Imaging of Abdominal Pain in Pregnancy

Is Appendectomy During Late Stages of Pregnancy Associated with an Increased Cesarean Delivery Rate? - a Retrospective Analysis of One Center During 10 Years

Introduction

About one in 500 pregnant women requires a surgical intervention that is not pregnancy-related. One of the most common surgical interventions during pregnancy is appendectomy. The primary aim of this study was to assess surgical access of appendectomy during pregnancy and pregnancy outcome. Secondary outcomes were clinical symptoms and diagnostics as well as histopathological analysis.

Methods and Material

This is a single-center retrospective data analysis conducted at a tertiary perinatal center. A digital search of the hospital record archive was conducted focusing on pregnant women beyond 24 0/7 weeks of pregnancy encoding appendectomy. Descriptive statistical analysis was performed.

Results

Between January 2013 and January 2023, a total of 20 appendectomies were performed during pregnancy with gestational age beyond 24 0/7 weeks of pregnancy. All of them were performed as lower midline laparotomy. The rate of appendix perforation was 3/20 (15.0%). 19/20 patients (95.0%) delivered via cesarean. In 7/20 patients (35.0%) appendectomy was performed during cesarean delivery due to incidental finding of irritated or abnormal vermiform appendix. In the pathological work-up, only 2/7 (28.6%) of these subjects had inflammation.

Conclusion

In this small monocentric cohort, only open appendectomies were performed. Our data indicate that it is safe to perform open appendectomy during pregnancy if necessary. In this small patient group, there was an increase in simultaneous cesarean deliveries.

Magnetic Resonance Imaging of Acute Abdominal Pain in the Pregnant Patient

Evaluation of a pregnant patient presenting with acute abdominal pain can be challenging to accurately diagnose for a variety of reasons, and particularly late in pregnancy. Noncontrast MR remains a safe and accurate diagnostic imaging modality for the pregnant patient presenting with acute abdominal pain, following often an initially inconclusive ultrasound examination, and can be used in most settings to avoid the ionizing radiation exposure of a computed tomography scan. Pathologic processes discussed in this article include some of the more common gastrointestinal, hepatobiliary, genitourinary, and gynecologic causes of abdominal pain occurring in pregnancy, as well as traumatic injuries.

Role of Ultrasound in the Assessment and Differential Diagnosis of Pelvic Pain in Pregnancy

Pelvic pain (PP) is common in pregnant women and can be caused by several diseases, including obstetrics, gynaecological, gastrointestinal, genitourinary, and vascular disorders. Timely and accurate diagnosis as well as prompt treatment are crucial for the well-being of the mother and foetus. However, these are very challenging. It should be considered that the physiological changes occurring during pregnancy may confuse the diagnosis. In this setting, ultrasound (US) represents the first-line imaging technique since it is readily and widely available and does not use ionizing radiations. In some cases, US may be conclusive for the diagnosis (e.g., if it detects no foetal cardiac activity in suspected spontaneous abortion; if it shows an extrauterine gestational sac in suspected ectopic pregnancy; or if it reveals a dilated, aperistaltic, and blind-ending tubular structure arising from the cecum in suspicious of acute appendicitis). Magnetic resonance imaging (MRI), overcoming some limits of US, represents the second-line imaging technique when an US is negative or inconclusive, to detect the cause of bowel obstruction, or to characterize adnexal masses.

Ischaemic bowel perforation secondary to a gravid uterus in a patient with treated inflammatory bowel disease and an ileoanal pouch: a case report

The diagnosis of visceral perforation during pregnancy is often delayed and the management complex. A 32-year-old primigravid woman in her second trimester presented with abdominal pain and a pre-existing ileoanal pouch. Initial imaging was negative but later imaging was suggestive of serious pathology. At laparotomy, a caesarean section was performed. Peritonitis was encountered secondary to two discrete perforations in the small bowel separate from her pouch. Histology found an ischaemic perforation secondary to a pressure effect from the gravid uterus. In pregnancy, ileoanal pouches may make the interconnected bowel vulnerable to the pressure effect of the gravid uterus and perforation. Pregnant women with such a surgical history who develop symptoms suggestive of bowel perforation should have rapid imaging and their clinical team should consider early definitive surgical intervention.

[Acute appendicitis during pregnancy]

Acute appendicitis is the most frequent surgical disease complicating pregnancy. Accurate diagnosis is difficult due to atypical and misleading clinical manifestations. Surgeons frequently do not know about advantages and disadvantages of different diagnostic methods applied during pregnancy. Treatment of acute appendicitis in pregnant women remains the real challenge for surgeons. There are enough researches indicating on benefits and risks of both open and laparoscopic operations. The main risk is due to fetal loss after laparoscopic procedure. Safety of diagnostic techniques and laparoscopic procedures, surgical tactics and independent risk factors of pregnancy loss are touched in the article.

