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Inicio Cirugía Española (English Edition) Update on the Management of Non-obstetric Acute Abdomen in Pregnant Patients
Journal Information
Vol. 94. Issue 5.
Pages 257-265 (May 2016)
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2956
Vol. 94. Issue 5.
Pages 257-265 (May 2016)
Review Article
DOI: 10.1016/j.cireng.2016.05.001
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Update on the Management of Non-obstetric Acute Abdomen in Pregnant Patients
Actualización en el manejo del abdomen agudo no obstétrico en la paciente gestante
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Sebastián Barber-Milleta,
Corresponding author
sebarmi@hotmail.com

Corresponding author.
, José Bueno Lledób, Pablo Granero Castrob, Immaculada Gómez Gavarab, Neus Ballester Plab, Rafael García Domínguezb
a Servicio de Cirugía, Hospital Francesc de Borja, Gandía, Spain
b Servicio de Cirugía, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Figures (1)
Tables (3)
Table 1. Physiological Changes During Pregnancy.5
Table 2. Effects of Ionising Radiation on the Foetus in Different Stages of Development.
Table 3. Comparison of Studies in Pregnant Women With Non-obstetric Acute Abdomen.
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Abstract

Acute abdomen is a rare entity in the pregnant patient, with an incidence of one in 500–635 patients. Its appearance requires a quick response and an early diagnosis to treat the underlying disease and prevent maternal and foetal morbidity. Imaging tests are essential, due to clinical and laboratory masking in this subgroup. Appendicitis and complicated biliary pathology are the most frequent causes of non-obstetric acute abdomen in the pregnant patient. The decision to operate, the timing, and the surgical approach are essential for a correct management of this pathology. The aim of this paper is to perform a review and update on the diagnosis and treatment of non-obstetric acute abdomen in pregnancy.

Keywords:
Pregnancy
Acute abdomen
Appendicitis
Biliary pathology
Diagnosis
Resumen

En la paciente embarazada, el abdomen agudo es una entidad infrecuente, cuya incidencia es de una por cada 500-635 gestantes. Pero su aparición requiere una respuesta rápida y un diagnóstico temprano para tratar la enfermedad de base y evitar la morbimortalidad maternofetal. Las pruebas de imagen son fundamentales para ello, dado el enmascaramiento clínico y analítico en estas pacientes. La apendicitis y la enfermedad biliar complicada son las causas más frecuentes de abdomen agudo no obstétrico. La decisión de intervenir, la elección del momento y la vía de abordaje son esenciales para un correcto manejo de esta dolencia. El objetivo de esta publicación es realizar una revisión y puesta al día sobre el diagnóstico y tratamiento del abdomen agudo de origen no obstétrico en la paciente gestante.

Palabras clave:
Embarazo
Abdomen agudo
Apendicitis
Enfermedad biliar
Diagnóstico
Full Text
Introduction

In pregnant patients with any type of condition requiring surgery that does not affect the well-being of the mother or foetus, it is commonly accepted that surgery should be postponed until after childbirth.1 Some 0.2%–1% of expectant mothers, however, will require non-obstetric surgical interventions.2–4 The incidence of acute abdomen during pregnancy is one out of every 500–635 pregnancies2; acute appendicitis and complicated biliary disease are the 2 most frequent surgical emergencies.3

Gestation causes anatomical and physiological variations to women's bodies, which can result in atypical clinical manifestations of acute abdomen. As the gestational period progresses, the uterus increases in size: it is considered intraabdominal in the 12th week and umbilical in the 20th. Consequently, this modifies the normal distribution of the surrounding intraabdominal organs. The expanding uterus makes it difficult to locate pain points and could disguise pain intensity.4 The main physiological changes are summarised in Table 1.5 Meanwhile, the high prevalence of nausea, vomiting and abdominal discomfort in obstetric populations, together with the habitual indecision as whether to perform imaging tests, create difficulties in the evaluation of these patients.2,4

Table 1.

Physiological Changes During Pregnancy.5

Cardiovascular 
• ↑ Blood volume 
• ↓ Diastolic pressure in 1st–2nd trimester 
• ↑ Venous pressure in legs 
• ↓ Vascular resistances 
• ↓ Oncotic pressure (oedemas) 
 
Haematological 
• Physiological dilutional anaemia 
• Leukocytosis with left deviation (15000mL) 
• Hypercoagulability 
 
Respiratory 
• Diaphragm elevation 
• Decreased residual volume 
• Decreased functional residual capacity 
 
Gastrointestinal 
• Nausea and vomiting 
• ↓ Gastric acidity 
• ↓ Intestinal motility 
• Gallstones 
• Alkaline phosphatases ×1.5 
 
Urinary 
• Urethral dilatation and vesicoureteral reflux 
• ↑ Renal plasma flow 
• ↓ Creatinine, urea, uric acid and amino acids 
 
Endocrine 
• ↑ Insulin resistance 
• ↓ Albuminaemia 
• ↑ Basal metabolism (20%) 

The objective of this study is to review the most frequent causes of non-obstetric acute abdomen during pregnancy, with an emphasis on the diagnostic and therapeutic tools currently available. We conducted a bibliographic search of the literature in PubMed, using the keywords “acute abdomen”, “pregnancy”, “non-obstetric”, “imaging”, “diagnosis” and “treatment”, as well as several combinations of these terms. The definitive list of articles was chosen after having read the abstracts, at which time we selected those that were relevant for this review.

