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The acute abdomen in obstetric and gynaecologic patients can should be cione. The retroplacental bloodclot may make
be classified lnto five broad categories: it dilficult to hear the fetal heart with a Pinard fetal
I Obstetric causes of an acute abdomen stethoscope. If the fetal heart cannot be heard, ultrasound
II Gynaecologic causes of an acute abdomen in the pregnant should be used to confim the presence or absence of the
patlent. f'etal heartbeat.
III Gynaecologic causes of an acute abdomen in the non- n If the fetus is dead an amniotomy is indicated, followed
pregnant patient. by vaginal delivery. Syntocinon should be used with
IV Surgical and medical causes of an actlte abdomen in the caution as it may not be possible to monitor uterine
pregnant patient. contractions accurately.3
V Surgical and medical causes of an acute abdomen in the d. The monitoring of urine outputby an inrJwelling transurethral
non-pregnant female. catheter. Serum urea shouid be estimated and if urinary
output is not adequate treatment for ollguria should be
I OBSTETRIC CAUSES OF AN ACUTE ABDOMEN stafted.
Abruptio placentae e. Preparedness to treat atonic postpartum haemorrhage. Intra-
Abruptio placentae is defined as the premature separation of a myometrial injection of prostaglandin F']-alpha (1,0 - 5,0 mg
normally situated placenta. The incidence is about I in 80 to 1 diluted in 10 ml sterile water) may be necessary.
in 200 pregnancies.l It is a serious condition which results in
loss of the fetus in 30 - 600/o of casesr and occasionaily in the Ectopic pregnancy
death of the mother, especially if not expeditiously treated' The The incidence ofectopic pregnancy is itrcreasings and rnaternal
clinical f'eatures of a classical case are: deaths due to ectopic pregnancy have increased from 7,87o ot
a. Acute abdominal pain with or without vaginal bleeding. The all maternal deaths to 11,57o between 1970 and 1978.6 The
pain is sudden in onset and continuous in character' clinical features of ruptured ectopic pregnancy are:
b. A rigid tender uterus - the fetal pafis are therefore difficult a. The sudden onset of acute abdominal pain, sometimes
to feel. accompanied by shoulder-tip pain.
c. Signs of f'etal distress or absent fetai hearl sounds. b. Hypovolaemic shock and anaemia.
d. Hypovolaemic shock of varying degree - if the patient had c. With abdominal palpation a full, doughy feeling. When the
previously been hypertensive, ar-terial blood pressure may intra-abdominal blood starts to clot with the resultant fbrma-
be misieading.l tion of fibrin bands attached to the peritoneum, rebound
e. Anaemia. tendemess becomes marked.
The clinical features may be atypicai in the case of abruption cl. During vaginal examination acute tendemess is elicited by
of a posteriorly inserred placenta when the patient may only moving the cervix frorn side to side"
complain of backache and vaginal bleeding'r'a The clinical features of unruptured ectopic pregnancy, chronic
The principles of treatment of abruptio placentae are: ectopic pregnancy and advanced extra-uterine pregnancy ffe
a. The replacement of blood volume mainly by whole blood non-specific and may consist of:
transtusion. Blood loss is nezdy always more than can be a. Chronic abdominal discomfbrt.
seen externally. Central venous pressure should be used to b. Oceasional faiuting.
monitor transfusion.3 c. Metrorrhagia or bloodstained vaginai discharge.
b. The doing of clotting tests on the first specimen of blood d. In the case ofadvanced extra-uterine pregnancy easily pal-
taken for cross-matching and if a clotting def'ect is found, the pable f'etal pafls and/or abnotmal 1ie of the fetus.
institution of appropriate treatment. Fresh frozen plasrna If the diagnosis is uncerlain, the following diagnostic aids
transfusion is an imporlant first aid measure.:l rnay help:
c. The expedition of delivery. a. Laparoscopy: This is the most valuable of a1l the diagnostic
n If the fetus is still alive an emergency caesarean section aids. If blood is seen in the peritoneal cavity an emergency
laparotomy shouid be performed. iv The uterine tube must be normal and intact on the affected
r. A pregnancy test: Radioimmuno-assay of the beta sub-unit side of the pelvis.