Small bowel volvulus in pregnancy with associated superior mesenteric artery occlusion

Here we report the case of a pregnant 28-year-old who presented with acute upper abdominal pain. CT demonstrated midgut volvulus with short segment occlusion of the superior mesenteric artery (SMA). Emergent detorsion of the small bowel was performed, at which time underlying intestinal malrotation was discovered. Following detorsion, the SMA had a bounding pulse and did not require thrombectomy or revascularization. Fewer than 25 cases of midgut volvulus during pregnancy have been reported over the past 20years. To our knowledge, this is the first report of maternal midgut volvulus in which imaging captures the resultant occlusion of the SMA.

Evolving Practice Patterns in Imaging Pregnant Patients With Acute Abdominal and Pelvic Conditions

OBJECTIVE

The purpose of our study was to determine the current practice patterns of U.S. radiologists in imaging pregnant or potentially pregnant patients with acute abdominal and pelvic conditions.

MATERIALS AND METHODS

After obtaining an Institutional Review Board waiver, all members of the Association of University Radiologists, the Association of Program Directors in Radiology, and the Society of Radiologists in Ultrasound were invited via e-mail to take a 23-question online survey on radiology practices and clinical scenarios about acute abdominal and pelvic imaging of pregnant patients.

RESULTS

Comparisons were made with previously published surveys. A total of 225 responses were received. Areas of high consensus included pregnancy assessment (97%) and obtaining informed consent (87%) before imaging, having a written policy on imaging pregnant patients (79%), modification of computed tomography (CT) protocols (74%), avoiding gadolinium contrast in magnetic resonance imaging (MRI) (74%), using ultrasound for initial imaging in some scenarios, and using CT in trauma cases after inconclusive ultrasound. Areas of emerging consensus compared to 2007 included the use of serum or urine testing to confirm pregnancy status (59.4%; previously 14%) and the use of MRI in suspected appendicitis after an inconclusive ultrasound (73% in first trimester and 67% in third trimester; previously 46% and 29%, respectively). Areas without clear consensus included policy development, additional modifications to MRI protocols, choice of imaging modality, radiation dose, and the use of contrast agents in some scenarios.

CONCLUSION

In conclusion, high or increasing consensus exists in some areas of imaging pregnant patients with acute abdominal and pelvic conditions, but has yet to emerge in other areas.

Premedication of pregnant patients with history of iodinated contrast allergy

Pregnant patients can receive allergy premedication prior to a contrast-enhanced computed tomography exam if the exam is indicated. The risks and benefits of allergy premedication for pregnant patients will be discussed, as well as imaging strategies for the pregnant patient with a contrast allergy. Alternative imaging including ultrasound, noncontrast magnetic resonance imaging, or noncontrast computed tomography can be diagnostic depending on the clinical scenario and is usually preferred, allowing physicians to avoid giving allergy premedication in pregnancy, a 13 h delay, and risking a breakthrough reaction.

A free terminal ileal perforation from active crohn disease in pregnancy: a diagnostic challenge

The surgical management of the complications of Crohn disease is often challenging. These difficulties are compounded in pregnancy by competing interests of the mother and the baby. In this report, we describe the presentation and surgical management of a patient in her second trimester with active Crohn disease who required emergent surgical intervention. She had presented with the uncommon complication of a free perforation in the presence of active untreated disease.

Magnetic Resonance Imaging of Abdominal and Pelvic Pain in the Pregnant Patient

The utility of MR imaging in evaluating abdominal and pelvic pain in the pregnant patient is discussed. Details regarding the indications, technical aspects, and imaging findings of various common abdominal and pelvic abnormalities in pregnancy are reviewed.

Update on the management of non-obstetric acute abdomen in pregnant patients

Acute abdomen is a rare entity in the pregnant patient, with an incidence of one in 500-635 patients. Its appearance requires a quick response and an early diagnosis to treat the underlying disease and prevent maternal and fetal morbidity. Imaging tests are essential, due to clinical and laboratory masking in this subgroup. Appendicitis and complicated biliary pathology are the most frequent causes of non-obstetric acute abdomen in the pregnant patient. The decision to operate, the timing, and the surgical approach are essential for a correct management of this pathology. The aim of this paper is to perform a review and update on the diagnosis and treatment of non-obstetric acute abdomen in pregnancy.

Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment

BACKGROUND

Acute appendicitis during pregnancy may be associated with serious maternal and/or fetal complications. To date, the optimal clinical approach to the management of pregnant women suspected of having acute appendicitis is subject to debate. The purpose of this retrospective study was to provide recommendations for prospective clinical management of pregnant patients with suspected appendicitis.

METHOD

Case records of all pregnant patients suspected of having appendicitis whom underwent appendectomy at our hospital between 1990 and 2010 were reviewed.

