exam : Os is
-No urinary symptoms
GCS : 15/15 closed , no
-No diarrhea
UPT:+ve bleeding
-No previous illnesses
-No previous scan
Action :
= no Ultrasound facility
=Buscopan Inj given
DDX = referred to Obe/Gyne
oncall
= Gyne scan : SLF ,
BPD 13 weeks , FHR +,
placenta Upper posterior
Advise :
Nill Gyne
Surgical Referral
5. Physiological changes in vitals in 12 weeks
pregnant lady
BP:Diastolic and systolic blood pressure tend to fall during
mid pregnancy and then return to normal by week 36
Diastolic pressure decreases more than systolic
◦ Heart rate: +10 beats/min (5%)
◦ Respiratory rate: no change
7. A : patent
B : 18/min o/e :
Bilateral Air entry Pain in severe pain
C : BP 110//70 progressively p/a : Tenderness all
mmhg getting worse over , Guarding++,
Pr : 120/min Rigidity++
, regular BS absent
GCS : 15/15
Action : Surgical Opinion :
=Pain killer
Buscopan Inj = Admittion
, Morphine 5 mg IV =NPO , IV fluid
DDx = NPO , IV fluid = US abdomen
still in pain
US Vs Surgical
referral
9. Dilutional anaemia is caused by the rise in plasma
volume.
Serum alkaline phosphatase increases during
pregnancy - due to placental production.
Serum albumin decreases.
A modest leukocytosis is observed
Fibrinogen: 300 mg/dl 450 mg/dl
D-dimer increase
Platelet decrease due to hemodilution
Define thrombocytopenia: < 116,000
10. Limited study due to gravid uterus
appendix could not be visualized
RIF cyst like mass the origin of this
mass could be ?? Appendicular
?? Ovarian
Small amount of free fluid seen in RIF &
Morison pouch
11. Abdomen was opened by McBurneys incision , on
Opening the cavity , appendex found normal . Dirty
fluid in the cavity with flakes of old hemorrhage
Gyne called intraoperativly : rt sided ovary
enlarged 6 cm , old chocolate coloured materia
over the uterus , omentum & abdominal wall
Appendicectomy done , rt ovarian chocolate cyst
aspirated , Peritonial lavage done
12. Pt admitted to ICU postoperativly , remain
stable , remain in the hospital for 5 days
then dischrged
13.
14. Incidence of acute abdomen during
pregnancy is 1 in 500
# 1 Acute Appendicitis
# 2 Acute Cholecystitis
15. Symptoms
◦ Nausea, vomiting, and abdominal pain are
common in the normal obstetric population. N/V
are most common in weeks 4-16.
Physical Exam
◦ Expanding uterus dislocates other
intraabdominal organs.
Labs
◦ Leukocytosis and anemia are common in normal
pregnancies and thus, not as predictive of
infection or blood loss.
19. Acute pyelonephritis
Acute cystitis
Acute cholecystitis
Acute fatty liver of pregnancy
Rupture of rectus abdominus muscle
Torsion of pregnant uterus
20. Ectopic pregnancy
Septic abortion with peritonitis
Acute urinary retention due to retroverted uterus
Round ligament pain
Torsion of pedunculated myoma
Placental abruption
Placenta percreta
HELLP Syndrome
Acute Fatty Liver of Pregnancy
Uterine rupture
Chorioamionitis
21.
22. It affects 1 in 1500 pregnancies, less common
than in non-pregnant women , mortality is higher
(esp. from 20 weeks), Perforation is commoner
(15%-20%), Fetal mortality is ~1.5% for simple
appendicitis , ~30% if perforation.
Diagnosis is complicated by change in position of
appendix as it migrates upwards, outwards and
posteriorly as pregnancy progresses, so pain is
less well localized (often paraumbilical or
subcostal but right lower quadrant still
commonest) and tenderness, rebound, and
guarding less obvious. Peritonitis can make the
uterus tense and woody-hard.
23. Leucocytosis is suggestive..
< 10,000 leucocyte may be
reassuring
Operative delay is dangerous.
Appendicitis is not diagnosed
in 1 in 5 cases in pregnant
women until the appendix has
ruptured causing peritonitis,
which can cause premature
labour or abortion.
24. Graded compression ultrasonography
accurate in 1st and 2nd trimesters
, difficult in 3rd.
98% ACCURATE.
25. Adnexal disorders requiring surgical intervention
occur in approximately one in 1000 pregnancies.
Ovarian masses may be problematic during
pregnancy because of their risk for
torsion, rupture, or hemorrhage.
large ovarian lesions may also become impacted in
the pelvis and even obstruct labor. While most
adnexal masses in pregnancy are functional cysts
that resolve by 18 weeks' gestation,
26. ultrasound. Simple cysts smaller than 6 cm are more likely
to be functional, but extremely large functional cysts may
sometimes be seen., also be used when adnexal torsion is
suspected.
Masses greater than 6 cm that persist should generally be
removed in the early second trimester to reduce the risk of
complications such as rupture, torsion, or hemorrhage.
Large masses that are symptomatic may sometimes
require earlier intervention
27. Conclusion
Remember that acute abdomen in
pregnant ady might be sillent