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Moradi B, Banihashemian M, Radmard AR, Tahmasebpour AR, Gity M, Zarkesh MR, Piri S, Zeinoddini A. A Spectrum of Ultrasound and MR Imaging of Fetal Gastrointestinal Abnormalities: Part 1 Esophagus to Colon. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2601-2613. [PMID: 34962317 DOI: 10.1002/jum.15932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 11/03/2021] [Accepted: 11/20/2021] [Indexed: 06/14/2023]
Abstract
Ultrasound (US) and magnetic resonance imaging (MRI) are two modalities for diagnosing fetal gastrointestinal (GI) anomalies. Ultrasound (US) is the modality of choice. MRI can be used as a complementary method. Despite its expanding utilization in central nervous system (CNS) fetal malformation, MRI has not yet been established for evaluation of fetal GI abnormalities. Therefore, more attention should be paid to the clinical implications of MRI investigations following screening by US.
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Affiliation(s)
- Behnaz Moradi
- Department of Radiology, Yas Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoumeh Banihashemian
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Masoumeh Gity
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zarkesh
- Department of Neonatology, Yas Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Solmaz Piri
- Department of International Affairs, National Association of Iranian Gynecologists and Obstetricians, Tehran, Iran
| | - Atefeh Zeinoddini
- Department of Radiology, University of Texas Medical Branch, Galveston, TX, USA
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2
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Surgery in Pregnancy. Am J Gastroenterol 2022; 117:53-59. [PMID: 36194034 DOI: 10.14309/ajg.0000000000001961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/23/2022] [Indexed: 12/11/2022]
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3
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Dempsey PJ, Delaney FT, Geoghegan T, Lawler L, Bolster F. MR imaging of acute abdominal pain in pregnancy. Br J Radiol 2022; 95:20211114. [PMID: 35604640 PMCID: PMC10162063 DOI: 10.1259/bjr.20211114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/06/2022] [Accepted: 02/02/2022] [Indexed: 11/05/2022] Open
Abstract
Abdominal pain in pregnancy is a diagnostic challenge with many potential aetiologies. Diagnostic imaging is a valuable tool in the assessment of these patients, with ultrasound commonly employed first line. MRI is an excellent problem-solving adjunct to ultrasound and has many advantages in terms of improved spatial resolution and soft tissue characterisation. This pictorial review aims to outline the role of MRI in the work up of acute abdominal pain in pregnancy and provide imaging examples of pathologies which may be encountered.
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Affiliation(s)
| | | | - Tony Geoghegan
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Leo Lawler
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ferdia Bolster
- Mater Misericordiae University Hospital, Dublin, Ireland
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4
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Shah N, Deshmukh H, Akbar MJ, Saeed Y, Akbar S, Malik S, Allan B. Unilateral adrenal infarction in pregnancy with associated acute hypoadrenalism and subsequent spontaneous biochemical and radiological resolution. Clin Case Rep 2022; 10:e05442. [PMID: 35169476 PMCID: PMC8831941 DOI: 10.1002/ccr3.5442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Abstract
Adrenal infarction is a rare cause of abdominal pain during pregnancy, and if missed, it can result in devastating clinical consequences for the mother and the child. The authors report a case of a young female who presented with severe abdominal pain and nausea. The biochemistry showed raised inflammatory markers and significant lactic acidosis. As the cause of the symptoms was not clear and the patient continued to deteriorate, a contrast‐enhanced CT abdomen and pelvis was done which was suggestive of an acute left adrenal infarction. Subsequently, the patient was confirmed to have biochemical hypoadrenalism and required replacement doses of hydrocortisone until recovery of the adrenal glucocorticoid reserve and anticoagulation for the duration of pregnancy. We discuss the workup including diagnostic imaging, follow‐up, and considerations for future pregnancies in this case.
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Affiliation(s)
- Najeeb Shah
- Hull University Teaching Hospitals NHS TrustHull Royal Infirmary Hull UK
- University of Hull Hull UK
| | - Harshal Deshmukh
- Hull University Teaching Hospitals NHS TrustHull Royal Infirmary Hull UK
- University of Hull Hull UK
| | | | - Yamna Saeed
- Hull University Teaching Hospitals NHS TrustHull Royal Infirmary Hull UK
| | - Shahzad Akbar
- York and Scarborough Teaching Hospitals NHS Foundation Trust York UK
| | - Shah Malik
- Hull University Teaching Hospitals NHS TrustHull Royal Infirmary Hull UK
| | - Belinda Allan
- Hull University Teaching Hospitals NHS TrustHull Royal Infirmary Hull UK
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5
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Coleman B, Ramakrishnan K. Surgical Problems of the Digestive System. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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6
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Safety of appendectomy during pregnancy in the totally laparoscopic age. JOURNAL OF MINIMALLY INVASIVE SURGERY 2021; 24:68-75. [PMID: 35600787 PMCID: PMC8965996 DOI: 10.7602/jmis.2021.24.2.68] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/29/2022]
Abstract
Purpose Acute appendicitis is the most common nonobstetric indication for surgical intervention during pregnancy. In the argument of the optimal surgical approach to acute appendicitis in pregnancy, laparoscopy seems to be won with a similar complication rate and shorter postoperative recovery than open. We aimed to compare perioperative outcomes of appendectomy in pregnant and nonpregnant women in the totally laparoscopic age. Methods We retrospectively analyzed 556 nonincidental appendectomies performed in women (aged 18–45 years) between January 2014 and December 2018. To reduce the confounding effects, we used propensity score considering the variables age, American Society of Anesthesiologists physical status classification, and the operative finding; whether the appendicitis was simple or complicated. After propensity score matching, the outcomes of 15 pregnant women were compared with those of the 30 nonpregnant women. Results All the operations were performed with laparoscopy. Most of the pregnant cases were in their first and second trimester. The postoperative morbidity rate was significantly higher in the pregnant group before propensity score matching; however, the significance disappeared after matching. Operative outcomes and the parameters related to the postoperative recovery were not different between the two groups. Two patients in their first trimester decided to terminate the pregnancy after appendectomy. One patient in her second trimester experienced preterm labor which was resolved spontaneously. There was no other obstetric adverse outcome. Conclusion In the laparoscopy age, appendectomy during pregnancy is safe and not associated with a significantly increased risk of postoperative complication.
