Management of the acute abdomen in pregnancy: a review

Charlie C. Kilpatrick and Francisco J. Orejuela

Department of Obstetrics, Gynecology and
Reproductive Sciences, University of Texas Health
Science Center, Houston, Texas, USA
Correspondence to Charlie C. Kilpatrick, MD,
LBJ Hospital, 5656 Kelley Street, Annex #111,
Houston, TX 77026, USA
Tel: +1 713 566 5926; fax: +1 713 566 4644;
e-mail: Charles.C.Kilpatrick@uth.tmc.edu
Current Opinion in Obstetrics and Gynecology
2008, 20:534–539
Purpose of review
The acute abdomen remains a challenge for all physicians who take part in the care of
women in pregnancy. Obstetricians must be abreast of current topics, especially
critical when having to consult other specialties for assistance in managing these
conditions.
Recent findings
We will highlight recent observations in the literature concerning the ability to perform
laparoscopy safely in pregnancy, the accuracy of diagnosing appendicitis, and new
methods to accurately diagnose urolithiasis with less ionizing radiation effect on the
fetus. Finally, with the proficiency of laparoscopy and choledochoscopy improving, we
will review several articles underlining their safety.
Summary
Laparoscopy appears to be well tolerated in pregnancy, but larger multicenter
prospective studies are required to make better recommendations concerning its use,
with a registry needed to facilitate this endeavor. Conservative management of gallstone
pancreatitis may fall out of favor, and choledochoscopy for symptomatic gallstones in
the biliary tree may become the treatment of choice. Most cases of urolithiasis resolve
with conservative management, but the possibility of preterm labor in these patients
must be recognized and newer imaging techniques for diagnosis containing less
radiation be used. Adnexal torsion in pregnancy may be another condition that is
managed through the laparoscope as the gynecologic community’s laparoscopic skills
improve.

Keywords
appendicitis, pancreatitis, pregnancy with laparoscopy, urolithiasis

Curr Opin Obstet Gynecol 20:534–539

ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
1040-872X

in the third trimester [2]. Recently, Upadhyay et al. [3]

Introduction
We will review recent literature published since last year
updating our review of the acute abdomen in pregnancy.
Special attention will be given to the following circum-
stances in pregnancy: laparoscopic procedures, diagnostic
accuracy of appendicitis, management of urinary calculi,
symptomatic uterine leiomyomas, biliary tract disease,
and acute pancreatitis.
Laparoscopy in pregnancy
Laparoscopy in pregnancy was once considered contra-
indicated for numerous reasons, including fear of damage
to the gravid uterus upon veress/trocar insertion, tech-
nical difficulty in performing the case with the presence
of a gravid uterus, concern for the possibility of fetal
acidemia and decreased maternal venous return second-
ary to increased intraperitoneal pressure from CO2 insuf-
flation. More recently, this has been challenged with
numerous case series describing single institutions’
experience with laparoscopy during pregnancy [1], even
1040-872X ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
added a series of 15 cases in the third trimester, 11 of
which performed through the laparoscope, gestational
ages ranging from 28 to 38 weeks. Most of the cases
were for cholecystectomy, with appendectomy the sec-
ond most common. Interestingly, in most of the cases,
they used the veress needle inserted in either mid-
clavicular line approximately 2 cm below the inferior
costal margin, recommended intraoperative fetal
monitoring, and remarked that a 15 mmHg intraperito-
neal pressure was well tolerated by the fetus. A mid-
clavicular insertion and insufflation with the veress and
subsequent use of an optical trocar in experienced hands
could be safely performed varying the trocar insertion site
based on the gestational age. There was no mention in
the review by Upadhyay et al. [3] whether an optical
trocar was employed. Compared with blind veress inser-
tion, the Hasson technique is simple, with negligible
difference in surgical time and would negate the possi-
bility of pneumoamnion and its fatal consequence [4].
Even in the most experienced hands, caution should be
taken when employing the veress needle in pregnancy.
DOI:10.1097/GCO.0b013e328317c735

