ACUTE ABDOMEN

DISORDERS IN PREGNANCY

Gastrointestinal

disorders

•

The most common during pregnancy –

acute

appendictitis.

•

Pregnancy often makes the diagnosis of appendictitis

more difficult for the following reasons:

1. Anorexia, nausea, and vomiting that accompany

normal pregnancy are olso common symptoms of

appendictitis.

2. As the uterus enlarges, the appendix commonly

moves upward and outward toward the flank, so that

pain and tenderness may not be prominent in the

right lower quadrant

3. Some degree of leukocytosis is the rule during normal

pregnancy

4. Appendictitis may be confused with preterm labor,

pyelonephritis, renal colic, placental abruption,

degeneration of a uterine myoma

5. Pregnant women, especially those in late gestation,

frequantly do not have symptoms considered

„typical” for appendictitis

Acute appendictitis

•

Diagnosis – persistent abdominal pain and tenderness

•

Management – if appendictitis is suspected, treatment

is prompt surgical exploration, even if diagnostic errors

sometimes lead to removal of normal appendix, it is

better to operate than to postpone intervention until

generalized peritonitis develops

•

Diagnostic laparoscopy in the first half of pregnancy

is the norm, if laparotomy is chosen most practitioners

prefer an incision over the McBurney point

•

Before exploration, intravenous antimicrobial therapy

is begun, usually with a second-generation of

cephalosporin or third-generation penicillin.

•

Uterine contractions are common, but tocolysis is not

nessesary

•

If appendictitis is undiagnosed before delivery often

after the large uterus rapidly epties, walled-off infection

is disrupted causing an acute surgical abdomen

Effects on pregnancy

• Appendictitis increases the likelyhood

of abortion or preterm labor,
especially when there is peritonitis

Cholelithiasis and

cholecystitis

• Gallbladder disease during pregnancy – there

is no doubt that pregnancy is

lithogenic

and

increases the risk of gallstones

• After the first trimester both gallbladder

volume during fasting and residual volume

after contracting in response to a meal are

doubled

• Incomplete emptying may result in retension

of cholesterol crystals, and prerequisite for

cholesterol gallstones

• Biliary sludge, which can be a forerunner to

gallstones, develops in 30% women during

pregnancy

Management

• Symptomatic cholecystitis is intially managed

in a manner similar to that for nonpregnant

women.

• Nowadys there is a trend to favoring surgical

therapy, if treated conservatively, there is a

high reccurance rate during the same

pregnancy. Moreover, if cholecystitis recurs

later in gestation, preterm labor is more likely

and cholecystectomy more difficult technically.

• Laparoscopic surgery is as equally acceptable

as open cholecystectomy

Endoscopic retrograde

cholangiopancreatography

• Relief in biliary duct gallstones during

pregnancy has been greatly facilitated

by ERCP.It is performed when common

duct obstruction is suspected

• It has become commonplace to

perform endoscopic sphincterotomy

and gallstone extraction to be

followed in a few days by laparoscopic

cholecystectomy,

especially with

associated biliary pancreatitis.

Asymptomatic gallstones in

pregnancy

• The incidance is 2.5-10%
• Cholecystectomy is not indicated for

silent stones