Diagnostic Imaging in Pregnant Patients With Acute Abdomen

Diagnostic problems in expectant mothers with acute abdomen are derived from the modifications in the baseline conditions of these patients, as previously stated. In addition to hyperthermia and functional leukocytosis, physical examination of the abdomen is made difficult by the progressive displacement of the intraabdominal organs with the expansion of the uterus, as occurs with the appendix.6

There is controversy about which diagnostic imaging test is ideal for pregnant patients with an acute abdomen. The risks and benefits of each of the methods should always be considered. There are 2 fundamental principles that should govern these cases. The first was coined by Cope in 1921: “Earlier diagnosis means better prognosis”.6 The second states that the first option is to always select the method that exposes the foetus to the lowest possible dose of radiation.4

Ultrasound

Due to both its efficacy and innocuity,3,7,8 ultrasound is universally accepted as the technique of choice in pregnancy and is, therefore, the first radiological examination done. It also provides elevated sensitivity and specificity in cases of acute abdomen, especially cholecystitis and appendicitis.2,3 Nonetheless, the efficacy of this test diminishes after week 32 because of the technical difficulties secondary to uterine growth. Moreover, appendiceal perforation can reduce the sensitivity of the test to 28.5%, which contrasts with the finding of non-complicated appendicitis (80.5%), or appendiceal adhesions (89%).9 If a diagnosis cannot be reached with ultrasound, the following step is to order other diagnostic imaging studies.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is an excellent diagnostic tool that presents a sensitivity and specificity of 91% and 85%, respectively.10 Since the advent of this technique, many studies have been done on pregnant women and there have been no demonstrated adverse effects on foetuses.7,8,11–14 Some authors have hypothesised about the noise, which could cause stress and excessive movement of the foetus, thereby affecting the quality of the images. This risk seem to be more theoretical than real.12,14,15

MRI surpasses some of the limitations of ultrasound, mainly those caused by the size of a pregnant uterus.8 As for the use of intravenous contrast with gadolinium, even though there have been no reported adverse effects after its administration,13,14 it is classified as category C by the US Food and Drug Administration, so its use should therefore be relegated to cases where it is considered essential and after having discussed the case with the radiologist and the risks and benefits with the patient.3,15,16

The main advantage of this test is that it does not subject the patient or the foetus to radiation. On the other hand, it is a test that is not available at all hospitals, nor is it always readily available. It is expensive and not always well tolerated due to the possible claustrophobic sensation and the discomfort generated by the noise.

Computed Tomography

Computed tomography (CT) usually reaches better diagnostic levels than ultrasound and MRI. It presents a sensitivity and specificity of up to 93% in cases of acute abdomen,17 although it poses the problem of the risk of malformations and carcinogenesis.

The well-known effects of radiation on the foetus, especially in the first weeks of gestation, make most physicians uncomfortable about its use in pregnant patients. Nonetheless, the literature does not support these fears. Estimated data for radiation dose thresholds and possible effects on the foetus in different stages of development are presented in Table 2.4 The accumulated radiation dose is the main risk factor, but the gestational age is also important.17,18 Foetal mortality rates are higher when the exposure occurs within the first week of conception.3 Furthermore, the ionising radiation could eventually increase the risk for the development of haematologic neoplasias in childhood.3,19 It has been indicated that the risk of malformations is insignificant at 5rad or less and that the risk for malformation significantly increases at doses above 15rad.4 It has therefore been recommended that the accumulated radiation dose in the embryo during pregnancy should be less than 5–10rad, and that no single diagnostic study should exceed 5rad.3,17 The typical exposure level for a CT scan is 2.5rad.4,20

Table 2.

Effects of Ionising Radiation on the Foetus in Different Stages of Development.

Gestational period  Effects  Radiation dose thresholds in rad 
Implantation: 0–2 weeks  Death  5–10 
Organogenesis: 2–8 weeks  Malformation
Delayed growth 
20
20–25 
Foetal period: 8–15 weeks  Mental retardation
Intellectual disability
Microcephaly 
6–50
↓ 25 points in intellectual quotient every 100
20 
Foetal period: 16–25 weeks  Mental retardation  2.5–2.8 

Thus, the use of CT is justified to make an early diagnosis, but only in cases of unclear diagnosis after ultrasound or if it is impossible to do an MRI.7,8,21 One CT scan in a pregnant patient does not exceed the radiation dose established as the safety threshold and can, in uncertain situations, avoid a delay in diagnosis that could be fatal for maternal/foetal prognosis.7,8,21

Simple Abdominal Radiograph

Given the greater efficacy of the aforementioned imaging tests, X-rays are currently not often used in the diagnosis of acute abdomen. They are useful, however, in cases of suspected obstruction, especially if caused by adhesions. Simple radiography can be used both for diagnosis as well as follow-up by spacing out the repetition of the test by several hours in order to observe the improvement, if any, of the radiological signs of obstruction. An abdominal X-ray involves a radiation exposure of 0.325rad.20

Surgical Treatment of Pregnant Patients With Acute Abdomen

The reason for the use of all the diagnostic tests available, including CT scan, is the evidence of worsening foetal prognosis as the intraabdominal infection advances. A delay in diagnosis is considered malpraxis as it would delay any possible indication for surgery. There are extensive and diverse reports in the literature about the time at which surgery should be indicated, anaesthesia risks and the choice of approach according to the weeks of gestation.