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 Management of the acute abdomen in pregnancy Kilpatrick and Orejuela 535
The rationale in Upadhyay’s article, stated to support
intraoperative fetal monitoring, was not given. Intrao-
perative fetal monitoring during nonobstetric surgery is of
questionable benefit if the following precautions are
taken: the patient is positioned with a left lateral tilt,
there is diligent attention to maternal end tidal CO2, and
systolic blood pressure within 20% of baseline to avoid
episodes of maternal hypotension is maintained. Cur-
rently, we are conducting a survey of practicing obste-
tricians concerning their attitude on fetal monitoring
during nonobstetric surgery in pregnancy, and prelimi-
narily most of the obstetricians, 57%, do not do so. Our
survey is mainly of obstetricians who are university based.
There are two cases within the review concerning the
management of ovarian torsion that merit comment. In
both instances, salpingoophorectomy was performed.
There are numerous reports demonstrating laparoscopic
detorsion of the ovary in the nonpregnant patient with
preservation of ovarian function [5,6]. This has also been
demonstrated in the pregnant patient [7]. Unfortunately,
this was not attempted. Many more studies concerning
the safety of laparoscopy in the third trimester of preg-
nancy with long-term neonatal follow-up are needed.
The Society of American Gastrointestinal and Endo-
scopic Surgeons (SAGES) has updated its guidelines
on this important topic and published them recently
[8]. Its recommendations are listed in Table 1. Aware-
ness of the guidelines created by the general surgery
community would be beneficial, given that approxi-
mately one in 635 women, in a single center 10-year
review, will require nonobstetrical abdominal surgery
during her pregnancy [9]. Most of its guidelines are based
on expert opinion and until more prospective data are
compiled, it will remain that way.
Imaging in pregnancy
Imaging in pregnancy remains a controversial issue with
concern for the possibility of the effect of ionizing radi-
ation on the developing fetus and the possibility of
development of childhood leukemia. Ultrasound and
MRI have classically been considered safe modalities,
and first choice options when feasible. In a survey per-
formed by Jaffe et al. [10] involving 183 radiology
residency programs in the United States, 96% of respon-
dents reported that computed tomography (CT) scan of
the pregnant woman was performed when benefits out-
weighed the risk of delay. In the second and third
trimester, CT was the imaging of choice over MRI for
the suspicion of appendicitis, urinary calculi, and sus-
pected abscess. The same findings were not true during
the first trimester, with more favoring MRI. There were
some limitations such as only 46% of those queried
responded, the responses were limited to the chief of
the department limiting the generalizability to the rest of
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the staff, and all those surveyed were academicians.
Furthermore, no obstetricians were polled. They also
found that most of the departments surveyed have some
policy in place when it comes to imaging of the pregnant
patient. Brenner and Hall [11] in a recent publication
expressed the concern over the number of CT scans
performed in the United States and the subsequent
development of cancer due to radiation exposure. They
outlined three important measures to reduce the CT-
related radiation exposure: reduce the CT-related dose
when possible, consider other imaging modalities when
feasible, and decrease the overall number of studies
performed [11].
The negative appendectomy rate, preoperative accuracy
of diagnostic imaging in predicting pathologically con-
firmed appendicitis, was addressed in numerous studies.
Wallace et al. [12], in a retrospective look at 86 women who
underwent appendectomy for suspected appendicitis in
pregnancy, found the combination of clinical examination,
ultrasound and CT, to have the lowest negative appen-
dectomy rate. They suggested an algorithm but given the
low numbers and the retrospective nature of the study,
better studies are needed prior to creating a clinical pro-
tocol for diagnosis of appendicitis in pregnancy. Lazarus
et al. [13], in another retrospective review, noted that the
addition of CT scan to initial ultrasound evaluation when
imaging the abdomen in pregnancy for abdominal pain
improved diagnostic accuracy 30% of the time. One
additional study concerning the diagnosis of appendicitis
in pregnancy was produced by McGory et al. [14] using the
California Inpatient File to retrospectively review over
3100 pregnant women who underwent appendectomy
between 1995 and 2002. The preoperative diagnostic
accuracy of appendicitis in pregnancy was 77% compared
with 82% in the nonpregnant patient population. They
also found that the fetal loss rate was higher in the laparo-
scopic rather than open appendectomy group. Unfortu-
nately, they had no access to the patient’s medical records
to determine clinical reasons for proceeding with appen-
dectomy, gestational age of the patient that might influ-
ence the route of surgery and outcome, and there was no
long-term follow-up on these patients to determine how
the pregnancy fared after surgery.
Adnexal masses
A case report concerning recurrent adnexal torsion in
pregnancy by Weitzman et al. [15] demonstrated a novel
approach to this uncommon condition. During the second
episode of ovarian torsion in the same patient during
pregnancy, they shortened the uteroovarian ligament
with the use of an atraumatic grasper and endoloop.
The patient subsequently did not experience another
episode of torsion and delivered a healthy infant at term.
Given the rarity of three episodes of ovarian torsion in
 536 Women’s health

