Differential Diagnoses for Surgical Abdomen in Pregnancy

The differential diagnoses for a surgical abdomen in pregnancy can be complex and varied, given the physiological changes and the potential for both obstetric and non-obstetric causes. Here's a comprehensive list, categorized for clarity:

• Single Most Likely Diagnosis

  • Appendicitis: This is one of the most common non-obstetric surgical emergencies in pregnancy. The symptoms can include abdominal pain (which may initially be diffuse and then localize to the right lower quadrant), nausea, vomiting, and fever. The diagnosis can be challenging due to the upward displacement of the appendix by the gravid uterus, potentially altering the classic presentation.

• Other Likely Diagnoses

  • Placental Abruption: Characterized by vaginal bleeding and abdominal pain, this condition occurs when the placenta separates from the uterus. It's a significant cause of maternal and fetal morbidity and mortality.
  • Ureteral Stones: Pregnancy increases the risk of ureteral stones due to urinary stasis and hypercalciuria. Symptoms include severe flank pain (colic), nausea, vomiting, and possibly hematuria.
  • Ovarian Torsion: Although less common, ovarian torsion can occur in pregnancy, especially in the first trimester. It presents with sudden, severe pelvic pain, often accompanied by nausea and vomiting.
  • Gallbladder Disease: Pregnancy increases the risk of gallstones due to bile stasis and increased cholesterol secretion. Symptoms include right upper quadrant pain, especially after eating fatty foods, nausea, and vomiting.

• Do Not Miss Diagnoses

  • Ectopic Pregnancy: A life-threatening condition where the embryo implants outside the uterus, commonly presenting with abdominal pain and vaginal bleeding. It's crucial to consider this diagnosis, especially in the first trimester.
  • Uterine Rupture: Although rare, uterine rupture is a catastrophic event that can occur in women with a previous uterine scar (e.g., from a cesarean section). It presents with sudden, severe abdominal pain and potentially fetal distress.
  • Hepatic Rupture: A rare but potentially fatal condition associated with severe abdominal pain, hemodynamic instability, and often a coagulopathy.

• Rare Diagnoses

  • Adrenal Hemorrhage: A rare condition that can present with abdominal pain, potentially mimicking other surgical conditions. It's associated with significant morbidity and mortality if not promptly recognized and treated.
  • Splenic Artery Aneurysm Rupture: Although rare, this condition can occur in pregnancy and presents with sudden, severe abdominal pain and hemodynamic instability.
  • Intestinal Obstruction: This can occur due to various reasons like adhesions from previous surgeries, volvulus, or intussusception. Symptoms include abdominal pain, nausea, vomiting, and obstipation.

Each of these diagnoses requires careful consideration based on the patient's presentation, history, and physical examination, along with appropriate diagnostic tests to guide management. The key to managing a surgical abdomen in pregnancy is a high index of suspicion for conditions that could compromise maternal or fetal well-being.