In general terms, we should avoid surgical interventions in expectant mothers.22–24 Although a greater incidence of malformations or miscarriages has not been demonstrated, there does seem to be more newborns with low birth weight as well as sudden infant deaths within the first 4 months of life.23,24 Contrarily, other authors defend the use of diagnostic laparoscopy, which they justify as a reasonable alternative to ionising radiation as it provides the ability to treat the patient at the time of diagnosis.25

There are several considerations to keep in mind during the intra- and postoperative management of pregnant patients when there is a need for emergency surgery. It is recommended to place the patient in a slightly left lateral decubitus position, which avoids compression of the uterus on the vena cava and, therefore, a drop in venous return that could result in hypotension in the mother and foetus. Thromboembolic prophylaxis is necessary because of the thrombophilic tendency of pregnancy itself. Compressive measures of the lower extremities and heparin are recommended by most specialists, as well as foetal monitoring and maternal capnography.3,22,26–34

Laparoscopic Approach

Initially, laparoscopy was contraindicated in pregnant patients, based on the risk for foetal hypoperfusion due to uterine compression caused by the pressure induced by intraabdominal CO2.3 Nonetheless, as surgeons gained experience in laparoscopic techniques, this fear diminished.25,35–37 In the 1990s, Gurbuz et al.35 presented their results of the treatment of non-obstetric abdominal pain during pregnancy, which concluded that laparoscopy is a safe technique that can be done at any time during pregnancy without any additional risk to the foetus in patients requiring urgent surgery. Reedy et al.25 compared the perinatal results of 2233 laparoscopies and 2491 laparotomies in pregnant women over a period of 20 years. Most of the surgeries were done during the first trimester. Their results showed a greater risk for low birth weight and premature labour in patients who had undergone surgery when compared with the national registry of full-term pregnancies without surgical intervention, but no differences were found in the rates of malformations or miscarriages. When the results were compared between the two approaches in the case of surgically treated patients, no significant differences were found for foetal morbidity either. In 2010, Corneille et al.38 presented a review of 94 pregnancies with surgery for non-obstetric acute abdomen (mainly cholecystitis and appendicitis): 53 underwent laparoscopy and 41 laparotomy. The authors concluded that both approaches presented similar results for morbidity and mortality and that the perinatal complications were independent of the technique employed. Disease severity was the factor with the greatest influence on prognosis.

Another subject for debate is the indication of the approach according to gestational age. Although it has been accepted that the second trimester is the best to reduce complications, other series demonstrate that laparoscopic surgery can be done during any trimester, with very low rates of maternal and foetal morbidity.3,25,27,28

As for the access to the abdominal cavity, although both the open (Hasson trocar) as well as the closed techniques (Veress needle) have been described as safe,1,3,26,28 there have been reports of cases with uterine injury using the closed technique.34 Open access therefore seems more recommendable.2,3,31

The CO2 used to create pneumoperitoneum is usually at pressure levels of 13–14mmHg in non-obstetric patients. During pregnancy, a gas pressure of 8–12mmHg avoids uterine hypoperfusion and maternal pulmonary complications3; some series, however, have demonstrated that the use of pressures of up to 15mmHg caused no injury to the mother or foetus.26,27

Most Frequent Causes of Non-obstetric Acute Abdomen in Pregnant Patients

Table 3 compares studies of pregnant women with non-obstetric acute abdomen. The most common causes are acute appendicitis and biliary disease, followed by bowel obstruction. With lower prevalence and in decreasing order of frequency, other causes include hernias, inflammatory bowel diseases, perforated ulcers, intraabdominal bleeding, tumours and abdominal pain of unknown aetiology. We will focus the remainder of this review on the 2 most prevalent causes.

Table 3.

Comparison of Studies in Pregnant Women With Non-obstetric Acute Abdomen.

