Abdominal Pain in a Pregnant Patient

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Abdominal Pain in a

Pregnant Patient

Megan Browning,

Harvard Medical School Year III

Gillian Lieberman, MD

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(23+6 weeks gestation)

HPI

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Woke with 5/10 crampy abdominal pain followed by nausea, vomiting,

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Pain intensified over 12 hours

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Presented to the ED at St. Luke’s Hospital

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Diagnostic tests and an imaging study were inconclusive.

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Monitored over next 12 hours

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Transferred to BIDMC 24 hours after the onset of pain

ROS

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Occasional flatus

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No hx of pain after eating, flank pain, dys/hematuria, hematochezia, melana,

vaginal discharge, new sexual partners, PID, no ingestion of exotic

foods/undercooked meats

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Physical Exam

(pertinent points)

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Vitals

T 99.4 BP 123/79 P 91 O2sat 98%

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HEENT

Dry mucous membranes

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Abdomen

Gravid, Distended, marked RUQ and moderate diffuse

abdominal tenderness,

no rebound or guarding, negative

Rovsing’s sign

Pertinent Labs

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WBC 13.9

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UA negative

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LFTs normal

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Amylase and Lipase normal

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Acute Appendicitis

Acute Cholecystitis

Intestinal Obstruction

Nephrolithiasis

Gastroenteritis

*Special concerns during pregnancy*

Ligamentous Laxity, Preterm Labor, Abruption,

Miscarriage, and Ovarian Torsion

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Netter,2003

Female pelvic anatomy

The female abdomen and pelvis is full of

structures that may develop pathology and

result in abdominal pain. The history,

physical, labs, and studies, help narrow the

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Anatomy of the appendix

The vermiform appendix projects off of the cecum

distal to the ileocecal valve.

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Definition

Inflammation of the appendix due to obstruction by

fecalith (appendicolith), lymphoid hyperplasia, or

rarely, parasite, foreign bodies, or tumor

Classic

Presentation

Peri-umbilical (visceral) pain followed by nausea and

vomiting that ultimately migrates to become right

lower quadrant (somatic) pain within 24 hours

Associated

Findings

Rovsing’s sign, leukocytosis (>10,000) , tachycardia, hypotension

Incidence during

Pregnancy

0.05-0.07% (similar to general population)

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Diagnostic Challenges in Pregnancy

www.pamf.org/pregnancy/first www.pamf.org/pregnancy/second www.pamf.org/pregnancy/third

Anatomic Changes

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Enlarging uterus displaces appendix cephalad

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Separation of visceral & parietal peritoneum

(impaired pain localization)

Physiologic Changes

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Masking of leukocytosis

(normal pregnancy WBC range 6-16,000)

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Increased blood volume blunts tachycardia and hypotension

Creasy, 1984.

1

st

trimester

2

nd

trimester

3

rd

trimester

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A pregnant woman with

appendicitis

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Increased risk of perforation

(43%) compared to general

population 4-19%)

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If perforation occurs, risk of

fetal mortality increases from

1.5% to up to 35%

Appendectomy during

pregnancy

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Usual risks of surgery

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Spontaneous abortion

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Preterm labor

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premature delivery

Appendicitis in pregnancy: a risky situation

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Imaging studies in appendicitis

Key Findings

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Diameter > 7mm

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Fluid filled structure

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Wall thickening >3mm

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periappendiceal fluid

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Appendicolith

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CT Scan

Sensitivity 94% Specificity 95%

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Ultrasound

Sensitivity 86% Specificity 81%

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MRI

Sensitivity 100% Specificity 94%

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Frontal Plain Film

Appendicolith

(Lateral to S.I. Joint)

http://www.learningradiology.com

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Companion Patients #2 and 3:

Appendicitis on CT Scan

Mullins, Rhea and Novelline, 2003

Blind tip

Appendicolith

fat stranding

Findings:

Image from PACS

Exposure to ionizing radiation.

Drawback:

11 mm appendix

CT with colon contrast

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Graded-Compression Sonography

Benefits: readily available and no associated ionizing radiation

Drawbacks: operator dependent, pain and/or gravid uterus may hinder

exam, a normal or perforated appendix may not be visualized

MRI

Benefits: no ionizing radiation and excellent sensitivity and specificity

Drawbacks: limited availability, contraindications, cost, claustrophobia

Appendiceal Imaging modalities during

Pregnancy

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Companion Patients #4 and 5: Appendicitis on

Graded-Compression Sonography

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Compress abdomen with high resolution transducer

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Identify terminal ileum

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Scan for cecal tip and adjacent appendix

How is it performed?

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Enlarged, fluid-filled appendix

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Appendicolith

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Periappendiceal

Inflammation

What are the findings?

