Prevalence, Aetiology, and Clinical Profile of Acute Abdomen in Pregnancy in Southwest Cameroon: A 5-Year Retrospective Study ()
1. Introduction
Acute abdomen refers to severe abdominal pain of unknown aetiology, lasting less than 24 hours duration, and which demands immediate medical attention [1]. Globally, it accounts for 10% of all visits to the emergency department [2]. Pregnancy increases the chances of developing acute abdomen [3] [4]. The global incidence of acute abdomen in pregnancy is 1 in 500 to 1 in 600 pregnant women [5]. In a study in Azerbaijan in 2018, the prevalence was 25% [6]. In Subsaharan Africa, studies have been conducted on the causes of acute abdomen in pregnancy and these include medical causes (gastroenteritis, gastro-oesophageal reflux disease, urinary tract infection, etc.), surgical causes (acute appendicitis, acute cholecystitis, intestinal obstruction, etc.), as well as gynaeco-obstetrical causes (ectopic pregnancy, uterine rupture, ovarian cyst, etc.) [7] [8] [9]. However there are little or no studies on the epidemiological profile.
The numerous causes and varied/altered clinical presentation makes diagnosis very difficult [8]. Delayed/missed diagnosis and hesitancy to operate during pregnancy increase maternal morbidity and poor foetal outcome [10]. The aetiologic diagnosis is uncertain or missed in 30% of patients [11]. Delayed/missed diagnosis is associated with 50% maternal and 100% perinatal mortality [10]. It is well established that missed/delayed diagnosis is fatal to both the mother and the foetus [10]. To curb the morbidity and mortality associated with delayed/missed diagnosis, knowledge of the frequency, aetiologies, and clinical presentation of acute abdomen in pregnancy is needed to aid physicians to make prompt and accurate diagnoses. In Cameroon, there are little or no published data on the epidemiological and clinical profile of acute abdomen in pregnancy. Therefore, this study aimed to determine the prevalence, ascertain the aetiologies, and assess the clinical presentation of acute abdomen in pregnancy at 3 major centers in the Southwest Cameroon.
2. Patients and Methods
This study is a preliminary analysis of retrospective data collected on pregnant women admitted to the three referral hospitals (Kumba, Buea and Limbe Regional Hospitals) in southwest Cameroon within the last five years (1st January 2017 to 31st December 2021). Kumba, Buea and Limbe Regional Hospitals are regional referral centers with a mixed urban/rural catchment population in Southwest Cameroon. Although being teaching hospitals with lecturers and interns, at least one doctor is on duty at all times and consultant surgeons and gynecologist are called upon to direct management and carryout emergency surgeries if required.
Between January 2017 to December 2021, all pregnant women who were admitted to emergency department, Obst/Gyn and surgical wards of the hospitals mentioned with history of abdominal pain were included. Data was collected with a pre-tested data entry form and included the age of patient, gestational age, symptoms, signs, ultrasound findings, diagnosis, treatment (medical or surgical), treatment outcome. The data was collected using a structured checklist and entered into an excel spreadsheet and exported to the statistical package for social sciences (SPSS) version 25. Descriptive statistics and statistical testing was carried out. We presented continuous variables as mean +/− SD, and categorical variables as absolute values and percentages. A Chi-square test was used to ascertain the association between categorical variables. Statistical significance was considered at p < 0.05.
3. Results
Out of the Fourteen thousand one hundred and six (14106) pregnant women admitted in study area, a total of 335 pregnant women with acute abdomen were collected, giving a prevalence of 2.4%. Most participants were in their twenties (Table 1). The youngest was 17 years old while the oldest was 43 years. The mean age of the study was 28 years.
Concerning gravidity, 27.5% of patients were primigravida (first pregnancy). Most patients (62.7%) were multi-gravida (2 - 4 pregnancies). And very few (9.7%) were grand multi-gravida (5 or more pregnancies).
Most cases (65.4%) of acute abdomen in pregnancy were observed during the first trimester of pregnancy. 29% and 5.6% occurred in the 2nd and 3rd.
The aetiology of acute abdomen in pregnancy can be divided into obstetric and non-obstetric causes (Table 2).
Gynaeco-Obstetrics aetiologies of acute abdomen in pregnancy comprise a vast majority (87.5) of causes. Medical and surgical aetiologies make up 10.5 and 2.0% respectively (Figure 1).