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Collard MK, Christou N, Lakkis Z, Mege D, Bridoux V, Millet I, Sabbagh C, Loriau J, Lefevre JH, Ronot M, Maggiori L. Adult appendicitis: Clinical practice guidelines from the French Society of Digestive Surgery and the Society of Abdominal and Digestive Imaging. J Visc Surg 2021; 158:242-252. [PMID: 33419677 DOI: 10.1016/j.jviscsurg.2020.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The French Society of Digestive Surgery (SFCD) and the Society of Abdominal and Digestive Imaging (SIAD) have collaborated to propose recommendations for clinical practice in the management of adult appendicitis. METHODS An analysis of the literature was carried out according to the methodology of the French National Authority for Health (HAS). A selection was performed from collected references and then a manual review of the references listed in the selected articles was made in search of additional relevant articles. The research was limited to articles whose language of publication was English or French. Articles focusing on the pediatric population were excluded. Based on the literature review, the working group proposed recommendations whenever possible. These recommendations were reviewed and approved by a committee of experts. RESULTS Recommendations about appendicitis in adult patients were proposed with regard to clinical, laboratory and radiological diagnostic modalities, treatment strategy for uncomplicated and complicated appendicitis, surgical technique, and specificities in the case of macroscopically healthy appendix, terminal ileitis and appendicitis in the elderly and in pregnant women. CONCLUSION These recommendations for clinical practice may be useful to the surgeon in optimizing the management of acute appendicitis in adults.
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Affiliation(s)
- M K Collard
- Department of digestive surgery, Sorbonne université, Saint-Antoine hospital, AP-HP, Paris, France
| | - N Christou
- Department of digestive, general and endocrine surgery, CHU Dupuytren, Limoges, France
| | - Z Lakkis
- Department of visceral, digestive and oncological surgery, CHU Besançon, Besançon, France
| | - D Mege
- Department of digestive and general surgery, Timone hospital, Marseille, France
| | - V Bridoux
- Department of digestive surgery, Charles-Nicolle hospital, Rouen, France
| | - I Millet
- Radiology department, Lapeyronie hospital, Montpellier, France
| | - C Sabbagh
- Department of digestive surgery, CHU Amiens-Picardie, Amiens, France
| | - J Loriau
- Department of digestive surgery, Saint-Joseph hospital, Paris, France
| | - J H Lefevre
- Department of digestive surgery, Sorbonne université, Saint-Antoine hospital, AP-HP, Paris, France
| | - M Ronot
- Radiology department, Beaujon hospital, Clichy-la-Garenne, France
| | - L Maggiori
- Department of digestive, oncologic and endocrine surgery, Saint-Louis Hospital, Assistance Publique-Hopitaux de Paris (AP-HP), Université de Paris, Paris, France.
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Kim AM, Kim JW, Kim YH, Kim TY, Ryu HK, Choi MG. Corrective surgery using a gridiron incision for abdominal pain caused by a folded ovary in the third trimester of pregnancy. J Int Med Res 2021; 49:300060521997743. [PMID: 33729868 PMCID: PMC7975525 DOI: 10.1177/0300060521997743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Sonography and magnetic resonance imaging (MRI) may be helpful to obtain an accurate
diagnosis of acute abdominal pain in pregnancy. Adnexal torsion presenting in the first
or second trimester can be confirmed and treated through laparoscopic surgery; however
laparoscopic surgery in the third trimester can be difficult owing to the large uterus,
and a gridiron incision can be useful. Case Report/Case presentation An 18-year-old gravida 1, para 0 (G1P0) woman at 30 + 4 weeks of gestation presented
with sudden-onset cyclic pain in the right lower quadrant. Abdominal ultrasonography
showed a normal appendix, and MRI showed a normal appendix and normal ovaries. The
patient’s prominent tender point was marked and compared with the MR images, which
confirmed the mark as the position of the right ovary. Laparotomy was performed through
a gridiron incision, and a folded right ovary was identified. The ovary was unfolded,
and TachoSil® and Surgicel® were used to maintain the unfolded position. The patient’s
pain resolved, and her postoperative course was uneventful. She delivered a healthy,
2540-g male baby at 35 weeks’ gestation. Discussion/Conclusions A gridiron incision was useful to treat a folded ovary in the third trimester and to
evaluate the adnexa and minimize uterine manipulation.
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Affiliation(s)
- A Mi Kim
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, South Korea
| | - Jong Woon Kim
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, South Korea
| | - Yoon Ha Kim
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, South Korea
| | - Tae Young Kim
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, South Korea
| | - Hyun Kyung Ryu
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, South Korea
| | - Myeong Gyun Choi
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, South Korea
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Surgical Problems of the Digestive System. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_100-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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10
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Tarannum A, Sheikh H, Appiah-Sakyi K, Lindow SW. The diagnostic use of magnetic resonance imaging for acute abdominal and pelvic pain in pregnancy. Eur J Obstet Gynecol Reprod Biol 2019; 246:177-180. [PMID: 31955872 DOI: 10.1016/j.ejogrb.2019.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Acute abdomino-pelvic pain in pregnancy represents a diagnostic challenge. In many cases, radiological and laparoscopic diagnostic modalities are hazardous or contraindicated. Magnetic Resonance Imaging (MRI) is not commonly used for this indication and the results are not widely published. DESIGN AND SETTING A single-center retrospective observational study. POPULATION 34 cases of pregnant women with abdomino-pelvic pain who underwent MRI as an additional modality when clinical, laboratory and ultrasound (USS) findings were indeterminate. METHODS Case notes were reviewed where pregnant women underwent a MRI investigation for abdominal-pelvic pain. Primary Obstetric indications for an MRI eg placenta accreta were excluded. MAIN OUTCOME MEASURES The differential diagnosis after; 1) history and physical examination and 2) with the addition of USS and 3) with the further addition of an MRI were all individually compared to the eventual diagnosis. RESULTS The diagnoses reached by MRI corresponded with the final diagnosis in 22 out of 23 cases. In the remaining 11 cases MRI accurately ruled out presence of pathology. MRI was inaccurate in 1 case. CONCLUSION The additional use of MRI was more accurate than clinical assessment and USS combined. The accurate exclusion of pathology in 11 cases is particularly significant. MRI should be considered in cases of abdomino-pelvic pain in pregnant women.