of human chorionic gonadotrophin is of value, butit does not Treatment consists of resection of the trophoblast fiom the
differentiate between ectopic and intra-uterine pregnancy. ovary, preserving as much ovarian tissue as possible. To
:. Ultrasound: Transvaginal ultrasound is of value in the early decrease the risk for postoperative peri-ovarian adhesions
detection of an unruptured tubal pregnancy. Transabdominal the ovarian capsule should be meticulously repaired, prefer-
ultrasound may be of value as a complementary investiga- ably with PDS 6/0 on a micro-cutting needle, using an
tion to a positive pregnancy test, by demonstrating the inversion technique. 1o
presence or absence of intra-uterine pregnancy. The pres- e. Advanced extra-uterine pregnancy: Laparotomy with re-
ence of intra-uterine pregnancy makes the diagnosis of moval of the fetus andplacenta. Ifthe location of the placenta
ectopic pregnancy extremely unlikely, since a combined is such that removal would be dangerous, it should be left in
intra-uterine and extra-uterine pregnancy is very rare. situ. Rh negative women can become sensitized by Rh
Ultrasound is also of value in the diagnosis of advanced positive blood from an ectopic pregnancy and should be
extra-uterine pregnancy, by demonstrating the fetus outside treated with 300 pg Rh immunoglobulin.rr
the uterus. An alterrative investigation in these cases is a
lateral abdominal X-ray, which may show the fetal bones Rupture of the uterus
overlapping the matemal vertebral column. Rupture of the uterus is a serious condition which occurs fairly
l. Culdocentesis or abdominal paracentesis: These two inves- rarely. Mokgokong and Marivate report an incidence of 1 in 545
tigations are seldom of value in the diagnosis of ectopic in a very large series of more than 180 000 deliveries.r2
pregnancy. Ifblood originating from an ectopic pregnancy Uterine rupture mostly occurs secondary to obstructed la-
is aspirated, the typical appearance is that of mainly unclotted bour or trauma to the uterus. Spontaneous t'rrpture of the uterus
blood with small clots which can be seen if the blood is may occur if there is a scar in the uterus and in exceptional cases
filtered through gauze. with an intact uterus. Spontaneous rupture of the intact uterus
The treatment of ectopic pregnancy consists of the follow- mostly occurs in grand multiparae, but in exceptional cases it
.lg: may also be seen rn a primigravida.13
. Ruptured tubal pregnancy: Treatment of hypovolaemic Threatening uterine rupture is clinically characterised by
shock, laparotomy and blood transfusion. Resuscitation continuous pain between contractions, tenderness over the
should be simultaneous with surgery as there is no point in utems and haematuria. After the uterus has ruptured the classic
delaying operation while blood is pouring into the abdo- ciinical picture is that of shock, vaginal bleeding, an acute
men.3 A partial or total salpingectomy is performed, depend- abdomen, absent uterine contractions or a fibrillary pattern of
ing on the degree of tubal destruction. uterine contractions, easily palpable fetal parls and fetal distress
r. Unruptured tubal pregnancy: Laparotomy and partial or death. However, the classic clinical picture is not always
salpingectomy or salpingotomy. Conservative surgery has present.ra
the advantage that microsurgical re-anastompsis of the The treatnent of uterine rupture consists of resuscitating the
uterine tube can be performed at a later stage. patient (oxygen and intravenous administration of fluid, includ-
OR ing blood, according to the central venous pressure) and an
Laparoscopic salpingotomy (this should only be done by a emergency laparotomy. A total abdominal hysterectomy (or a
gynaecologic surgeon properly trained in endoscopic sur- subtotal hysterectomy if the practitioner has not been trained in
gery). the technique of atotalhysterectomy) is mostly necessary. Ifthe
OR patient desires furlher children the area of rupture can some-
Parenteral methotrexate and citrovorum factor provided the times be repaired, provided it is small or it is a lower segment
ectopic pregnancy is smaller than 3 cm.7 scar which has ruptured.
