Acute abdomen during pregnancy is one of the most challenging emergencies in clinical practice. Due to significant physiological and anatomical changes during pregnancy, including hormonal fluctuations, displacement of abdominal organs, and immune system adjustments, the clinical presentation of acute abdomen is often atypical, making diagnosis significantly more difficult. Previous studies report that approximately 0.1% to 2% of pregnant individuals require non-obstetric emergency surgical intervention, with appendicitis, gallbladder disease, and intestinal obstruction being the most common causes. Improper management of acute abdomen during pregnancy can lead to serious complications such as septic shock, preterm birth, and even fetal death, posing a serious threat to maternal and fetal safety.

The special physiological changes during pregnancy not only affect disease recognition but also impose strict requirements on the selection of diagnostic and treatment strategies. For example, imaging studies must weigh the potential risks of ionizing radiation to the fetus, and medication choices must avoid teratogenicity and pregnancy contraindications. Furthermore, clinical research on acute abdomen during pregnancy is often excluded from clinical trials due to ethical restrictions, leading to a scarcity of evidence-based medical data, with clinical decisions often relying on observational studies and expert consensus.

To address this challenge, the Association of Surgeons of Great Britain and Ireland (ASGBI) led the formation of a multidisciplinary expert team to develop the "Guidelines for the Management of General Surgical Emergencies in Pregnancy" (hereinafter referred to as the Guidelines). Based on systematic literature reviews and Delphi consensus, following the AGREE II methodological framework, and incorporating the Oxford Centre for Evidence-Based Medicine evidence grading standards, the Guidelines were developed through searches of PubMed, Cochrane databases, and manual supplementation. They cover seven core topics including appendicitis, gallbladder disease, intestinal obstruction, and anorectal diseases, and include new special recommendations on "Imaging Assessment in Pregnancy" and "Multidisciplinary Collaborative Management."

The core philosophy of the Guidelines aligns with the basic principles of managing surgical emergencies during pregnancy in China, both prioritizing maternal and fetal safety. However, differences exist between China and other countries in terms of medical resource distribution, patient population characteristics, and the prevalence of diagnostic and therapeutic technologies. Therefore, when applying the guideline recommendations, adjustments need to be made based on the actual situation in China.

I. Key Points of Obstetric Management for Patients Requiring Emergency Surgery During Pregnancy

The Guidelines propose systematic recommendations for the obstetric management of patients requiring emergency surgery during pregnancy, covering key aspects such as early warning, timing of delivery, fetal protection, and imaging choices, emphasizing the importance of multidisciplinary collaboration.

1.1 Application of Modified Early Warning Score (MEWS) in Obstetrics

Physiological changes during pregnancy can mask disease progression, and delayed intervention often leads to adverse outcomes. The Modified Early Warning Score (MEWS) developed by the UK National Health Service (NHS) can identify changes in condition through different trigger thresholds during pregnancy and postpartum, promoting early intervention. It can be used from hospital admission during pregnancy up to 6 weeks postpartum. Clinical practice has confirmed that it can reduce the morbidity and mortality of pregnancy-related diseases, providing support for maternal and fetal safety. MEWS has been promoted and used in most tertiary hospitals in China, but its application rate is low in primary hospitals due to lack of training and insufficient awareness. The existing scoring system does not incorporate factors common in pregnancy, such as hypertension and diabetes, leading to insufficient sensitivity. Future improvements are needed to enhance applicability.

1.2 Pros and Cons of Preterm Delivery and Decision-Making

Preterm delivery is a critical obstetric decision. The obstetric team needs to comprehensively assess obstetric history, gestational age, and maternal health status to decide whether to induce labor or choose the mode of delivery (vaginal or cesarean section). However, preterm delivery carries risks of complications for both mother and baby. Clinical decisions must weigh the pros and cons, prioritizing maternal health while considering fetal well-being. In China, decisions regarding preterm delivery must also consider the regional distribution of Neonatal Intensive Care Unit (NICU) resources, the family's willingness to treat a preterm infant, and traditional perceptions about delivery methods. Clinicians should strengthen communication with patients and their families under the medical principles of the guidelines, balancing medical advice with humanistic needs to ensure maternal and infant safety.

1.3 Intrauterine Transfer Strategy and Significance

For cases where preterm birth is anticipated, especially extremely preterm (before 28 weeks), the choice of delivery location is crucial. The British Perinatal Medical Association emphasizes the benefits of delivering in a hospital with neonatal intensive care capabilities. Clinicians need to discuss neonatal intensive care with expectant parents, considering clinical circumstances, likelihood of intervention, risk of preterm birth, gestational age, and local neonatal care levels, to determine whether to transfer the pregnant woman to a higher-level NICU. China has established a relatively comprehensive maternal critical care transport system, including "Maternal Emergency Green Channels." However, the effectiveness of intrauterine transfer is constrained by traffic conditions and the configuration of the transport team. In the future, it is necessary to continuously improve regional medical collaboration mechanisms, strengthen multidisciplinary team building for transport teams, and optimize transport routes to enhance the safety and timeliness of intrauterine transfer.

