Abdominal pain during pregnancy

Liver infarctions as the first manifestation of antiphospholipid antibody syndrome in pregnancy: a case report

Background

The differential diagnosis of abdominal pain in pregnant women is broad. Liver diseases as the origin of abdominal pain in pregnancy are rare, and severe forms occur in less than 0.1% of pregnancies. Some disorders, such as hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and preeclampsia, are unique to pregnancy, while others, such as antiphospholipid antibody syndrome, may manifest in pregnancy but have consequences beyond the current pregnancy. All of them require prompt identification and treatment.

Case presentation

A 27-year-old Caucasian woman who was 15⁺¹ weeks pregnant reported to the emergency department twice due to stabbing right-upper-quadrant abdominal pain. Initial laboratory testing revealed mild leukocytosis and slightly elevated liver enzymes. On second presentation, the patient was febrile and had an increased C-reactive protein concentration. Over the course of the next days, nonhemolytic anemia and thrombocytopenia emerged with elevated liver enzymes. Coagulation studies also revealed a prolongation of activated partial thromboplastin time. Magnetic resonance imaging showed nonspecific alterations in the right liver lobe, possibly corresponding to infection or infarction. A hepatic viral infection was ruled out. At that time, the most likely diagnosis was cholangitis with liver abscess formation, and antibiotic therapy was started. Further worsening of the anemia and thrombocytopenia, development of proteinuria, together with a miscarriage on the fourth day of hospitalization resulted in the tentative diagnosis of (triple-positive) antiphospholipid antibody syndrome, which was confirmed 12 weeks after the initial investigation. Treatment consisted of prompt anticoagulation with heparin and later on with a vitamin K antagonist as well as high-dose glucocorticoid therapy. There was no need for intravenous immunoglobulin therapy or plasma exchange, although we suspected a catastrophic form of antiphospholipid antibody syndrome due to infarctions of the liver, placenta, and possibly kidneys (proteinuria). The outcome was favorable.

Conclusion

We report a 27-year-old pregnant woman whose abdominal pain was caused by liver infarctions as the first manifestation of catastrophic antiphospholipid antibody syndrome. The antiphospholipid antibody syndrome was possibly secondary to hitherto clinically silent systemic lupus erythematosus since the antinuclear antibodies were increased later on. Hydroxychloroquine therapy was initiated to prevent antiphospholipid antibody syndrome recurrence in a future pregnancy.

MRI of suspected appendicitis during pregnancy: interradiologist agreement, indeterminate interpretation and the meaning of non-visualization of the appendix

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.

Does pregnancy increase the risk of abdominal hernia recurrence after prepregnancy surgical repair?

BACKGROUND

By increasing intraabdominal pressure, pregnancy may increase the risk of abdominal hernia recurrence. Current data are limited to studies with small sample size and thus the impact of pregnancy on recurrence is unclear.

OBJECTIVE(S)

The objective of this analysis was to evaluate the impact of pregnancy on clinically significant abdominal hernia recurrence in a large multicenter cohort.

STUDY DESIGN

A multiinstitution deidentified electronic health record database, EPM: Explore (Explorys Inc, Cleveland, OH) was utilized to perform a retrospective cohort study of women aged 18-45 years with a history of an abdominal hernia repair from 1999 through 2013. Abdominal hernia was defined to include ventral and incisional hernias, and other types were excluded. The presence or absence of a pregnancy following primary hernia repair was elucidated from the database. Subjects were excluded if a hernia repair occurred during pregnancy. The rate of hernia recurrence, defined as reoperation, was calculated. The association between pregnancy and hernia recurrence was evaluated with logistic regression, both unadjusted and adjusted for diabetes, obesity (body mass index >30 kg/m(2)), tobacco abuse, and wound complication at the time of initial hernia repair.

