Acute Abdomen and Pregnancy

Acute abdomen as "any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered."

The approach to pregnant patients with severe abdominal pain is very similar to that for nonpregnant patients with acute abdomen. However, the physiologic changes associated with pregnancy must be considered when interpreting findings from the history and physical examination.

History

Obtain as detailed a history as possible regarding the time of onset, duration, intensity, and character of the pain and any associated symptoms. Establishing the gestational age early in the evaluation is essential because the likelihood of different etiologies changes with different gestational ages. Accurate knowledge of gestational age is required to make appropriate decisions regarding fetal viability and the need for fetal evaluation. Nausea, vomiting, constipation, increased frequency of urination, and pelvic or abdominal discomfort are frequently experienced in normal pregnancy.

Physical examination

Upon physical examination, findings may be less prominent compared to those of nonpregnant patients with the same disorder . Peritoneal signs are often absent in pregnancy because of the lifting and stretching of the anterior abdominal wall. The underlying inflammation has no direct contact with the parietal peritoneum, which precludes any muscular response or guarding that would otherwise be expected. The uterus can also obstruct and inhibit the movement of the omentum to an area of inflammation, distorting the clinical picture.

To help distinguish extrauterine tenderness from uterine tenderness, performing the examination with the patient in the right or left decubitus position may prove helpful. When performing a physical examination of the gravid abdomen, it is essential to recall the changing positions of the intra-abdominal contents at different gestational ages. For example, the appendix is located at the McBurney point in patients in early pregnancy and in nonpregnant patients. After the first trimester, the appendix is progressively displaced upward and laterally, until it is closer to the gallbladder in late pregnancy . Such alterations in physical assessment can delay diagnosis, and many authorities attribute the increased morbidity and mortality of acute abdomen in gravid patients to this delay.

When evaluating the gravid patient, the clinician must evaluate 2 patients at the same time, the mother and the fetus. Prior to viability, evaluation of the fetus can be limited to documentation of the presence or absence of fetal heart tones by Doppler or ultrasound. When the fetus is considered viable, a more thorough evaluation is required. The age of viability varies from institution to institution. Monitor the fetal heart rate and uterine tone continuously throughout the period of evaluation.

A nonreassuring tracing or evidence of fetal distress may suggest an obstetric etiology for the acute abdomen (eg, placental abruption, uterine rupture). A reassuring tracing allows the evaluation to continue at an appropriate pace. Monitoring for uterine contractions throughout the evaluation period and even after definitive treatment is important. A strong correlation is observed between intra-abdominal infectious or inflammatory processes and preterm labor and delivery.

Laboratory Studies

When evaluating the gravid patient with acute abdominal pain,  some very commonly used laboratory tests have altered reference ranges in pregnancy. These changes can make the initial evaluation process somewhat more difficult. For example, an inflammatory process such as appendicitis would be expected to produce an elevated white blood cell count. Yet, pregnancy alone can produce white blood cell counts ranging from 6000-16,000/mm³ in the second and third trimesters and from 20,000-30,000/mm³ in early labor .

Ultrasound

Ultrasound is probably the most frequently used radiologic modality for evaluating a pregnant abdomen. The maternal gallbladder, pancreas, and kidneys can be evaluated easily. Ultrasound is also used with graded compression as a diagnostic aid for appendicitis. The size of the gravid abdomen may limit this approach in pregnancy. The use of ultrasound is essential for fetal evaluation. Ultrasound helps to establish gestational age and fetal viability, to exclude congenital anomalies, and to assess amniotic fluid volume and fetal well-being. This information may become critical later in the management of a gravid patient with an acute abdomen, when decisions regarding delivery, mode of delivery, and the use of tocolytics and steroids must be made.

Radiograph

While ionizing radiation in the evaluation of patients who are pregnant is often a source of anxiety for the practicing clinician, radiograph exposure from a single diagnostic procedure does not result in harmful fetal effects.

Estimated Fetal Exposure from Some Common Radiologic Procedures

*Exposure depends on the number of films.

If multiple diagnostic procedures are needed exposure to less than 0.05 Gy has not been associated with an increase in fetal anomalies or pregnancy loss. During pregnancy, perform medically indicated diagnostic radiograph procedures when needed, but consider other imaging procedures not associated with ionizing radiation instead of radiographs when possible . Due to the possible association of prenatal radiation exposure with childhood cancer , use ionizing radiation only when medically necessary and minimize that exposure when possible, without compromising patient care.

