Acute appendicitis is present in 1/500–2000 pregnancies (which amount to 25 % of operative indications for the acute abdomen in pregnancy) [3].

The following features suggest acute appendicitis [3]: (1) severe abdominal pain, (2) pain in the right lower quadrant – the most reliable symptom, (3) nausea (nearly always present), (4) vomiting (2/3 of patients), and (5) after the third month of pregnancy, the pain could migrate progressively upward and laterally.

Abdominal tenderness is almost always present, rebound tenderness in 55–75 % [4], and abdominal muscle rigidity in 50–65 % of patients [3]. The psoas sign is observed less frequently during pregnancy when compared with the nonpregnant woman [5]. Fever and tachycardia may be present, but these are not sensitive signs.

Leukocytosis is not diagnostic because it raises in the second and third trimesters and can reach 20 × 10⁹/l in early labor in normal pregnancy. A raised C-reactive protein (CRP) is not specific but the increase correlates with the disease severity. Neutrophil granulocytosis with left shift is diagnostic and indicates bacterial infection. Pyuria (pus in the urine) is observed in 10–20 % of patients [6]. This may also represent concurrent asymptomatic bacteriuria.

There are no Royal College of Obstetricians and Gynaecologists guidelines about the use of transvaginal ultrasound but it can define [7]: (1) the presence of adnexal or uterine pathology ruling out acute appendicitis, (2) free fluid in the pouch of Douglas, and (3) abnormal pathology in the ileocecal region – appendicitis, cecal tumors, or cecal diverticulitis.

Abdominal ultrasound is the modality of choice with variable sensitivity and specificity [8]. It has good accuracy in the first and second trimesters with less accuracy in the third.

Magnetic resonance imaging (MRI) is the modality of choice when the risk of radiation or the potential nephrotoxicity of iodinated contrast agents is a major concern [9, 10]. The patient’s informed consent is mandatory; the safety of MRI for the fetus has not been proved according to the US Food and Drug Administration (FDA) guidelines and the American College of Radiology [9]. Thus, it is prudent to perform an MRI in pregnant patients only when ultrasound findings fail to establish a diagnosis.

The computed tomography (CT) scan is used when there is an uncertain clinical diagnosis or equivocal laboratory or ultrasound findings, or where access to MRI is limited. It is preferable to use the multidetector row CT scan with high-speed mode since it has half the radiation dose of the high-quality mode and its scanning parameters are otherwise identical.

Management is surgical either by laparotomy or by laparoscopy. Even if the appendix appears normal, there are two reasons for removal: (1) early disease may be present despite its grossly normal appearance and (2) diagnostic confusion can be avoided if the condition recurs. Despite the surgical approach, the most experienced abdominal surgeon should perform the procedure to shorten the operation time and possible postoperative complications as much as possible.

Pathological confirmation of inflamed appendix is found in about 67 % of patients [11]. Appendix in pregnant patient should always be removed since pregnancy is not affected by removal of a normal appendix [12].

Fetal mortality when the appendix is not perforated is 1.5–5 % [13, 14], while when perforated, fetal mortality rises to 20–35 % [13, 15]. Maternal mortality is less than 1 %. It is rare in the first trimester, and increases with advancing gestational age [12]. It is associated with: (1) a delay in surgery of more than 24 h [16, 17], and (2) appendiceal perforation – maternal mortality in up to 4 % [15, 18].

Acute cholecystitis is found in 1/1600–10,000 pregnancies. It is caused by gallstones in over 90 % of patients. The incidence of symptomatic and asymptomatic gallstones is 3.5–10 % in primiparous women, and up to 19 % in multiparous women [19].

Features suggesting acute cholecystitis are [20]: (1) a history of previous episodes of acute cholecystitis; (2) a history of nausea, dyspepsia, and an intolerance of fatty foods; (3) vomiting (in 50 % of patients); (4) abdominal pain in the right hypochondrium or epigastrium; and (5) pain also radiating to the back and around to the right scapula.

Abdominal tenderness on direct palpation and Murphy’s sign are present. The rigid abdomen is found with gallbladder perforation and biliary peritonitis. Fever and tachycardia may not be present and so are not sensitive signs.