Study  Year  No.  Gestational age (weeks)  Disease (number of patients)  Approach (number of patients)  Variables-primary objectives studied 
Reedy24  1997  3703  4–20  Acute abdomen, no specified cause  Laparoscopy 2181
Laparotomy 1522 
Miscarriage
Postoperative complications
Foetal growth
Preterm labour
Weight at birth
Malformations
Foetal mortality
Maternal mortality 
Gurbuz25  1997  47  1–38  Acute abdomen
Biliary disease 34
Appendicitis 9
Incarcerated hernia 2
Pelvic mass 2 
Laparoscopy 15
Laparotomy 8
Conservative 24 
Miscarriage
Postoperative complications
Congenital malformations
Preterm birth
Recurrence 
Glasgow55  1998  47  6–26  Biliary disease
Biliary colic 33
Cholecystitis 12
Pancreatitis 2 
Laparoscopy 14
Laparotomy 3
Conservative 47a 
Apgar
Postoperative complications
Hospitalisation
Preterm birth
Birth weight
Type of childbirth
Tocolytics
Recurrence 
Affleck29  1999  98  1–38  Acute abdomen
Appendicitis 40
Cholecystitis 58 
Laparoscopy 67
Laparotomy 31 
Miscarriages, postoperative complications
Malformations
Preterm birth
Foetal mortality
Maternal mortality 
Patel53  2002  50  6–27  Biliary disease (subclassification not specified)  Laparoscopy 8
Laparotomy 2
Conservative 40 
Postoperative complications
Hospitalisation
Birth weight
Type of childbirth
Recurrence
ER visit, hospitalisation 
Oelsner31  2003  389  1–38  Acute abdomen
Appendicitis 105
Cholecystitis 21
Adnexal 244
Other 19 
Laparoscopy 192
Laparotomy 197 
Miscarriage
Postoperative complications
Hospitalisation
Malformations
Preterm birth
Birth weight 
Rizzo27  2003  11  16–28  Acute abdomen
Biliary disease 6
Appendicitis 3
Subocclusion 2 
Laparoscopy  Miscarriage
Conversion
Malformations
Foetal monitoring
Preterm birth
Tocolytics 
Lu51  2004  78  22–37  Biliary disease
Biliary colic 43
Cholecystitis 20
Pancreatitis 12
Choledocholithiasis 3
 
Laparoscopy 6
Laparotomy 4
Conservative 68 
Miscarriage
Apgar
Postoperative complications
Tocolytics
Foetal mortality
Birth weight
Recurrence 
Chiappetta57  2009  122  24.6 (median)  Biliary disease
Biliary colic 55
Cholecystitis 41
Choledocholithiasis 18
Pancreatitis 8 
Laparoscopy 54
Conservativea 122 
Postoperative complications
Hospitalisation
Foetal mortality
Maternal mortality 
Kirshtein42  2009  42  5–25  Appendicitis  Laparoscopy 23
Laparotomy 19 
Miscarriage
Apgar
Postoperative complications
Conversion
Hospitalisation
Surgical time 
Corneille28  2010  94  8–24  Acute abdomen
Appendicitis 49
Cholecystitis 40
Salpingitis 5 
Laparoscopy 53
Laparotomy 41 
Miscarriage
Postoperative complications
Foetal mortality
Maternal mortality 
Hernández Estrada1  2011  10  15–25  Cholecystitis  Laparoscopy  Miscarriage
Postoperative complications
Hospitalisation
Foetal mortality
Maternal mortality
Tocolytics 
Othman52  2012  112  1–38  Biliary disease
Biliary colic 56
Pancreatitis 27
Cholecystitis 17
Choledocholithiasis 12 
Laparoscopy 31
ERCP 17
Conservative 68 
Apgar
Hospitalisation
Birth weight
Type of childbirth
Recurrence
ER visit, hospitalisations 
Chung34  2013  61  10–21  Appendicitis  Laparoscopy 22
Laparotomy 39 
Apgar
Postoperative complications
Foetal mortality
Maternal mortality
Preterm birth
Birth weight
Surgical time
Type of childbirth 
Peled45  2014  85  1–38  Appendicitis  Laparoscopy 26
Laparotomy 59
 
Miscarriage
Postoperative complications
Preterm birth
Foetal mortality 

ERCP: endoscopic retrograde cholangiopancreatography.

a

Start of conservative management in all patients.

Acute Appendicitis

Appendicitis is the most frequent cause of non-obstetric acute abdomen in pregnant women. The general prevalence is reportedly one for every 1500 pregnancies.39,40 Out of the total of acute appendix episodes, 40% appear during the second trimester of gestation.2,41

The location of the appendix may or may not be influenced by the expanding uterus, depending on the attachment of the caecum. If the appendix is retrocaecal, the displacement of the caecal pole may cause atypical symptoms, such as flank or dorsal pain, which may be confused with infection of the urinary tract or pyelonephritis.2

Pregnancy is not a risk factor for appendicitis. Nonetheless, pregnancy is associated with a higher rate of appendiceal perforation, which can reach 43%,4,38,42 which contrasts with the 19% observed in the general population.31,43 Foetal mortality is closely linked to perforation rates.2 Foetal loss rates with appendiceal perforation reach 20%–35%, which contrasts with 1.5% in cases of non-complicated appendicitis. It has been demonstrated that more than half of perforations occur due to diagnostic delay, which emphasises the importance of utilising the imaging tests necessary to reach a diagnosis. Thus, the rate of perforations is 66% in patients in whom the surgical delay is greater than 24h, while they practically do not exist in patients treated with surgery in the first 24h after the onset of symptoms.2 In addition to symptoms and laboratory testing,2–4 imaging studies are essential. Ultrasound should be done initially. If it is not conclusive, MRI can be used or even CT if necessary, but under no circumstance should the diagnosis be delayed for fear of ionising radiation.

