Evaluation and Management of Patients Requiring Non-Obstetrical Abdominal Surgery during Pregnancy: A Framework

The evaluation and management of acute abdominal pain is often delayed during pregnancy. This delay may lead to adverse maternal fetal outcomes. We present a framework to approach the care of the pregnant patient with acute abdominal pain. This proposed framework may be applied to other non-obstetric surgery regardless of anatomic location with modifications as appropriate.

Acute abdominal pain requiring surgical management can occur at any point in pregnancy. Classic recommendations for nonelective surgery during pregnancy favor surgical intervention during the second trimester. Critical review of the literature cited to make these recommendations has been called into question for numerous reasons. First, studies evaluating surgical vs. nonoperative management for these diagnoses during each trimester of pregnancy are lacking and inherently difficult to perform. Second, comparing pregnant patients with surgical diagnoses to pregnant patients without surgical diagnoses does not provide an appropriate control population for study. The disease process even without surgical intervention may contribute to adverse outcomes and this has not been considered in many reviews. Laparoscopic surgery may be performed in any trimester with the same benefits experienced by non-pregnant patients. Acute cholecystitis and appendicitis should be managed operatively as nonoperative management has been associated with increased maternal and fetal morbidity and mortality. Open approaches may be preferable for some diagnoses.

Acute abdominal pain during pregnancy warrants timely, thorough and thoughtful multidisciplinary evaluation and management to optimize maternal fetal outcomes. We provide a framework to approach the pregnant patient with abdominal pain noting issues that often delay indicated surgical intervention. Diagnosis, preoperative planning, surgery and postoperative management for the pregnant surgical patient will be reviewed.