Sivit and Applegate, 2003 Sivit and Applegate, 2003

Transverse

US

Sagittal

US

Sagittal

US

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Companion patient #6: Appendicitis on MRI

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Dilated tubular appendix

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Periappendiceal edema

C=cecum, U=uterus

Pedrosa et al, 2006

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Oral contrast is given 1 hour prior to the study

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Patients are placed feet first into the magnet.

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Numerous images* are obtained during breath holds (20-24 seconds)

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Exam time takes approximately 30 minutes

How is it performed?

What are the findings?

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Advantages of MRI Pro

to

cols

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HASTE or SSFSE images have less motion artifact and can visualize

periappendiceal fat stranding

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Fat-saturated T-2 images reveal high-intensity-signal inflammatory fluid

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Fat-saturated T-1 images reveal hemorrhage

Safety of MRI in Pregnancy

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Radiofrequency pulses may cause tissue heating

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No adverse fetal affects have been linked to MRI

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Gadolinium is used cautiously in 2

nd

and 3

rd

trimesters, avoided in the 1st

Current Practice at BIDMC

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Perform MRI only when ultrasound is inconclusive

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Use extra caution with MRI during the first trimester

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Back to our

p

atient...

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Ms.0 is tearful and complaining of continuous

8/10 pain in her abdomen—worst in her RUQ

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Our Patient Ms.O’s Ultrasound Study

No appendix is visualized.

normal gallbladder

normal rt. ovary

(good flow on doppler)

Proximal ureter 1.6 cm

Rt.Hydronephrosis

(common in pregnancy)

Sagittal gallbladder

Sagittal rt. ovary

Sagittal rt. kidney

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Normal caliber, non-fluid filled

Appendicolith

(intraluminal low-signal-intensity foci)

Distal Appendix

Proximal Appendix

Mid Appendix

(site of obstruction)

9mm diameter,

high-signal-intensity

fluid-filled lumen

Axial SSFSE Images with oral contrast

Right hydronephrosis

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Coronal SSFSE with oral contrast

Appendiceal Tip

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8.75mm diameter

(normal <7mm)

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High intensity fluid

within lumen

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Minimal periappendiceal

inflammation

More of Ms.O’s MRI Imaging Study

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Diagnosis

Acute appendicitis involving the distal 3.5 cm

Intervention

Emergent appendectomy with removal of

mottled appendix and perforated tip

Pathologic Diagnosis

Acute gangrenous appendicitis,

average diameter 1.3 cm and obstructing fecalith in the lumen.

Outcome

Ms.O recovers gradually and is sent home on post-op

day 9 in stable condition.

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Clinical signs and symptoms of appendicitis may be masked

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Delayed diagnosis may lead to perforation

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Surgery may lead to premature delivery and fetal loss

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Ultrasound is the initial imaging modality of choice

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MRI is performed if the ultrasound is inconclusive

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Key findings include an enlarged fluid-filled appendix and

periappendiceal inflammation

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Netter F. H., M.D. Atlas of Human Anatomy, Third Edition; John T. Hansen, Ph.D. Consulting

Editor. Teterboro, NJ.: Icon Learning Systems, 2003.

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Creasy R.K., M.D., Resnick R., M.D. Maternal-Fetal Medicine, Principles and Practice;

Philidelphia, PA.: W.B. Saunders Company, 1984.

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Levine D., MD. Obstetric MRI. Journal of Magnetic Resonance Imaging 2006; 24: 1-15.

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Goran Augustin, Mate Majerovic, Non-obstetrical acute abdomen during pregnancy, European

Journal of Obstetrics&Gynecology and Reproductive Biology (2006),

doi:10.10/ejogrb.2006.07.052

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Humes D., Simpson, J. Acute Appendicitis. BMJ 2006; 333: 530-534.

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Pedrosa I., M.D., Levine D., M.D., Eyvassadeh A., M.D., Siewert B., M.D., Ngo L., Ph.D.,

Rofsky N., M.D. MR Imaging Evaluation of Acute Appendicitis in Pregnancy. Radiology 2006;

238: 891-899.

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Mullins M., Rhea J, Novelline R. Review of Suspected Acute Appendicitis in Adults and

Children using CT and Colonic Contrast Material. Seminars in Ultrasound, CT, and MRI 2003;

24: 107-113.

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Sivit C., Applegate K. Imaging of Acute Appendicitis in Children. Seminars in Ultrasound, CT,

and MRI 2003; 24: 74-82.

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Brown M., Birchard K., Smelka R. Magnetic Resonance Evaluation of Pregnant Patients with

Acute Abdominal Pain. Seminars in Ultrasound CT and MRI 2005; 26: 206-211.

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http://z.about.com/d/p/440/e/f/7028.jpg

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http://www.learningradiology.com/images/giimages1/gigallerypages/appendicolith.jpg

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http://www.pamf.org/pregnancy/first/fetal.html

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Gillian Lieberman, MD

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Pamela Lepkowski

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Larry Barbaras, Webmaster

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References