Magnetic resonance imaging

MRI uses magnets rather than ionizing radiation to alter the energy state of hydrogen protons. This may prove useful in the evaluation of the maternal abdomen and of the fetus. Although no adverse fetal effects have been documented,advice against the use of MRI in the first trimester .

Differential diagnosis

Acute abdomen, as it presents with pregnancy, has many possible causes. Clearly, the case of a pregnant patient with acute abdomen is a clinical scenario that overlaps specialties.  Involve a surgeon,  when dealing with this challenging situation. Any cause for acute abdomen can occur coincident with pregnancy. Some clinical conditions are more likely to occur in pregnancy. Other conditions are specific to pregnancy. Thus, a wide range of possible differential diagnoses should be considered.

Incidental to pregnancy

·         Acute appendicitis

·         Acute pancreatitis

·         Peptic ulcer

·         Duodenal ulcer

·         Gastroenteritis

·         Hepatitis

·         Bowel obstruction

·         Bowel perforation

·         Herniation

·         Meckel diverticulitis

·         Toxic megacolon

·         Splenic rupture

·         Pancreatic pseudocyst

·         Toxic megacolon

·         Genitourinary

·         Ovarian cyst rupture

·         Adnexal torsion

·         Ureteral calculus

·         Rupture of renal pelvis

·         Ureteral obstruction

Vascular

·         Thrombosis/infarction

·         Respiratory

·         Pneumonia

·         Pulmonary embolism

·         Other

·         Intraperitoneal hemorrhage

·         Abdominal trauma

·         Acute intermittent porphyria

·         Diabetic ketoacidosis

·         Sickle cell disease

Conditions associated with pregnancy

·         Acute cystitis

·         Acute cholecystitis

·         Acute fatty liver of pregnancy

·         Rupture of rectus abdominus muscle

·         Torsion of the pregnant uterus

Due to pregnancy

·         Ruptured ectopic pregnancy

·         Septic abortion with peritonitis

·         Acute urinary retention due to retroverted gravid uterus

·         Later pregnancy

·         Red degeneration of myoma

·         Torsion of pedunculated myoma

·         Placental abruption

·         Placenta percreta

·         HELLP (hemolysis, elevated liver function, and low platelets) syndrome

·         Spontaneous rupture of the liver

·         Uterine rupture

·         Chorioamnionitis

Treatment

Treatment of acute abdomen in pregnancy depends on the specific diagnosis. Indications for emergency surgery are the same for patients who are pregnant as they are for any other patients. If surgery is required but is considered elective, waiting until after the pregnancy is completed is prudent. If surgery is deemed necessary during pregnancy, perform it in the second trimester if possible; the risk of preterm labor and delivery is lower in the second trimester compared to the third, and the risk of spontaneous loss and risks due to medications such as anesthetic agents are lower in the second trimester compared to the first.

Laparoscopy during pregnancy

Laparoscopy has become increasingly popular in the treatment and evaluation of acute abdomen. In the past, pregnancy was considered a contraindication for laparoscopy, although multiple reports of the successful use of diagnostic and therapeutic laparoscopy have been published more recently .

The Hasson technique, an open approach to entering the abdomen, has been suggested. Advantages of laparoscopy over laparotomy include shortened hospital stay, less need for narcotics, easier postoperative ambulation, and earlier tolerance of oral intake postoperatively. Care must be taken to minimize manipulation of the uterus. Adjust the location of trocar placement based on uterine size. Monitor fetal heart tones during the surgical procedure. The surgeon must work closely with the obstetrician to maintain fetal well-being during the surgical procedure. An experienced laparoscopist is important to keep surgical times as short as possible .

Obstetrical concerns

Preterm labor and delivery is the most significant threat to the fetus in the management of acute maternal intra-abdominal disease. Insufficient data are available to quantitate the risk, but the severity of the disease process appears to be a major determinant of that risk .

The prophylactic effect of tocolytics remains unproven in these patients. If used, tocolytics should be administered with care. Monitor the patient carefully, and bear in mind the potential for pulmonary complications. Magnesium sulfate, beta-mimetics (eg, ritodrine, terbutaline), and indomethacin .

Delivery

Base delivery decisions on obstetric indications. The mode of delivery used should also be decided based on obstetric indications. If continuation of the pregnancy is expected to lead to maternal morbidity or mortality, delivery is indicated. If improvement of the maternal condition cannot be expected with delivery, treat the patient with the fetus in utero.