Pregnant women with a diagnosis of appendicitis should be operated on immediately, regardless of the gestational age.31,44 Prospective studies have demonstrated that laparoscopy is the approach of choice as it provides the advantages of rapid recovery and less postoperative pain; it has become established as a safe and effective technique.3,26,27,31,43,45,46

Complicated Biliary Disease

Pregnancy is a situation prone to lithogenesis as a consequence of the hormonal changes and the delayed gallbladder emptying that these patients present.2,47,48 Biliary disease is the second most frequent cause for urgent non-obstetric surgery during pregnancy.1,4,49,50 Nonetheless, many expectant mothers do not present symptoms secondary to gallstones. This disease is more frequent in pregnant women than in non-pregnant women. The incidence in this subgroup is 0.05%–0.8%.4

The clinical symptoms that are most frequently observed are maintained biliary colic, cholecystitis, lithiasic pancreatitis and choledocholithiasis. These 4 entities are encompassed in the global term of symptomatic biliary disease. In pregnant women affected by this condition, the most frequent cause for surgical indication is maintained biliary colic (37.5%–70% of cases) followed by acute cholecystitis (20%–32%), choledocholithiasis (7%) and, finally, acute biliary pancreatitis (3%).51,52

Maintained Biliary Colic and Cholecystitis

The diagnostic imaging method used is abdominal ultrasound, which has a sensitivity of 80%–90% and a specificity of 88%–100% in the detection of morphological changes.2,4,53

For years, the treatment of symptomatic biliary disease in pregnancy involved conservative management and surgery was delayed until after childbirth in order to avoid foetal risks.48 However, several authors in recent years have refuted this therapeutic strategy. Lu et al.54 report a higher incidence of premature labour in patients with recurring biliary disease treated conservatively compared with those who undergo cholecystectomy. There is also an associated greater number of Emergency Room visits and hospitalisations.3,25,55 Furthermore, there is evidence that conservative management involves an important recurrence rate.3,48 The risk for recurrence is related with the trimester when symptoms appear. If the symptoms start in the first trimester of pregnancy, recurrence reaches 92%. In the second and third trimesters, the risk is 64% and 44%, respectively.3,49,50

Moreover, conservative treatment of symptomatic biliary disease increases the risk of the appearance of cholecystitis by 23%3 and biliary pancreatitis by 13%, which was observed to be associated with foetal death in 10%–20% of cases.2

Choledocholithiasis

The frequency of choledocholithiasis requiring treatment during pregnancy is one out of every 1200 pregnant women.2 Although cholangitis and pancreatitis secondary to choledocholithiasis are uncommon, they are conditions that can increase maternal/foetal morbidity and mortality.2,3

The suspected diagnosis is symptom-based, which usually includes jaundice, but the definitive diagnosis must once again involve diagnostic imaging. Although ultrasound usually shows us indirect signs, such as common bile duct dilatation, it is frequent for the lithiasis not to be visualised in the main bile duct. In these cases, MRI should be ordered for a correct and complete study of the biliary tree.

Once the diagnosis is confirmed, we should conduct an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. This procedure is safe during gestation, and it diminishes the postpartum recurrence rate of biliary symptoms.3,48,55,56 However, it does have a rate of complications of 7%–16%, mainly pancreatitis after manipulation, pre-term labour and post-sphincterotomy bleeding.56 To date, there are no clinical trials comparing the intraoperative exploration of the bile tract and ERCP followed by cholecystectomy in these patients. The few cases published about intraoperative exploration show good results.

Biliary Pancreatitis

Pancreatitis is usually mild and receptive to conservative treatment, just as in non-pregnant patients. Only in the case of acute or necrotising pancreatitis would emergency surgery be considered. Once the inflammatory symptoms of the pancreatic gland are resolved, we should opt for cholecystectomy.2 As previously stated, conservative management is linked to a high rate of recurrence, and pancreatitis can cause foetal death in 10%–20%2 or even up to 60% according to some authors.3

Treatment of Complicated Biliary Disease

Currently, most publications support surgical instead of conservative management for symptomatic biliary disease during pregnancy. However, not all authors concur about which moment is ideal. Although some defend its use at any time,51,57–59 others prefer surgical intervention during the second trimester as it is the safest and most technically feasible.48,52 Meanwhile, others prefer conducting percutaneous cholecystostomy in cases with acute cholecystitis and delaying surgery until after childbirth.3

To date, laparoscopy has repeatedly demonstrated its advantages over open techniques. It can be done during any trimester of pregnancy, it is safe for both the mother and foetus2,3,51,52,57–59 and, although at the end of the third trimester it can be somewhat more difficult, it does not interfere with visualisation of the surgical field.1 The rate of miscarriages and premature labour is lower with laparoscopic cholecystectomy than with laparotomy.3

The therapeutic algorithm for biliary disease in pregnant women is summarised in Fig. 1.

Fig. 1.

Therapeutic algorithm for biliary disease during pregnancy.