1.4 Use of Antenatal Corticosteroids and Magnesium Sulfate

•   1.4.1 Corticosteroids: Antenatal use of corticosteroids (such as betamethasone or dexamethasone) has significant benefits in cases of preterm birth, reducing perinatal and neonatal mortality and the incidence of Neonatal Respiratory Distress Syndrome (NRDS). Current evidence indicates that antenatal corticosteroid therapy between 24 and 34+6 weeks of gestation is beneficial, reducing neonatal morbidity and mortality, with optimal benefit occurring between 48 hours and 7 days after the first injection. When used between 34 and 37 weeks, although evidence shows a reduction in NRDS, there is a risk of neonatal hypoglycemia. Therefore, blood glucose monitoring should be strengthened when using corticosteroids. Clinical practice in China has widely adopted antenatal corticosteroid regimens that are basically consistent with the guidelines for preventing NRDS.

•   1.4.2 Magnesium Sulfate: Intravenous magnesium sulfate for deliveries before 32 weeks of gestation has a certain neuroprotective effect on the fetus and should be considered for pregnancies at risk of delivery before 34 weeks. Previous studies have shown that magnesium sulfate can reduce the incidence of cerebral palsy and motor dysfunction. Magnesium sulfate is commonly used in China during pregnancy for fetal neuroprotection, treatment of gestational hypertension, and tocolysis. However, monitoring of magnesium sulfate levels is not yet widespread in China and is only conducted in some tertiary hospitals, increasing the risk of medication safety. In the future, it is necessary to establish detailed indications for use and monitoring standards, and promote blood concentration monitoring in primary hospitals to ensure safe and effective medication use.

1.5 Imaging Selection Strategy

•   1.5.1 Ultrasound as First Choice: Ultrasound is safe, non-invasive, and rapid. When conditions permit, ultrasound imaging should be the preferred imaging method for patients with traumatic emergencies during pregnancy, providing preliminary important diagnostic information. The application of ultrasound as the first choice for imaging during pregnancy aligns with the advantages outlined in the guidelines. However, diagnostic levels vary significantly among hospitals at different levels. Promoting "ultrasound first" requires strengthening training for primary care physicians and updating equipment to improve diagnostic accuracy.

•   1.5.2 Timing of Magnetic Resonance Imaging (MRI): If ultrasound cannot provide a definitive diagnosis, non-contrast MRI is recommended as part of the subsequent imaging evaluation. Current evidence indicates that 1.5T MRI has good safety during pregnancy, with no related adverse outcomes found in postpartum follow-up. For patients with traumatic emergencies during pregnancy, MRI can serve as an important auxiliary diagnostic tool, especially when ultrasound diagnosis is doubtful or insufficient, providing richer soft tissue contrast and pathological details to help clarify the cause and assess the severity of the condition. The application of MRI in diagnosing acute abdomen during pregnancy in China is limited, mainly due to equipment availability and cost. In the future, it is necessary to promote the popularization of MRI equipment in primary hospitals and strengthen training for radiologists in interpreting MRI images during pregnancy to improve diagnostic accuracy.

•   1.5.3 Cautious Use of CT: CT scans involve ionizing radiation, which is associated with fetal teratogenicity and long-term disease risks. Although the radiation dose from diagnostic imaging is usually far below the teratogenic threshold, the potential risk should still be considered. Previous studies suggest that fetal radiation exposure below 50mGy is generally considered a safe range. Given that most diagnostic imaging radiation doses are well below this limit, clinical practice should not excessively worry about fetal radiation exposure to the point of delaying necessary imaging evaluation. All radiological examinations should follow the "As Low As Reasonably Achievable" (ALARA) principle, reasonably controlling radiation doses while ensuring diagnostic efficacy. In clinical practice in China, there is a phenomenon of "excessive avoidance" of CT scans during pregnancy. Most doctors, due to concerns about radiation risks and doctor-patient disputes, avoid using CT even when ultrasound and MRI are inconclusive and the condition is urgent, leading to delayed diagnosis and treatment. Patients and their families also often have misconceptions that radiation during pregnancy inevitably causes fetal malformations, making it difficult to accept. In the future, it is necessary to strengthen public education to clarify the appropriate scenarios for CT use, safe doses, and protection standards (such as apron shielding) to avoid excessive avoidance leading to delayed treatment.