RESULTS

Appendicitis was histologically verified in fifteen of twenty-one pregnant women, of whom six were diagnosed with perforated appendicitis. Maternal morbidity was seen in two cases. Premature delivery occurred in two out of six cases with perforated appendicitis cases and two out of six cases following a negative appendectomy. Perinatal mortality did not occur.

CONCLUSION

Both (perforated) appendicitis and negative appendectomy during pregnancy are associated with a high risk of premature delivery. Clinical presentation and imaging remains vital in deciding whether surgical intervention is indicated. We recommend to cautiously weigh the risks of delay until correct diagnosis with associated increased risk of appendiceal perforation and the risk of unnecessary surgical intervention. Based upon current literature, we recommend clinicians to consider an MRI following an inconclusive or negative abdominal ultrasound aiming to improve diagnostic accuracy to reduce the rate of negative appendectomies. Accurate and prompt diagnosis of acute appendicitis should be strived for to avoid unnecessary exploration and to aim for timely surgical intervention in pregnant women suspected of having appendicitis.

Imaging for acute pelvic pain in pregnancy

Acute pelvic pain in pregnancy presents diagnostic and therapeutic challenges. Standard imaging techniques need to be adapted to reduce harm to the foetus from X-rays because of their teratogenic and carcinogenic potential. Ultrasound remains the primary imaging investigation of the pregnant abdomen. Magnetic resonance imaging (MRI) has been shown to be useful in the diagnosis of gynaecological and obstetric problems during pregnancy and in the setting of acute abdomen during pregnancy. MRI overcomes some of the limitations of ultrasound, mainly the size of the gravid uterus. MRI poses theoretical risks to the foetus and care must be taken to minimise these with the avoidance of contrast agents. Teaching Points • Ultrasound and MRI are the preferred investigations for acute pelvic pain during pregnancy. • Ultrasound remains the primary imaging investigation because of availability and portability. • MRI helps differentiate causes of acute pelvic pain when ultrasound is inconclusive.

MR imaging for acute nontraumatic abdominopelvic pain: rationale and practical considerations

Medical imaging is becoming an increasingly vital component of patient care in the emergency department. Computed tomography has been the diagnostic imaging method of choice for emergency department patients with acute abdominopelvic pain; however, the use of ionizing radiation and the potential need for exogenous contrast material adversely affect patient safety and work flow efficiency, respectively. Magnetic resonance (MR) imaging holds promise as an alternative for the evaluation of acute abdominopelvic pain. Critical causes of abdominopelvic pain may be detected with MR imaging without exogenous contrast material. MR imaging is sensitive for depicting tissue or fluid changes related to inflammation, a common process in causes of acute abdominopelvic pain. Fat suppression allows the detection of abnormal signal caused by inflamed tissue. MR imaging has proved sensitive in the detection of acute inflammatory diseases of the gallbladder and bile ducts, liver, pancreas, kidneys, collecting system, bowel, and pelvic soft tissues. Moreover, MR imaging without exogenous contrast material may be safely used in pregnant patients. Evolving roles for emergency department MR imaging include the assessment of vascular disease (including thromboembolic disease) and right upper quadrant pain. Emergency department MR imaging currently has limited availability, and its continued use will require further education regarding operation and image interpretation as well as further validation of cost-effectiveness. Nevertheless, current understanding of the diagnostic utility of this imaging method warrants continued study and the increased use of MR imaging in the evaluation of emergency department patients with acute abdominopelvic pain.

Nonobstetric abdominal pain and surgical emergencies in pregnancy

The focus of this article is the evaluation and management of pregnant patients with nonobstetric abdominal pain and surgical emergencies. The anatomic and physiologic changes that occur during pregnancy can cause difficulties in interpreting patients' signs and symptoms in emergency departments. This article reviews some of the common causes of nonobstetric abdominal pain and surgical emergencies that present to emergency departments and discusses some of the literature surrounding the use of imaging modalities during pregnancy. After a review of these changes and their causes, imaging modalities that can be used for the assessment are discussed.

APPENDICITIS IN PREGNANCY

Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnancy, complicating 1/500 to 1/2000 deliveries. Due to the anatomical and physiological changes associated with pregnancy, appendicitis may present a diagnostic dilemma, leading to management delays and thus increasing the risk of appendiceal perforation. Many of the common presenting symptoms of appendicitis are common features of normal pregnancy including lower abdominal pain, nausea, vomiting and leukocytosis. Furthermore, the enlarging gravid uterus may displace the appendix to varying degrees thus altering the classic symptom pattern of appendicitis. The often nonspecific presentation in pregnancy may necessitate the utilization of diagnostic imaging to aid in accurate diagnosis. However, the perforated appendix is the most common surgical cause of fetal loss and the time required for any diagnostic aid must be weighed against the increasing risk of perforation caused by delay in surgical intervention.