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Affiliation(s)
- Asma Tarannum
- Womens Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar.
| | - Haifa Sheikh
- Womens Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
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Seak CJ, Goh ZNL, Wong AC, Seak JCY, Seak CK. Unilateral live twin tubal ectopic pregnancy presenting at 12 weeks of gestation: A case report. Medicine (Baltimore) 2019; 98:e17229. [PMID: 31567985 PMCID: PMC6756681 DOI: 10.1097/md.0000000000017229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Abdominal pain in pregnancy represents a demanding diagnostic challenge in the emergency department (ED) due to the extensive list of differential diagnoses to be considered, coupled with the possibility of each disease having nonclassical, atypical signs and symptoms, resultant from the patient's pregnant state. Additionally, emergency physicians (EPs) face limitations on investigative imaging modalities because of the need to minimize fetal radiation exposure. EPs have to tackle this diagnostic challenge while performing a balancing act to maximize both maternal and fetal outcomes in a time-sensitive manner, becauser any delays in decision-making at the ED may threaten the safety of mother and child. Two common causes of abdominal pain in pregnancy presenting to the ED are acute appendicitis and ectopic pregnancy. The latter is almost always diagnosed by 10 weeks of gestation. Here, we report an extremely rare case of unilateral live spontaneous twin tubal ectopic pregnancy presenting past 12 weeks of gestation, diagnosed after magnetic resonance imaging (MRI) of the abdomen. PATIENT CONCERNS A 37-year-old gravida 2 para 1 at 12 weeks and 6 days of gestation presented to our ED with a 2-day history of right iliac fossa pain, not associated with vaginal bleeding, fever, diarrhea, and vomiting. On examination, she was tachycardic (pulse rate 124 beats/min) and hypertensive (blood pressure 142/88 mm Hg). There was marked tenderness and guarding at the lower abdomen. DIAGNOSES Blood investigations were unremarkable, while abdominal ultrasonography found a live twin gestation with foetal heartbeats of 185 and 180 beats/min. MRI of the abdomen revealed an empty uterine cavity; 2 amniotic sacs and fetuses of diameter 10 cm, and a single placenta were noted in the right uterine adnexa. The patient was diagnosed with right live monochorionic diamniotic twin tubal pregnancy. INTERVENTION Our patient underwent emergency laparoscopic right salpingectomy. OUTCOMES The operation was successful and her postoperative care remained uneventful up to discharge. LESSONS Ectopic pregnancy cannot be ruled out based on prior normal antenatal examinations and gestational age of >10 weeks. EPs should not hesitate to order MRI scans for further evaluation if ultrasonography and laboratory findings are equivocal.
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Affiliation(s)
- Chen-June Seak
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | | | | | | | - Chen-Ken Seak
- Sarawak General Hospital, Kuching, Sarawak, Malaysia
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Mervak BM, Wilson SB, Handly BD, Altun E, Burke LM. MRI of acute appendicitis. J Magn Reson Imaging 2019; 50:1367-1376. [PMID: 30883988 DOI: 10.1002/jmri.26709] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/21/2019] [Indexed: 12/12/2022] Open
Affiliation(s)
- Benjamin M. Mervak
- University of North Carolina Department of RadiologyDivision of Abdominal Imaging Chapel Hill North Carolina USA
| | - Sarah B. Wilson
- University of North Carolina Radiology Residency Program Chapel Hill North Carolina USA
| | - Brian D. Handly
- University of North Carolina Department of RadiologyDivision of Pediatric Imaging Chapel Hill North Carolina USA
| | - Ersan Altun
- University of North Carolina Department of RadiologyDivision of Abdominal Imaging Chapel Hill North Carolina USA
| | - Lauren M. Burke
- University of North Carolina Department of RadiologyDivision of Abdominal Imaging Chapel Hill North Carolina USA
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Abstract
Although trauma in pregnancy is rare, it is one of the most common causes of morbidity and mortality to pregnant women and fetus. Pathophysiology of trauma is generally time sensitive, and this is still true in pregnant patients, with the additional challenge of rare presentation and balancing the management of two patients concurrently. Successful resuscitation requires understanding the physiologic changes to the woman throughout the course of pregnancy. Ultimately, trauma management is best approached by prioritizing maternal resuscitation.
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Affiliation(s)
- Jeffrey Sakamoto
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Suite 350, Palo Alto, CA 94304, USA
| | - Collin Michels
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Suite 350, Palo Alto, CA 94304, USA
| | - Bryn Eisfelder
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Suite 350, Palo Alto, CA 94304, USA
| | - Nikita Joshi
- Alameda Health Systems, 490 Grand Avenue, Oakland, CA 94610, USA.
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Rottenstreich M, Rottenstreich A, Rottenstreich M. Fetal distress and urgent cesarean delivery due to new-onset peripartum Crohn's disease. Taiwan J Obstet Gynecol 2019; 57:901-902. [PMID: 30545552 DOI: 10.1016/j.tjog.2018.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2018] [Indexed: 11/16/2022] Open
Affiliation(s)
- Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University Medical School of Jerusalem, Jerusalem, Israel.
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Moshe Rottenstreich
- Department of Gastroenterology, Shaare Zedek Medical Center, Hebrew University Medical School of Jerusalem, Jerusalem, Israel
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Zachariah SK, Fenn M, Jacob K, Arthungal SA, Zachariah SA. Management of acute abdomen in pregnancy: current perspectives. Int J Womens Health 2019; 11:119-134. [PMID: 30804686 PMCID: PMC6371947 DOI: 10.2147/ijwh.s151501] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.
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Affiliation(s)
- Sanoop Koshy Zachariah
- Department of General, Gastrointestinal & Laparoscopic Surgery, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India,
| | - Miriam Fenn
- Department of Obstetrics and Gynecology, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India
| | - Kirthana Jacob
- Department of Obstetrics and Gynecology, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India
| | - Sherin Alias Arthungal
- Department of General, Gastrointestinal & Laparoscopic Surgery, MOSC Medical College, Kolenchery Cochin, Cochin 682311, India,
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Suspicion of appendicitis in pregnant women: emergency evaluation by sonography and low-dose CT with oral contrast. Eur Radiol 2018; 29:345-352. [PMID: 29948087 DOI: 10.1007/s00330-018-5573-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/07/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate non-intravenously enhanced low-dose computed tomography with oral contrast (LDCT) for the assessment of pregnant women with right lower quadrant pain, when magnetic resonance imaging (MRI) is not immediately available. METHODS One hundred and thirty-eight consecutive pregnant women with acute abdominal pain were admitted in our emergency centre. Thirty-seven (27%) of them, with clinical suspicion of acute appendicitis, underwent abdominal ultrasonography (US). No further examination was recommended when US was positive for appendicitis, negative with low clinical suspicion or showed an alternative diagnosis which explained the clinical presentation. All other patients underwent LDCT (<2.5 mSv). Standard intravenously enhanced CT or MRI was performed when LDCT was indeterminate. RESULTS Eight (22%) of 37 US exams were reported normal, 25 (67%) indeterminate, 1 (3%) positive for appendicitis, 3 (8%) positive for an alternative diagnosis. LDCT was obtained in 29 (78%) patients. It was reported positive for appendicitis in 9 (31%), for alternative diagnosis in 2 (7%), normal in 13 (45%) and indeterminate in 5 (17%). Further imaging (standard CT or MRI) showed appendicitis in 2 of these 5 patients, was truly negative in 1, indeterminate in 1 and falsely positive in 1. An appendicitis was confirmed at surgery in 12 (32%) of the 37 patients. The sensitivity and the specificity of the algorithm for appendicitis were 100% (12/12) and 92% (23/25), respectively. CONCLUSIONS The proposed algorithm is very sensitive and specific for detection of acute appendicitis in pregnant women; it reduces the need of standard CTs when MRI is not available as second-line imaging. KEY POINTS • In pregnant women, US is limited by an important number of indeterminate results • Low-dose CT can be used after an inconclusive US for the diagnosis of appendicitis in pregnant women • An algorithm integrating US and low-dose CT is highly sensitive and specific for appendicitis in pregnant women.