•   1.5.4 Principles of Contrast Agent Use: Regarding contrast agents, iodine-based contrast agents appear safe during pregnancy with no teratogenic risk, although there may be a risk of postpartum hypothyroidism. Intravenous gadolinium-based contrast agents are usually not necessary for diagnosing acute abdominal diseases during pregnancy and should not be used unless there is a clear specific indication. When choosing any imaging method or contrast agent during pregnancy, a strict risk-benefit assessment should be conducted, and full communication with the patient and family is essential to ensure their participation in clinical decision-making based on an understanding of the potential risks.

II. Appendicitis During Pregnancy

2.1 Scoring Systems

Appendicitis during pregnancy is one of the common acute abdominal conditions, with an incidence of about 1 in 1,000. Diagnosis is difficult due to physiological and anatomical changes during pregnancy, and delayed diagnosis and treatment can lead to adverse outcomes. Various scoring systems are used to assist in the diagnosis of appendicitis during pregnancy, such as the Alvarado score, RIPASA score, and Tzanakis score. However, most of these systems were designed based on data from non-pregnant adults, and their accuracy during pregnancy has not been fully validated. Studies show that the RIPASA score is relatively accurate in pregnant women, with a positive predictive value of 94%, negative predictive value of 44%, sensitivity of 78%, and specificity of 79%. Therefore, the guidelines recommend using this scoring system in daily practice for appendicitis during pregnancy. However, if there is diagnostic uncertainty, it should be combined with imaging studies for comprehensive judgment to improve diagnostic accuracy. The application rate of scoring systems for appendicitis during pregnancy is low in China. Most doctors rely on symptoms, signs, and ultrasound for diagnosis, mainly due to a lack of clinical evidence leading to insufficient trust in scoring systems, and the cumbersome calculations make primary care doctors prefer intuitive judgment. In the future, it is necessary to develop scoring systems suitable for China, develop tools like mobile apps to simplify calculations, and promote the popularization of combined "scoring + imaging" diagnosis.

2.2 Diagnosis

Ultrasound is the preferred imaging modality for suspected appendicitis during pregnancy due to its convenience and lack of radiation. However, its diagnostic accuracy is relatively low, with an overall sensitivity of 78% and specificity of 75%. In recent years, the use of MRI in diagnosing appendicitis during pregnancy has increased, offering high sensitivity and specificity, but it is not always readily available clinically. Konrad et al. compared the value of ultrasound and MRI in diagnosing appendicitis during pregnancy, showing that MRI has higher diagnostic accuracy. Previous studies indicate that the pooled sensitivity and specificity of MRI are 92% and 98%, respectively. Therefore, the guidelines recommend that ultrasound or MRI should be the initial imaging examination for any pregnant patient with suspected appendicitis. CT is used cautiously during pregnancy due to concerns about fetal radiation exposure and is typically considered only when ultrasound or MRI results are inconclusive.

2.3 Treatment

Treatment options for appendicitis during pregnancy include surgical and non-surgical management. Studies show that surgical and non-surgical management have similar outcomes regarding fetal loss and preterm birth, but non-surgical management carries a high risk of failure, and delayed surgery may increase the risk of preterm birth and fetal loss. Non-surgical management is limited during pregnancy and is usually only suitable for patients with uncomplicated appendicitis under specific circumstances. The risk of non-surgical management failure is high and may lead to serious maternal and fetal complications. Therefore, the guidelines recommend surgery as the primary treatment for appendicitis during pregnancy, especially for patients with complicated appendicitis. For pregnant women, timely surgery can effectively reduce the risk of preterm birth and complications, improving maternal and fetal outcomes. The guidelines do not provide specific recommendations regarding the optimal gestational stage for surgery or the choice between laparoscopic and open surgery. The 2022 guidelines from the European Endoscopic Surgery Association (EAES) suggest that for appendicitis during pregnancy, laparoscopic appendectomy can be performed if the patient is before 20 weeks of gestation or if the uterine fundus is below the level of the umbilicus. For patients beyond 20 weeks or with the uterine fundus above the umbilicus, the choice of surgical approach depends on the surgeon's skill and expertise. Treatment strategies for appendicitis during pregnancy in China are similar to the guidelines, but surgical methods and multidisciplinary collaboration still need improvement. Laparoscopic appendectomy is highly prevalent in tertiary hospitals, while primary hospitals often use open surgery due to technical limitations, increasing postoperative pain and recovery time. In the future, it is necessary to strengthen laparoscopic treatment in primary hospitals and establish standardized multidisciplinary collaboration processes to enhance treatment safety.

