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Emergency Radiology

E2432. Pregnant and in Pain!

Subhash A1,  Shahane S2,  Kennedy A.1 1. University of Utah, Salt Lake City, UT; 2. Baylor College of Medicine, Houston, TX

Address correspondence to A. Kennedy (anne.kennedy@hsc.utah.edu)

Background Information: Abdominal emergencies, excluding obstetrical emergencies, occur in approximately 1 in 500 pregnancies. Etiologies of abdominal pain during pregnancy include gastrointestinal, gynecologic, urologic, and traumatic causes. Due to the anatomic and physiologic changes associated with pregnancy, the clinical presentation can often be confounding. As a result, the diagnosis of acute abdomen pain during pregnancy can be challenging; however, the dictum that, the morbidity of abdominal pain in pregnancy is the morbidity of delay, still holds true. Knowledge of the best imaging modality in a given clinical scenario as well as the ability to tailor an examination to assess specific risks in pregnancy is vital.

Educational Goals/Teaching Points: The following will serve as an educational guide to tips and tricks in the sonographic evaluation of acute abdominal pain during pregnancy. Suggestions are given regarding transducer selection, scan planes, and scan techniques to improve sensitivity and specificity of the examination. The role of MRI as a problem solver will also be illustrated.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: Possible causes of acute abdominal pain during pregnancy (and associated factors to be addressed) include fibroid degeneration (commonest solid adnexal mass, find the ovary, find bridging vessels, acute red degeneration, infarction or infection), ovarian torsion (dual blood supply, maximum risk at end first trimester and at uterine involution, impact of assisted reproductive technology), appendicitis (location of appendix and pain, what happens when she moves, use of coronal retroperitoneal images, vaginal ultrasound, role of Doppler), and renal stones or pyelonephritis (use of coronal retroperitoneal images, lateral decubitus positioning and vaginal ultrasound, role of Doppler.; check urinalysis but beware of appendicitis as a cause of pyuria). We will also address right upper quadrant pain (it’s not just the gallbladder; preeclampsia may also present with abnormal liver function tests and abdominal pain), bowel obstruction (not all vomiting in pregnancy is hormonal or hyperemesis), placental abruption (placental thickness, use of color Doppler, signal changes on MRI), and trauma (mom comes first; use CT if needed).

Conclusion: In an effort to minimize fetal radiation, ultrasound and MRI are the typical imaging modalities used outside the setting of major trauma; however, the use of CT is not contraindicated in pregnancy. Complications from delayed diagnosis can adversely impact maternal and fetal morbidity and mortality. Accurate and timely diagnosis by using of appropriate imaging modalities is crucial. Knowledge of specific “tips and tricks” for evaluation of abdominal pain in pregnancy is essential for the radiologist working in the acute care setting.