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Lotfipour S, Jason M, Liu VJ, Helmy M, Hoonpongsimanont W, McCoy CE, Chakravarthy B. Latest Considerations in Diagnosis and Treatment of Appendicitis During Pregnancy. Clin Pract Cases Emerg Med 2018; 2:112-115. [PMID: 29849258 PMCID: PMC5965106 DOI: 10.5811/cpcem.2018.1.36218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 08/26/2017] [Accepted: 01/19/2018] [Indexed: 12/29/2022] Open
Abstract
Pregnancy can obscure signs and symptoms of acute appendicitis, making diagnosis challenging. Furthermore, avoiding radiation-based imaging due to fetal risk limits the diagnostic options clinicians have. Once appendicitis has been diagnosed, performing appendectomies has been the more commonly accepted course of action, but conservative, nonsurgical approaches are now being considered. This report describes the latest recommendations from different fields and organizations for the diagnosis and treatment of appendicitis during pregnancy.
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Affiliation(s)
- Shahram Lotfipour
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Max Jason
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Vincent J Liu
- Taipei Medical University, College of Medicine, Taipei, Taiwan
| | - Mohammad Helmy
- University of California, Irvine, Department of Radiological Sciences, Orange, California
| | | | - C Eric McCoy
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Bharath Chakravarthy
- University of California, Irvine, Department of Emergency Medicine, Orange, California
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18
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Posthumus L, Donker ME. Uterine rupture in a primigravid patient, an uncommon but severe obstetrical event: a case report. J Med Case Rep 2017; 11:339. [PMID: 29208037 PMCID: PMC5718063 DOI: 10.1186/s13256-017-1507-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 11/06/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND A spontaneous rupture of the unscarred uterus in a primigravid patient is extremely rare and is associated with high perinatal and maternal morbidity and mortality. CASE PRESENTATION A 34-year-old white primigravid woman, 31 + 3 weeks of gestation, presented with pre-eclampsia and developed a sudden acute abdomen. An emergency laparotomy was performed and a uterine rupture was found as the cause of the event. A stillborn girl was born. CONCLUSION A rupture of the pregnant uterus should always be considered in a pregnant woman presenting with abdominal pain, even in a primigravid patient.
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Affiliation(s)
- Lotte Posthumus
- Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
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Tsai R, Raptis C, Fowler KJ, Owen JW, Mellnick VM. MRI of suspected appendicitis during pregnancy: interradiologist agreement, indeterminate interpretation and the meaning of non-visualization of the appendix. Br J Radiol 2017; 90:20170383. [PMID: 28869395 DOI: 10.1259/bjr.20170383] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the degree of interradiologist agreement between the MRI features of appendicitis during pregnancy, the outcomes associated with an indeterminate interpretation and the negative predictive value of non-visualization of the appendix. METHODS Our study was approved by the institutional review board at the Washington University in St. Louis, Missouri (WUStL) and was HIPAA (Health Insurance Portability and Accountability Act of 1996)-compliant. The informed consent requirement was waived. Cases of suspected appendicitis during pregnancy evaluated using MRI were retrospectively identified using search queries. Scans were re-reviewed by two radiologists (7 and 9 years experience, respectively) to evaluate the interradiologist agreement of different MRI features of appendicitis during pregnancy (visualization of the appendix, appendiceal diameter, appendiceal wall thickening, periappendiceal fat stranding, fluid-filled appendix and periappendiceal fluid). The radiologists were blinded to patient outcome, patient intervention, laboratory data, demographic data and the original MRI reports. Clinical outcomes were documented by surgical pathology or clinical observation. Interradiologist agreement was analysed using Cohen's κ, while patient demographic and clinical data was analysed using Student's t-testing. RESULTS 233 females with suspected appendicitis during pregnancy were evaluated using MRI over a 13-year period (mean age, 28.4 years; range, 17-38 years). There were 14 (6%) positive examinations for appendicitis during pregnancy, including 1 patient whose MRI was interpreted as negative, proven by surgical pathology. The presence of periappendiceal soft-tissue stranding and the final overall impression had the most interradiologist agreement (к = 0.81-1). There were no pregnant patients found to have acute appendicitis who had an indeterminate MR interpretation or when the appendix could not be visualized. CONCLUSION The final impression by the two retrospectively reviewing radiologists of MR examinations performed for suspected appendicitis during pregnancy had near-perfect agreement. In patients where the appendix could not be visualized or in patients that were interpreted as indeterminate, no patients had acute appendicitis. Advances in knowledge: MR impression for suspected appendicitis in the pregnant patient has high interradiologist agreement, and a non-visualized appendix or lack of inflammatory findings at the time of MR, reliably excludes surgical appendicitis.