RESULTS

A total of 11,020 women with a history of hernia repair were identified, of whom 840 had a subsequent pregnancy. Overall, 915 women in the cohort had a hernia recurrence (8.3%). Women with a history of pregnancy following primary hernia repair were more likely to have a body mass index >30 kg/m(2), a history of tobacco abuse, and a wound complication at the time of primary repair. In an unadjusted analysis, pregnancy was associated with an increase in the risk of hernia recurrence (13.1% vs 7.1%, odds ratio, 1.96, 95% confidence interval, 1.60-2.42). The association between pregnancy and hernia recurrence was attenuated but persisted after adjusting for confounding factors (adjusted odds ratio, 1.73, 95% confidence interval, 1.40-2.14).

CONCLUSION

Pregnancy is associated with an increased risk of abdominal hernia recurrence after adjusting for confounding factors. The magnitude of this association is likely underestimated, given that the risk of recurrence was defined as reoperation, which captures only the most clinically significant group of recurrences. This information will facilitate counseling for reproductive-aged women planning elective ventral or incisional hernia repair. The risk of recurrence and subsequent reoperation should be balanced against the risk of incarceration and emergent surgery during pregnancy. As such, the desire for future pregnancy and/or contraception should be considered when planning asymptomatic hernia repair for women of reproductive age.

Magnetic resonance imaging of acute abdominal and pelvic pain in pregnancy

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.

Abdominal wall hernia and pregnancy: a systematic review

PURPOSE

There is no consensus as to the treatment strategy for abdominal wall hernias in fertile women. This study was undertaken to review the current literature on treatment of abdominal wall hernias in fertile women before or during pregnancy.

METHODS

A literature search was undertaken in PubMed and Embase in combination with a cross-reference search of eligible papers.

RESULTS

We included 31 papers of which 23 were case reports. In fertile women undergoing sutured or mesh repair, pain was described in a few patients during the last trimester of a subsequent pregnancy. Emergency surgery of incarcerated hernias in pregnant women, as well as combined hernia repair and cesarean section appears as safe procedures. No major complications were reported following hernia repair before or during pregnancy. The combined procedure of elective cesarean section and abdominal wall hernia repair was reported in 102 patients without major complications.

CONCLUSIONS

The literature on abdominal wall hernia and pregnancy is sparse. Abdominal wall hernia repair with suture or mesh may cause pain in the last trimester of a subsequent pregnancy. Hernia repair in conjunction with cesarean section appear as the optimal treatment of a pregnant patient with a symptomatic abdominal wall hernia.

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 evaluation of abdominal pain during pregnancy: appendicitis and other nonobstetric causes

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.

Nontraumatic abdominal pain in pregnancy: imaging considerations for a multiorgan system problem

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.

Appendicitis During Pregnancy

Acute appendicitis is the most common extra-uterine surgical emergency requiring immediate surgical intervention during pregnancy [1]. Six young female patients presented with appendicitis during May 1996 to May 2001 in different service hospitals. Five patients underwent emergency appendectomy successfully. Gestational age at presentation included first trimester in 4 patients, second trimester in 2 patients and none in third trimester. 84% had pathologically proven acute appendicitis. One patient presented with appendicular lump in first trimester, proved on ultra sonography examination, which was treated by Oshner Sherren regime and subsequently interval appendectomy was done in second trimester. No long term adverse maternal morbidity or mortality was reported. One patient had premature onset of labour and delivered. Natural history of acute appendicitis is not changed during pregnancy while gestational physiological changes obscure the accurate diagnosis of acute appendicitis.

Abdominal pain in pregnancy: diagnoses and imaging unique to pregnancy--self-assessment module

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of the imaging evaluation of abdominal pain during pregnancy.

Pregnant patients suspected of having acute appendicitis: effect of MR imaging on negative laparotomy rate and appendiceal perforation rate

PURPOSE

To investigate the effect of magnetic resonance (MR) imaging on the negative laparotomy rate (NLR) and the perforation rate (PR) in pregnant patients suspected of having acute appendicitis (AA) and to assess the need for computed tomography (CT) in this setting.