OR The matemal mortality of uterine rupture varies between 5
Transvaginal salpingocentesis with potassium chlorides or and25c/o and the perinatal mortality between 13 and 7007o.
methotrexate.e
:. Ruptured comual pregnancy: Treatment of hypovolaemic Torsion of the uterus
shock, laparotomy, blood transfusion and partial Dextrorotation of the uterus is a normal physiological phenom-
salpingectomy withexcision andrepairof the cornu. In some enon which occurs in more than 80Vo of pregnancies. The
cases ahysterectomy may be necessary because of extensive rotation is normally not more than 30"to 40., but in exceptional
uterine damage. cases it may be more than 90" with a resultant acute torsion of
[. Ovarian pregnancy: The classic criteria of Spiegelberg the uterus. The last-mentioned condition clinically presents
needed for the diagnosis of an ovarian pregnancy are: with abdominal pain, retention of urine and even shock. The
i The fetal sac must occupy a portion of the ovary. diagnosis is usually made at laparotomy. Treatment consists of
ii The ovary and sac must be connected to the uterus by the turning the uterus back to its normal position, followed by
ovarian ligament. caesarean section. An altemativetreatmentis to dothe caesarean
iii Ovarian tissue must be identified in the sac. section through the posterior wall of the uterus, after which the
cially if multiple leiomyomas are present. A diagnosis of appendicitis should always be considered if
unexplained abdominal symptoms occur during pregnancy.
Torsion of a hydatid cyst of Morgagni The classic symptom of peri-umbilical pain shifting to the right
A hydatid cyst of Morgagni is a congenital remnant of the fossa iliaca is also the commonest way in which appendicitis
cranial end of the paramesonephric duct. It can be seen as a presents during pregnancy.
cystic appendix to the Fallopian tube and it is fairly frequently The sign of Alders can be used to distinguish between the
incidentally discovered at operation (Figure 3). tenderness caused by appendicitis and that caused by
A Morgagni hydatid is usually asymptomatic and no specific gynaecologic pathology - gentle pressure is exerted on the point
treatment is needed. In rare cases it may undergo torsion and of maximal tenderness and the patient is then asked to turn on
cause the symptoms and signs of peritoneal irritation.26 The her left side - in the case of gynaecologic pathology the'
diagnosis can be confirmed by laparoscopy and the peduncu- tenderress will frequently disappear because the uterus and,
lated cyst is easily removed by laparoscopic surgery. tubes move to the left under the influence of gravity, whereas
the tenderness caused by appendicitis will usually remain in the
Traumatic perforation of the uterus during a dilatation and same place, as the appendix is less mobile.
curettage Treatment consists of a laparotomy and appendectomy. The
In the case of a small perforation the patient must be carefully operation should be carried out with the patient tilted 30" to the
observed for symptoms and signs of intra-peritoneal bleeding. left, as this position helps the surgeon to avoid handling the
In most cases the myometrium will spontaneously contract uteflrs. This is imporlant as handling of the uterus can cause
around the area of perforation and no further intervention will premature labour. A caesarean section is only carried out if
be necessary. An immediate laparoscopy may be of value to pregnancy duration is 38 weeks or more, as it is very uncomfort-
assess the damage to the uterus and the degree of bleeding. able to be in labour with a fresh abdominal wound.
If symptoms and signs of intra-peritoneal bleeding develop
or if the uterine damage is extensive, a laparotomy should be Trauma
done. A small perforation can be sutured but a hysterectomy Blunt abdominal trauma occurs most frequently because of a
may be necessa.ry in cases of extensive uterine damage. motorcar accident. Possible consequences include abruptio
placentae, uterine rupture, splenic rupture and liver rupture. A11
Ovarian vein rupture as a result of blunt abdominal trauma cases should be observed for at least 24 hours, including
Ovarian vein rupture secondary to blunt abdominal trauma is monitoring of the fetal hearl rate, as retarded separation of the
extremely rare in the non-pregnant patient. Blumenthal and placenta sometimes occurs. If signs of intra-abdominal haem-
Burgin repofied a case resulting from a motor vehicle acci- orrhage are present or develop, a laparotomy must be done.
dent.27 An emergency laparotomy is necessary in order to Penetrating abdominal trauma occurs most frequently be-
secure haemostasis. cause of a knife wound or a gunshot wound. In the second and
third trimesters the uterus is frequently injured with a subse-
IV. SURGICAL AND MEDICAL CAUSES OF AN quenl40Vo to70Vo perinatal mortality. A penetrating injury to
ACUTE ABDOMEN IN THE PREGNANT PATTENT the upper abdomen can cause severe injury to the bowel, as the
Appendicitis loops of bowel are compressed by the enlarged pregnant uterus."