Appendicitis is the most common nonobstetric cause of surgical emergency in pregnancy. The case-to-delivery ratio ranges from 1:2000 to 1:6000 . Pregnancy does not affect the overall incidence of appendicitis, but the severity may be increased in pregnancy. Appendicitis seems to be more common in the second trimester .

History and physical examination

Symptoms include the following:

·         Pain is located in right lower quadrant in the first trimester.

·         In the second trimester, the appendix is located at the level of the umbilicus.

·         Pain is diffuse or in the right upper quadrant in the third trimester.

·         Nausea is present in nearly all cases.

·         Vomiting is present in two thirds of pregnant patients.

·         Anorexia is present in only one third to two thirds of pregnant patients, while it is present almost universally in nonpregnant patients .

Signs include the following:

·         In the first trimester, tenderness is well localized in the right lower quadrant.

·         Later in pregnancy, the tenderness is in the right periumbilical area, in the right upper quadrant, or is diffuse.

·         Rebound tenderness may be present in  patients .

·         Abdominal muscle rigidity may be observed in  patients .

·         The Rovsing sign (pain at the McBurney point when pressure is exerted over the descending colon) is observed as frequently in pregnant persons with appendicitis as in nonpregnant persons with appendicitis.

·         Psoas irritation is observed less frequently during pregnancy compared to nonpregnant states .

·         Rectal tenderness is usually present, particularly in the first trimester .

·         Fever and tachycardia are variably present; they are not sensitive signs.

Laboratory Studies

• White blood cell count: In pregnancy, the white blood cell count is often as high as 15,000/mm³. The wide reference range limits the usefulness of white blood cell counts during pregnancy . Severe disease can occur with a normal count. Polymorphonuclear leukocytes are often greater than 80% when appendicitis is present.

·         Urinalysis: Pyuria is observed in 10-20% of patients with appendicitis . This may represent coincident asymptomatic bacteriuria.

·         Ultrasound: In some centers, ultrasound has been used to help diagnose appendicitis.

·         Upright abdominal radiograph: In severe disease, a right-sided mass or free air may be visualized.

Treatment

Treatment of appendicitis is surgical. Perform surgery as soon as the diagnosis is seriously considered. Either laparotomy or laparoscopy can be performed. Even if the appendix appears normal, 2 reasons exist to remove it: (1) early disease may be present despite its grossly normal appearance and (2) diagnostic confusion can be avoided if the condition recurs .

Most authorities suggest a right midtransverse incision directly over the point of maximal tenderness . Others suggest a lower abdominal midline incision to accommodate unexpected surgical findings and the possibility of the need for cesarean delivery .

Tailor the surgical approach to the clinical situation. Remember to tilt the operating table 30° to the patient's left to help bring the uterus away from the surgical site and to improve maternal venous return and cardiac output.

Perforation and abscess formation are more likely to occur in pregnant patients with appendicitis than in nonpregnant patients with appendicitis . The rate of generalized peritonitis relates directly to the interval of time from symptom onset to diagnosis . Maternal and fetal morbidity and mortality rates increase once perforation occurs .

Estimates of occurrence of acute cholecystitis vary widely. The case-to-delivery ratio varies between 1:1130 and 1:12,890.Asymptomatic gall bladder disease is more common, occurring in 3-4% of pregnant women. Chronic hemolytic conditions, such as sickle cell disease, increase the risk for gallstone formation.

History and physical examination

·         Right upper quadrant pain is the most reliable symptom.

·         Pain may radiate to the back.

·         Vomiting occurs in approximately 50% of cases.

·         Fever occurs in very few instances .

·         Direct tenderness is usually present in the right upper quadrant.

·         Rebound tenderness is rare.

·         Cholecystitis can mimic appendicitis in the third trimester.

Laboratory Studies

• Gallstones are present in more than 95% of patients with acute cholecystitis.

·         Ultrasound is diagnostic and safe.

·         If a radionucleotide scan of the gallbladder is needed, the radiation dose is not prohibitive.

·         Blood tests are of limited value.

·         Leukocytosis is observed in normal pregnancy.

·         Serum alkaline phosphatase levels are normally elevated in pregnancy.

·         Aspartate transferase and alanine transferase levels may help distinguish cholecystitis from hepatitis.

·         Serum amylase levels are elevated transiently in up to a third of patients . A markedly elevated amylase level suggests pancreatitis.

·         Serum electrolyte evaluations are needed if vomiting has been persistent.

