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      Management of acute abdomen in pregnancy: current perspectives

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          Abstract

          Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.

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          Pregnancy-related mortality in the United States, 1998 to 2005.

          Cynthia Berg, William Callaghan, Carla Syverson … (2010)
          To estimate the risk of women dying from pregnancy complications in the United States and to examine the risk factors for and changes in the medical causes of these deaths. De-identified copies of death certificates for women who died during or within 1 year of pregnancy and matching birth or fetal death certificates for 1998 through 2005 were received by the Pregnancy Mortality Surveillance System from the 50 states, New York City, and Washington, DC. Causes of death and factors associated with them were identified, and pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births) were calculated. The aggregate pregnancy-related mortality ratio for the 8-year period was 14.5 per 100,000 live births, which is higher than any period in the previous 20 years of the Pregnancy Mortality Surveillance System. African-American women continued to have a three- to four-fold higher risk of pregnancy-related death. The proportion of deaths attributable to hemorrhage and hypertensive disorders declined from previous years, whereas the proportion from medical conditions, particularly cardiovascular, increased. Seven causes of death--hemorrhage, thrombotic pulmonary embolism, infection, hypertensive disorders of pregnancy, cardiomyopathy, cardiovascular conditions, and noncardiovascular medical conditions--each contributed 10% to 13% of deaths. The reasons for the reported increase in pregnancy-related mortality are unclear; possible factors include an increase in the risk of women dying, changed coding with the International Classification of Diseases, 10th Revision, and the addition by states of pregnancy checkboxes to the death certificate. State-based maternal death reviews and maternal quality collaboratives have the potential to identify deaths, review the factors associated with them, and take action on the findings.
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            Radiation exposure and pregnancy: when should we be concerned?

            Cynthia McCollough, Beth A Schueler, Thomas D Atwell … (2015)
            The potential biological effects of in utero radiation exposure of a developing fetus include prenatal death, intrauterine growth restriction, small head size, mental retardation, organ malformation, and childhood cancer. The risk of each effect depends on the gestational age at the time of exposure, fetal cellular repair mechanisms, and the absorbed radiation dose level. A comparison between the dose levels associated with each of these risks and the estimated fetal doses from typical radiologic examinations lends support to the conclusion that fetal risks are minimal and, therefore, that radiologic and nuclear medicine examinations that may provide significant diagnostic information should not be withheld from pregnant women. The latter position is advocated by the International Commission on Radiological Protection, National Council on Radiation Protection, American College of Radiology, and American College of Obstetrics and Gynecology. However, although the risks are small, it is important to ensure that radiation doses are kept as low as reasonably achievable. RSNA, 2007
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              Guidelines for computed tomography and magnetic resonance imaging use during pregnancy and lactation.

              R K Laros, Anjali Kaimal, Fergus Coakley … (2008)
              There has been a substantial increase in the use of computed tomography (CT) and magnetic resonance imaging (MRI) in pregnancy and lactation. Among some physicians and patients, however, there are misperceptions regarding risks, safety, and appropriate use of these modalities in pregnancy. We have developed a set of evidence-based guidelines for the use of CT, MRI, and contrast media during pregnancy for selected indications including suspected acute appendicitis, pulmonary embolism, renal colic, trauma, and cephalopelvic disproportion. Ultrasonography is the initial modality of choice for suspected appendicitis, but if the ultrasound examination is negative, MRI or CT can be obtained. Computed tomography should be the initial diagnostic imaging modality for suspected pulmonary embolism. Ultrasonography should be the initial study of choice for suspected renal colic. Ultrasonography can be the initial imaging evaluation for trauma, but CT should be performed if serious injury is suspected. Pelvimetry now is used rarely for suspected cephalopelvic disproportion, but when required, low-dose CT pelvimetry can be performed with minimal risk. Although iodinated contrast seems safe to use in pregnancy, intravenous gadolinium is contraindicated and should be used only when absolutely essential. It seems to be safe to continue breast-feeding immediately after receiving iodinated contrast or gadolinium. Although teratogenesis is not a major concern after exposure to prenatal diagnostic radiation, carcinogenesis is a potential risk. When used appropriately, CT and MRI can be valuable tools in imaging pregnant and lactating women; risks and benefits always should be considered and discussed with patients.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Int J Womens Health
                Journal ID (iso-abbrev): Int J Womens Health
                Journal ID (publisher-id): International Journal of Women’s Health
                Title: International Journal of Women's Health
                Publisher: Dove Medical Press
                ISSN (Electronic): 1179-1411
                Publication date Collection: 2019
                Publication date (Electronic): 08 February 2019
                Volume: 11
                Pages: 119-134
                Affiliations
                [1 ]Department of General, Gastrointestinal & Laparoscopic Surgery, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India, skzach@ 123456yahoo.com
                [2 ]Department of Obstetrics and Gynecology, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India
                [3 ]Department of Obstetrics and Gynecology, Sultan Qaboos Hospital, Salalah PO 601, Oman
                Author notes
                Correspondence: Sanoop Koshy Zachariah, Department of General, Gastrointestinal & Laparoscopic Surgery, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India, Tel +91 944 730 9299, Email skzach@ 123456yahoo.com
                Article
                Publisher ID: ijwh-11-119
                DOI: 10.2147/IJWH.S151501
                PMC ID: 6371947
                PubMed ID: 30804686
                SO-VID: dd01e2df-fc4d-4b9a-ac23-e56c0b1f3db3
                Copyright © © 2019 Zachariah et al. This work is published and licensed by Dove Medical Press Limited
                License:

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Subject: Review

                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: ectopic pregnancy,rupture uterus,abdominal pain,appendicitis,cholecystitis,acute abdomen,pregnancy
                Data availability:
                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: ectopic pregnancy, rupture uterus, abdominal pain, appendicitis, cholecystitis, acute abdomen, pregnancy

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