ULTRASOUND OF THE PREGNANT

ACUTE ABDOMEN
THE ACUTE ABDOMEN IN THE PREGNANT PATIENT
Introduction
Abdominal pain in a patient is one f the most common reasons for visits to
the emergency room.
Although for most patients, symptoms are benign and self-limited, a subset
will be diagnosed with an ‘acute abdomen’, as a result of serious intra
abdominal pathology often necessitating emergency intervention.
An expeditious work up involving judicious use of both laboratory and
radiological studies is necessary while evaluating patients with an ‘acute
abdomen’.
 Delays in presentation, diagnosis and subsequent intervention in a pregnant patient with
abdominal pain can result in increased risk of morbidity and mortality for both the patient and
her unborn fetus.
 This is often worsened by delays due to hesitancy in obtaining certain radiological studies like
plain films or CT scans due to the concerns of radiation exposure associated with these
modalities.
 Ultrasound has been used as the initial imaging study in most evaluations of the pregnant
acute abdomen.
 Many of the presenting signs and symptoms often mimic those of normal early pregnancy.
This often delays presentation, diagnosis and treatment. Such include; abdominal pain, nausea,
vomiting, anorexia etc.
 Vital signs and laboratory findings are often hard to interpret as these are routinely altered in
pregnancy. An example is, the ‘physiological anemia’.
 Presentation of certain disease processes in relation to physical exam may differ in the
pregnant patient owing to the upward displacement of the gravid uterus. A classic example is
the case of acute appendicitis in pregnancy where tenderness may be palpated at the RUQ
instead of the traditional Mc Burney’s point. This knowledge helps us learn where to locate
the appendix during interrogation for appendicitis in a pregnant patient.
Acute abdomen in the pregnant patient may be due to obstetric and non obstetric causes.
Common non obstetric causes include

 Uterine leiomyoma - with carneous or red degeneration

 Haemorrhagic ovarian cyst
 Torsion of ovarian cyst
 Acute appendicitis
 Acute cystitis
 Acute fatty liver of pregnancy
 Rectus haematoma
 Porphyria
 Intestinal obstruction
 Acute cholesystitis and cholelithiasis
 Acute pancreatitis
 Pelvic inflammatory disease and Tubo ovarian abscess
 
Obstetric causes may include
 Ruptured ectopic pregnancy
 Miscarriage
 Round ligament pains (physiological)
 Severe uterine torsion (physiological)
 Chorioamnionitis
 Placenta abruptio
 Uterine rupture
Uterine rupture:
 Uterine rupture during pregnancy is a rare and often catastrophic complication frequently resulting
in life- threatening maternal and fetal compromise. It can either occur in women with a surgical scar
from a previous c section delivery or a native unscarred uterus.
 Uterine rupture involves a full thickness disruption of the uterine wall involving the overlying
uterine serosa. This must be differentiated from uterine scar dehiscence(disruption and separation
of a preexisting scar).
 Uterine rupture is a life –threatening obstetrical complication whose incidence has been rising.
 The incidence of rupture in scarred uteri has been increasing in the last few years, probably
reflecting the increasing c section rates in most resource- rich countries, now exceeding 20%.
 Usually it occurs in the setting of trial of labor after caesarian delivery.
 Overall incidence of uterine rupture in women with a previous c section varies from 0.3 to 1%.
 Previous c section scars together with a short inter pregnancy interval (< 18to24 months), advanced
maternal and gestational age, high parity, and macrosomia contribute a big risk factor for uterine
rupture.
 Poor Bishop Score on admission to labor, labor induction with prostaglandins (mainly misoprostol)
and labor dystocia have been established as important risk factors that affect the incidence of uterine
rupture during TOLAC.
 Almost all uterine ruptures in developed countries occur in the 3 rd trimester of pregnancy, near term,
and mainly in the setting of trial of labor after caesarian delivery (TOLAC).
 However, few reports have described its occurrence in early pregnancy.
 Routine screening of c section scars in early pregnancy must be considered therefore.
 Clinical/sonographic features
The premonitory signs and symptoms of uterine rupture are inconsistent, and the short time for
instituting definitive therapeutic action makes uterine rupture in pregnancy a much feared event
among medical practitioners.
• The initial signs and symptoms of uterine rupture are nonspecific, making the diagnosis difficult
and thus sometimes delaying the definitive therapy.
From the time of diagnosis to delivery, generally only 10-37 minutes are available before clinically
significant fetal morbidity occurs as a result of catastrophic hemorrhage, fetal anoxia or both.
• Clinical signs of uterine rupture in early pregnancy must be distinguished from other acute
abdominal and obstetric emergencies.
• The most relevant ddx here is ectopic pregnancy, although hemorrhagic corpus luteum, heterotopic
pregnancy, miscarriage and an invasive molar pregnancy can be considered.
• Common clinical features include; Abdominal pain, vaginal bleeding and vomiting.
• Emergent surgical intervention is generally required since intraabdominal hemorrhage can lead to
progressive maternal hemodynamic deterioration.