Treatment

Initial treatment is supportive in nature.

·         Nasogastric suction: This may be necessary if vomiting has been significant

If the patient does not tolerate supportive therapy or has recurrent bouts, surgery is indicated; a percutaneous drainage procedure may be indicated in select patients in order to defer definitive surgery. The timing of surgery for acute cholecystitis is controversial. Some researchers promote surgery during pregnancy to avoid recurrent episodes and hospitalization ; others promote delaying surgery until the postpartum period . No prospective information is available. When a choice is available regarding the timing of surgery, operating in the second trimester minimizes fetal risk. A growing body of evidence supports the safety of laparoscopic cholecystectomy during pregnancy .

Complications can occur, including empyema, perforation, pancreatitis, and failure to respond to medical management. With conservative management, 62-84% of patients can continue through delivery without surgery .

Pancreatitis is an unusual and potentially devastating occurrence. The issue of whether pregnancy predisposes patients to pancreatitis is controversial . Risk factors include the following:

• Cholelithiasis: This is the most common risk factor in pregnant patients with pancreatitis, observed in 90% of pregnancy-associated pancreatitis .

·         Alcohol use

·         Hyperlipidemia

·         Hyperparathyroidism

·         Abdominal trauma

·         Viral infections

History and physical examination

• The presentation is similar to that of patients who are not pregnant.

·         Acute abdominal pain is observed in 75% of cases

·         Onset is usually sudden.

·         Pain is located in the epigastrium.

·         Nausea and vomiting are usually present and may be severe.

·         Low-grade fever may be present.

·         Jaundice is observed in a few patients.

·         Epigastric tenderness is the most reliable physical finding.

·         Peritoneal signs are minimal or absent.

·         Bowel sounds are diminished.

Laboratory Studies

• Serum amylase testing is the most useful test for diagnosis. During normal pregnancy, amylase levels are slightly elevated. View such slight elevations with caution because they can occur with other disease entities (eg, intestinal perforation, infarction, intestinal obstruction).

·         Other lab values may be helpful, including the following:

• Hyperglycemia

o        Hyperbilirubinemia

o        Hypocalcemia

o        Hemoconcentration

o        Electrolyte abnormalities

·         Ultrasound of the upper abdomen may be helpful for confirming gallbladder disease.

Treatment

Initial treatment is supportive.

• Provide intravenous fluids for hypovolemia.

·         Correct electrolyte imbalances.

·         Correct glucose levels.

·         Correct calcium disturbances.

·         Withhold oral intake.

·         With severe disease, continuous nasogastric suctioning may be necessary.

·         Total parenteral nutrition may be needed if disease is prolonged .

·         If gallbladder disease is causative, surgery can be performed when the patient's condition stabilizes.

Acute symptoms last for approximately 6 days. The maternal mortality rate ranges from 0-37%, while the perinatal mortality rate is approximately 11% or less. The risk of perinatal death increases with the severity of disease.

The case-to-delivery ratio ranges from 1:3600 to 1:5700. The frequency of this condition is increasing, due to a higher incidence of intra-abdominal surgery. Intestinal obstruction rarely occurs during the first trimester and occurs with equal frequency in the second and third trimester and puerperium.

Causes

Simple obstruction is the most common cause, most likely due to prior surgery and adhesions. Volvulus is the second most common etiology and is also predominantly due to adhesions. Intussusception is less common, and incarcerated inguinal or femoral hernia and carcinoma are extremely rare.

History and physical examination

• Abdominal pain is observed in 90% of patients and may be constant or periodic, mimicking labor. Pain may radiate to the flank, imitating pyelonephritis . The severity of pain may not reflect the severity of disease.

·         Vomiting is a highly variable symptom. If the obstruction is more proximal, vomiting occurs earlier in the course. Severe obstruction can be present with no vomiting .

·         Constipation is different from the usual constipation in pregnancy. Patients experience a complete cessation of stool and flatus.

Physical findings

• Classic distended tender abdomen with high-pitched bowel sounds is the exception in pregnancy.

·         Abdominal tenderness may be absent.

·         Pressure on the uterus often causes pain due to transmitted pressure to the bowel, misleading the clinician to consider a uterine process.

·         Bowel sounds are often normal upon presentation.

·         A tender cystic mass can sometimes be palpated .

·         Rebound tenderness, fever, and tachycardia occur late in the course.

• Leukocytosis: Leukocytosis may be present. Remember that leukocytosis is also observed in normal pregnancy.