In decreasing incidence it includes: pyelonephritis, pancreatitis, peptic ulcer disease, acute appendicitis, pre-eclampsia, pneumonia, acute fatty liver of pregnancy, HELLP syndrome, myocardial infarction, and herpes zoster.

Leukocytosis is not diagnostic because it is raised in the second and third trimesters and can reach 20 × 10⁹/l in early labor in normal pregnancy. A raised CRP correlates with the disease severity. Neutrophil granulocytosis with left shift indicates bacterial infection. Bilirubin and transaminases may be elevated, but are not specific. Raised alkaline phosphatase is also not helpful as estrogen causes elevation (levels may double during normal pregnancy). Serum amylase is transiently raised in up to 33 % in pregnant and nonpregnant women.

Gallstones are diagnosed by abdominal ultrasound in 95–98 % of patients [21]. If gallstones without wall thickening are found, then the diagnosis is biliary colic, not acute cholecystitis. In acute cholecystitis, findings include: (1) gallbladder calculi, (2) wall thickening (>3 mm), (3) pericholecystic fluid, (4) sonographic Murphy’s sign (focal tenderness under the ultrasound transducer when it is positioned over the gallbladder), and (5) dilation of the intra- and extrahepatic ducts when the common bile duct is obstructed.

Magnetic resonance cholangiography is used if dilation of the intra- and extrahepatic ducts is found on abdominal ultrasound, especially when the cause of the dilatation is not certain.

Medical treatment is commonly used initially, especially with biliary colic. It consists of a low-fat diet, analgesia, antibiotics, and anticholinergic antispasmodics such as dicyclomine. Patient should be admitted to hospital for a week, and then followed-up weekly. A second reason for conservative therapy is to delay surgery until the second trimester because the spontaneous abortion rate after open cholecystectomy is 12 % in the first, and only 5.6 % in the second trimester. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, naproxen, or diclofenac can be used for pain relief. Paracetamol and weak opioids such as codeine are used if nonsteroidal anti-inflammatory drugs are not tolerated or are contraindicated. First-line treatments are ampicillin and sulbactam, cefoxitin, or cefuroxime (US FDA category B).

Recommendations for early and initial surgery are based on [22]: (1) reduced likelihood of recurrence – the recurrence rate during pregnancy is around 50 % [23]; (2) avoidance of medications during pregnancy; (3) elimination of potentially life-threatening complications – perforation, sepsis, and peritonitis; (4) lowering the incidence of gallstone pancreatitis, which causes fetal loss in 10–20 % of patients; and (5) lowering the incidence of spontaneous abortions, preterm labor, and preterm delivery.

Open cholecystectomy is performed by right subcostal incision or an upper midline incision. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) published guidelines in 2007 that stated ‘Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with gallbladder disease, regardless of trimester’ [24].

Prognosis is excellent because inflammatory disease is mostly away from the uterus. If outcomes are compared, laparoscopic access has significant advantages in all outcomes measured.

Intestinal obstruction is found in 1/1500–16,000 pregnancies [25]. The most common cause are adhesions, present in 60–70 %. They arise following previous abdominal or pelvic surgery, or pelvic inflammatory conditions [26]. The second most common cause is large bowel volvulus, which occurs in 25 % of pregnant patients (it is the cause in only 3–5 % of nonpregnant patients). Cecal volvuli are found in 25–45 % of large bowel volvuli. Other causes include small bowel volvulus (in 9 %), intussusception (in 5 %), and other rare conditions such as hernia, cancer, and diverticulitis.

Rapid changes in uterine size can cause obstruction; at 16–20 weeks the uterus becomes an intra-abdominal organ, at 32–36 weeks the fetus enters the pelvic inlet, and at the puerperium the uterus involutes and shrinks rapidly again. The redundant or abnormally mobile colon is predisposed to torsion or twisting because of uterine pressure [27].

Features suggesting intestinal obstruction are [26]: (1) previous episodes of colicky abdominal pain; (2) abdominal pain is observed in 90 % of patients and may be constant or periodic, mimicking labor; (3) nausea and vomiting; vomiting is not always present, but if the obstruction is more proximal, vomiting occurs earlier; and (4) constipation, different from the usual constipation in pregnancy; there is complete cessation of stool and flatus.