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Affiliation(s)
- Richard Tsai
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Constantine Raptis
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Kathryn J Fowler
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Joseph W Owen
- 2 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Vincent M Mellnick
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
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Pearl JP, Price RR, Tonkin AE, Richardson WS, Stefanidis D. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc 2017. [DOI: 10.1007/s00464-017-5637-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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El abdomen agudo en el embarazo aumenta el riesgo de complicaciones obstétricas sin influir en el pronóstico materno-fetal. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2017. [DOI: 10.1016/j.gine.2015.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Guterman S, Mandelbrot L, Keita H, Bretagnol F, Calabrese D, Msika S. Laparoscopy in the second and third trimesters of pregnancy for abdominal surgical emergencies. J Gynecol Obstet Hum Reprod 2017; 46:417-422. [PMID: 28934085 DOI: 10.1016/j.jogoh.2017.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 03/16/2017] [Accepted: 03/23/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess complications and outcomes of pregnancies following laparoscopic abdominal surgery during the second and third trimesters of pregnancy. MATERIAL AND METHODS Retrospective single-center study of 23 cases of laparoscopic surgery in the second or third trimesters of pregnancy between January 2005 and May 2016. RESULTS The laparoscopies were performed between 15 and 33 weeks of gestation, a mean of 23 weeks+2 days, with 6 cases in the 3rd trimester. The operations were: 11 cholecystectomies, 6 appendectomies, 1 intestinal occlusion (volvulus on a gastric band), 3 adnexal torsions, 1 ovarian cyst and 1 paratubal cyst with torsion. No secondary laparotomy was required. The postoperative courses were favorable in most cases. However, 3 appendectomies were complicated, one by chorioamnionitis and miscarriage at 20½ weeks of gestation and 2 by right iliac fossa abscesses requiring percutaneous radiological drainage, one of these women delivered a healthy term baby and the other had chorioamnionitis and preterm delivery at 34 weeks, followed by neonatal death. CONCLUSION Laparoscopy can be safely performed for surgical indications in the second and third trimesters of pregnancy. In case of abdominal symptoms, a timely diagnosis is required to decide whether or not to operate and imaging should not be withheld particularly in case of suspected appendicitis which has a high risk of complications.
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Affiliation(s)
- S Guterman
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 178, rue des Renouillers, 92700 Colombes, France; Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Département hospitalier universitaire risques et grossesse, 75018 Paris, France
| | - L Mandelbrot
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 178, rue des Renouillers, 92700 Colombes, France; Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Département hospitalier universitaire risques et grossesse, 75018 Paris, France.
| | - H Keita
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service d'anesthésie-réanimation, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
| | - F Bretagnol
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service de chirurgie digestive, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
| | - D Calabrese
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service de chirurgie digestive, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
| | - S Msika
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service de chirurgie digestive, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
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Furey EA, Bailey AA, Twickler DM. Fetal MR Imaging of Gastrointestinal Abnormalities. Radiographics 2017; 36:904-17. [PMID: 27163598 DOI: 10.1148/rg.2016150109] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Fetal magnetic resonance (MR) imaging plays an increasing and valuable role in antenatal diagnosis and perinatal management of fetal gastrointestinal (GI) abnormalities. Advances in MR imaging data acquisition and use of motion-insensitive techniques have established MR imaging as an important adjunct to obstetric ultrasonography (US) for fetal diagnosis. In this regard, MR imaging provides high diagnostic accuracy for antenatal diagnosis of common and uncommon GI pathologic conditions. In the setting of fetal GI disease, T1-weighted images demonstrate the amount and distribution of meconium, which is crucial to the diagnostic capability of fetal MR imaging. Specifically, knowledge of the T1 signal intensity characteristics of fetal meconium, the normal pattern of meconium with advancing gestational age, and the expected caliber of small and large bowel in the fetus is key to diagnosis of abnormalities of the GI tract. Use of ultrafast T2-weighted sequences for evaluation of the expected location and morphology of fluid-containing structures, including the stomach and small bowel, in the fetal abdomen further aids in diagnostic confidence. Uncommonly encountered fetal GI pathologic conditions, especially cloacal dysmorphology, may demonstrate characteristic MR imaging patterns, which may add additional information to that from fetal US, allowing improved fetal and neonatal management. This article discusses common indications for fetal MR imaging of the GI tract, imaging protocols for fetal GI MR imaging, the normal appearance of the fetal GI tract with advancing gestational age, and the imaging appearances of common fetal GI abnormalities, as well as uncommon fetal GI conditions with characteristic appearances. (©)RSNA, 2016.
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Affiliation(s)
- Elizabeth A Furey
- From the Departments of Radiology (E.A.F., A.A.B., D.M.T.) and Obstetrics and Gynecology (A.A.B., D.M.T.), University of Texas Southwestern Medical Center, Dallas, Tex
| | - April A Bailey
- From the Departments of Radiology (E.A.F., A.A.B., D.M.T.) and Obstetrics and Gynecology (A.A.B., D.M.T.), University of Texas Southwestern Medical Center, Dallas, Tex
| | - Diane M Twickler
- From the Departments of Radiology (E.A.F., A.A.B., D.M.T.) and Obstetrics and Gynecology (A.A.B., D.M.T.), University of Texas Southwestern Medical Center, Dallas, Tex
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The Effects of Fibromyalgia Syndrome on Physical Function and Psychological Status of Pregnant Females. Arch Rheumatol 2017; 32:129-140. [PMID: 30375568 DOI: 10.5606/archrheumatol.2017.6028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/21/2016] [Indexed: 12/20/2022] Open
Abstract
Objectives This study aims to investigate the frequency and most common symptoms of fibromyalgia syndrome (FS) among pregnant females and determine the impacts of FS on physical functioning and psychological status. Patients and methods A total of 360 pregnant females (mean age 26.5 years, range 19 to 42 years) were included. The subjects were divided into two groups in terms of having (FS group; n=136; mean age 27 years; range 19 to 41 years) or not having FS (control group; n=224; mean age 26.5 years; range 20 to 42 years). The impact of FS on physical functions was evaluated using Fibromyalgia Impact Questionnaire. Psychological statuses of the subjects were evaluated using State-Trait Anxiety Inventory, Wijma Delivery Expectancy/Experience Questionnaire, and Beck Depression Inventory. Results Low back pain was the most common complaint while fatigue was the most common symptom in FS group. FS group had higher levels of pain and physical disability (p<0.001) and also higher values of anxiety, fear of childbirth, and depression (p<0.001, for all values) compared to control group. Symptom severity and physical function scores were significantly correlated with increased levels of pain, depression, anxiety, and fear of childbirth (p<0.001, for all values). Conclusion Fibromyalgia syndrome is common among pregnant females. The existence of FS in pregnancy is a severe factor contributing to maternal stress, anxiety, and depression. Therapeutic measures for fibromyalgia syndrome should be well-established to support healthy pregnancy and good child health outcome.
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Surgical Problems of the Digestive System. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
ABSTRACTOvarian torsion is an uncommon gynecological emergency that requires prompt recognition and treatment. It may present with nonspecific signs and symptoms, and should be considered in any female with acute abdominal pain. The diagnosis is based on an awareness of the relevant risk factors, the clinical presentation, and a high index of suspicion. Timely investigation and management can make the difference between ovarian loss and salvage — an outcome of great importance in the population of reproductive age females.