III. Gallstone Disease During Pregnancy

Gallstone disease during pregnancy is a common complication that adversely affects maternal and fetal health. Elevated estrogen levels during pregnancy increase bile saturation, and increased progesterone concentrations lead to bile stasis, promoting gallstone formation, which usually resolves about 2 months postpartum. Nearly 8% of pregnant women develop gallstones in the third trimester, with about 1% becoming symptomatic. Although the incidence of complicated gallstone disease (cholecystitis, obstructive jaundice, cholangitis, pancreatitis) during pregnancy is low, it carries risks of high recurrence, miscarriage, and preterm birth.

3.1 Cholecystitis During Pregnancy

Acute cholecystitis is the second most common non-obstetric acute abdominal condition during pregnancy. Compared to non-pregnant patients, pregnant women with acute cholecystitis have a higher incidence of preoperative Systemic Inflammatory Response Syndrome (SIRS). Treatment options include laparoscopic cholecystectomy (LC) and non-surgical management. Among patients treated with antibiotics, about 10% experience recurrence of acute cholecystitis during pregnancy, leading to miscarriage in 10%–20% of patients. LC can be safely performed at any stage of pregnancy, but for late pregnancy, postponing surgery until after delivery may be more appropriate. Performing LC during pregnancy may increase the risk of preterm birth, readmission rates, and hospital stay. Studies across different trimesters have found a relatively high proportion of LC performed during pregnancy. The guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommend that acute cholecystitis can be treated with LC at any stage of pregnancy, but a comprehensive assessment of patient benefit is required. Surgery becomes more difficult due to the enlarged uterus during pregnancy and requires careful evaluation, with full communication with the patient's family regarding the indications for surgery. For patients with acute cholecystitis during pregnancy, surgery should be performed by experienced surgeons. The guidelines recommend performing LC as soon as possible, ideally within 7 days of symptom onset. In China, there is a tendency towards "excessive conservatism" in the treatment of acute cholecystitis during pregnancy. Most doctors, concerned about the impact of surgery on the fetus and often facing refusal from the patient's family, prioritize non-surgical treatment even when LC is indicated and there are no contraindications, leading to high recurrence rates. In the future, it is necessary to strengthen patient education, standardize LC treatment for acute cholecystitis during pregnancy.

3.2 Common Bile Duct Stones During Pregnancy

Gallstones during pregnancy increase the risk of bile duct stones, but clinical research on this disease is insufficient. There is no consensus on the treatment of common bile duct stones during pregnancy, and management requires consideration of the condition and available medical resources. Relevant guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) suggest that Endoscopic Retrograde Cholangiopancreatography (ERCP) is a safe and effective procedure for common bile duct stones during pregnancy. ERCP with sphincterotomy can be performed at any stage of pregnancy, but concerns exist regarding radiation from traditional fluoroscopy. This can be avoided by shielding the fetus or using non-radiation ERCP (NR-ERCP). Azab et al. compared outcomes of traditional ERCP and NR-ERCP and found no statistically significant differences in fetal adverse outcomes or maternal pregnancy-related outcomes. Therefore, NR-ERCP has become the primary treatment for common bile duct stones during pregnancy. Laparoscopic Common Bile Duct Exploration (LCBDE) is performed in some tertiary medical centers and can be combined with LC, reducing the risk of gallstone complications and readmission during pregnancy. However, surgery in the third trimester increases the risk of obstetric complications and is not advisable. This procedure requires high technical conditions and thorough preoperative assessment of maternal safety and surgical risks. Additionally, case reports have shown successful treatment of common bile duct stones during pregnancy via Percutaneous Transhepatic Biliary Drainage (PTBD). In China, access to treatment for common bile duct stones during pregnancy faces challenges. NR-ERCP is only available in some tertiary hospitals, often requiring patient transfer, increasing the risk of delayed treatment and costs. The guidelines suggest that for patients with common bile duct stones during pregnancy, the treatment plan depends on available technical conditions. ERCP is an appropriate and safe choice, and LC can be considered postpartum. The overall evidence level is low.

3.3 Biliary Pancreatitis During Pregnancy

Biliary pancreatitis during pregnancy is relatively rare, mostly occurring in the third trimester and postpartum, with a high recurrence rate, potentially leading to readmission and affecting the fetus. For patients with biliary pancreatitis in the first trimester, there is controversy between surgical treatment and delayed surgery. For mild biliary pancreatitis in the second trimester, the guidelines recommend performing LC within 48 hours of admission to reduce the threat to the fetus. Although LC can be performed at any stage of pregnancy, it is usually avoided in the first trimester due to the fetus's susceptibility to teratogenic effects of drugs. Delaying surgery to the second trimester can reduce risks to the fetus, while surgery in the third trimester increases obstetric complication risks and is not advisable. There is no statistically significant difference in maternal mortality between non-surgical and surgical management, but non-surgical management has a higher fetal mortality rate. Therefore, the guidelines recommend that biliary pancreatitis during pregnancy can be treated with LC in the second trimester. China lacks a unified consensus on the diagnosis and treatment of biliary pancreatitis during pregnancy, and the assessment system is imperfect. In the future, it is necessary to clarify the timing of LC, promote precise stratification using scoring systems, and improve maternal-fetal safety and efficacy.