·         Electrolyte abnormalities

·         Hemoconcentration

·         Elevated serum amylase levels

·         Radiograph: An upright plain film of the abdomen is the best initial study. Do not avoid diagnostic radiography out of concern for fetal effects. This diagnosis is difficult to make without the use of radiography. Sequential films may be needed (Davis, 1983).

Treatment

Treatment is surgical, the same as for patients who are not pregnant. Clinical management includes the following:

• Correct fluid and electrolyte imbalances.

·         Perform decompression of the bowel.

·         Help relieve the obstruction.

·         Resect nonviable tissue.

·         Fluid management is critical during pregnancy because uterine blood flow depends on normal maternal blood volume

·         A midline abdominal incision is optimal.

Prognosis

Intestinal obstruction is a serious complication in pregnancy, with maternal mortality rates ranging from 10-20%. Perinatal mortality rates range from 20-30% .

The case-to-delivery ratio is approximately 1:1600.

History and physical examination

• Pain, usually in the flank - Almost always the presenting complaint

·         Nausea and vomiting

·         Dysuria

·         Urgency

·         Fever

·         Gross hematuria

·         Possible history of a prior episode in 25% .

·         Costovertebral angle tenderness - Almost always present

·         Abdominal tenderness - May be observed

Laboratory Studies

• Patients may have coexisting urinary tract infection.

·         Microscopic hematuria is observed in 75% of cases. The absence of hematuria does not exclude a stone.

·         Strain urine in search of a stone.

·         Perform an ultrasound on the urinary tract to check for evidence of obstruction.

·         Remember the physiologic dilatation of the right side in the second half of pregnancy.

Treatment

Treatment depends on the size and location of the stone, the degree of obstruction, the severity of symptoms, and the presence of infection. Most stones pass with hydration. Minimally invasive procedures can be considered, including ureteral stent placement, ureteroscopic retrieval, and percutaneous nephrostomy. Extracorporeal shock-wave lithotripsy has not been approved for use in pregnancy.

A good perinatal outcome is expected, unless a severe infection is present.

Rupture of ovarian cyst

Incidence

Ovarian cysts occur in pregnancy with a frequency ranging from 1 in 81 to 1 in 1000 (Booth, 1963; Eastman, 1966; Ballard, 1984; Hopkins, 1986). Rupture of ovarian cysts is rare.

History and physical examination

• Patients may have a history of mild trauma, such as caused by a fall, intercourse, or a vaginal examination.

·         Rupture may occur spontaneously.

·         The patient may have mild chronic lower abdominal discomfort that suddenly intensifies.

·         Upon physical examination, the lower abdomen may demonstrate peritoneal signs, and tenderness and guarding may be present.

Workup

• The hemoglobin level may drop.

·         Ultrasound can help detect the presence of fluid in the cul-de-sac.

Treatment

• Treatment is surgical.

·         Conserve as much ovarian tissue as possible.

Prognosis

In the absence of malignancy, the prognosis is excellent (Chamberlain, 1969).

Adnexal torsion

Incidence

Adnexal torsion is unusual and occurs predominantly in teenagers and young women. Pregnancy predisposes to adnexal torsion, with 1 in 5 adnexal torsions occurring during pregnancy (Hibbard, 1985). The condition is associated with an ovarian mass in 50-60% of patients, and the mass is most often a dermoid. Adnexal torsion occurs more frequently on the right than on the left, by a ratio of 3:2. It occurs most frequently in the first trimester, occasionally in the second, and rarely in the third (Hibbard, 1985).

History and physical examination

• Patients present with acute, severe, colicky, unilateral, lower abdominal and pelvic pain.

·         Two thirds of patients also have nausea and vomiting (Lomano, 1970; Mashiach, 1990).

·         Patients may provide a history of prior intermittent episodes of similar pain.

·         A low-grade fever can occur.

·         A tender adnexal mass is palpated in 90% of patients with adnexal torsion.

Workup

• If adnexal necrosis has occurred, leukocytosis and fever can occur. Leukocytosis is also observed in normal pregnancy.

·         Ultrasound can be useful for documenting the presence of an ovarian cyst.

·         Color Doppler findings can possibly help document absent ovarian flow in the central ovarian parenchyma (Fleischer, 1995).

·         If the diagnosis is uncertain, diagnostic laparoscopy can be used.