Table 1 The Society of American Gastrointestinal and Endoscopic Surgeons recommendations for laparoscopy during pregnancy
Diagnosis and work-up
Imaging techniques Ultrasonographic imaging during pregnancy is safe and useful in identifying the cause of
acute abdominal pain in the pregnant patient
Risk of ionizing radiation Expeditious and accurate diagnosis should take precedence over concerns for ionizing
radiation. Radiation dosage should be limited to 5–10 rads in the first 25 weeks of pregnancy
CT Contemporary multidetector CT protocols deliver a radiation dose to the fetus below detrimental
levels and may be considered as an appropriate test during pregnancy depending on the
clinical situation
Magnetic resonance imaging Imaging can be performed at any stage of pregnancy without intravenous gadolinium
Nuclear medicine Nuclear medicine administration of radionucleotides can generally be accomplished at fetal
radiation levels of exposure that are well below any known detrimental levels
Cholangiography Intraoperative and endoscopic cholangiography exposes the mother and fetus to minimal radiation
and may be used selectively during pregnancy. The lower abdomen should be shielded when
performing cholangiography during pregnancy to decrease the radiation exposure to the fetus
Surgical techniques Diagnostic laparoscopy is well tolerated and effective when used selectively in the work-up
and treatment of acute abdominal processes in pregnancy
Patient selection
Preoperative decision-making Laparoscopic treatment of acute abdominal processes has the same indications in pregnant
and nonpregnant patients
Laparoscopy and trimester of pregnancy Laparoscopy treatment of acute abdominal processes has the same indications in pregnant
and nonpregnant patients
Treatment
Patient positioning Gravid patients should be placed in the left lateral recumbent position to minimize
compression of the vena cava and the aorta
Initial port placement Initial access can be safely accomplished with an open or Hassan, veress needle or optical
trocar if the location is adjusted according to fundal height, previous incisions, and
experience of the surgeon
Insufflation pressure CO2 insufflation of 10–15 mmHg can be safely used for laparoscopy in the pregnant patient.
Intraabdominal pressure should be sufficient to allow for adequate visualization
Intraoperative CO2 monitoring Intraoperative CO2 monitoring by capnography should be used during laparoscopy in the
pregnant patient
Venous thromboembolic prophylaxis Intraoperative and postoperative pneumatic compression devices and early postoperative
ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient
Gall bladder disease Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with gall
bladder disease regardless of trimester
Choledocholithiasis Choledocholithiasis during pregnancy may be managed with preoperative ERCP with
sphincterotomy followed by laparoscopic cholecystectomy, intraoperative laparoscopic
transystic or choledochotomy common bile duct exploration, or postoperative ERCP,
depending on local resources and clinical scenario
Laparoscopic appendectomy Laparoscopic appendectomy may be performed safely in any patients with suspicion
of appendicitis
Solid organ resection Laparoscopic adrenalectomy, nephrectomy, splenectomy, and mesenteric cyst excision are well
tolerated procedures in pregnant patients when indicated and standard precautions are taken
Adnexal mass Laparoscopy is well tolerated and effective treatment in gravid patients with symptomatic cystic
masses. Observation is acceptable for all other cystic lesions, provided ultrasound is
uncomplicated for malignancy and tumor markers are normal. Initial observation is warranted
for most cystic lesions
Adnexal torsion Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion, unless
clinical severity warrants laparotomy
Perioperative care
Fetal heart monitoring Fetal heart monitoring should occur pre and postoperatively in the setting of urgent abdominal
surgery during pregnancy
Obstetrical consultation Obstetric consultation can be obtained pre and/or postoperatively based on the acuteness
of the patient’s disease and availability
Tocolytics Tocolytics should not be used prophylactically, but should be considered perioperatively
when signs of preterm labor are present in coordination with obstetric consultation
CT, computed tomography; ERCP, endoscopic retrograde cholangiopancreatography.

pregnancy in the same patient, it is difficult to say
whether this procedure had any effect. Although some
might recommend oophoropexy or shortening of the
uteroovarian ligament at the time of torsion to prevent
recurrence, the incidence of torsion and recurrent torsion
in pregnancy is so low that this is hard to justify [16].
Larger ovarian masses managed in pregnancy have been
reported in the literature and Johnson et al. [17]
reported on the laparoscopic management of a
28 cm  27 cm  14 cm ovarian serous cystadenoma at
21-week gestation. After appropriate tumor markers
and diagnostic imaging were performed, the case began
with a modified open Hasson technique through an
umbilical incision. Initially, a 60-cc syringe and 18-gauge
needle were used to remove enough fluid to allow the
cyst to be exteriorized, grasped with allises and through a
0.5 cm cyst incision, the rest of the contents were drained