IV. Small and Large Bowel Diseases During Pregnancy

4.1 Adhesive Small Bowel Obstruction (SBO) During Pregnancy

Small bowel obstruction (SBO) is a common acute abdominal condition during pregnancy, yet related research is relatively scarce, with literature mainly consisting of case reports, small case series, and reviews. Adhesions are the most common cause of SBO during pregnancy. Due to the displacement of the intestines by the enlarging uterus, SBO caused by inguinal hernias is relatively rare. The incidence of SBO during pregnancy increases with gestational age, being particularly common before the uterus enters the abdominal cavity in the second trimester. SBO during pregnancy poses a significant threat to maternal and fetal health, with a fetal loss rate of 17%–26% and a maternal mortality rate of 2% in the first trimester, which can rise to 10%–20% in the third trimester. Because typical symptoms and signs, especially abdominal distension, can be masked by pregnancy, clinical diagnosis is difficult, making early imaging confirmation crucial.

For non-pregnant SBO patients, oral water-soluble contrast agents are often used. However, the safety of these agents in pregnant women is not yet clear. Considering their minimal absorption and lack of harmful effects on the fetus in animal experiments, oral water-soluble contrast agents can help assess treatment and prognosis. The guidelines recommend weighing the risks and benefits before deciding whether to use them. In clinical practice in China, there is a gap between the application of oral water-soluble contrast agents and the guideline recommendations. Most hospitals in China lack evidence-based data supporting their safety during pregnancy, and both doctors and patients are overly concerned about the "unknown risks" of the medication. Therefore, it is rarely actively recommended to use oral water-soluble contrast agents for diagnosing SBO in the Chinese pregnant population. In the future, clinical research on the safety and effectiveness of oral water-soluble contrast agents specific to the Chinese pregnant population is needed, along with the development of usage standards more suitable for domestic clinical scenarios to promote the rational application of this technology.

The management of SBO during pregnancy can refer to guidelines for non-pregnant SBO. The guidelines suggest that the timing of surgical intervention should be determined based on the presence or absence of flatus and/or bowel movements. In non-pregnant women, laparoscopic adhesiolysis is beneficial for some patients, but in pregnant women, laparoscopic surgery is more challenging due to the pregnancy state. Relevant guidelines indicate that laparoscopic treatment of acute abdomen has similar benefits in pregnant and non-pregnant women, including less postoperative pain, shorter hospital stay, and faster recovery. They emphasize that laparoscopic surgery can be performed at any stage of pregnancy. In clinical practice, some doctors and families, concerned about potential risks to the fetus, tend to adopt overly conservative treatment, which may instead increase adverse maternal and fetal outcomes. Gestational age, patient preference, and other factors should be considered, and individualized management should be carried out with multidisciplinary team collaboration.

4.2 Meckel's Diverticulum (MD) During Pregnancy

The latest evidence on Meckel's Diverticulum (MD) during pregnancy is limited. A recent systematic review shows that MD during pregnancy mostly presents in the second or third trimester, with main symptoms including abdominal pain, nausea, and vomiting. Most cases present as emergencies, diagnosis is difficult and often misdiagnosed, and commonly used diagnostic imaging methods have low accuracy and limitations. MD has an insidious onset and is easily confused with common causes of acute abdominal pain. Awareness and differential diagnosis should be strengthened. In summary, the diagnosis and treatment of MD during pregnancy are challenging. Non-surgical management is ineffective, and surgery should be performed as soon as possible after diagnosis.

4.3 Sigmoid Volvulus (SV) During Pregnancy

The incidence of Sigmoid Volvulus (SV) during pregnancy is low and increases with gestational age, with over 75% of cases occurring in the third trimester. Common symptoms include abdominal pain and distension. Due to non-specific symptoms and concerns about radiological examinations, diagnosis is often delayed, threatening maternal and fetal safety. Non-surgical management, such as endoscopic decompression, may be effective for SV caused by uterine compression but is less effective for SV due to adhesions, and endoscopic reduction has a high recurrence rate. In cases of SV due to adhesions, laparoscopic or open surgery to release adhesions and correct the volvulus is decisive for disease outcome. Laparoscopic exploration is helpful in the diagnosis and treatment of pregnant women with suspected SV. Therefore, for abdominal pain in the third trimester, SV should be suspected, and rational use of imaging studies for timely diagnosis and treatment is essential to improve outcomes.