MATERIALS AND METHODS

The data of 148 consecutive pregnant patients (mean age, 29 years; age range, 15-42 years; mean gestational age, 20 weeks; gestational age range, 4-37 weeks) who were clinically suspected of having AA and examined with MR imaging between March 2002 and August 2007 were retrospectively analyzed in an institutional review board-approved HIPAA-compliant protocol. One hundred forty patients underwent ultrasonography (US) before MR imaging. The clinical and laboratory data and the findings of the initial US and MR image interpretations were recorded and analyzed at Student t and Fisher exact testing. The NLR and PR were calculated.

RESULTS

Fourteen (10%) patients had AA, and perforation occurred in three (21%) of them. US results were positive for AA in five (36%) patients with proved AA. MR results were positive in all 14 patients with AA. MR results were negative in 125 of the 134 patients without AA; there were nine false-positive cases (two positive, seven inconclusive). Among the patients without AA, the normal appendix could be visualized on US images in less than 2% (two of 126) of cases and on MR images in 87% (116 of 134) of cases (P < .0001). Twenty-seven (18%) patients underwent surgical exploration, and eight of them had negative laparotomy results, yielding an NLR of 30% and a PR of 21% (three of 14 patients). Only four (3%) patients underwent CT.

CONCLUSION

For pregnant patients clinically suspected of having AA, use of MR imaging yields favorable combinations of NLR and PR compared with previously reported values. The radiation exposure associated with CT examination can be avoided in most cases.

Surgical gastrointestinal disorders during pregnancy

All gastrointestinal (GI) disorders can present during pregnancy, and in fact 0.2% to 1.0% of all pregnant women require non-obstetrical general surgery. All of the clinical decision-making skills of the experienced surgeon must come into play in order to make the correct therapeutic decisions when evaluating the pregnant patient with a GI disorder that potentially requires surgery. While in general the principles of diagnosing and treating a pregnant woman with an acute surgical abdominal problem remain the same as those governing the treatment of the non-pregnant patient, some important differences are present and can pose problems. As a general rule the condition of the mother should always take priority because proper treatment of surgical diseases in the mother will usually benefit the fetus as well as the mother.

MR imaging evaluation of acute appendicitis in pregnancy

PURPOSE

To retrospectively assess the diagnostic performance of magnetic resonance (MR) imaging in pregnant patients suspected of having acute appendicitis.

MATERIALS AND METHODS

The study was approved by the committee on clinical investigations and was HIPAA compliant. The informed consent requirement was waived. MR images were obtained in 51 consecutive pregnant patients (mean age, 28.3 years) who were clinically suspected of having acute appendicitis. In this protocol for pregnant patients, MR imaging is performed when findings at ultrasonography (US) are inconclusive or additional information is needed. Four patients had appendicitis, which was confirmed at surgery in three patients and at follow-up computed tomography in one patient. Initial interpretations were used for patient care and to calculate diagnostic accuracy. The appendix was considered normal at MR imaging if its diameter was less than or equal to 6 mm or if it was filled with air, oral contrast material, or both. An enlarged fluid-filled appendix (>7 mm in diameter) was considered an abnormal finding. An appendix with a diameter of 6-7 mm was considered an inconclusive finding; in those cases, the presence of periappendiceal inflammation was used for the final diagnosis. Three radiologists retrospectively assessed the visualization of the appendix by using a 5-point scale. Statistical analysis was performed by using the median and Fisher exact tests and the Spearman correlation coefficient.

RESULTS

MR images were positive for appendicitis in four patients and inconclusive in three. In the three patients with inconclusive results, the appendix was not seen in two patients and was borderline enlarged (7 mm in diameter) in the third. The overall sensitivity, specificity, prevalence-adjusted positive and negative predictive values, and accuracy for MR imaging was 100%, 93.6%, 1.4%, 100%, and 94.0%, respectively.

