Abdomen Agudo en El Embarazo

Acute Abdomen in PregnancyRole of Sonography

Phyllis Glanc, MD, FRCP(C), Cynthia Maxwell, MD, FRCSC, RDMS

Objective. The purpose of this presentation is to review the role of sonography in evaluation of acuteabdomen during pregnancy. Methods. Illustrative cases were collected from gravid patients who pre-sented with signs and symptoms suspicious for acute abdomen and subsequently underwent sonog-raphy. Results. This presentation shows sonographic findings of various maternal complications thatcan present with acute abdominal pain in pregnant patients. Conclusions. Sonography remains thefirst line of imaging in pregnant patients presenting with acute abdomen. Patient triage or additionalimaging may be obtained on the basis of the sonographic findings. Key words: acute abdomen; com-plications of pregnancy; pregnancy; sonography.

Received April 6, 2010, from the University ofToronto, Sunnybrook Health Sciences Center (P.G.),Toronto, Ontario, Canada; and University ofToronto, Mount Sinai Hospital (C.M.), Toronto,Ontario, Canada. Revision requested April 21, 2010.Revised manuscript accepted for publication May26, 2010.

Address correspondence to Phyllis Glanc, MD,FRCP(C), Obstetric Ultrasound Center, Departmentof Medical Imaging, Sunnybrook Health SciencesCenter, Bayview Campus, 2075 Bayview Ave, MG104,Toronto, ON M4N 3M5, Canada

E-mail: [email protected]

AbbreviationsCDS, color Doppler sonography; GB, gallbladder; MRI,magnetic resonance imaging

onography remains the initial imaging study ofchoice in the evaluation of the pregnant womanpresenting with acute abdomen. It is a safe, rela-tively inexpensive, and versatile technique that is

readily available. The traditional definition of acuteabdomen is any serious intra-abdominal condition forwhich emergency surgery must be considered. In preg-nancy, this definition may be expanded to include condi-tions that may result in preterm labor or emergencycesarean delivery for fetal well-being. Prompt clinicaldiagnosis and intervention may minimize maternal andfetal morbidity and mortality.

The evaluation of acute abdomen in pregnancy is com-plicated by both physiologic and anatomic changes thatoccur during pregnancy. Generalized symptoms of nau-sea, vomiting, constipation, increased frequency ofurination, and abdominal and pelvic discomfort may benormal accompaniments of pregnancy. Localization ofdisease may be limited because of the enlarging graviduterus, which both displaces and compresses structures.Peritoneal signs may be absent secondary to the liftingand stretching of the anterior abdominal wall. Somecommonly used laboratory tests have altered referenceranges for pregnancy, limiting their utility. For example,pregnancy alone can produce white blood cell counts ashigh as 16,000/mm3 in second and third trimester and upto 30,000/mm3 in labor.1 Similarly, anemia is commonand thus not predictive of blood loss. Coincidentalasymptomatic pyuria can occur in 10% to 20% of gravid

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Acute Abdomen in Pregnancy

women with appendicitis.1 The use of conven-tional imaging algorithms is constrained by thepotential risk of harm to the fetus from ionizingradiation. All of the usual medical and surgicalconditions must be considered within the con-text of two patients: the mother and her fetus. Tofurther complicate the evaluation, there are anumber of medical conditions that are specific topregnancy that must be added to the differentialdiagnosis. In summary, the physical and clinicalexamination is limited; laboratory values can bemisleading; and the usual imaging algorithmsare altered to minimize exposure to ionizing radi-ation. Nonetheless, as in the nongravid patient,the two most common abdominal surgical emer-gencies remain acute cholecystitis and acuteappendicitis.

Pregnancy and the Gallbladder

Symptomatic gallstone disease is the second mostcommon abdominal emergency in pregnantwomen, requiring hospitalization in 0.5% withinthe first postpartum year. Pregnancy is a high-riskperiod for formation of biliary sludge and stonesdue to increased estrogen and progesterone levels,which lead to biliary cholesterol hypersecretion andgallbladder (GB) stasis; 4.2% of women develop newsludge or gallstones during pregnancy (Figure 1).2,3

The most sensitive combination of findings for thediagnosis of acute cholecystitis is the presence ofcholelithiasis with a positive sonographic Murphysign, resulting in a positive predictive value of 92%.4