4.4 Diverticular Disease During Pregnancy

With the trend of younger onset of diverticular disease and the increasing age of mothers, diverticular disease during pregnancy is gradually gaining attention, although it remains uncommon overall. It can cause intra-abdominal sepsis leading to preterm birth and is a key point in the differential diagnosis of abdominal pain during pregnancy. Currently, there is no standard management protocol for symptomatic diverticular disease during pregnancy. Diagnosis commonly uses ultrasound and MRI. Treatment involves non-surgical management with antibiotics and dietary restrictions; surgery may be considered if non-surgical management is ineffective. Diet-wise, adequate dietary fiber intake is beneficial and may prevent recurrence, while the previous practice of clear liquid diets has been abandoned due to restrictions. The focus of diverticular disease during pregnancy is on diagnosis. Timely and appropriate use of imaging studies is crucial. Improving maternal and fetal outcomes can be achieved through tiered diagnosis and treatment, standardized medication use, and individualized nutritional management.

V. Perianal Diseases During Pregnancy

5.1 Hemorrhoids During Pregnancy

Physiological changes during pregnancy can lead to perianal diseases, most commonly hemorrhoids and anal fissures. 15%–41% of pregnant women develop hemorrhoids, mainly in the third trimester. Their occurrence is closely related to physiological changes during pregnancy, such as increased blood volume, elevated intra-abdominal pressure, and hormonal changes, leading to venous congestion in the perianal area and causing hemorrhoids. Treatment methods include surgical and non-surgical management. Meta-analyses show limited clinical evidence on the safety of oral medications during pregnancy, and their use should be cautious. Topical hydrocortisone is relatively safe in the third trimester. Surgical intervention for hemorrhoids during pregnancy is rare. Rubber band ligation is a commonly used low-risk method to control symptoms. Additionally, lifestyle modifications (such as high-fiber diet, moderate exercise, using ice packs, and avoiding straining during defecation) can reduce the incidence of hemorrhoids during pregnancy. Therefore, the guidelines recommend that lifestyle changes help reduce the incidence of hemorrhoids. Since hemorrhoid symptoms usually resolve spontaneously after delivery, surgical intervention is generally not recommended during pregnancy. In clinical practice, considering the cautious attitude of pregnant women towards medication, the tendency for conservative treatment in primary care, and insufficient intervention for severe cases, it is necessary to gradually build a stepped management strategy suitable for Chinese pregnant women through rational medication education, structured health management, and individualized non-surgical interventions.

5.2 Thrombosed Hemorrhoids During Pregnancy

Thrombosed hemorrhoids are prone to occur postpartum and in the late third trimester due to constipation, with an incidence of 2%–8%. Treatment options include conservative management and early surgical intervention. Although evidence for early surgical intervention is limited, an increasing number of retrospective center studies show that for pregnant women with severe symptoms, early surgical intervention (such as hemorrhoidectomy under local anesthesia) can shorten the duration of symptoms without affecting pregnancy outcomes. For pregnant women with thrombosed or gangrenous hemorrhoids, the guidelines recommend discussing the risks and benefits of surgical intervention with the patient before deciding on surgery. In light of clinical practice in China, efforts are needed to address the issues of overly conservative surgical intervention for thrombosed hemorrhoids in late pregnancy and postpartum, the lack of high-quality clinical evidence, and poor doctor-patient communication. This can be achieved by establishing multidisciplinary cooperation, conducting multicenter studies, and optimizing shared decision-making to promote safe and effective individualized treatment.

5.3 Anal Fissures During Pregnancy

Anal fissures during pregnancy are mainly caused by constipation or, in rare cases, chronic diarrhea, and are more common in the third trimester and postpartum. Acute anal fissures (duration <6 weeks) are mostly treated conservatively, including dietary adjustments, using ice packs, high-fiber diet, and sitz baths. For chronic anal fissures (duration ≥6 weeks) or those unresponsive to conservative treatment, topical medications like nitroglycerin rectal ointment are used in non-pregnant individuals. Given that there is currently no evidence showing that topical drug therapy causes significant harm during pregnancy, the American Gastroenterological Association (AGA) recommends using the aforementioned drugs to treat anal fissures during pregnancy. For anal fissures during pregnancy, most pregnant women have concerns about the safety of topical medications. In the future, multicenter clinical studies should be actively conducted to provide evidence for diagnosis and treatment, thereby improving the level of care for anal fissures during pregnancy.