t
Appendicitis is the most common general surgical emergency A laparotomy is indicated under the following circum- ,
Next to appendectomy, cholecystectomy is the most frequent should be avoided, but it may occasionally be necessary to
non-gynaecological abdominal operation performed on preg- enable access to the site ofobstruction.
nantwomen.2e Changes which occurin the composition of bile'
predispose the pregnant woman to an increase in the size of Rupture of a splenic artery aneurysm
existing stones and/or the formation of new cholesterol stones. A ruptured splenic artery aneurysm is very rare, but 207o of all
However, doubt exists as to whether there is a true increase in reported cases had occur:red during pregnancy, mainly in the
the incidence of cholelithiasis and cholecystitis during preg- third trimester. The maternal and fetal mortality is high. Treat-
nancy when compared to matched non-pregnant patients. mentconsists of ligatingthe splenic artery andsplenectomy. As
The clinical picture of cholecystitis during pregnancy is as most cases occur in the third trimester, a caesarean section is
in the non-pregnant patient. However, jaundice occurs rarely usually necessary to make proper access to the upper abdomen
because dilatation ofthe bile ducts during pregnancy decreases possible.
the risk for obstruction by a stone. Cholangiography should be
avoided during pregnancy because of radiation hazards to the Peptic ulcer
fetus. Ultrasound can be used to confirm the presence or Because of decreased gastric secretion an existing peptic ulcer
absence of gallstones. frequently improves during pregnancy. Treatment is as in the
The treatment of gallbladder disease during pregnancy is non-pregnant patient.
usually medical (sedation, bedrest, intravenous fluid and naso-
gastric suction). Antibiotics are sometimes necessary. The Renal calculi
administration of chenodeoxycholic acid to dissolve gallstones The incidence ofrenal calculi during pregnancy is as in the non-
is contra-indicated, especially during early pregnancy as doubt pregnant population. Pain is usually less because ofphysiologi-
exists as to the safety of the drug for the developing fetus. A cal dilatation of the ureters during pregnancy' Treatment is as
laparotomy and cholecystectomy are indicated in the following in the non-pregnant patient.
circumstances:
n Obstruction of the common bile duct Porphyria
n Empyema of the gallbladder Porphyria is an inherited abnormality of porphyrin metabolism
n Cholangitis with resultant abnormal porphyrin synthesis. The condition can
n Pancreatitis be diagnosed antenatally by amniotic fluid analysis.
n The patient does not improve with conservative treatment. In Southern Africa there is a relatively high incidence of
variegate porphyria in the white population, especially amongst
Pancreatitis Afrikaners. Porphyria cutanea tarda is les s common and mainly
Acute pancreatitis rarely occurs during pregnancy. It is a' prevalent in the black population. Acute intermittent porphyria
serious disease with a high morbidity and mortality. The is the type which occurs most frequently during pregnancy. The
condition should always be considered in the differential diag- clinical picture can be confusing with symptoms and signs like
nosis of upper abdominal pain in a pregnant patient. The use of psychosis, acute abdominal pain and hypertension.
thiazide diuretics may be a precipitating factor.3o Grey-Turner's An acute attack of porphyria can be precipitated by preg-
sign (a blue discolouration in the loins) is sometimes present in nancy and also by certain drugs like harbiturates.
acute pancreatitis. The serum amylase increases slightly during chloramphenicol, ergometrine, erythromycin, ethanol,
pregnancy, but not as much as in acute pancreatitis. Treatment halothane, hydralazine, mercaptopurine, methyldopa' nalidixic
is conservative as in the non-pregnant patient. acid, oestrogen, progesterone, oral contraception.
phenobarbitone, phenytoin, sulphonamides, thiopentone, etc.