Sonography is approximately 95% sensitive in thedetection of gallstones larger than 2 mm. Secondaryfindings include GB distension (>5 cm diameter),wall thickening (>3 mm), pericholecystic fluid, andwall hyperemia. The secondary signs are nonspe-cific and may be associated with a variety of othermedical conditions (Figures 2 and 3). Gangrenouscholecystitis will result in a negative sonographicMurphy sign in two-thirds of patients, may show aloss of wall vascularity on color Doppler sonogra-phy (CDS), and may contain irregular linearechoes within the lumen, which represent fibri-nous exudates and sloughing of the GB mucosa(Figure 4).5 If the GB is not distended but the wall ismassively thickened, viral hepatitis, the most com-mon cause of jaundice in pregnancy, should beconsidered. Acalculous acute cholecystitis may

Figure 1. Tumefactive sludge can mimic a solid GB lesion.Repositioning of the patient will cause the sludge to move andreform, thus enabling the diagnosis. A, Sagittal sonogram show-ing “tumefactive” or ball-like sludge. B, Repositioning of thepatient permits the sludge to reform, confirming the diagnosis.

A

B

Figure 2. Acute cholecystitis in the third trimester. Sagittalsonogram showing a single calculus impacted in the neck of theGB. The patient had a positive sonographic Murphy sign.Additional findings included a mildly distended GB and striatedwall thickening.

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Figure 3. Acute cholecystitis in the third trimester with perforation. Interrogation of the entire GB wall is important to identify smallwall disruptions that may be associated with perforation. A, Transverse sonogram showing a markedly thickened, striated GB wallwith a diameter of 1.2 cm. B, Transverse sonogram showing discontinuity in the wall (arrows). C, Transverse sonogram with CDSshowing corresponding discontinuity in wall hyperemia (arrows). D, Transverse sonogram showing a corresponding wall perichole-cystic collection, consistent with perforation (arrow).

A

C

B

D


occur, most typically in the setting of intensive careunits and hyperalimentation.

The traditional management of acute cholecysti-tis in pregnancy has been initial conservative ther-apy in the first and third trimesters, with surgicalintervention preferably occurring in either the sec-ond trimester or postpartum period. Althoughapproximately 25% of pregnant patients fail torespond to conservative therapy, the results of con-servative and surgical management are similarwith respect to maternal and fetal morbidity andmortality. Laparoscopic cholecystectomy mayhave some advantages related to its less invasivenature.6–8

Pregnancy and the Bowel

Acute appendicitis is the most common cause ofacute abdomen in pregnancy, complicatingapproximately 1 per 1500 pregnancies.9 Althoughthe actual incidence of acute appendicitis is notincreased in pregnancy, an associated delay indiagnosis leads to increased perforation rates.Fetal loss rates are less than 2% in uncomplicat-ed acute appendicitis, whereas they can begreater than 30% if perforation has occurred.9,10

Perforation rates rise from 30% in the first andsecond trimesters to as high as 70% in the thirdtrimester. The same criteria of a noncompress-

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Figure 4. Gangrenous cholecystitis in patient with poorly local-ized pain, fever, and poorly controlled insulin-dependent diabetesat 32 weeks’ gestation. The diagnosis is considered when a neg-ative sonographic Murphy sign is present in combination withsonographic findings indicative of GB wall ischemia and denerva-tion. A, The gallbladder contains small calculi, echogenic bile, anddebris. The wall is thickened with abnormal structures consistentwith sloughed membranes (arrow). B, A small localized perfora-tion is shown at the medial aspect of the GB (arrows). C, ColorDoppler sonogram showing the avascular GB wall.

A

C

B


ible, nonperistaltic, tender, blind-ending tubularstructure with a diameter of greater than 6 mm isused in the pregnant patient; however, compres-sion sonography may be limited by the enlarginggravid uterus and displacement of the surround-ing bowel as pregnancy progresses (Figures 5

and 6). If sonography is inconclusive, then mag-netic resonance imaging (MRI) may be appro-priate to identify the normal appendix, thuspotentially avoiding unnecessary delays in diag-nosis, surgery, or use of ionizing radiation.11,12

