ACUTE ABDOMEN in PREGNANCY : AETIOLOGY & OUTCOME in BASRAH

This is a prospective study conducted in all major hospitals in Basrah (Basrah Maternity & Child Hospital, Basrah Teaching hospital and Basra General hospital) to prove that ‘acute abdomen in pregnancy’ is common and that the effect of delayed diagnosis can have serious implication on both maternal and fetal outcome. Two hundred and fourteen pregnant females were included. Their age ranged from 16-42 years (mean age was 27 years). Operations were performed whenever indicated by a registrar or consultant gynecologist. Abruption placenta was the causative factor in 33.17% of cases, ectopic gestation in 24.7%, acute appendicitis in 11.21% and the remaining 30.9% resulted from miscellaneous conditions. Most of the patients (94.39%) presented within the first twenty-four hours of their initial complaint. Delayed diagnoses were made in 12 with 50% maternal mortality and 100% perinatal mortality. One hundred and sixty nine patients (78.97%) underwent emergency operations, while forty-five patients (21.02%) were treated conservatively. Various complications were encountered; the most common was wound infection (19.8%).


Introduction
n acute abdomen of pregnancy a major problem is delay in the diagnosis and definitive treatment which represents the most significant risk for poor outcome for both the mother and the fetus.Acute abdomen is any situation in which the patient complains of acute abdominal symptoms that suggest a disease which definitely or possibly threatens life 1 .Acute abdomen is a common surgical emergency; the diagnosis is usually made by junior surgical staff in the majority of cases being satisfactorily treated as part of day-to-day work in hospital.To find that I a patient presenting with an "acute abdomen" is pregnant seems to lead to many problems.The morbidity, and indeed mortality, of such conditions is relatively high in pregnancy due to delay, or sometimes, failure and in making the diagnosis and the prompt institution of the correct treatment 2 .A pregnant abdomen can be difficult to examine and may hide or change what would otherwise be a classic finding in several diseases.Many physicians tend to be more cautious and conservative with pregnant patients which may actually lead to more harm by causing a delay in diagnosis and treatment 4 .Incidence, maternal morbidity & mortality in addition to fetal outcome were studied including obstetrical and non-obstetrical conditions.

Patient & Methods
This is a prospective study conducted from May 2000 till June 2001 at Basrah General Hospital, Basrah Maternity & Child Hospital and Basrah Teaching Hospital.A total of 214 pregnant female patients were included with an age range of 16-42 years (mean age 27 was years).Seventy-five pts (35%) were referred from private clinics of either specialist Gynecologist, Surgeon or Physician and the other 139 (65%) were first seen by a Senior House Officers in gynecology or surgery at the Casualty Department.Detailed history was taken and careful physical examination was made.We investigated them with routine general investigations and specific investigations like ultrasonography (abdominal and pelvic) were made to some of them according to their availability and to the patient"s general conditions.Plain x-ray was done to patients with suspected intestinal obstruction some of whom were in critical general condition with signs of severe hypovolemic shock.Resuscitation was routinely carried out through two intravenous lines with intravenous Ringer Lactate solution.Blood transfusion was given when necessary.Laparoscopy was performed in some cases of suspected ectopic pregnancy.Either a Consultant surgeon, Gynecologist or the Registrar on duty performed the operations.

No. percent
Abdominal One hundred sixty nine patients (78.97%) underwent emergency surgical operations while 45 (21.02%) were treated conservatively.We found that right-sided ectopic gestation formed (77.3%) of the total while the left side formed (22.7%).Our study revealed various degrees of complications.The most common of which was wound infection (19.8%) followed by preterm labor (9.3%) and abortion (3.2%); (Table V).