(0.15MB).
Postoperative Pain Control

Several consensus groups have proposed the analgesia scale of the World Health Organisation for the initial pharmacological approach of acute postoperative pain.60

Postsurgical pain is a trigger for uterine activity, and its optimal management is therefore important. Although some physicians have used progesterone as a tocolytic to prevent post-op uterine irritability and the resulting risk of premature labour, the efficacy of this measure has not been demonstrated.61

Non-opioid analgesics are the most extensively used. Specifically, there is a generalised use of paracetamol and metamizole, as they have demonstrated no harmful effects on the foetus or newborn. Non-steroid anti-inflammatory drugs, such as dexketoprofen or ibuprofen, are also safe, although their use is not recommended after week 32 of gestation because they can cause closure of the ductus arteriosus.62,63

Opioid analgesia can be used in cases with poor pain control in spite of the non-opioid analgesia. Fentanyl, morphine and hydromorphine are safe alternatives. Oral oxycodone is another option. Nonetheless, it seems that their use in the weeks prior to childbirth can lead to neonatal abstinence syndrome.62,63

Recently, locoregional techniques are gaining in popularity (in these cases, either epidural or intradural) versus systemic analgesia because they have fewer reactions with the foetus and present fewer adverse effects for the mother.64

Conclusion

Acute abdomen in pregnant patients is challenging for surgeons. It is of vital importance to reach an early, correct diagnosis supported by the complementary tests necessary to be able to make a therapeutic decision for optimal patient management.

Although surgery may have some risk for low birth weight or premature death, the literature supports its use as any delay could involve a much greater risk for loss of the foetus.

Appendicitis and cholecystitis are the first causes of non-obstetric surgical abdomen during pregnancy. In both cases, the laparoscopic technique has been shown to be at least as safe as laparotomy, and it is associated with faster recovery and shorter hospitalisation. The conservative management of biliary disease is associated with high rates of recurrence. Cholecystectomy is unanimously supported in the second trimester. At other times of the pregnancy, it can be as valid as ERCP (for choledocholithiasis) or cholecystostomy (for cholecystitis) and later postpartum cholecystectomy.

Conflict of Interests

The authors have no conflict of interests to declare.

