© Springer International Publishing AG 2018Peter Bogach Greenspan (ed.)The Diagnosis and Management of the Acute Abdomen in Pregnancy doi.org/10.1007/978-3-319-62283-5_3
3. General Principles in the Diagnosis of the Acute Abdomen
Department of Obstetrics and Gynecology, University of Missouri – Kansas City School of Medicine, Kansas City, MO, USA
Obstetrical and Gynecological Services, Truman Medical Center Lakewood, Kansas City, MO, USA
Peter Bogach Greenspan
KeywordsHistoryPhysical examinationObservationAuscultationPalpationPercussionPelvic examination
The overall antenatal hospitalization rate is approximately 10.1 per 100 deliveries . One third is for nonobstetrical conditions that includes renal, pulmonary, and infectious diseases. One in every 635 pregnant women will undergo a nonobstetrical surgical procedure [2, 3].
The obstetrician may be qualified to manage many nonobstetrical disorders . Other conditions will require consultation, and others still may require a multidisciplinary team. Consultants may include maternal–fetal medicine specialists, internists and medical subspecialists, surgeons, anesthesiologists, and numerous other disciplines . Obstetricians should have knowledge of a wide range of surgical disorders frequently diagnosed in women of childbearing age. Consequently, nonobstetricians who care for these women and their unborn fetuses need to be familiar with pregnancy-induced physiological changes that occur in the gravida as well as special fetal considerations. Often normal pregnancy distresses have clinically significant effects on various diseases and may cause aberrant changes in routine laboratory values.
It is obvious that a woman should never be punished because she is pregnant. Gravid women are susceptible to any of the medical and surgical maladies that can affect women of childbearing age. A number of questions should be addressed to assure appropriate evaluation and management :
Would a different management plan be recommended if the woman was not pregnant?
If the management plan is different because the woman is pregnant, can this be justified?
What are the risks versus benefits to the mother and her fetus, and are they counter to each other?
Are there individualized management plans that balance the benefits versus risks of any alterations?
This approach allows individualization of care for women with most surgical disorders complicating pregnancy. This may be specifically helpful for consideration by nonobstetrical consultants.
The foundation of the diagnostic process is the patient’s history . Skilled history taking is acquired with experience and the utilization of the examiners’ senses. An understanding of body language often significantly contributes to the history-taking process .
Aside from patients who are unconscious, obtaining a coherent, accurate history is often challenging. Language barriers, educational disparities, and cultural differences among other things can make obtaining a clear history very difficult. At times, even with a conscious patient, getting a coherent history is all but impossible.
Often, an emergency is pending and time for history taking can be severely curtailed. In such cases, the most essential information to be obtained includes the patients’ allergies, medications, major prior medical and surgical problems, etc.
When the clinical setting allows for more time, then a general history should be ascertained on all patients with whom the examiner is otherwise, unfamiliar. This is essential in the determination of the type and urgency of the proposed surgery, if that is warranted.
The interview typically begins with the elicitation of a chief complaint from which the examiner develops the history of the present illness. Often, there is more than one chief complaint; therefore, each one should be explored, as well. In some instances, multiple complaints can be coalesced into a single history.
One should be cautious not to develop the notion of a “routine” history as each patient is entirely unique. Observation of the patient while questioning them is critical.
The examiner should sit while interviewing the patient affording him or her enormous amounts of information. Furthermore, this usually makes the suffering patient feel more at ease.
Observations of the patients’ position in the bed, facial expressions, degree of stillness versus movement (such as rocking back and forth) provides very useful clues to the clinician [5, page 19].
Determining the acuteness of onset of the pain provides clues to its severity. Determination of what the patient was doing when the pain began is very useful. Was the gravida asleep and awakened by the pain? Was she standing, sitting, or lying down when the pain began? Was she walking, running, exercising, etc.? Did the pain begin during or after sexual intercourse ?
Rarely, patients will develop sudden-onset severe pain that will cause them to fall down or faint. However, in pregnant women, fainting or collapse is associated with ovarian torsion and rupture of an ectopic pregnancy [5, page 21].
Characterization of pain regarding onset and distribution is greatly important. Pain that is felt throughout the abdomen is associated with sudden exposure of the peritoneum to fluids such as blood, pus, or succus entericus. When generalized pain can be further characterized to specific locations in the abdomen, this aids the clinician in focusing on the likely source. For example, if a pregnant patient has generalized abdominal pain but the greatest intensity is in the left lower quadrant, then the most likely explanation is ovarian, sigmoid or rectal pathology and not appendix or ileocecal disease.
Pain associated with small bowel obstruction or colic is first noted in the epigastrium and periumbilical regions, which corresponds to the innervation by the ninth and tenth thoracic nerves. These nerves also supply the appendix; hence, early appendicitis pain is often felt in the epigastrium. Typically, the pain from large bowel pathologies is felt in the hypogastrium [5, page 22].
An accurate description of the pain regarding severity or quality is often an indication of the seriousness of the underlying cause. For example, burning is used to describe pain from gastric ulcer , whereas pancreatitis may cause agonizing pain. Colicky pain is sharp and constricting, whereas tearing pain may be described in an aortic dissecting aneurysm, albeit rare in pregnant women. Obstructions of the bowel may be described as gripping pain, but appendicitis may produce dull aching. Pelvic abscess may also be described as dull pain as well [5, page 22].