Treatment

Treatment is surgical, with preservation of as much ovarian tissue as possible (Chamberlain, 1969). If the tissue is necrotic, removal is warranted and unilateral salpingo-oophorectomy is appropriate. If a partial torsion is confirmed, conservative management is appropriate. Untwist the pedicle, remove the cyst, and stabilize the ovary. If removal of the corpus luteum is necessary prior to 10 weeks of gestation, progesterone supplementation is warranted.

Prognosis

Pregnancy outcome associated with adnexal torsion generally is good (Mashiach, 1990).

Degenerating myoma

Incidence

Red degeneration occurs in 5-10% of pregnant women with myomas. Degenerating myoma often occurs between 12 and 20 weeks' gestation.

History and physical examination

• Patients present with an acute onset of significant localized abdominal pain.

·         They may experience vomiting and tenderness over a mass in the uterus.

·         Patients may experience a low-grade fever (Chamberlain, 1969).

Workup

Ultrasound is helpful when used directly over the area of pain. A degenerating myoma has a mixed echodense or echolucent appearance.

Treatment

During pregnancy, treatment is medical in nature because red degeneration is a self-limited process. Treatment includes analgesia with narcotic or anti-inflammatory agents. If narcotics are ineffective, a short course of indomethacin can provide effective pain relief. Because indomethacin has fetal effects, including oligohydramnios and partial constriction of the fetal ductus arteriosis, its use is limited to less than 32 weeks. Patients should be monitored closely.

Prognosis

Pregnancy outcome associated with red degeneration usually is good.

Placental abruption

Incidence of placental abruption varies depending on the population. Generally, abruption occurs in 1 in 150 deliveries, but the rate ranges from 1 in 75 to 1 in 225 deliveries. Risk increases with (1) hypertension, (2) preterm premature rupture of the membranes, (3) cocaine abuse, (4) cigarette smoking, and (5) uterine myoma.

History and physical examination

Symptoms include the following:

• Vaginal bleeding

·         Uterine tenderness and back pain  

·         Uterine contractions

Signs include the following :

• Fundal tenderness

·         High frequency of contractions or hypertonus  

·         Nonreassuring fetal heart rate

·         Intrauterine fetal demise  

·         In advanced cases, shock, evidence of disseminated intravascular coagulation, or renal failure possible

Laboratory Studies

• Monitor the fetus for signs of distress.

·         Monitor contractions for evidence of hypertonus.

·         Obtain a complete blood cell count, coagulation profile, and type and screen.

·         Perform the Kleihauer-Betke test.

·         Ultrasound can be performed, but, at most, only 25% of placental abruptions are detected.

Treatment

At term, delivery is treatment. The mode of delivery depends on obstetrical indications. When remote from term and if the abruption is mild, conservative management can be attempted with intravenous fluid, tocolytics, bedrest, steroids, and continuous fetal monitoring.

Maternal morbidity depends on the presence of consumptive coagulopathy, shock, and renal failure. Perinatal mortality rates range from 20-35%.

Uterine rupture

The frequency of uterine rupture varies widely among different institutions. The case-to-delivery ratio ranges from 1 in 1235 to 1 in 3000.

History and physical examination

Symptoms include the following:

• Severe abdominal pain

·         Chest pain from hemoperitoneum

Signs include the following:

• Nonreassuring fetal heart rate pattern, severe bradycardia (most common sign)

·         Loss of station of presenting part

·         Vaginal bleeding

·         Hypovolemia

·         Possible history of prior uterine surgery or uterine anomaly

Laboratory Studies

• Diagnosis is clinical.

·         Ultrasound may be useful if immediately available.

Treatment

Treatment consists of immediate cesarean delivery with probable hysterectomy. Repair of the uterus may be possible in select cases. Blood products may be needed.

The maternal mortality rate reportedly is as high as 44% in Zambia . Prompt diagnosis and surgery, large amounts of blood products, and antibiotics improve maternal outcome. Fetal mortality rates range from 50-75% .

Hepatic rupture

The case-to-delivery ratio is 1:45,000 . Hepatic rupture may be spontaneous. Most are associated with preeclampsia and eclampsia .

History and physical examination

• Right upper quadrant pain and tenderness

·         Possible history of pregnancy-induced hypertension

·         Hemorrhagic shock

·         Distended abdomen

Diagnosis can be confirmed based on CT scan findings.

Treatment

• Correct any associated coagulopathy.

·         Repair the liver laceration.

·         Use packing.

·         Hepatic artery ligation and resection may be needed.

Maternal mortality rates range from 20-75% .