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References
[1]
A.I. Hernández Estrada, X. Aguirre Osete, L.A. Pedraza González.
Laparoscopic cholecystectomy in pregnancy. Five years experience at the Spanish Hospital of Mexico and literature review.
Ginecol Obstet Mex, 79 (2011), pp. 200-205
[2]
G. Augustin, M. Majerovic.
Non-obstetrical acute abdomen during pregnancy.
Eur J Obstet Gynecol Reprod Biol, 131 (2007), pp. 4-12
[3]
J. Pearl, R. Price, W. Richardson, R. Fanelli.
Society of American Gastrointestinal Endoscopic Surgeons. Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy.
Surg Endosc, 25 (2011), pp. 3479-3492
[4]
L. Diegelmann.
Nonobstetric abdominal pain and surgical emergencies in pregnancy.
Emerg Med Clin North Am, 30 (2012), pp. 885-901
[5]
P. Pérez Tejada, A. Cohen, I. Font, C. Bermúdez, J. Schuitemaker.
Modificaciones fisiológicas del embarazo e implicaciones farmacológicas.
Rev Obstet Ginecol Venez, 67 (2007), pp. 246-247
[6]
J. Baer, R. Reis, R. Arens.
Appendicitis in pregnancy with changes in position and axis of the normal appendix in pregnancy.
JAMA, 98 (1932), pp. 1359-1364
[7]
M. Karul, C. Berliner, S. Keller, T.Y. Tsui, J. Yamamura.
Imaging of appendicitis in adults.
Rofo, 186 (2014), pp. 551-558
[8]
G. Masselli, R. Brunelli, R. Monti, M. Guida, F. Laghi, E. Casciani, et al.
Imaging for acute pelvic pain in pregnancy.
Insights Imaging, 5 (2014), pp. 165-181
[9]
J.B. Puylaert, P.H. Rutgers, R.I. Lalisang.
A prospective study of ultrasonography in the diagnosis of appendicitis.
N Engl J Med, 317 (1987), pp. 666-669
[10]
K.T. Baron, E.K. Arleo, C. Robinson, P.C. Sanelli.
Comparing the diagnostic performance of MRI versus CT in the evaluation of acute nontraumatic abdominal pain during pregnancy.
Emerg Radiol, 19 (2012), pp. 519-525
[11]
J.P. De Wilde, A.W. Rivers, D.L. Price.
A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus.
Prog Biophys Mol Biol, 87 (2005), pp. 335-353
[12]
J.R. Leyendecker, V. Gorengaut, J.J. Brown.
MR imaging of maternal diseases of the abdomen and pelvis during pregnancy and the immediate pospartum period.
Radiographics, 24 (2004), pp. 1301-1316
[13]
D.S. Katz, M.A. Klein, G. Ganson, J.J. Hines.
Imaging of abdominal pain in pregnancy.
Radiol Clin North Am, 50 (2012), pp. 149-171
[14]
S.J. Patel, D.L. Reede, D.S. Katz, R. Subramaniam, J.K. Amorosa.
Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations.
Radiographics, 27 (2007), pp. 1705-1722
[15]
M.M. Chen, F.V. Coakley, A. Kaimal, RK Laros Jr..
Guidelines for computed tomography and magnetic resonance imaging use during pregnancy and lactation.
Obstet Gynecol, 112 (2008), pp. 333-340
[16]
K.R. Birchard, M.A. Brown, W.B. Hyslop, Z. Firat, R.C. Semelka.
MRI of acute abdominal and pelvic pain in pregnant patients.
Am J Roentgenol, 184 (2005), pp. 452-458
[17]
J.K. Timmins.
Radiation during pregnancy.
N J Med, 98 (2001), pp. 29-33
[18]
K.S. Toppenberg, D.A. Hill, D.P. Miller.
Safety of radiographic imaging during pregnancy.
Am Fam Physician, 59 (1999), pp. 1813-1820
[19]
L.M. Hurwitz, T. Yoshizumi, R.E. Reiman, P.C. Goodman, E.K. Paulson, D.P. Frush, et al.
Radiation dose to the fetus from body MDCT during early gestation.
Am J Roentgenol, 186 (2006), pp. 871-876
[20]
E. Lazarus.
Utilization of imaging in pregnant patients: 10-year review of 5270 examinations in 3285 patients – 1997–2006.
Radiology, 251 (2009), pp. 517-524
[21]
A. Khandelwal, N. Fasih, A. Kielar.
Imaging of acute abdomen in pregnancy.
Radiol Clin North Am, 51 (2013), pp. 1005-1022
[22]
R.I. Mazze, B. Kallen.
Reproductive outcome after anesthesia and operation during pregnancy: a registry of 5405 cases.
Am J Obstet Gynecol, 161 (1989), pp. 1178-1185
[23]
C.C. Kilpatrik, M. Monga.
Approach to the acute abdomen in pregnancy.
Obstet Gynecol Clin North Am, 34 (2007), pp. 389-402
[24]
D.M. Moaveni, D.J. Birnbach, J.S. Ranasinghe, S.Y. Yasin.
Fetal assessment for anesthesiologists: are you evaluating the other patient?.
Anesth Analg, 116 (2013), pp. 1278-1292
[25]
M.B. Reedy, B. Kallen, T.J. Kuelh.
Laparoscopy during pregnancy: a study of 5 fetal outcome parameters with use of the Swedish Health Registry.
Am J Obstet Gynecol, 177 (1997), pp. 673-679
[26]
D. Affleck, D. Handrahan, M. Egger, R. Price.
The laparoscopic management of appendicitis and cholelithiasis during pregnancy.
Am J Surg, 178 (1999), pp. 524-528
[27]
M.D. Rollins, K.J. Chan, R.R. Price.
Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new standard of care.
Surg Endosc, 18 (2004), pp. 237-241
[28]
G. Oelsner, D. Stockheim, D. Soriano, M. Goldenberg, D.S. Seidman, S.B. Cohen, et al.
Pregnancy outcome after laparoscopy or laparotomy in pregnancy.
J Am Assoc Gynecol Laparosc, 10 (2003), pp. 200-204
[29]
Obstetrics: normal and problem pregnancies, pp. 63-91
[30]
J.D. Friedman, P.S. Ramsey, K.D. Ramin, C. Berry.
Pneumoamonion and pregnancy loss after second-trimester laparoscopic surgery.
Obstet Gynecol, 99 (2002), pp. 512-513
[31]
J.C. Chung, G.S. Cho, E.J. Shin, H.C. Kim, O.P. Song.
Clinical outcomes compared between laparoscopic and open appendectomy in pregnant women.
Can J Surg, 56 (2013), pp. 341-346
[32]
M.A. Malangoni.
