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Acute Abdomen
During Pregnancy
Goran Augustin
Third Edition
123
Acute Abdomen During Pregnancy
GoranAugustin
https://t.me/medicina_free
Acute Abdomen During
Pregnancy
Third Edition
GoranAugustin
https://t.me/medicina_free
Department of Surgery
University Hospital Centre Zagreb
Zagreb, Croatia
School of Medicine
University of Zagreb
Zagreb, Croatia
ISBN 978-3-031-26020-9 ISBN 978-3-031-26021-6 (eBook)
https://doi.org/10.1007/978-3-031-26021-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2014, 2018, 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this
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The publisher, the authors, and the editors are safe to assume that the advice and information in
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This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my father, an abdominal surgeon whose ability to make an
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accurate diagnosis of emergency abdominal condition only
with history taking and physical examination was never
outperformed. He taught me great things in this “clinical
magic.”
To my wife Katarina, despite having two small children,
understood the importance of this work to me and sacriced
almost a decade of many weekends, evenings, nights, and
journeys to allow me and provide me enough time to create
both the rst and the second edition of this book.
To my children (Lara and Lukas), who remind me every day
that teaching others is a great opportunity and pleasure that
cannot be substituted.
To my mother, whose mathematically functioning brain is
fascinating, and now I realize that it is a fortune that I inherited
most parts of it.
And… to all pregnant women… who are healthy… and to all
who need the clinicians’ consultations from this book, whose
lives and lives of their future babies will be saved and
normal….
Foreword I to the Second Edition
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Diagnosis and treatment of abdominal surgical emergencies during pregnancy are challenging. Abdominal examination is difcult, and organs may
be pushed by the uterus in relation to gestation age, obscuring abdominal
pathologies. Physiological parameters are altered due to pregnancy-induced
changes, and laboratory tests could be deranged due to pregnancy-induced
variations. In evaluating abdominal emergencies in gravid women, the physician is advised to use computed tomography for diagnosis. Radiation exposure may affect the fetus’s normal development. Indeed a perplexing clinical
setup.
Delay in the diagnosis of surgical emergencies is associated with the
amplied risk to the mother and the fetus. The need for nonobstetrical surgery
during pregnancy is low. However, nonobstetric surgery is fraught with
increased risk to the fetus. Fortunately, in most cases, the gravid woman is a
young and healthy individual, and the surgical emergencies are conned to
young patients. The gestational risk in pregnant women with an acute abdomen is multifactorial. Some relate to the patient and her well-being, and some
relate to the fetal age of gestation at the time of diagnosis. Peritonitis and
sepsis contribute to the risks, and the surgical approach (laparoscopic vs.
open) has a great deal of impact.
Dr. Goran Augustin has assembled data on surgical emergencies in pregnant women and wisely outlined recommendations for the practicing surgeon
faced with a gravid patient endangered with an abdominal surgical
emergency.
Any surgery during pregnancy confers signicant obstetrical risk. Delaying
investigation and diagnosis may render the patient and her fetus to worse
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Foreword I to the Second Edition
outcomes. Surgeons should be aware of pregnancy physiology and the precise algorithm for diagnosis and management during gestation. This book
offers exactly that.
Division of General Surgery, Pancreatic Surgery Center YoramKluger
Rambam Health Care Center, Haifa, Israel
Israeli Surgical Association, Tel Aviv, Israel
World Society of Emergency Surgery, Jerusalem, Israel
World Society of Emergency Surgery FaustoCatena
Jerusalem, Israel
Department of Emergency Surgery
Parma University Hospital, Parma, Italy
World Society of Emergency Surgery LucaAnsaloni
Jerusalem, Israel
Department of General Surgery I
Papa Giovanni XXIII Hospital, Bergamo, Italy
Foreword II to the Second Edition
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I have been invested with the honor (and responsibility) of writing a “FORE”
“WORD” meaning to write thoughtful comments made about a book, to give
the impression as to what this book is all about. Acute abdomen during pregnancy is a dramatic event, with signicant morbidity and mortality for both
mother and fetus. Despite this, acute abdomen during pregnancy does remain
a neglected and not well-known topic.