VI. Hernias During Pregnancy

6.1 Umbilical and Ventral Wall Hernias During Pregnancy

Emergency surgery for umbilical and ventral wall hernias during pregnancy is primarily indicated for incarcerated or strangulated hernias. The treatment plan mainly depends on two factors: symptoms at diagnosis and pregnancy status. During pregnancy, open suture repair is the preferred method for emergency surgery of umbilical and ventral wall hernias. The advantage of this method is that it is simple, safe, and can quickly relieve incarceration. In contrast, mesh repair, while effective, may increase the risk of complications during pregnancy, especially potentially causing pain at the repair site in subsequent pregnancies. Data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program show that open suture repair is widely used for hernia repair during pregnancy without significant postoperative complications. Therefore, for patients with incarcerated primary umbilical or ventral wall hernias during pregnancy, the guidelines recommend managing them according to the protocol for non-pregnant patients: if surgical repair is needed, open suture repair is the preferred option. In clinical practice, due to significant differences in surgical capabilities among hospitals at various levels, insufficient awareness of mesh use, and anxiety about surgery among pregnant families, future efforts should focus on strengthening multidisciplinary collaboration, standardizing training in open suture repair techniques, and conducting public education to improve the standardization and safety of emergency diagnosis and treatment for incarcerated hernias during pregnancy.

Laparoscopic hernia repair is widely used in non-pregnant individuals, offering advantages such as reduced surgical site infection and shorter hospital stay. Although there are concerns about using laparoscopic hernia repair during pregnancy, with technological advancements, increasing studies show it is safe during pregnancy. The success of laparoscopic hernia repair depends on the patient's physiological condition, gestational age, and the surgeon's skill level. For pregnant women presenting with abdominal pain or incarcerated hernia, existing surgical expertise is capable of performing laparoscopic hernia repair. The guidelines suggest that laparoscopic hernia surgery can be considered, but the patient's physiological state and gestational age must be taken into account. Currently, there are no unified technical standards for laparoscopic hernia repair during pregnancy. In the future, it is necessary to strengthen surgeon training and develop technical standards for laparoscopic repair during pregnancy to promote its safe application and leverage its minimally invasive advantages.

6.2 Inguinal Hernia During Pregnancy

Inguinal hernia during pregnancy is relatively rare. However, due to uterine enlargement, hernia symptoms may be masked, leading to delayed diagnosis. For unincarcerated and non-strangulated inguinal hernias, non-surgical management, such as using a truss, is recommended. If surgery is necessary, the timing should be chosen appropriately, usually recommended in the second trimester to reduce surgical risks. When applying the guidelines, the use of trusses should be standardized, the timing of second-trimester surgery refined, and multidisciplinary collaboration strengthened.

VII. Upper Gastrointestinal Complications During Pregnancy

7.1 Peptic Ulcer Disease (PUD) During Pregnancy

The incidence of PUD during pregnancy is low. Although physiological changes during pregnancy often exacerbate reflux symptoms, the occurrence of PUD and its complications is relatively rare. Retrospective studies show that compared to non-pregnant women with PUD, pregnant women with PUD are less likely to receive invasive diagnosis and treatment. PUD during pregnancy is mostly managed conservatively, with fewer adverse outcomes. Therefore, for PUD during pregnancy, non-invasive diagnostic methods should be prioritized, medication use standardized, and relevant diagnostic and treatment protocols gradually established.

7.2 Boerhaave Syndrome During Pregnancy

Boerhaave syndrome is esophageal rupture due to severe vomiting. If not detected early, the mortality rate can be as high as 40%. Although vomiting during pregnancy is common, especially in women with hyperemesis gravidarum, Boerhaave syndrome remains an extremely rare complication during pregnancy. Related case reports indicate that Boerhaave syndrome during pregnancy occurs in the first trimester, and all reported patients did not undergo surgery. Boerhaave syndrome should be suspected in patients with hyperemesis gravidarum who develop subcutaneous emphysema or severe radiating back pain. Boerhaave syndrome during pregnancy has an insidious onset. Vigilance should be increased for patients with hyperemesis gravidarum, regional referral mechanisms established, and multidisciplinary teams formed to reduce its mortality rate.

7.3 Complications of Bariatric Surgery During Pregnancy

With the increasing popularity of bariatric surgery among women of childbearing age, long-term complications of such surgeries are gradually gaining attention. The specific complication rate depends on the surgical method used. Previous studies report that up to 50% of patients who undergo Laparoscopic Adjustable Gastric Banding (LAGB) and up to 20% of patients who undergo Roux-en-Y Gastric Bypass (RYGB) may require long-term revision surgery. Meta-analyses show that pregnancy itself does not increase the incidence of bariatric surgery complications. In recent years, the incidence of complications related to bariatric surgery during pregnancy has been rising, and surgeons need to pay attention to this trend.

