Summary
Diagnostic challenges and pitfalls
Urgent Considerations
Obstetric emergencies
- The danger to the mother depends on the severity of the abruption, whereas the risk to the fetus is related to both the severity of the abruption and the gestational age at which the abruption occurs. As well as causing hemorrhage, it may lead to disseminated intravascular coagulation (DIC). In cases where the abruption is severe and both maternal and fetal wellbeing are compromised, urgent delivery of the fetus is indicated, usually by cesarean section.
- An obstetric catastrophe that can lead to massive intra-abdominal hemorrhage, maternal mortality, and fetal death. The initial signs and symptoms may be nonspecific, making diagnosis difficult and delaying vital life-saving surgery. As timing is critical, the diagnosis of a ruptured uterus is usually based on clinical findings. An urgent cesarean section is required to deliver the fetus and repair the uterus. A hysterectomy may be considered in cases of severe intractable uterine bleeding or extensive uterine damage.
- If undiagnosed or incorrectly managed, may lead to maternal death due to rupture of the implantation site and intraperitoneal hemorrhage. Patients with a positive urine pregnancy test and the absence of an intrauterine pregnancy on transvaginal ultrasound are considered to have an ectopic pregnancy until proven otherwise. Urgent laparoscopy with salpingectomy or salpingotomy is performed for a ruptured ectopic pregnancy.
- In cases of HELLP syndrome, maternal mortality rates vary from 0% to 24%, with the most common causes being cerebral hemorrhage, cardiopulmonary arrest, and DIC.[15] In addition, mothers with HELLP syndrome are at increased risk for preterm delivery, placental abruption, and subcapsular hepatic hematoma. Perinatal mortality ranges from 11% to 37%.[31] [32] Most of the neonatal complications seem to be the result of prematurity and placental insufficiency. Treatment includes delivery of the fetus as soon as possible.
- If left untreated, the prodromal phase is often followed by jaundice, which may progress to fulminant hepatic failure. Treatment involves immediate delivery of the fetus and correction of hepatic failure.
- The most life-threatening iatrogenic complication, occurring in 2% of women undergoing gonadotropin stimulation. In its severe form (0.2%), OHSS is characterized by enlarged ovaries, ascites, increased blood viscosity, and renal or hepatic dysfunction.[9] Severe cases require hospitalization, with close monitoring and care by a physician with experience in treating OHSS.
- Uterine contractions, leading to possible premature labor and preterm rupture of membranes, can be triggered by nephrolithiasis, urinary tract infections (UTIs) (particularly pyelonephritis), HELLP syndrome, placental abruption (implicated in up to 10% of premature deliveries), chorioamnionitis, and appendicitis, thus endangering survival of the fetus.[10] Tocolytic agents are used to suppress contractions if <34 weeks' gestation.
Adnexal masses
Urologic emergencies
Gastrointestinal emergencies
Trauma
Etiology
Early pregnancy
- Usually diagnosed in the first trimester, most commonly affecting the fallopian tube[4]
- Strongly associated with conditions that damage the fallopian tube, such as pelvic inflammatory disease (PID), previous ectopic pregnancy, and previous tubal surgery
- Also associated with current IUD users and women whose pregnancy is the result of assisted reproductive technologies.
- Other causes include multiple pregnancy, uterine pathology (e.g., fibroids), cytotoxic drugs, radiation, and systemic conditions (e.g., antiphospholipid syndrome).
- At least 2% of pregnancies in industrialized countries are consequent to advanced fertility treatment such as in vitro fertilization
- The most life-threatening iatrogenic complication, occurring in 2% of women undergoing gonadotropin stimulation
- Risk highest in young women with polycystic ovary syndrome or low BMI
- Severe form (0.2%) characterized by enlarged ovaries, ascites, increased blood viscosity, and renal or hepatic dysfunction.[9]
Late pregnancy
- May be triggered by nephrolithiasis, urinary tract infections (UTIs) (particularly pyelonephritis), hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, placental abruption (implicated in up to 10% of premature deliveries), chorioamnionitis, and appendicitis[10]
- Acute cystitis may irritate the uterine segment and trigger uterine contractions
- More likely to occur with nonoperative management of cholecystitis than with those undergoing cholecystectomy.[11]
- Complicates 1% to 5% of full-term pregnancies and is seen in about 25% of preterm deliveries[12]
- Associated organisms include Ureaplasma urealyticum, Mycoplasma hominis, Gardnerella vaginalis, Peptostreptococcus, and Bacteroides species
- Risk increased following chorionic villus sampling (CVS) and amniocentesis.
- High risk in patients who have had previous uterine surgery (e.g., myomectomy).[13]
- Risk factors include maternal age ≥35 years, multiparity, cigarette smoking, cocaine and other drug use, multiple gestation, chronic hypertension, mild and severe preeclampsia, premature rupture of membranes, oligohydramnios, and chorioamnionitis.[14]
- Characterized by hemolytic anemia, elevated liver enzymes, and thrombocytopenia
- Given its progressive nature, can be considered a variant of preeclampsia.[15]
- Rare but life-threatening condition characterized by microvesicular fatty infiltration of the liver
- Most commonly occurs in the third trimester.