Clearly, a pregnant patient presenting with an acute abdomen is a clinical
scenario that overlaps specialties. Common sense suggests the early involvement of specialists such as a surgeon, obstetrician/gynecologist, and a specialist in maternal-fetal medicine when dealing with this challenging
situation.
Unfortunately, the diagnosis and treatment often tend to be delayed due to
the peculiar physiological features of pregnancy and the restrictions imposed
on diagnostic imaging techniques such as X-ray and CT due to the fear of
radiation exposure. MRI is gaining an increasingly relevant role in the diagnostic workup but is not always and everywhere available or easily and readily accessible. Nevertheless, acute abdomen needs to be diagnosed in the
shortest time possible and promptly treated. Physicians should pay attention
in this regard as any delay may seriously deteriorate the condition of both
mother and fetus.
The editor, Dr. Goran Augustin, is an internationally recognized expert in
the eld of the acute abdomen during pregnancy and given his research and
clinical activity over the last decade, I can wholeheartedly state that he is now
considered an internationally recognized expert in the management of acute
appendicitis and other acute surgical diseases in pregnant patients. His dedication to this critical subset of patients has to be commended, and Dr.
Augustin has made this delicate issue become his area of clinical practice and
his eld of scientic research throughout the years. Textbooks and surgical
journals appear to be the written resource of the fundamentals and the research
reporting archives of the knowledge and the craft of this surgical discipline.
This textbook is one of those resources and represents a landmark textbook in
the eld of the care of a pregnant patient. Both the trainee and the practitioner
of acute care surgery but also gynecology and obstetrics as well as emergency
physicians and family doctors will nd this textbook useful and a ready
resource for current approaches to surgical emergencies.
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Foreword II to the Second Edition
This will soon be a standard text used by surgeons who practice Acute
Care Surgery worldwide and any physician dealing with critical surgical care
during pregnancy. It has been a privilege to review it.
Maggiore Hospital Acute Care and Trauma Center SalomoneDi Saverio
AUSL Bologna, Bologna, Italy
Cambridge Colorectal Unit, Addenbrooke’s Hospital
University of Cambridge, London, UK
Preface to the Third Edition
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Only those who know the past & present of science and art will boost their progress
with awareness. (Christian Albert Theodor Billroth)
Times are bad. Children no longer obey their parents, and everyone is writing a
book. (Marcus Tullius Cicero)
As Theodor Billroth said, I know the past and present of this book. That is
how I know it should be improved in every way. And that is the future of this
book. To be better. To give a reader new insights into every detail of the acute
abdomen during pregnancy. That is why the third edition is in front of us. The
knowledge about these rare entities expands with every new case treated and
every new article or case report on the subject published. As always, new
knowledge opens new questions and new dilemmas. During writing this third
edition again, I recall Marvin Corman’s Preface to the sixth edition of Colon
and Rectal Surgery (see Preface for the second edition). Probably I will recall
him with every new edition.
This new edition has been almost completely rewritten. For example,
completely new chapters include Bariatric Surgery, Fetal Trauma, Vernix
Caseosa Peritonitis, and Radiology. Interestingly, I could not nd these chapters in any book. Dealing with pregnant patients after bariatric surgery is
extremely important due to the increasing frequency of these procedures in
the general population. The important nding is that plain abdominal X-ray
is frequently normal, delaying accurate diagnosis and surgical treatment. All
this can have deleterious consequences on the mother and fetus. The chapter
dealing with intrauterine fetal trauma is also important. It adds the knowledge
on intrauterine injuries with their inuence on the timing and type of delivery.
The chapter on vernix caseosa peritonitis is very interesting because surgeons
never consider this condition a cause of postdelivery complications. Accurate
diagnosis can sometimes avoid unnecessary operations or organ resections
due to the suspicion of a cause of peritonitis or even an underlying tumor. The
chapter Urologic emergencies from the previous edition was divided into
three chapters which are expanded and updated: Complicated Urinary Tract
Infections, Urinary Tract Obstruction, and Urinary Tract Bleeding. The text
is signicantly expanded and reorganized. It is published in two volumes for
easier handling and reading. Many procedures are written in more detail with
additional photographs to help in their comprehension.
It is difcult to construct data-based guidelines on these rare occurrences.
Even a rarer occurrence is the detection of intrauterine fetal injuries. Should
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