The most consistent symptom and signs were abdominal pain (100%) and abdominal tenderness (98.5%) respectively. 21% had nausea/vomiting, 15% had a fever, and 14% presented with anorexia. 14% of patients had signs of peritonism (rebound, guarding, and rigidity) (Table 3).
Bivariate analysis of age group and aetiology revealed an association between age group and an ectopic pregnancy that was statistically significant (p < 0.05) (Table 4).
We found an association between the trimester (gestational age) of pregnancy and the aetiology of acute abdomen (Table 5).
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Table 2. Frequency distribution of aetiology.
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Table 4. Relationship between age group and aetiology.
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Table 5. Relationship between trimester and aetiology.
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Figure 1. Aetiology of acute abdomen in pregnancy.
4. Discussions
We reviewed fourteen thousand one hundred and six files; three hundred and thirty-five files met our inclusion criteria, giving a prevalence of 2.4%. This finding was similar to the global prevalence of 0.2% [5]. However, it was far lower than the 25% reported by Ojaghihaghighi et al. in Azerbaijan province [6]. This disparity could be attributed to the difference in study settings. We conducted our study at the Obstetric ward which receives both outpatients and patients from the emergency department. The study by Ojaghihaghighi et al. was conducted at an Emergency Department that receives only hot cases like acute abdomen.
In our study, we found out that 2% of acute abdomen in pregnancy was due to surgical causes. This was in concordance with the findings of Zachariah et al. [3] [5] who reported that 1% - 2% of all pregnant women will require surgery.
Acute appendicitis was the most common non-obstetric surgical aetiology of acute abdomen in our study. This finding was consistent with previous studies in neighbouring Nigeria [12] [13], the United Kingdom [14] [15], and India [16]. Also, it agrees with the global picture where acute appendicitis in pregnancy is the most common cause of emergency non-obstetric surgical abdomen affecting 1 in 1500 pregnancies [17]. All our appendicitis cases appeared in the 2nd trimester of pregnancy.
Cholecystitis was the 2nd most common non-obstetric surgical aetiology of acute abdomen. Similar findings have been reported by other studies [2] [18] [19] [20]. However, this was different from a study by Shambe and friends at Jos University Teaching Hospital in Northern Nigeria who found that splenic and transverse colon injury was the 2nd most common aetiology of acute abdomen in pregnancy [12]. This disparity could be explained by the fact that they included injury pregnant women.
Ectopic pregnancy was the most common obstetric cause of acute abdomen in this study with an incidence of 1.0% in 5 years. This is similar to the 1.4% observed by Njingu et al. in Buea [21], 1.1% by Priso et al. in Douala [22], and 1.3% by Udigwe in Nigeria [20], and the global range of 1% - 2% [23] [24]. Nonetheless, it was slightly higher than the 0.79% reported by Kouam et al. in Yaounde [25]. This discrepancy could be attributed to the fact that the study by Kouam et al. was a community-based study. It took into account all deliveries in the population including centers without a theater. Our study was a hospital-based study at 3 referral centers with a higher number of operative cases.
Abdominal pain and abdominal tenderness were the most consistent symptom and signs respectively. This finding was in line with that of Woodhead et al. 2019 [14] who reported that abdominal pain and tenderness were found in 100% of participants.
In this study, we also found that vomiting was the commonest associated symptom. This result is similar to that of Jain et al. [7] who showed that abdominal pain was the commonest symptom (100%) followed by vomiting (71.4%).
5. Conclusions
The prevalence of acute abdomen in pregnancy in the Southwest Cameroon is higher than the global prevalence hence; this study should serve as an alarm or alert to primary care physicians.
The aetiology of acute abdomen in pregnancy can be broadly classified as pregnancy-related (obstetric) and non-pregnancy-related (non-obstetric) causes. Ectopic pregnancy is the commonest Obstetric aetiology whereas acute appendicitis is the commonest Non-obstetric surgical aetiology of acute abdomen in pregnancy.
Abdominal pain and tenderness were the most consistent clinical presentation.
Limitation
The main limitation of this study was incomplete data (aetiologic diagnosis) in some files. To overcome this, we excluded 20 files that had no aetiologic diagnoses.