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 Management of the acute abdomen in pregnancy Kilpatrick and Orejuela 537
with a laparoscopic suction irrigator. Once adequate
decompression was obtained, the cyst was oversewn to
ensure a watertight seal and the rest of the procedure,
salpingoophorectomy, performed without issue through
the laparoscope. The patient went home the next day and
through communication with Dr Johnson delivered a
healthy infant at term.
Urologic conditions
Approach to urologic conditions in pregnancy may be
technically challenging and there are two recent reviews
concerning this topic. Symptomatic urolithiasis in preg-
nancy may complicate between 1/200 and 1/2000 preg-
nancies [18]. Swartz et al. [19], in a retrospective cohort
study, identified an odds ratio of 1.8 of preterm labor in
patients admitted to the hospital with the diagnosis of
nephrolithiasis. The signs/symptoms associated are most
commonly flank pain (89%) and microscopic hematuria
(95%) [18]. Most often (64–84%) with conservative
medical management in the form of intravenous
hydration and pain medication, the process resolves with-
out issue [20]. If these fail, then diagnostic imaging to
confirm the presence of stone is indicated. First line is the
use of ultrasound, based on its safety profile and although
the use of the resistance index (peak systolic velocity–
peak diastolic velocity/peak systolic velocity) looks prom-
ising, it can sometimes miss a partial obstruction and the
expertise required to perform this is limited. Magnetic
resonance urography may accurately locate the level of
obstruction but may miss the actual stone. Limited
intravenous urography is useful to provide anatomic
and functional information concerning the kidney
[20]. Radiation exposure can be reduced if a limited
sequence is employed and also by decreasing exposure
times, low voltages, tight collimation, maximal fetal
shielding, and prone patient positioning [20]. In the
nonpregnant state, unenhanced helical CT scan is the
gold standard for diagnosing urinary calculi. Recently,
White et al. [21], in a retrospective look at 20 pregnant
patients who underwent renal ultrasound followed by
low-dose CT scan found that when compared with renal
ultrasound, CT is more sensitive in locating urinary
calculi. The largest single radiation dose was 1.372 rads.
This is down from an average dose of 2.2 rads [22]. The
numbers in this study are too small to make general
recommendations, but CT holds promise as a future
modality. Indications for intervention are required if
the following circumstances occur: single kidney obstruc-
tion, urosepsis, uncontrolled pain management, and
obstetrical complications (preterm labor). Temporary
diversion can be accomplished with percutaneous
nephrostomy (PCN) drainage that will immediately
decompress the obstruction, can be done without ionizing
radiation, and can be performed on patients with acute
sepsis, though sometimes is associated with bleeding
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during insertion, dislodgement, and the social aspect of
dealing with the device [20]. Ureteral stents may be
placed but are associated with increased lower urinary
tract symptoms, may cause damage to the ureter during
placement, and ultimately may encrust over leading to
obstruction. Classically, the decision to perform PCN
versus stent placement was based on gestational age,
with the former placed prior to 22 weeks and the latter
afterward. Each may need to be evaluated to be changed
every 6–8 weeks as they both can develop obstruction.
Ureteroscopy with Holmium laser has become the pro-
cedure of choice in pregnancy for symptomatic stones less
than 1 cm, and in those without evidence of sepsis or
history of transplanted kidney. The Holmium laser has
very limited penetration, 0.5–1.0 mm, making it well
tolerated for surrounding tissue and has decreased sound
intensity compared with the ultrasound, negating the
possibility of fetal hearing damage [22].
Uterine fibroids
Symptomatic uterine leiomyomas may complicate preg-
nancy in a number of ways. Recently, Rose et al. [23]
published a case report of a large anterior uterine myoma
that led to uterine incarceration. Incarceration is a con-
dition in which the uterus is fixed in the hollow of the
sacrum wedged between the sacral promontory and pubic
rami, unable to leave the pelvis. This condition is rare and
estimates range from 1/3000 to 1/10000 pregnancies [23]
and can lead to fetal growth restriction. In this case, MRI
confirmed clinical suspicion and the condition resolved
with expectant management. If conservative manage-
ment is not successful, intermittent bladder catheteriza-
tion may provide relief and be necessary as urinary
retention in these patients is not uncommon [24]. When
attempts at intermittent catheterization are not success-
ful, gentle manipulation of the uterus in dorsolithotomy
position or knee chest position may relieve the condition,
