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Acute Abdominal Emergencies Associated with Pregnancy

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in pregnancy increases 30 50%, peaking late in the second trimester, with output ... UTERINE ATONY. postpartum hemorrhage are due to uterine atony ... – PowerPoint PPT presentation

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Title: Acute Abdominal Emergencies Associated with Pregnancy


1
Acute Abdominal Emergencies Associated with
Pregnancy
  • STONE, KEITH MD
  • Clinical obstetrisc and gynecology
  • Volume 45(2)  ,June 2002 , pp 553-561
  • Command ???
  • Report ???

2
Maternal Physiology
  • Cardiac output
  • in pregnancy increases 3050, peaking late in
    the second trimester, with output directed
    primarily to the uterus , KIDNEY, skin
  • BP
  • 5- to 10-mm Hg decrease in systolic pressure
  • 10- to 20-mm Hg decrease in diastolic pressure
  • HR
  • increase in the resting pulse 10 to 15 beats per
    minute over baseline.

3
  • Position
  • avoid the supine position, especially after 20
    weeks' gestation, left side tilt is prefered.
  • physiologic hypervolemia
  • makes the pregnant patient much less likely to
    show signs of hypovolemia until perhaps 3050 of
    blood volume has been lost
  • Anemia, hypercoagulate state

4
  • Respiratory
  • hyperventilation, maternal Pco2 is decreased and
    maternal Pco2 is increased
  • Digestive changes
  • gastroesophageal reflux , constipation
  • appendicitis is no more common in pregnancy, the
    death and complication rates of this condition
    are increased due to delay
  • increases the risk of cholecystitis (due to
    progesterone)

5
Fetal Physiology/Development
  • first trimester
  • avoid exposure to potentially teratogenic agents
  • maxim that indicated elective surgery be
    postponed until the second trimester
  • regional anesthesia is preferred
  • decision to obtain radiographic studies should be
    based on whether they are indicated
  • Most common radiographic studies involve fetal
    irradiation doses of 1 cGy or less. Direct
    irradiation to the fetus of 10 cGy or more is
    associated with adverse effects

6
  • Antibiotics following should be avoided
  • Gentamicin , (risk small)
  • Tetracyclines ,( bone, teeth)
  • fluoroquinolones (cartilage)
  • Fetal heart rate
  • Monitor is important, 120160 beats per minute

7
Surgical Conditions
  • APPENDICITIS
  • cephalad repositioning from the region of
    McBurney's point at 12 weeks
  • appendicitis is confirmed in 3650 of cases
  • more than 40 of patients who undergo
    appendectomy in the second and third trimester
    have a normal appendix
  • A fetal loss rate of 35 is observed with an
    unruptured appendix this rate increases up to
    20 if the appendix is ruptured
  • R/O APN, UTI, ovarian tumor

8
CHOLECYSTITIS/CHOLELITHIASIS
  • Symptoms commonly associated with gallbladder
    disease include nausea, vomiting, and epigastric
    or right upper quadrant pain.
  • Sonography is 9698 sensitive and specific for
    cholelithiasis
  • elevated conjugated bilirubin, alkaline
    phosphatase, and/or transaminase level
  • OP indication
  • recurrent attacks of biliary colic, acute
    cholecystitis, and obstructive cholelithiasis
    should be managed with cholecystectomy,
    preferably laparoscopically and preferably in the
    second trimester

9
BOWEL OBSTRUCTION
  • Most commonly caused by adhesions, bowel
    obstruction in pregnancy may also be a
    consequence of volvulus.
  • OP indication
  • tachycardia, and progressing leukocytosis, in
    association with abdominal pain and tenderness,
    warrant early surgical exploration.
  • Indications for cesarean section fetal distress
    or inability

10
Gastrointestinal surgical conditions during
pregnancy
Sharp HT.. Clin Obstet Gynecol. 1994 37306315
  • 66 pregnant patients undergoing exploration for
    bowel obstruction
  • 23 required bowel resection and the fetal death
    rate was 26
  • four maternal deaths were recorded

11
TRAUMA
  • primary cause
  • motor vehicle accidents
  • Unrestrained women
  • maternal death rates of 33 and fetal death rates
    of 47 and higher
  • Anatomic alterations
  • displace the bowel into the upper abdomen
  • increases the risk of retroperitoneal hemorrhage
    in the pelvis

12
  • placenta (abruptio placentae)
  • in 4050 of life-threatening injuries
  • uterine rupture.
  • in 0.6 of all injuries during pregnancy
  • Direct fetal injury
  • fetal skull and brain when pelvic fracture occurs
    in association with an engaged cephalic
    presentation.
  • penetrating trauma
  • perinatal death rate is 4771
  • rarely associated with maternal death

13
survey
  • Ultrasonography
  • fetal gestational age, fetal heart activity,
    fetal activity, and amniotic fluid volume
  • maternal intraperitoneal fluid, suggesting
    intraperitoneal hemorrhage
  • suspicion for abruptio placentae
  • The presence of uterine contractions
  • fetal monitoring may be performed for at least 4
    hours and then can be discontinued

14
  • peritoneal lavage indication
  • altered sensorium, unexplained shock, multiple
    thoracic injuries, or major orthopedic injuries
  • laparotomy is advised for gunshot wounds to the
    abdomen in pregnancy.
  • Rarely, selective observation may be entertained
    in a pregnant patient with a gunshot wound to the
    anterior abdomen in a subfundal location, with
    imaging studies showing the bullet has not
    crossed the posterior uterine wall.
  • Laparotomy for maternal indications is not an
    indication for a cesarean section

15
Kleihauer-Betke test
  • assess the level of fetal-maternal hemorrhage in
    Rh-negative mothers, allowing a more accurate
    determination of the amount of Rh immunoglobulin
    to administer
  • One ampule of 300 mg D-immunoglobulin protects
    against hemorrhage of less than 30 mL
  • D-immunoglobulin to all sensitized D-negative
    pregnant patients evaluated for abdominal trauma
  • tetanus toxoid (0.5 mL) if there has been no
    booster in 5 years

16
Perimortem cesarean
  • 75 of surviving infants had been delivered
    within 5 minutes and were neurologically intact
  • Four minutes of resuscitation and one minute to
    deliver the infant results in the 5-minute
    rule.

17
Uterine Emergencies
  • UTERINE ATONY
  • postpartum hemorrhage are due to uterine atony
  • multiple gestation, polyhydramnios, and
    macrosomia
  • diagnosis is easily made by palpating a boggy
    uterus in association with steady, usually
    significant blood loss

18
  • Management
  • medical
  • 20 to 60 units oxytocin in lactated Ringer's at
    200 to 500 mL per hour.
  • If bleeding persists, methylergonovine
    (Methergine) may be given intramuscularly at a
    dose of 0.2 mg
  • 15-methyl prostaglandin F2-alpha (PGF2a) as 0.25
    mg intramuscularly or intramyometrially every 15
    to 60 minutes (maximum 8 doses). Watch out for
    asthma.
  • Surgical
  • selective ligation of the ascending uterine
    arteries

19
UTERINE RUPTURE
  • association with
  • automobile accident in which the pregnant
    patient is not restrained and results in fetal
    death rates approaching 100 and maternal death
    rates approaching 10
  • C/S indication
  • Fetal bradycardia or severe decelerations if
    fetus (23 weeks or beyond).
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