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.