The abdomen is distended and tender on palpation. Hyperperistalsis is found early on, but later there is a complete absence of peristalsis. Palpation of the uterus often causes pain secondary to transmitted pressure to the bowel, misleading that the problem is in the uterus. Rebound tenderness, fever, and tachycardia occur late and suggest peritonitis. Examine hernia orifices for protrusions and contents. If present and irreducible, incarcerated hernia is the cause of the obstruction. With digital rectal examination, the presence of intrarectal or perirectal masses, such as stenosis, rectal cancer, or rectal prolapse, should be confirmed or ruled out.

Leukocytosis is not diagnostic because it is raised in the second and third trimesters and can reach 20 × 10⁹/l in early labor in normal pregnancy. The CRP correlates with the severity of obstruction, incarceration, and strangulation. Neutrophil granulocytosis with left shift is present. Electrolyte abnormalities are common due to dehydration, vomiting, and fluid shift into the bowel lumen. Elevated serum amylase is not specific.

The significant maternal and fetal mortalities associated with obstruction outweigh the potential risk of fetal radiation exposure. Plain abdominal X-rays are needed every 6 h if the obstruction is partial and in the absence of clinical improvement [26]. Contrast studies are needed if there is an absence of typical findings on plain abdominal films.

Colonoscopy can be therapeutic and result in the reduction of a sigmoid volvulus in 60–90 % of patients. The chance of reduction of cecal volvulus is low. There is more than a 50 % of recurrence of both sigmoid and cecal volvuli, which means that delayed surgery (fixation or resection) after delivery is mandatory [28]. Bloody intestinal contents or cyanotic mucosa suggests ischemia and are indications for emergent laparotomy.

Medical management is started once the diagnosis is established, regardless of the completeness of the obstruction. Vomiting can cause large losses of fluid and electrolytes. Moreover, during obstruction a large volume of fluid is contained within the bowel lumen, and this contributes to dehydration and electrolyte disturbances. These should be corrected by intravenous infusion titrated against the laboratory findings. Nasogastric decompression eliminates the gastric contents, thus decreasing the incidence of vomiting and aspiration, and also decreasing abdominal pain caused by distension. During bowel obstruction, aerobic and anaerobic bacterial overgrowth occurs. The first-line treatment is a combination of clindamycin and cefazolin (US FDA category B), which should be started once the diagnosis is confirmed.

Surgery is indicated when: (1) medical therapy fails, (2) clinical, laboratory, or radiographic findings of disease progression; and (3) complete obstruction initially. A midline vertical incision is always used, except when an incarcerated hernia is the cause and the incision is made over the incarcerated hernia. The type of midline incision is made according to the estimated site; a medial midline incision for small bowel obstruction, and a lower midline incision for large bowel obstruction. Laparoscopic procedures are rarely performed. Laparoscopic cecopexy (anchoring the cecum to the lateral abdominal wall) can be made in a pregnant patient without a history of previous abdominal operations that could potentially cause adhesions.

The fetal mortality is 20–26 %, and the maternal mortality is 6–20 % [29].

Typical symptoms are the same as in nonpregnant patients. Patients may have a history of previous episodes of upper abdominal pain. There is severe epigastric pain radiating to the back, nausea and vomiting, and fever.

On examination, your patient may be lying in the fetal position with flexed knees, hips, and trunk. Bowel sounds are usually hypoactive, secondary to paralytic ileus. There is diffuse abdominal tenderness. There may also be Grey Turner’s sign (bruising of the flanks) and Cullen’s sign (bruising around the umbilicus).

Leukocytosis is not diagnostic because it is raised in the second and third trimesters and can reach 20 × 10⁹/l in early labor in normal pregnancy. A CRP of 120 mg/l indicates necrotizing pancreatitis. Neutrophil granulocytosis with left shift is present. Serum levels of amylase and lipase may be raised; raised lipase levels are a better predictor of acute pancreatitis. Serial measurements on a daily basis reveal the progression/regression of the pancreatic inflammation. The amylase-creatinine clearance ratio is diagnostic [32]. It is low in normal pregnancy, but has a value of 5 % or more in pregnant women. Urea and electrolytes reveal acute prerenal insufficiency and electrolyte imbalance. Serum glucose confirms hyperglycemia or glucose intolerance. Hemoglobin and hematocrit levels confirm hemorrhage.