Gastrointestinal surgery and pregnancy.
Gastroenterol Clin North Am, 32 (2003), pp. 181-200
[33]
D.M. Melnick, W.L. Wahl, V.K. Dalton.
Management of general surgical problems in the pregnant patient.
Am J Surg, 187 (2004), pp. 170-180
[34]
H.L. Casele.
The use of unfractionated heparin and low molecular weight heparins in pregnancy.
Clin Obstetr Gynecol, 49 (2006), pp. 895-905
[35]
A.T. Gurbuz, M.E. Peetz.
The acute abdomen in the pregnant patient. Is there a role for laparoscopy?.
Surg Endosc, 11 (1997), pp. 98-102
[36]
M. Fatum, N. Rojansky.
Laparoscopic surgery during pregnancy.
Obstet Gynecol Surg, 56 (2001), pp. 50-59
[37]
A.G. Rizzo.
Laparoscopic surgery in pregnancy: long-term follow-up.
J Laparoendosc Adv Surg Tech, 13 (2007), pp. 11-15
[38]
M.G. Corneille, T.M. Gallup, T. Bening, S.E. Wolf, C. Brougher, J.G. Myers, et al.
The use of laparoscopic surgery in pregnancy: evaluation of safety and efficacy.
Am J Surg, 200 (2010), pp. 363-367
[39]
W. Kammerer.
Nonobstetric surgery during pregnancy.
Med Clin North Am, 63 (1979), pp. 1157-1164
[40]
A. Babaknia, H. Parsa, J.D. Woodruff.
Appendicitis during pregnancy.
Obstet Gynecol, 50 (1977), pp. 40-44
[41]
D. Murariu, B. Tatsuno, C.A. Hirai, R. Takamori.
Case report and management of suspected acute appendicitis.
Hawaii Med J, 70 (2011), pp. 30-32
[42]
N.B. Gilo, D. Amini, H.J. Landy.
Appendicitis and cholecystitis in pregnancy.
Clin Obstet Gynecol, 52 (2009), pp. 586-596
[43]
B. Kirshtein, Z.H. Perry, E. Avinoach, S. Mizrahi, L. Lantsberg.
Safety of laparoscopic appendectomy during pregnancy.
World J Surg, 33 (2009), pp. 475-480
[44]
M.L. McGory, D.S. Zingmond, A. Tillou, J.R. Hiatt, C.Y. Ko, H.M. Cryer, et al.
Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss.
J Am Coll Surg, 205 (2007), pp. 534-540
[45]
J.R. Korndorffer Jr., E. Fellinger, W. Reed.
SAGES guideline for laparoscopic appendectomy.
Surg Endosc, 24 (2010), pp. 757-761
[46]
Y. Peled, L. Hiersch, O. Khalpari, A. Wiznitzer, Y. Yogev, J. Pardo.
Appendectomy during pregnancy – is pregnancy outcome depending by operation technique.
J Matern Fetal Neonatal Med, 27 (2014), pp. 365-367
[47]
C.W. Ko.
Risk factors for gallstone-related hospitalization during pregnancy and the pospartum.
Am J Gastroenterol, 101 (2006), pp. 2263-2268
[48]
A. Veerappan, A.J. Gawron, N.J. Soper, R.N. Keswani.
Delaying cholecystectomy for complicated gallstone disease in pregnancy is associated with recurrent postpartum symptoms.
J Gastrointest Surg, 17 (2013), pp. 1953-1959
[49]
S.G. Swisher, K.K. Hunt, P.J. Schmit, D.T. Hiyama, R.S. Bennion, J.E. Thompson.
Biliary disease during pregnancy.
Am J Surg, 168 (1994), pp. 576-581
[50]
R.S. Date, M. Kaushal, A. Ramesh.
A review of the management of gallstone disease and its complications in pregnancy.
Am J Surg, 196 (2008), pp. 599-608
[51]
E. Ghumman, M. Barry, P.A. Grace.
Management of gallstones in pregnancy.
Br J Sur, 84 (1997), pp. 1646-1650
[52]
L.T. Chiappetta Porras, E.D. Nápoli, C.M. Canullán, B.M. Quesada, H.E. Roff, J. Alvarez Rodríguez, et al.
Minimally invasive management of acute biliary tract disease during pregnancy.
HPB Surg, (2009),
[53]
J.Y. Tseng, M.J. Yang, C.C. Yang, K.C. Chao, H.Y. Li.
Acute cholecystitis during pregnancy: what is the best approach?.
Taiwan J Obstet Gynecol, 48 (2009), pp. 305-307
[54]
E.J. Lu, M.J. Curet, Y.Y. El-Sayed, K.S. Kirkwood.
Medical versus surgical management of biliary tract disease in pregnancy.
Am J Surg, 188 (2004), pp. 755-759
[55]
M.O. Othman, E. Stone, M. Hashimi, G. Parasher.
Conservative management of cholelitiasis in pregnancy is associated with recurrent symptoms and more emergency department visits.
Gastrointest Endosc, 76 (2012), pp. 564-569
[56]
V.H. Chong, A. Jalihal.
Endoscopic management of biliary disorders during pregnancy.
Hepatobiliary Pancreat Dis Int, 9 (2010), pp. 180-185
[57]
S.G. Patel, T.J. Veverka.
Laparoscopic cholecystectomy in pregnancy.
Curr Surg, 59 (2002), pp. 74-78
[58]
B.J. Eichenberg, J. Vanderlinden, C. Miguel, C. Bianchi, A. Robles, R. McLarty, et al.
Laparoscopic cholecystectomy in the third trimester of pregnancy.
Am J Surg, 62 (1996), pp. 874-877
[59]
R.E. Glasgow.
Changing management of gallstone disease during pregnancy.
Surg Endosc, 12 (1998), pp. 241-246
[60]
A. Covarrubias-Gómez, A. Silva-Jiménez, E. Nuche-Cabrera, M. Téllez-Isaías.
El manejo del dolor postoperatorio en obstetricia ¿Es seguro?.
Rev Mex Anest, 29 (2006), pp. 231-239
[61]
K.R. Niswander.
Obstetrics essentials of clinical practice.
2nd ed., Editorial Reverté S.A., (1987),
[62]
P. Parrilla, J.I. Landa.
Cirugía AEC.
2nd ed., Editorial Médica Panamericana, S.A., (2010),
[63]
L.M. Torres.
Tratado de cuidados críticos y urgencias.
Arán Ediciones S.L., (2001),
[64]
N.I. Socha-García, J.C. Gómez-Morant, E. Holguín-González.
Cirugía no obstétrica durante el embarazo.
Rev Col Anest, 39 (2011), pp. 360-373

Please cite this article as: Barber-Millet S, Bueno Lledó J, Granero Castro P, Gómez Gavara I, Ballester Pla N, García Domínguez R. Actualización en el manejo del abdomen agudo no obstétrico en la paciente gestante. Cir Esp. 2016;94:257–265.

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