7.4 Internal Hernia After Roux-en-Y Gastric Bypass During Pregnancy

Internal hernia is a serious, life-threatening complication after Roux-en-Y gastric bypass. Previous studies found that most internal hernias present with abdominal pain in the third trimester, and about one-third of patients also have nausea and vomiting. Diagnosis is very challenging, as imaging studies like ultrasound, CT, and MRI have poor diagnostic value, with CT having the relatively best diagnostic performance. If the patient shows signs of obstruction or has severe abdominal pain, diagnostic laparoscopy or emergency laparotomy exploration is required. For patients with internal hernia during pregnancy, a multidisciplinary team and standardized imaging evaluation should be established, indications for emergency surgery clarified, and clinical research actively conducted to build early warning scoring systems and improve the level of maternal care.

VIII. Splenic Artery Aneurysm Rupture and Other Causes of Intra-Abdominal Hemorrhage

During pregnancy, Spontaneous Haemoperitoneum in Pregnancy (SHiP) is a rare but life-threatening complication requiring urgent management by general surgeons. SHiP is defined as acute intra-abdominal bleeding during pregnancy or within 42 days postpartum, excluding trauma, uterine rupture, or ectopic pregnancy. Although its incidence is low, maternal and fetal mortality rates are as high as 3% and 25%, respectively, necessitating high vigilance. SHiP most commonly occurs in the third trimester and is associated with advanced maternal age and the use of assisted reproductive technology. Patients typically present with abdominal pain and hypotension or shock, often misdiagnosed as placental abruption. The most common bleeding site is in the pelvis. Among non-pelvic causes, splenic artery aneurysm rupture is the most common, along with other causes such as spontaneous splenic rupture, splenic vein rupture, hepatic rupture, and iliac artery aneurysm rupture. Endometriosis is also a common cause. For SHiP, the guidelines recommend corresponding management measures based on the situation. If the patient has ongoing bleeding, immediate midline laparotomy and four-quadrant packing for hemostasis should be performed to quickly identify and control the bleeding source. If the patient is stable, CT angiography can be considered to identify the bleeding source. After determining the source, vascular interventional therapy can be considered. SHiP is one of the serious complications of pregnancy. Due to the lack of preventive measures, improving awareness, early diagnosis and treatment, and multidisciplinary collaboration are crucial for improving pregnancy outcomes.

IX. Department Selection for Diagnosis and Treatment of Surgical Diseases During Pregnancy

The choice of department for managing pregnant patients with surgical diseases is a key issue. Although existing literature does not provide a definitive answer, it emphasizes the importance of using MEWS and the necessity of establishing shared management pathways and determining the managing department for pregnant women. Surgical wards have significant advantages in the professional diagnosis and treatment of surgical diseases and emergency intervention, while obstetric wards are more skilled in managing pregnancy-related complications and continuous fetal monitoring. The guidelines recommend that for pregnant women with a confirmed surgical diagnosis, admission to a surgical ward is appropriate, with the obstetric team collaborating on maternal-fetal monitoring. If the diagnosis is not yet clear, it is recommended to first admit to the obstetric ward for observation and evaluation, while arranging for the surgical team to conduct regular rounds and assist in diagnosis and treatment. For surgical emergencies during pregnancy, standardized multidisciplinary assessment and rescue processes should be established, an obstetric-surgical joint diagnosis and treatment model promoted, and management pathways and evaluation systems based on the grading of medical resources explored to optimize collaborative rescue for surgical emergencies during pregnancy.

Summary

These guidelines focus on the clinical management of general surgical emergencies during pregnancy, aiming to provide evidence-based decision support for surgeons. Physiological changes during pregnancy may increase susceptibility to certain surgical diseases while also presenting unique challenges in clinical presentation, diagnostic evaluation, and treatment strategies. The guidelines emphasize that managing such emergencies requires a multidisciplinary collaborative approach, and all clinical decisions must comprehensively balance maternal and fetal safety outcomes. They also point out that existing evidence is limited. To optimize the diagnosis and treatment level of general surgical emergencies during pregnancy in China, it is necessary to strengthen domestic evidence production based on international guidelines, improve multidisciplinary collaboration, promote appropriate technologies, and strengthen guideline training to comprehensively enhance maternal and infant safety protection capabilities.

Source: 中国急救医学2025年11月第45卷第11期 Chin J Crit Care Med Nov. 2025, Vol 45, No. 11

Editor: Lily