Intestinal obstruction Before a drug is prescribed to a patient with porphyria it is
Intestinal obstruction rarely occurs during pregnancy. The advisable to consult manuals like the " South African Medicines
condition is especially rare in early pregnancy and more than Formulary" (see Holderness and Straughan 1991).31
507o of cases occur in the third trimester when the large uterus The effect of pregnancy on porphyria varies depending on
compresses the bowels with resultant distortion and stretching the type of porphyria. Acute intermittent porphyria can deterio-
of pre-existing adhesions. rate in lp to 757o of patients, whereas variegate porphyria is
The diagnosis of intestinal obstruction during pregnancy frequently not influenced by pregnancy. A worsening of the
may be difficult as the classic symptoms of vomiting, abdomi- condition frequently occurs postpartum.
nal pain and constipation also frequently occur during normal Specialised treatmentis necessary' Sunli ght mustbe avoided'
pregnancy. Intestinal obstruction should especially be consid- Termination of pregnancy is only indicated if conditions like
ered if the above symptoms and signs occur in a patient who has hypertension or psychosis warrant it.
had a previous abdominal operation, as the latter could have
caused adhesions. Tlphoid
Treatment consists of restoring fluid and electrolyte balance, Typhoid is associated with high morbidity and mortality, but
a
followed by a laparotomy with surgical correction of the the course of the disease is not changed by pregnancy. Fever
(1) Gangrene of the intestine 3. Willocks J, Neilson JP. Obsten'ics anrl G1'naecologl'' 'tth ed Edinburgh:
Churchill Livingstone, 1991: 104 - 106.
(m) Trauma with visceral injury or haemorrhage 4. Notelovitz M. Silent abruption of the posteriorly inserted placenta ' S AJr Med
(n) Unresolved severeupper gastro-intestinalhaemorhage J 1974t 482 93 - 95.
(o) 5. Stabile I, Grunzinkas JG. Ectopic pregnancy: a review of incidence, etiology
Ruptured abdominal aneurysm
antl diagnostic aspecls obstet Gltnecol Slrn' 1990; 45: 335 - 345'
2. Conditions not requiring immediate surgery 6. Weckstein LN. Current perspective on ectopic pregnancy Obstet G1'naecol
(a) Acute cholecYstitis srn.l9901 40:25q _ 271.
(b) Acute pancreatitis 7. Stovell TG, Ling F W, Buster JE. Outpatient chemotherapy of unruptured
ectopic pregnancy. Fertil Steril 1989;51: '135 - 438'
(c) Chronic pancreatitis 8. Timor-Tritsch I, Baxi L, Peisner DB. Transvaginal salpingocentesis A new
(d) Pseudocyst of the Pancreas technique for treating ectopic pregnancy. Am J Obstet GynecoL 19891 160:
(e) Responsive upper gastro-intestinal haemorrhage 459 - 461.
9 . Menard A, Cr6quat J, Mandelbrot L, Hauny J, Madelenat P Treatment of
(f) Sigmoiddiverticulitis unruptured tubal pregnancy by local injection of methotrexate under
(g) Haematoma of the abdominal wall transvaginal sonographic control. Ferlu 1 S/eri1 1990; 54:47 - 50'
3. Non-surgical conditions 10. Nel JT. Gynaecological microsurgery - a review' S Ali Jnl Contin Med Educ
1990:8: 175 - 183.
(a) Pyelonephritis 11. Charles D, Glover DD. Ectopic pregnancy. In: Charles C, Glover DD, eds '
(b) Renal colic Currert Tlterapy in Obstetrics. Philaclelphia: B C' Decker lnc 1 988: 239'
(c) Acute gastro-enteritis 12. Mokgokong ER, Marivate M. Treatment of the ruptured $et'ts S AJr Med J
1976;50: 1621 - 1624.
1d) Regionalenteritis 13. Nel JT. An unusual case ofuterine rupture. SAI'Med J 1981.65: 60 - 61'
(e) Non-pertbrated PePtic ulcer 14. Van cler Merwe JV, Onrbelet WUAM Rupture of the uterus: a changing
(t) Ulcerative colitis picture. Aru* Gynetttl 1981 ,240t 159 - 171.
15. Nel JT, Schaetzing AE. Fetale dwarsligging veroorsaak deur'n reuse-
(g) Mesenteric adenitis
leiomioom in clie Iaer segment van die uterus S Afr Med I I985: 68: 333 -
(h) Tuberculous Peritonitis 33.+.
(i) Porphyria t6. Buttery BW, Beischer NA, Fortune DW. Macaf'ee CAJ Ovarian tumours
(,) Acute retention of urine in pregnancy. Med J Aus 1973; 1: 3'15 3'19.