Sonographic features of uterine rupture in a pregnant patient

• Ultrasound features include abnormal relationships between the fetus, uterus, placenta and amniotic
fluid.
The typical ultrasound manifestation of uterine rupture include an endometrial or uterine wall
defect, with an empty uterus and fetus outside the uterine cavity.
• Unusual fetal lie(commonly transverse), oligohydramnios, maternal free peritoneal fluid and fetal
congenital anomalies should raise suspicion.
 A non viable secondary intra-abdominal pregnancy
resulting from uterine rupture in no previous scar
Case report
• A 23 year old gravida 2 para 1 was referred to our unit with five months
amenorrhea with suspected threatened abortion.
She presented with severe diffuse abdominal pain, with slight PVB for 3
days.
Obstetric ultrasound scan showed an empty uterus with a non viable
extrauterine pregnancy of 20 weeks GA.
She had no prior h/o caesarian section
• It’s claimed she attempted a criminal abortion after developing a
misunderstanding with the husband.
• It’s alleged that oxytocin was administered to her at the attempted
procedure, at some private clinic.
• Due to the damage on her uterus, hysterectomy was performed.
 ULTRASOUND IMAGES

Figure 1
An ultrasound image showing an empty contracted uterus.
Note the extrauterine amniotic sac and fetal parts (blue marking).
There were no fetal movements nor cardiac motions noted.
Transverse lie
 Ultrasound images

Figure 2
An ultrasound image showing the same empty uterus with a very tender area of
hypoechogenecity/inhomogeneity at the anterior aspect of lower uterine segment (red marking).
That was the point of uterine rupture
 Laparatomy images

• Image 1
 Laparatomy images

Image 2 Image 3
 Laparatomy images

• Image 4 Image 5
 Uterine rupture

Figure 3
An intraoperative gross specimen showing rupture at the lower uterine segment
 discussion

uterine rupture can be a catastrophic obstetric emergency.

Uterine rupture can be a fatal event for the fetus, with the mother
experiencing only minor symptoms
Ultrasound scan to date though remains the frontline modality albeit with
a diagnostic error of 50-90%.
Ultrasound has been shown to miss the diagnosis of intra-abdominal
pregnancy in 50% cases.
The other superior and more reliable modality is MRI especially when
ultrasound findings prove inconclusive.
This case illustrates a non viable secondary intra-abdominal pregnancy
resulting from rupture at the lower uterine segment.
We believe this was an effect of oxytocin use during the attempted
termination procedure.
 conclusion
 Pre-natal diagnosis of intra-abdominal
pregnancy isn’t any easy.
Advanced intra-abdominal pregnancy is rare
and the documentation of a viable full term
fetus is exceptional.
MRI has proven to be superior in confirming
inconclusive cases on ultrasound.
 REFERENCES
References

1. The Evaluation of the Acute Abdomen

Ashley Hardy, Bennet Butler and Marie Crandall
2. Acute Abdominal Pain
By Dr Ashraf ELFakry MD
3. Acute Abdomen in Gynaecological Practice
Devendra Arora, Bhattachryya, Kathpalia, Kochar
 
THANK YOU VERY
MUCH