but sometimes the use of an anesthetic and/or tocolytic
may be required [24].
In another case, Alanis et al. [25] report of a large,
30  27  19 cm uterine fibroid that caused intractable
pain leading to antepartum myomectomy. MRI again
was useful to delineate the characteristics of the uterine
fibroid that was pedunculated with a 3 cm base, which
allowed for removal without any disturbance of the gravid
uterus. The patient delivered a healthy term infant.
Pancreatitis
Acute pancreatitis in pregnancy is rare, but Hernandez
et al. [26] have reported their 10-year experience at
Brigham and Women’s hospital. One in roughly 4500
pregnancies was affected with pancreatitis, the majority
in the second trimester, with no maternal mortalities and
 538 Women’s health
only a single fetal loss. More than half, 57%, developed
pancreatitis secondary to biliary stones or sludge and of
those patients managed conservatively, 50% had a recur-
rence of pancreatitis [26]. As the safety and frequency
of laparoscopic cholecystectomy for symptomatic gall
bladder disease in pregnancy increases, the use of con-
servative management for pancreatitis, secondary to gall
bladder disease, is likely to be abandoned. In a decision
analysis study, Jelin et al. [27] created a Markov model
for the treatment of biliary tract disease during preg-
nancy. They determined that waiting to operate on
women who require hospitalization for symptomatic
biliary tract disease results in poorer outcomes. Unfortu-
nately, the basis for the model was based on retrospective
case series, which are fraught with bias. More prospective
studies are likely to appear in the future to determine
optimal management, specifically whether laparoscopic
cholecystectomy versus conservative management is
superior in terms of patient and fetal outcomes. Also, if
the surgery is superior, determining whether surgery can
be performed safely within the first trimester.
Biliary tract disease
In patients with choledocholithiasis leading to biliary
colic or pancreatitis, Shelton et al. [28] have reported
on a case series of 21 pregnant patients who underwent
nonradiation endoscopic retrograde cholangiopancreato-
graphy (ERCP) with sphincterotomy. They did not use
fluoroscopy because of the risk of radiation exposure to
the fetus. They were successful in removing the inciting
stones in all cases and only one patient developed post-
operative pancreatitis, a recognized postoperative com-
plication. Without fluoroscopy usage, locating the correct
duct appears to be more challenging, leading to the
possibility of inadvertently cannulating the cystic duct.
Other limitations are possibility of retained stones,
missed bile leak, perforation not noticed as quickly,
and nonrealization of biliary abnormalities [28]. The
use of choledochoscopy, endoscopically visualizing the
common bile duct, after the sphincterotomy holds
promise to curtail these limitations and was used in
the last five of the patients in this series.
Conclusion
The use of laparoscopy in pregnancy appears safe, but
larger, multicenter trials, and possibly a registry to study
and follow these patients are needed to make better
recommendations. Imaging using ionizing radiation
should not be withheld in the pregnant patient when
the potential benefits outweigh the risk. Most radiologic
departments have guidelines established for imaging in
the pregnant patient. Although ultrasound and MRI are
safe in pregnancy, technically they are more difficult to
interpret and improvement is needed in this area. Expec-
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
tant management of pregnancy with acute pancreatitis
secondary to gallstone disease is likely to be the thing of
the past as the safety of laparoscopy in pregnancy is
demonstrated as well as the proficiency of laparoscopic
general surgeons improves. Choledochoscopy rather than
ERCP with fluoroscopy may become the new standard in
patients with symptomatic cholelithiasis when ionizing
radiation is a concern.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
 of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 603).
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 Management of the acute abdomen in pregnancy Kilpatrick and Orejuela 539
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 10-year single center experience. J Gastrointest Surg 2007; 11:1623–1627.
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vative management was attempted.
27 Jelin EB, Smink DS, Vernon AH, et al. Management of biliary tract disease
 during pregnancy: a decision analysis. Surg Endosc 2008; 22:54–60.
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ment of biliary tract disease in pregnancy, suggesting surgical management is
superior in terms of ‘quality pregnancy weeks’.
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 tion, and clearance: new techniques for nonradiation ERCP during pregnancy
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promise for the future.