In the gravid patient, sonography is often thefirst choice in the evaluation of other bowel con-ditions such as small-bowel obstruction, inflam-matory bowel disease, diverticulitis, volvulus,and intussusception. One-third of women withinflammatory bowel disease will relapse duringpregnancy, with the most commonly cited rea-son being cessation or reduction of medications(Figures 7 and 8).7 Bowel obstruction in pregnan-cy is fairly uncommon, occurring in 1 per 2500 to1 per 3500 deliveries. Adhesions are responsiblefor most cases (60%–70%), followed by volvulus(≈25%).9 Maternal and fetal morbidity andmortality are often related to delays in diagnosis.The use of MRI in bowel conditions to other thanappendicitis is less well validated in pregnancybut may be justifiable if it can provide informa-tion that would otherwise require ionizing radia-tion exposure.13

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Figure 5. Acute appendicitis presenting in the first trimesterwith acute right-sided pain. A, Oblique sonogram showing theentire length of the appendix arising from the cecum, blindending, and mildly distended at 0.8 cm (calipers). B, Obliquesonogram with CDS showing hyperemia of the appendix wall.C, Transverse sonogram with CDS showing hyperemic adjacentfat, consistent with inflammation.

A

B

C

Figure 6. Distal tip appendicitis presenting in the first trimesteras vague right-sided and periumbilical pain. Sonogram showingthe mildly distended (0.7 cm) distal tip of the appendix (arrow)surrounded by echogenic fat, indicating adjacent inflammation.


Pregnancy and the Kidney

“Physiologic hydronephrosis of pregnancy”occurs in 70% to 90% of pregnant women by thethird trimester, thus representing the most com-mon cause of hydronephrosis in pregnancy, typ-ically asymmetric and more prominent on theright. It is due to a combination of mechanicalobstruction from an enlarged uterus and relax-ation of the smooth muscle of the urinary collect-ing system under the influence of progesterone.A smooth tapering of the ureter as it passesbetween the uterus and the iliopsoas muscle atthe level of the sacral promontory suggests thediagnosis (Figures 9 and 10).

Approximately 1 per 1500 pregnancies arecomplicated by urinary calculi, similar to thenongravid woman.1 Most pregnant women withrenal colic present in the second half of pregnan-cy with flank pain or hematuria. A urinary stonecan be diagnosed on sonography when there isdistinct focal echogenicity with discrete acousticshadowing. In equivocal cases, the presence ofthe twinkling artifact with the application of CDSmay improve confidence. The twinkling artifactoccurs behind a strongly reflecting granularinterface and appears as a fluctuating mixture ofCDS signals that imitate turbulent flow, but theDoppler spectrum is flat. This sign is present in86% of urinary calculi (Figure 11).14 Nonethelessthe diagnosis of renal colic remains challenging,

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Figure 7. Images from a 32-year-old patient who presented at12 weeks’ gestation with acute right-sided pain. The patienthad postpartum confirmation of new onset of Crohn disease.A, Transverse sonogram showing a normal appendix (arrow). B,Sonogram showing a markedly thickened terminal ileum wall at1.2 cm (calipers).

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B

Figure 8. Images from a 30-year-old patient with known Crohndisease who presented acutely in the first trimester with vagueright-sided abdominal pain and diarrhea. A, Oblique sonogramshowing the transition point between the thickened and non-thickened bowel wall. (arrow). B, Transverse sonogram showingseveral midabdominal distended fluid-filled loops with activeperistalsis in real time, consistent with small-bowel obstruction.

A

B


with almost one-third of cases incorrectly diag-nosed.15,16 The distinction of a mechanicalobstruction from physiologic hydronephrosis iscrucial in directing appropriate management(Figure 12). If direct visualization of an obstruct-ing calculus is not possible, then secondarysigns such as a disparity in resistive indices ofgreater than 0.1 between the kidneys may behelpful.17 Before diagnosing a unilateral absentureteric jet, this should be confirmed by reeval-uation with the patient in a contralateral decu-bitus position to ensure that the “absent” jet isnot secondary to compression by the graviduterus. The transvaginal approach is helpful forvisualization of distal ureteral calculi and uri-nary bladder jets (Figures 13 and 14). Fornicealrupture with formation of a perinephric urino-ma is rare in pregnancy, whereas distended per-

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Figure 10. Physiologic hydronephrosis of pregnancy is associat-ed with tapering of the right ureter as it passes over the sacralpromontory/pelvic brim. A, Sagittal sonogram showing the clas-sic smooth tapering of the ureter. B, Sagittal sonogram withCDS confirming that the tapering tubular structure is the ureter.