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Affiliation(s)
- Chris Martin
- Faculty of Medicine, University of Western Ontario, London, Ont
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Abstract
Evaluation of acute abdominal and pelvic pain in pregnancy presents a diagnostic challenge for clinicians and radiologists alike. The differential diagnosis includes obstetric and nonobstetric conditions unique to pregnancy, in addition to causes of acute abdominal and pelvic pain unrelated to the pregnancy. The clinical presentation and course of disease may be altered in pregnancy, and several pathologies are exacerbated by pregnancy. Discriminating clinical features in the diagnosis of abdominal and pelvic pain are often confounded by expected anatomic and physiologic changes in pregnancy. Moreover, while diagnostic pathways may be altered in pregnancy, the necessity for a timely and accurate diagnosis must be underscored, as delay in treatment may result in an undesirable increase in morbidity and/or mortality for both the patient and fetus. Advances in magnetic resonance imaging (MRI) through faster acquisition and motion-insensitive techniques, coupled with increased awareness and education regarding the value of MRI in diagnosing a wide range of pathology, have established MRI as a valuable strategy in the investigation of acute abdominal and pelvic pain in the pregnant patient. This review presents a practical approach to common obstetric and nonobstetric causes of acute abdominal and pelvic pain during pregnancy, as well as safety considerations for performing MRI in this patient population.
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Abstract
Abdominal pain is commonly reported by women seeking care in obstetric triage, and although it it is often benign, careful assessment is warranted. A rare cause of left upper quadrant pain during pregnancy is splenic artery aneurysm rupture, which can result in massive hemorrhage and maternal and fetal mortality. In women who survive, serious complications from bleeding and multiple transfusions require intensive care. There have been reports in the literature of improved outcomes with utilization of hemostatic resuscitation protocols. Nurses and other healthcare providers must be prepared to support families in the aftermath of this critical event. This article includes a case example of splenic artery aneurysm rupture that resulted in perinatal loss.
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MESH Headings
- Adult
- Aneurysm, Ruptured/diagnosis
- Aneurysm, Ruptured/surgery
- Cesarean Section
- Education, Nursing, Continuing
- Female
- Fetal Death
- Health Personnel/psychology
- Humans
- Infant, Newborn
- Outcome and Process Assessment, Health Care
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/surgery
- Pregnancy Trimester, Third
- Risk Factors
- Rupture, Spontaneous/diagnosis
- Rupture, Spontaneous/surgery
- Splenectomy
- Splenic Artery/pathology
- Splenic Artery/surgery
- Stress, Psychological/prevention & control
- Task Performance and Analysis
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Erkek A, Anik Ilhan G, Yildizhan B, Aktan AO. Location of the appendix at the third trimester of pregnancy: A new approach to old dilemma. J OBSTET GYNAECOL 2015; 35:688-90. [PMID: 25693051 DOI: 10.3109/01443615.2015.1006594] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of this study was to determine the location of the appendix at the third trimester of pregnancy as there are conflicting results in literature. Distances from the base of the appendix were measured intra-operatively to the anterior iliac spine (A), symphysis pubis (B) and the xyphoid process (C). The same measurements were taken from McBurney's point on the abdominal wall (A1, B1 and C1). In the allocated 21 pregnant and 18 non-pregnant women, distance A and B were 10.3 ± 0.9 cm and 18.3 ± 3.2 cm in pregnant and 6.7 ± 0.9 cm and 13.2 ± 0.9 cm in non-pregnant women (p < 0.001), respectively. Distance C was shorter in pregnant women (14.7 ± 2.5 cm vs. 23.8 ± 1.9, p < 0.001). Conversely, distance C1 was longer in pregnant women (30.3 ± 3.0 vs. 24.8 ± 5.1 cm, p = 0.004). This study provides evidence that the appendix moves cranially late in the course of the pregnancy. Therefore, McBurney's point cannot be used as a reference point to localise the appendix at the third trimester of pregnancy.
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Affiliation(s)
- A Erkek
- a Department of General Surgery , Marmara University School of Medicine , Istanbul , Turkey
| | - G Anik Ilhan
- b Department of Obstetrics and Gynecology , Marmara University School of Medicine , Istanbul , Turkey
| | - B Yildizhan
- b Department of Obstetrics and Gynecology , Marmara University School of Medicine , Istanbul , Turkey
| | - A O Aktan
- a Department of General Surgery , Marmara University School of Medicine , Istanbul , Turkey
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30
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Coleman B, Ramakrishnan K. Surgical Problems of the Digestive System. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_100-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Aksoy H, Ozyurt S, Aksoy U, Acmaz G, Karadag OI, Karadag MA. Ovarian torsion in puerperium: A case report and review of the literature. Int J Surg Case Rep 2014; 5:1074-6. [PMID: 25460478 PMCID: PMC4275863 DOI: 10.1016/j.ijscr.2014.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 11/16/2022] Open
Abstract
Ovarian torsion (OT) is a rare cause of acute abdominal pain during puerperium. The diagnosis of OT during puerperium is difficult, and occasionally remains a diagnostic dilemma. The clinical and laboratory findings are variable and nonspecific. Early use of bedside abdominal ultrasonography is important in differential diagnosis of OT from other acute abdominal pathologies. A heightened awareness of the relevant risk factors, the clinical presentation, and a high degree of clinical suspicion are essential for early and accurate diagnosis of OT.
INTRODUCTION Ovarian torsion (OT) is a rare cause of acute abdominal pain that requires prompt recognition and treatment during puerperium. Diagnosis of OT can be challenging due to nonspecific clinical features and uncommon objective findings. The management of OT is often delayed because of diagnostic uncertainty. Early and timely recognition and prompt intervention are crucial to preserve ovarian function and to minimize morbidity. PRESENTATION OF CASE We report a 29-year-old postpartum woman who presented to the emergency department (ED) with severe right flank pain, nausea and anorexia initially considered as renal colic. After further investigation, OT caused by large mucinous cyst was diagnosed. Right-sided salpingo-oophorectomy was performed due to hemorrhagic ovary and huge cystic mass causing ischemic OT. DISCUSSION OT is often diagnosed based on the clinical presentation, including severe, sharp, sudden onset of unilateral lower abdominal pain and tenderness with a palpable laterouterine pelvic mass and nausea/vomiting. Emergency surgical intervention should be performed if OT is suspected to confirm the diagnosis and uncoil the twist to prevent ovarian damage. CONCLUSION In conclusion, emergency physicians should be aware of the possibility of OT in postpartum women. Therefore, early and timely surgical intervention should be undertaken.