CONCLUSION

MR imaging is an excellent modality for use in excluding acute appendicitis in pregnant women who present with acute abdominal pain and in whom a normal appendix is not visualized at US.

Imaging modalities in obstetrics and gynecology

The practicing emergency physician often encounters diagnostic dilemmas involving the choice of the most appropriate radiologic study to evaluate patients in the emergency department. In addition, the uncertainty of potentially harmful fetal effects of radiation in the pregnant patient may add unnecessary delay and concern in the workup of obstetric emergencies. An emergency physician's in-depth understanding of the strengths, limitations, and potentially harmful effects of radiologic studies allows the safest and most appropriate studies to be ordered for the gynecologic and obstetric population. With the explosion of interest and growing level of expertise in focused emergency department ultrasonography during the last decade, the practicing emergency physician should add this skill to his or her armamentarium in the future. Many emergency physicians are already comfortable in using radiologic technologies in their daily practice and have discovered how quickly vital and specific information can be obtained.

Gastrointestinal surgery and pregnancy

Gastrointestinal disorders during pregnancy that require surgery often mimic the symptoms and signs of conditions that do not require surgery. Anatomic and physiologic changes of pregnancy can alter the usual clinical presentation of gastrointestinal disorders that require surgery. These alterations can be a challenge to diagnosis. Prompt treatment is critical to successful management. Most elective and urgent operations can be performed during pregnancy with minimal maternal and fetal risk. The condition of the mother should always take priority because proper treatment of the mother usually benefits the fetus as well.

Liposarcoma complicating pregnancy

BACKGROUND

An adnexal mass in pregnancy is a common occurrence. Malignancy is uncommon and only seven cases of liposarcoma have been reported in association with pregnancy.

CASE

We present a case of a pregnant patient who was diagnosed with an adnexal mass detected by ultrasound at 13 weeks gestation. The mass was surgically removed postpartum, when it was found to be a liposarcoma. Postoperatively she received chemotherapy but eventually succumbed to her disease.

CONCLUSIONS

Liposarcoma is rarely found in association with pregnancy and may follow an aggressive course.

Correlation between Helicobacter pylori infection and gastrointestinal symptoms in pregnancy

Nausea, vomiting, and other dyspeptic symptoms are common in pregnancy. This hospital-based, cross-sectional study was designed to determine the role of Helicobacter pylori infection in gastrointestinal (GI) symptoms during pregnancy. Standardized verbal scales were used to evaluate the frequency and severity of GI symptoms in 54 women whose pregnancies were in the first 16 gestational weeks. H. pylori infection was defined as a positive serum immunoglobulin G result on an immunochromatographic assay. The H. pylori seropositivity rate was higher in the pregnant women (69%) than in the general population (approximately 50%-55%), but seropositivity did not correlate with clinical symptoms. Moreover, no specific patterns of GI symptoms were uncovered in the H. pylori-infected patients. Maternal age, body weight, parity, gestational week, and educational level were not associated with H. pylori infection; neither were the prevalence and severity of GI symptoms.

Splenic infarction in pregnancy

We present a case of splenic infarction in pregnancy, secondary to acute bacterial endocarditis. Left upper quadrant pain in pregnancy can be due to a variety of causes and in the septic or unwell patient, splenic infarct should be considered in the differential diagnosis. The diagnosis of splenic infarct should be considered especially in those at increased risk of bacterial endocarditis. Acute bacterial endocarditis can occur even in patients without any risk factors. Bacterial endocarditis is rare in pregnancy and splenic infarction is even rarer. However when it occurs, rapid diagnosis and management are necessary to minimize embolic phenomena. With the increasing use of intravenous drugs and with increasing numbers of Pacific Islanders in our pregnant population, it is important to be alert to the risk of bacterial endocarditis and to avoid serious sequelae. Patient education to the importance of medical follow-up in order to prevent such a life-threatening condition, and to avoid more complicated acute treatment, is imperative.