A

B

Figure 11. Images from a 26-year-old patient who presented at25 weeks’ gestation with acute right flank pain. A small proxi-mal obstructing calculus was identified. A, Sagittal sonogramshowing minimal hydronephrosis secondary to a small proximalureteric calculus (arrow). B, Sagittal sonogram with CDS show-ing the twinkling sign (arrow).

A

B

Figure 9. Physiologic hydronephrosis of pregnancy in the thirdtrimester. Sagittal sonogram showing moderate hydronephrosisin the right kidney.


icapsular veins are not uncommon. The applica-tion of CDS can help distinguish between thesetwo entities.

The incidence of asymptomatic bacteriuria issimilar in both the gravid and nongravid popu-lations; however, the incidence of acutepyelonephritis is substantially increased in preg-nancy. Acute pyelonephritis occurs in 1% to 2%of pregnancies and is associated with pretermlabor.18,19 This may be related to the relativedecreased peristalsis of the ureters and urinarystasis under the influence of progesterone.Although sonographic findings are typicallynegative in the setting of acute pyelonephritis,

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Figure 12. Images from a patient with twin pregnancy whopresented at 27 weeks’ gestation with right flank pain. Surgicallaparoscopic resection revealed ovarian torsion with a necroticright ovary. A, Sagittal sonogram showing an abnormallyenlarged right ovary (5 × 7 cm), which was tender and avascu-lar, consistent with ovarian torsion. A small amount of free fluidis present (arrow). B, Transverse sonogram showing the normalleft ovary (calipers).

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B

Figure 13. Images from a patient with twin pregnancy whopresented at 33 weeks’ gestation with right-sided pain. Nopoint of mechanical obstruction was identified. Only a unilater-al left ureteric jet could be identified. The sonographic findingswere consistent with right-sided obstruction. A, Sagittal sono-gram showing moderate right hydronephrosis with perinephricfluid, consistent with a urinoma (arrow). B, Absent right ureter-ic jet. The left ureteric jet present.

A

Figure 14. Transvaginal sonogram from a third-trimester patientwith left-sided flank pain. A cephalic presentation obscuredtransabdominal visualization of the ureterovesical junction. Thesonogram shows a 2-mm calculus (arrow) in the ureterovesicaljunction, which is located in the anterior left aspect of the image.

B


findings such as renal enlargement, focal hyper-echogenicity, and perinephric fluid may be pre-sent (Figure 15).

Pregnancy and the Pancreas

Acute pancreatitis complicating pregnancy israre, affecting approximately 1 per 3333 gesta-tions.20 Gallstones are the most common etiology.Serum amylase testing is useful for diagnosis, butlevels may be mildly elevated during normal

pregnancy as well as in conditions such as intesti-nal obstruction, infarction, and perforation.21

Pregnancy and Cancer

Cancer complicating pregnancy is rare, affectingapproximately 1% of gestations.22,23 As the aver-age age of the gravid population increases, malig-nancy becomes a more important consideration.Appropriate imaging evaluation will depend onthe organ involved (Figures 16 and 17).

Pregnancy and the Liver

Hepatic diseases complicate approximately 3%of pregnancies; however, hepatic diseases thatare specific to pregnancy are rare.24–27 The keyrole of sonography in hepatic diseases specific topregnancy is to rule out alternate hepatic or bileduct conditions.

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Figure 15. Images from a patient with twin pregnancy whopresented at 29 weeks’ gestation with left-sided flank tender-ness. Right hydronephrosis was thought to be physiologic.Milder left hydronephrosis was associated with a thickeneduroepithelium and perinephric fluid indicative of inflammation,likely secondary to an ascending infection. The patient under-went left ureteric stenting. A, Sagittal sonogram showing mildleft hydronephrosis, but closer inspection shows layering debrisin the renal pelvis (arrow) and thickened ureter wall with peri-ureteric fluid, consistent with an edematous inflamed ureter(perforated arrow). B, Cross section through the lower pole ofthe left kidney showing perinephric fluid (arrow) and a thick-walled ureter with periureteric fluid (perforated arrow).