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Affiliation(s)
- Huseyin Aksoy
- Department of Obstetrics and Gynecology, Kayseri Military Hospital, Kayseri, Turkey
| | - Sezin Ozyurt
- Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital of Medicine, Kayseri, Turkey.
| | - Ulku Aksoy
- Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital of Medicine, Kayseri, Turkey
| | - Gokhan Acmaz
- Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital of Medicine, Kayseri, Turkey
| | - Ozge Idem Karadag
- Department of Obstetrics and Gynecology, Acibadem Kayseri Hospital, Kayseri, Turkey
| | - Mert Ali Karadag
- Department of Urology, Acibadem Kayseri Hospital, Kayseri, Turkey
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Masselli G, Brunelli R, Monti R, Guida M, Laghi F, Casciani E, Polettini E, Gualdi G. Imaging for acute pelvic pain in pregnancy. Insights Imaging 2014; 5:165-81. [PMID: 24535757 PMCID: PMC3999369 DOI: 10.1007/s13244-014-0314-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 01/08/2014] [Accepted: 01/21/2014] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Gabriele Masselli
- Umberto I Hospital, Radiology Department, Sapienza University, Viale del Policlinico 155, 00161, Rome, Italy,
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Masselli G, Derchi L, McHugo J, Rockall A, Vock P, Weston M, Spencer J. Acute abdominal and pelvic pain in pregnancy: ESUR recommendations. Eur Radiol 2013; 23:3485-500. [DOI: 10.1007/s00330-013-2987-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/10/2013] [Accepted: 07/13/2013] [Indexed: 12/19/2022]
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Dewhurst C, Beddy P, Pedrosa I. MRI evaluation of acute appendicitis in pregnancy. J Magn Reson Imaging 2013; 37:566-75. [PMID: 23423797 DOI: 10.1002/jmri.23765] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 06/29/2012] [Indexed: 12/13/2022] Open
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Diegelmann L. Nonobstetric abdominal pain and surgical emergencies in pregnancy. Emerg Med Clin North Am 2012; 30:885-901. [PMID: 23137401 DOI: 10.1016/j.emc.2012.08.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Laura Diegelmann
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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Abstract
Imaging of pregnant patients with non-obstetric abdominal pain is reviewed, with an accompanying pictorial essay of cases with concentration on magnetic resonance imaging. Non-obstetric causes of abdominal pain during pregnancy are similar to those of non-pregnant patients. The most common causes are appendicitis and cholecystitis. Other causes are myriad and include biliary, gastrointestinal, infectious, inflammatory, and malignant etiologies, among others. The approach to imaging in pregnant patient is unique, as it is imperative to minimize potentially harmful radiation exposures to the fetus. Ultrasound and MRI are the primary modalities for evaluation of the pregnant patient with abdominal pain. The use of intravenous contrast is discouraged, except in highly-selected patients where there is no other way to obtain vital diagnostic information. CT is still used as the mainstay of evaluation of blunt abdominal trauma and is commonly used for diagnosis of small bowel obstruction, stone disease, and work-up of malignancy during pregnancy. A discussion of test selection and underlying rationale is presented.
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Baron KT, Arleo EK, Robinson C, Sanelli PC. Comparing the diagnostic performance of MRI versus CT in the evaluation of acute nontraumatic abdominal pain during pregnancy. Emerg Radiol 2012; 19:519-25. [DOI: 10.1007/s10140-012-1066-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 08/01/2012] [Indexed: 11/25/2022]
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Spalluto LB, Woodfield CA, DeBenedectis CM, Lazarus E. MR imaging evaluation of abdominal pain during pregnancy: appendicitis and other nonobstetric causes. Radiographics 2012; 32:317-34. [PMID: 22411935 DOI: 10.1148/rg.322115057] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Clinical diagnosis of the cause of abdominal pain in a pregnant patient is particularly difficult because of multiple confounding factors related to normal pregnancy. Magnetic resonance (MR) imaging is useful in evaluation of abdominal pain during pregnancy, as it offers the benefit of cross-sectional imaging without ionizing radiation or evidence of harmful effects to the fetus. MR imaging is often performed specifically for diagnosis of possible appendicitis, which is the most common illness necessitating emergency surgery in pregnant patients. However, it is important to look for pathologic processes outside the appendix that may be an alternative source of abdominal pain. Numerous entities other than appendicitis can cause abdominal pain during pregnancy, including processes of gastrointestinal, hepatobiliary, genitourinary, vascular, and gynecologic origin. MR imaging is useful in diagnosing the cause of abdominal pain in a pregnant patient because of its ability to safely demonstrate a wide range of pathologic conditions in the abdomen and pelvis beyond appendicitis.
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Affiliation(s)
- Lucy B Spalluto
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Rhode Island Hospital, Providence, RI, USA.
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Imaging of pregnant and lactating patients: part 2, evidence-based review and recommendations. AJR Am J Roentgenol 2012; 198:785-92. [PMID: 22451542 DOI: 10.2214/ajr.11.8223] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objectives of this article are to discuss the current evidence-based recommendations regarding the use of diagnostic imaging in the evaluation of pulmonary embolism, appendicitis, urolithiasis, and cholelithiasis during pregnancy. CONCLUSION Diagnostic imaging should be performed during pregnancy only with an understanding of the maternal and fetal risks and benefits, the comparative advantages of different modalities, and the unique anatomic and physiologic issues associated with pregnancy.
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Mkpolulu CA, Ghobrial PM, Catanzano TM. Nontraumatic abdominal pain in pregnancy: imaging considerations for a multiorgan system problem. Semin Ultrasound CT MR 2012; 33:18-36. [PMID: 22264900 DOI: 10.1053/j.sult.2011.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Nontraumatic abdominal pain in the pregnant patient can present a clinician with a variety of diagnostic possibilities. The overlap between signs and symptoms expected in normal pregnancy and these many pathologic possibilities does little to help focus the clinician's diagnostic efforts. Fear of ionizing radiation's effects on the fetus has driven efforts to refine medical imaging algorithms in such a way as to attempt to eliminate its use at all cost. In today's world, we are nearly there. In this review the differential diagnosis of nontraumatic abdominal pain in the pregnant patient will be explored. Of note is the recurring theme that much of what can be done today with regard to diagnostic imaging, both in general and with regard to this specific subset of patients, centers on the use of the non-ionizing modalities of ultrasound and magnetic resonance imaging.