17. Curran JW. Economic consequences of pelvic inflammatorl disease in the
(k) Periarteritis nodosa United States. Am J Obstet Gt'necttl 1980; 138: 848 851'
(1) Henoch-Schonlein PurPura 18. Monif GRG. Clinical staging of acute bacterial salpingitis and its
(m) Abdominal crisis associated with syphilis, diabetes therapeutic ramifications. Am. J Obster Gt'necttl 19821 143: 489 - 495'
19. Allan LA, Schoon MG. Laparoscopic diagnosis of acute pelvic inflamma-
mellitus, sickle cell disease, systemic lupus erythema- tory disease. Brit J Ob.ster Gv-nuecol 1983; 90: 966 - 96ti'
tosus, acute lead poisoning and drug withdrawal' 20. Odendaal HJ. The management of acute pelvic rnflammatory disease' In:
(n) Miinchhausen sYndrome Bonnar J. ed. Recent Atlvan('es in Obsletrics ctncl Gynaecttlogy l6th ed'
London: Churchill Livingstone 1990: 165 - 183'
21. Pruessner HT, Hansel NK, Griffiths M. Diagnosis and treatment of 26. Nel JT. Tumore van die buise, ligamente, para-ovarium en retroperitoneale
chlamydial infections. Am Fam Phvscian 1986; 34: 8l - s2' tumore. In: Odendaal HJ , ed. Ginekologie. 2nd ed. Cape Town: Juta and
22. Kiviat HB, Wolner-Hanssen P, Peterson ]|r{CT et al. Localization of Kie 1989: 329 - 334.
Chlamydia trachomatis infection by direct immunofluorescence and 27. Blumenthal NJ, Burgin S. Ovarian vein rupture sustained in a motor
culture in pelvic inflammatory disease. Am J Obstet Glnecol 1986; 154: vehicle accident. S Afr Med J \982t 62l.9O1.
865 - 873. 28. Rode H, Millar AJW, Cywes S el a/. Thermal injury in pregnancy - the
23. Nel JT. Die voorkoming van peritoneale vergroeiings tydens neglected tragedy. S Afr Med J 1990:77:346 - 348.
bekkenchirurgie by die vrou. Geneeskunde l98T;29':213 - 216. 29. Amias AG. Abdominal pain in pregnancy. In: Turnbull A, Chamberlain G,
24. Nel JT. Aborsie. In: Odendaal HJ, ed. Ginekologie.2nd ed. Cape Town: eds. Obstetrics. London: Churchill Livingstone 1989:605 - 621.
Juta and Kie i989: 155 -172. 30. Wilkinson EJ. Acute pancreatitis in pregnancy: a review of 98 cases and a
25. Weingold AB. Pelvic pain. In: Kase HG, Weingold AB, Gershenson DM, report of 8 new cases. Obstet Gynecol Survey 1973].28: 28i - 303.
eds. Principles and Practice of Clinical Gynecolog.t.2nd ed. New York: 31. Holderness M, Straughan J. South African Medicines Formulary.2nd ed-
Churchill Livingstone 1990:479 - 5O9. Puhlications Division: Medical Association of South Africa 1991.
organs to adhere abnormally to one another) are a major cause (either right or left) for each patient was made prior to the study
of infertility and pain in women. The74 women participating using a computerized algorithm to ensure randomness.
in the randomized trials consented to undergo a traditional During surgery, drawings and photographs were taken and
surgical procedure, adhesiolysis, to restore fertility through a written evaluation was done to document the extent and
excision of scars and adhesions resulting from endometriosis or severity ofadhesions. These data were recorded on standard-
pelvic infl ammatory disease. ized forms for computerized data entry. Ten days to 14 weeks
"The effectiveness of a cornmon procedure, adhesiolysis, after the surgery, surgeons inserted a fibre-optic scope
has been limited in the past; the same procedure intended to (laparoscope) into the abdomen to record the incidence, extent
remove adhesions may themselves cause additional scarring and severity of recurrent adhesions on the pelvic sidewalls.
and adhesions. Data were recorded in a manner similar to that used at the
"After the removal of adhesions at laparotomy, the original surgery.