Gynecologic
- Pelvic masses should be considered cancerous until proven otherwise
- Persistent masses (that have not resolved by the second trimester) are at risk of malignancy and have an occurrence of 2% to 3% during pregnancy[18]
- Adnexal masses causing abdominal pain (torsion, hemorrhage, and rupture) more likely to present in the first trimester
- About 20% of adnexal torsions occur during pregnancy, are common in the right adnexa, and predominantly affect teenagers and young women. Torsions are often associated with an increased weight of the adnexa due to the presence of masses that are usually >5 cm
- Ovarian cyst rupture is rare and may occur in conjunction with torsion
- Massive hemorrhage into an ovarian cyst (particularly a malignant cyst) occurs infrequently and causes pain similar to that of torsion
- Hemorrhage may also result in a corpus luteum cyst. At the time of formation of the corpus luteum, there is always a little bleeding into the follicle that has discharged its ovum. If the bleeding is excessive, the corpus luteum becomes distended with blood. Cysts vary in size from 2.5 to 10 cm.
- Occur in approximately 20% to 30% of women of reproductive age
- Most growth happens in early pregnancy
- Cause pain in pregnancy mainly because of red degeneration (necrobiosis), which occurs in 5% to 10% of pregnancies between 12 and 20 weeks' gestation[19]
- Pain may also result from torsion of a pedunculated fibroid or from fibroid impaction.
Urologic
- Most frequently Escherichia coli (80% to 90% of UTIs during pregnancy)
- Other gram-negative rods isolated: Proteus mirabilis,Klebsiella pneumonia
- Incidence increases with low socioeconomic status, increasing age, sexual activity, and diabetes mellitus.
- Most common during the second half of pregnancy, as a result of increased ureteral obstruction and urinary stasis[20]
- Usually unilateral and more common in the right kidney
- E coli is the predominant organism.
- Usually occurs during the second and third trimesters
- Three times more likely in multiparous women
- Ureteric stones more common than kidney stones.[21]
- Common physiologic condition in pregnancy; disappears rapidly after birth[22]
- Most commonly (90%) occurs after the 20th week of gestation, being more pronounced in primigravidae
- Dilatation only seen above the linea terminalis and is more frequently right sided
- Compression of the ureters by the uterus (causing hydronephrosis) can result in acute attacks of pain triggered by ureteral obstruction.
Gastrointestinal
- Acute appendicitis occurs approximately at a rate of 1:1250 to 1:1500[23]
- No single symptom, sign, or laboratory finding is diagnostic for acute appendicitis[24]
- Diagnosis complicated by anatomic changes in the location of the appendix as pregnancy progresses[25]
- Clinical judgment vital in deciding whether surgical management is needed.Image
- Caused by cholelithiasis in >90% of cases in pregnancy[26]
- Cholelithiasis risk is increased by progesterone-induced smooth muscle relaxation of the gallbladder (which promotes stasis of the bile) and elevated levels of estrogens (which increase the lithogenicity of bile).
- Most cases in pregnancy are the result of cholelithiasis[27]
- Tends to occur late in the third trimester, possibly due to increased intra-abdominal pressure on the biliary ducts.
- Incidence increasing with increased frequency of intra-abdominal surgery, pelvic surgery, and PID
- Most commonly caused by simple obstruction, mainly as a result of adhesions (60% to 70% of cases) or volvulus (25%)[2]
- Rarely caused by intussusception, hernias, and neoplasms.
Traumatic
Musculoskeletal
Differential Diagnosis
Diagnostic Approach
History
- Location: sudden-onset flank pain can indicate nephrolithiasis or pyelonephritis
- Intensity and characteristics: mild, moderate, or severe; intermittent, sharp, full, or achy
- Radiation: for example, abdominal pain radiating to the back may suggest cholecystitis or pancreatitis
- Localization: for example, pain in the right lower quadrant (RLQ) can indicate appendicitis, ovarian torsion, or ectopic pregnancy
- Acute or chronic: previous ultrasound reports should be requested.
Abdominal examination
Pelvic examination
Cardiotocography (CTG)
Imaging
Laboratory investigations
- Serum beta-hCG should be the initial test requested for all patients presenting with abdominal pain when <20 weeks pregnant. This, in combination with the use of transvaginal ultrasound, confirms or excludes the presence of an intrauterine pregnancy. CBC should also be included in the initial workup, particularly estimation of hemoglobin (Hb), platelets, and hematocrit (if vaginal bleeding is present). Type and screen is necessary in the presence of abnormal vaginal bleeding (as may occur with ectopic pregnancy, miscarriage, uterine rupture, or placental abruption) or if there is concern regarding the possibility of an intra-abdominal/intra-peritoneal bleed (e.g., splenic rupture). If ovarian hyperstimulation syndrome (OHSS) is suspected, additional tests indicated include a serum electrolyte panel, liver function tests (LFTs), and coagulation screen.
- CBC (particularly estimation of Hb, platelets, and hematocrit) is the initial investigation requested for all patients presenting with abdominal pain beyond 20 weeks pregnant. Type and screen is also recommended for all patients presenting at this stage, as well as a serum electrolyte panel and LFTs (abnormalities found in acute pancreatitis; acute fatty liver of pregnancy; and hemolysis, elevated liver enzymes, and low platelet count [HELLP] syndrome). A coagulation screen is indicated as clotting abnormalities may occur in placental abruption, uterine rupture, and HELLP syndrome.
Library
Citations
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