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Affiliation(s)
- Chiedozie A Mkpolulu
- Department of Radiology, Tufts School of Medicine, Baystate Medical Center, Springfield, MA 01199, USA.
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45
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Abstract
Although gastrointestinal endoscopy is generally safe, its safety must be separately analyzed during pregnancy with regard to fetal safety. Fetal risks from endoscopic medications are minimized by avoiding FDA category D drugs, minimizing endoscopic medications, and anesthesiologist attendance at endoscopy. Esophagogastroduodenoscopy seems to be relatively safe for the fetus and may be performed when strongly indicated during pregnancy. Despite limited clinical data, endoscopic banding of esophageal varices and endoscopic hemostasis of nonvariceal upper gastrointestinal bleeding seems justifiable during pregnancy. Flexible sigmoidoscopy during pregnancy also appears to be relatively safe for the fetus and may be performed when strongly indicated. Colonoscopy may be considered in pregnant patients during the second trimester if there is a strong indication. Data on colonoscopy during the other trimesters are limited. Therapeutic endoscopic retrograde cholangiopancreatography seems to be relatively safe during pregnancy and should be performed for strong indications (for example, complicated choledocholithiasis). Endoscopic safety precautions during pregnancy include the performance of endoscopy in hospital by an expert endoscopist and only when strongly indicated, deferral of endoscopy to the second trimester whenever possible, and obstetric consultation.
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Jang KM, Kim SH, Choi D, Lee SJ, Rhim H, Park MJ. The value of 3D T1-weighted gradient-echo MR imaging for evaluation of the appendix during pregnancy: preliminary results. Acta Radiol 2011; 52:825-8. [PMID: 21835887 DOI: 10.1258/ar.2011.110116] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The use of oral contrast has been essential for the identification of a normal appendix on MR imaging during pregnancy. However, stool could be used as a positive oral contrast as it is characterized by a relatively high signal on T1-weighted imaging, and 3D T1-weighted gradient-echo (T1W-GRE) MR imaging has been used to evaluate 3 mm diameter intestines in fetuses. PURPOSE To evaluate the added value of 3D T1W-GRE MR imaging in combination with T2-weighted imaging (T2WI) compared to T2WI alone for evaluating the appendix during pregnancy. MATERIAL AND METHODS Eighteen consecutive pregnant patients who were clinically suspected of having acute appendicitis underwent appendix MR imaging which included T2WI with or without spectral presaturation attenuated inversion-recovery (SPAIR) fat suppression, and 3D T1W-GRE with SPAIR fat suppression. Two radiologists reviewed the two image sets (the T2WI set and the combined set of T2WI and 3D T1W-GRE images). Pathologic and clinical results served as the reference standard. The differences in the degree of visibility of the appendix and confidence scale for diagnosing acute appendicitis between two image sets were compared by using the paired Wilcoxon signed rank test. RESULTS For both reviewers, the degree of visibility of the appendix using the combined T2WI and 3D T1W-GRE images was significantly higher than using T2WI alone (P < 0.01), and the confidence levels for acute appendicitis using combined T2WI and 3D T1W-GRE images were significantly different from those using T2WI alone (P < 0.01). In the 13 patients with a normal appendix, both reviewers showed improved confidence levels for appendicitis using combined T2WI and 3D T1W-GRE images than T2WI alone. CONCLUSION Adding 3D T1W-GRE images to T2WI is helpful for identification of the appendix, as compared to T2WI alone in pregnant women without ingestion of oral contrast material. This may improve diagnostic confidence for acute appendicitis in pregnant patients.
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Affiliation(s)
- Kyung Mi Jang
- Departments of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyun Kim
- Departments of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dongil Choi
- Departments of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soon Jin Lee
- Departments of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyunchul Rhim
- Departments of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Jung Park
- Departments of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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47
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Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 2011; 25:3479-92. [PMID: 21938570 DOI: 10.1007/s00464-011-1927-3] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 08/24/2011] [Indexed: 12/11/2022]
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Chen Y, Hou Q, Zhang Z, Zhang J, Xi M. Diaphragmatic hernia during pregnancy: a case report with a review of the literature from the past 50 years. J Obstet Gynaecol Res 2011; 37:709-14. [PMID: 21410835 DOI: 10.1111/j.1447-0756.2010.01451.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Diaphragmatic hernia is a rare complication during pregnancy. Only 30 reports have been published on this subject in English between 1959 and 2009. Due to misdiagnoses and management delays, diaphragmatic hernia usually presents itself as a life-threatening emergency. Here, we present a case report of a patient with a traumatic diaphragmatic hernia who became acutely symptomatic during pregnancy. The diaphragmatic hernia was managed successfully, and we describe the presentation, management and outcome of this case. We also present a review of all of the reported cases of diaphragmatic hernias complicating pregnancy that have been published in English during the past 50 years.
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Affiliation(s)
- Yue Chen
- West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
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Beddy P, Keogan MT, Sala E, Griffin N. Magnetic resonance imaging for the evaluation of acute abdominal pain in pregnancy. Semin Ultrasound CT MR 2011; 31:433-41. [PMID: 20974361 DOI: 10.1053/j.sult.2010.08.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The investigation of acute abdominal pain in pregnancy is challenging. The use of ultrasound may be limited due to the patient's change in body habitus and computed tomography is not desirable due to fetal irradiation. Magnetic resonance imaging (MRI) has thus become increasingly popular in the evaluation of such patients, due to its lack of ionizing radiation, multiplanar capability and high contrast resolution. This review will detail the MRI technique required to image the pregnant abdomen and describe the MRI features of common causes of acute abdominal pain in pregnancy.
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Affiliation(s)
- Peter Beddy
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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50
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Efthimiadis C, Kosmidis C, Grigoriou M, Anthimidis G, Vasiliadou K, Ioannidis A, Basdanis G. The Role of Laparoscopic Surgery in Pregnant Women with Nonobstetric Acute Abdomen. J Gynecol Surg 2010. [DOI: 10.1089/gyn.2009.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Marios Grigoriou
- Department of Surgery, Interbalkan European Medical Center, Thessaloniki, Greece
| | - George Anthimidis
- Department of Surgery, Interbalkan European Medical Center, Thessaloniki, Greece
| | - Kalliopi Vasiliadou
- Department of Surgery, Interbalkan European Medical Center, Thessaloniki, Greece
| | - Aristidis Ioannidis
- Department of Surgery, Interbalkan European Medical Center, Thessaloniki, Greece
| | - George Basdanis
- Department of Surgery, Interbalkan European Medical Center, Thessaloniki, Greece
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