A

B

Figure 16. Bowel carcinoma resembling acute complicatedappendicitis in a 47-year-old primigravida who presented at 12weeks’ gestation with right lower quadrant pain and fever.Sonogram showing a complex 5 × 4 × 2.7-cm hypoechoic mass(calipers) surrounded by echogenic fat, consistent with bowelperforation and an abscess, suspected to be appendiceal in ori-gin. In view of a long infertility history, the patient requestedconservative therapy. She underwent percutaneous drainageand received antibiotic therapy. She returned in 1 week withincreasing pain and underwent surgery. The pathologic diagno-sis was perforated aggressive adenocarcinoma arising from thebase at the junction of the appendix and cecum.


Pregnancy and Trauma

Trauma occurs in 5% of pregnancies and is theleading nonobstetric cause of maternal death.28

Even minor maternal trauma may result in fetaldeath, typically due to placental abruption.28,29

Placental abruption occurs as a shear injurybetween the relatively nonelastic placenta and theuterine wall; thus, trauma protocols are amendedfor the pregnant patient to include a 24-hourobservation period in the labor and delivery unitfor fetal monitoring and potential delivery.

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Figure 17. Images from a 43-year-old infertility patient with twin pregnancy who presented at 33 weeks’ gestation with acute right-sided pain that had progressed for 2 days. Her clinical history revealed appendectomy and low-grade right-sided pain for 2 to 3 months.Her pregnancy weight gain was only 13 pounds, less than anticipated for a third-trimester twin gestation, indicating weight loss.Sonography revealed serosal uterine and liver metastases from right colon primary carcinoma. Per the patient’s request, presurgical MRIwas performed to confirm the diagnosis. Primary resection and anastomosis were performed at the time of cesarean delivery, andchemotherapy was begun 4 weeks after surgery. A, Transverse sonogram showing uterine serosal surface drop metastases (arrow) andascites. B, Sagittal sonogram of the right flank showing an abnormally thickened segment of the colon (arrows) of concern for prima-ry colon cancer. C, Coronal T2-weighted MRI showing hepatic lesions and incidental physiologic right hydronephrosis. D, Coronal T2-weighted MRI showing an abnormal thickened loop of the right colon (arrows), consistent with primary colon carcinoma.

A

B

C

D


The size of the placental abruption or degree ofintrauterine hemorrhage is related to morbidityand mortality. Blunt abdominal trauma is typical-ly evaluated by screening abdominal computedtomography; however, the 90% negative rate sug-gests that this is hard to justify in the pregnantpopulation. Sonography is only moderately sensi-tive for detection of intra-abdominal injury in thepregnant patient (≈60%) but is highly specific.30

This permits a rapid triage of a group of patientswho require additional evaluation. Sonographyis most sensitive in the first trimester. Placentalabruption is the most common injury, followed bysplenic, liver, and then bowel injury.

Conclusions

Sonography is the first-line screening tool in acuteabdomen during pregnancy (Table 1). Pregnancyincreases the technical challenge of the exami-nation. If the sonographic results are inconclu-sive or inadequate, additional imaging such as

MRI may be indicated. Computed tomographicexaminations are reserved for cases in whichMRI is unavailable or inconclusive or when rapidimaging is indicated. At times, surgery may berequired without a diagnosis (Figure 18).

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Table 1. Can We Rely on Positive or Negative Sonographic Findings?

Sonographic Finding Positive Negative

Acute cholecystitis Excellent ExcellentBile duct stones Excellent Limited valueAcute appendicitis Very good Limited valueHydronephrosis due to calculus Excellent Limited valuePyelonephritis Rarely NoneHepatic disease specific to pregnancy Occasionally NoneTrauma Good Limited value

A

Figure 18. Images from a 23-year-old patient who presented at19 weeks’ gestation with severe diffuse abdominal pain.Sonography showed large amounts of complex fluid, indicativeof high-risk findings, although nondiagnostic. Computed tomog-raphy was performed and suggested possible gastric perfora-tion. The surgical diagnosis was gastric volvulus with perforationand contamination of the intrathoracic and intra-abdominalcontents. Intrauterine fetal death occurred. A, Sonogram of thepelvis showing the gravid uterus surrounded by complex freefluid. Note the fluid-debris level anterior to the uterus (arrow). B,Sagittal computed tomogram showing large amounts of free air(arrows) and complex fluid with layering in the posterior cul desac (perforated arrow). The stomach (S) is intrathoracic.

B


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Abdomen Agudo en El Embarazo

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