Discussion
Acute abdomen is a common problem facing every doctor during his medical practice representing a serious challenge, which should be solved properly, and urgently 4 .Surgical disorders may be either incidental to or directly related to the pregnancy and experienced judgment is important regarding the timing, methods and extent of treatment 5 .This study revealed that about two thirds of our patients were in the second half of the third decade of age with a mean age of 26 years.The vast majority of our patients presented before the elapse of 24 hours from the first complaint.The diagnosis of acute abdomen has been made in some of the cases on clinical basis only.In other patients, where the diagnosis was not sure, ultrasound examination was done and was very helpful in the diagnosis of 92.5% of the cases.This was consistent with other studies 6,7,8 .Ultrasonography has proven to be an accurate complementary imaging method in acute abdominal conditions in pregnancy.It proved to be useful if correlated with an accurate history and clinical examination with an accuracy rate of 96 % 9 .Diagnostic laparoscopy was done to three patients only.In this series, placental abruption formed 33.17% of the cases of acute abdomen during pregnancy; approximately 0.5% of all pregnancies attending the hospital during the period of the study.This result is lower than that reported by Sharief 1996 10 (2%) where all cases of abruption were included.Our study, in comparison, included the high-risk moderate to severe cases of acute abdominal conditions during pregnancy.Ectopic pregnancies formed 24.7% of the cases.We disagrees with Stephen (1990) who found that about 40% of the cases were due to ruptured ectopic gestation and stated that "any women in the reproductive age group presenting with sever abdominal pain with signs of hypovolaemia is suffering from ruptured ectopic gestation until proved otherwise 11" .We found a predominance of right sided ectopic gestation (77.3%) compared to left ectopic gestation (22.7%); this fact is possibility explained by the proximity of the appendix to the right tube which could be involved by inflammation in appendicitis 12,13 .Acute appendicitis formed 11.2% of cases in this series of cases and this is comparable with other studies of acute appendicitis in pregnancy, which generally represents around 12% of the case 14 .

Gestational
There was a delay in the diagnosis of 3 cases of acute appendicitis, which could be due to the change in the anatomical position of the appendix 14 .It is the commonest nonobstetric surgical cause in this study; just like the observation of Epstein FB. 1994 15 .Ovarian tumors or cysts occurring during pregnancy pose considerable problems in respect of diagnosis and treatment 17 .This study revealed that complicated ovarian cyst accounted for (9.34%) of the cases of acute abdomen in pregnancy.One percent of all complicated ovarian cysts were ruptured, while torsion accounted for 5% of the cases of ovarian cyst during pregnancy and this is comparable with a study conducted by Schmid-Matthiesen 18 , in 1993, which stated that "only 2% of complicated ovarian masses will rupture during gestation and much more likely undergo torsion (50-60%)" a rate higher than that reported in this study.Renal problem accounted for 6.54% of the cases.Out of them, 2.33% were due to acute pylonephritis which is the most serious bacterial infection of pregnancy affecting 1-3% of women 17 .Ruptured uterus occurred in 3.27% of cases, approximately 0.3/1000 pregnancies.This is comparable to study of Fedorkow et al (1987) 17.Out of our cases, 98% were referred from rural areas with a history of midwife interference.Complicated fibroid with pregnancy formed 1.87% of the cases which is again comparable to a study performed by Allen-JR.(0.3-2.6) 19 .Acute intestinal obstruction accounted for 1.87% of the cases, of which adhesions were the cause in 60% of instances.Allen reported 8% incidence of intestinal obstruction in pregnancy, 55% of them due to adhesions from previous surgery .A similar result was also reported by other authors 19 .Volvulous was reported in 1 of our patients (25%) with intestinal obstructtion; just similar to that reported by Allen 19 .Plain x-ray of the abdomen was done only to 9 patients in whom the suspicion of intestinal obstruction or perforated duodenal ulcer was suspected, and gave a positive result in 6 patients.Any irradiation carries a potential risk for oncogenesis and increases cancer risk.Despite this fact, there must be no delay in ordering radiological studies because delay can lead to increased complication 3 .Although pregnancy appears to be somewhat protective against the development of gastro-intestinal ulcers 20 ulcers have been reported in two patients (0.93%), both of whom had history of using non-steroidal anti-inflammatory drugs before pregnancy.Burch   24 .Other complications included abortion (6.3%) and acute renal failure (4.9%).Surgical treatment was used in 78.97% of our patients with success, this is because of the large number of patients with placental abruption and ectopic gestation, while 21.02 % of the patients were treated conservatively.We noticed that the morbidity and mortality was more in the late-presenting group, all of whom developed some sort of complication to various degree of severity with a 50% maternal mortality and 100% fetal loss.This could be due to severe hypovolaemic shock or presence of septicaemia.The overall maternal mortality rate was 7 (3.27%) and fetal loss rate (20.3%) mainly due to placental abruption.TableV: Distribution of the complications according to the condition of acute