Acute Abdomen

Question 1

Mx of acute abdomen

scenario 1 - 26yo/21/40/upper abdomen

scenario 2 - NESB/mid trimester

scenario 3 - min AN care, socially complex, PTL

scenario 4 - 26yo, 33/40, PTL, sinusoidal trace

scenario 5 - 25yo, 28/40, PTL/fetal distress, IUGR in setting of previous early demise of DCDA

scenario 6 - 43yo, 23/40, acute abdo pain, bkg of renal stones

scenario 7 - 39yo, P0, 36/40, acute abdominal pain, known large fibroid

scenario 8 - 33yo, G2P1, 28/40, p/w APH, previous CS for breech @33/40, rural hospital

scenario 9 - 27yo, BMI35, 11cm dermoid on 8/40, p/w acute abdo pain in preg ahead of planned removal in T2

scenario 10 - 29/40 acute abdomen -> appendicitis

scenario 11 - post appendicectomy -> PTL/breech presentation

Answer 1

Upper DDx
- cholecystitis/cholelithiasis
- pancreatitis
- appendicitis (change of position with gestation)
- splenic artery aneurysm
- acute fatty liver
- preeclampsia
- pneumonia
- PTL

Lower DDx
- abruption
- rupture
- ovarian/fibroid torsion/degeneration
- cystitis, appendicitis, pyelonephritis
- renal colic
- PTL

Principles
- Ensure mat/fetal well-being
- Delay labor for steroid
- Nifedipine if MI, no APH
- Identify/rx reversible
- Transfer if no capacity/expertise

Hx
- pain loc/colic/severity/rad
- assoc HA/visua/coryzal
- urine-haem/dys/bowel
- systemic fever/chills/anorexia
- FM, APH/SROM/contractions
- OGHx …
- AN Course …?LLP
- PHx … smoking…
- RFs - cervical insufficiency, previous hx, uterine anomalies, UTI, fibroids, trauma, genital tract infection, drug use, DV, extremes of age, poly, APH/abruption/PET, short preg interval

Exam
- weight/height/vitals
- cardioresp - consolidation
- abdopelvic - ?Murphy ?contraction ?woody abdomen
- spec - liquor, blood, cervix
- HVS+FFN+/-amnisure
- FHR +/- RTS +/- CTG

Ix
- FBE/UEC/LFT/CRP/Lipase/G&S
- Urine - MCS +/- uPCR
- Obs USS (wellbeing + cervical length)
- +/- abdo USS +/- CXR +/- CTAP

Immediate Mx
- Resus/stabilization vs Immediate del
- MDI - Obs +/- MFM +/- Paeds Gen surg
- Inform consultant
- Follow local guideline
- Admission -> observation/analgesia
- +/- tocolytic +/- steroid +/- MgSo4
- +/- antibiotic +/- IVT
- +/- Piper transfer expertise/capacity
- delivery planning IOL vs emCS
- emCS consent/planning

Additional mx plan
- Identify and mx pre-existing AN issues
- Timing/MOD
- Postpartum - placenta for MCS & Histo
- Education - smoke, nutrition

Future plan
- screen & rx asx bacteruria
- cervical surveillance
- progesterone/cervical cerclage

-> see PPROM section for further

Question 2

Renal stone mx in pregnancy
- 43yo p/w acute abdomen on bkg of known renal stones

Answer 2

• MDI - Obs/Rad/Urology
• Admission
• Analgesia/Antiemetic +/- Antibiotic/IVT
• IVC/Bloods ?AKI ?pyelo ?infected renal stone
• renal tract USS
• Urology opinion +/- intervention (e.g. nephrostomy)

Question 3

Consent for laparoscopy in preg

scenario 1 - ovarian torsion x2
scenario 2 - appendicitis
scenario 3 - cholecystitis

Answer 3

Pros
- safe, under vision
- untreated -> PTL
- avoid peritonitis-adhesion-fertility/pain
- protect ovary - endocrine

Cons
- MC/PTL/PTB/LBW/SB

Ways to reduce risk
- Steroid loading
- CTG before/after
- regional>GA
- wedge to improve perfusion
- min uterine/cervical manipulation
- limit IAP<12mmHg

Postop (appendicitis)
- immediately post - FHR
- wound care
- growth/wellbeing scan
- f/u AN visit
- gen surg postop rv

Note - re: torsion -> consent should include +/- USO - can’t leave necrotic tissue in-situ…thorough intra-op exam +/- GONC opinion is required if suspicious findings on entry into abdomen

Question 4

Fibroid in preg counselling

Scenario 1 - fundal fibroid 8x9 cm, incidental finding

Scenario 2 - 39 P0 36/40, abdo pain bkg degen fibroid, counsel ongoing care

Answer 4

Antenatal
- detorsion/degeneration -> PTL/PTB
- Abruption risk (SMF/Retroplacental)
- FGR - FH measurements -> G/S
- malpresentation

Intrapartum
- Labor dystocia
- Obstructed labor
- Difficult CS

Postpartum
- PPH -> OT
- Blood transfusion