ABDOMINAL PAIN DURING PREGNANCY

s.k.s

Abdominal pain is a very common symptom in pregnant women. It may be due to pregnancy itself e.g red degeneration in a fibroid or may arise from some concomitant lesion such as appendicitis.

It is convenient to divide the causes of pain due to pregnancy into those most commonly found in each of the three trimesters,though of course there is considerable overlap.

Introduction

A 22 yr old para 1 with 6-8 wks gestation presents with abdominal pain.

WHAT ARE YOU THINKING OF ?

The History

Colicky Pain - Localized one sided pain, no radiation, spasmodic to start with, now constant.

Mild bleeding p/v.

Some chest pain and shoulder tip pain.

Has been feeling faint.

Pregnancy test positive.

THINK ECTOPIC

VITAL SIGNS

B HCG – QUANTITATIVE

URGENT PELVIC USS

REFER/ADMIT TO HOSPITAL

ECTOPIC PREGNANCYPit falls in diagnosis

Wide variation in clinical presentation.

Pregnancy test can be negative at times of diagnosis. ( However it must have been positive at some time or another).

TV USS even at the best of hands is only 50% accurate in picking up an ectopic pregnancy.

B HCGs can double in very early ectopics.

Doubling time varies from 1.4 to 7.2 days depending on gestation.

Mx of Ectopic Pregnancy

Medical with Methotrexate with or without folinic acid.

Surgical – laparotomy and laparoscopy salpingostomy and salpingiectomy

Follow up and prognosis

First Trimester

1. Abortion

2. pregnancy in rudimentary horn

3. Acute salpingitis

4. Acute Retention of urine

5. Hydatidiform mole

First Trimester pain

Abortion

Pain preceeded by vaginal bleeding.

Cervix, closed (threatened abortion)or open (inevitable)..U/S.gestational sac inside uterine cavity.

First Trimester Pain

Pregnancy in rudimentary hornpain resemble that of ectopic and usually the condition discovered during laparotomy.

If rupture occurs it usually in the midtrimester and of sudden onset with collapse.

First Trimester Pain

Acute SalpingitisMay develop up to the 10th.weeks after conception, due to gonococcal infection or infection at attempted attempted abortion

Pain felt in both iliac fossae & is continuous

There is associated tenderness,tachycardia and elevated temperature,culture of discharge may reveal pathogens

First Trimester Pain

Acute retention of urineis usually due to enlargement of a cervical fibroid in response to pregnancy and may occur very early.

Severe lower abdominal wall, large tender bladder which may be mistaken for ovarian cyst.

Catheterisation causes immediate relief of pain.

First Trimester Pain

Hydatidiform molePain in lower abdomen.

Pain due to Overdistention of uterus

Concealed haemorrhage

Perforation

Infection

Uterine contraction for expulsion

A 22 yr old para 1 with 6-8 wks amenorrhea presents with abdominal pain

The history changes:

Crampy lower abdominal

Heavy bleeding p/v

Speculum examinationcx os closed

cx os open

DIAGNOSIS - ? MISCARRIAGE

Assess hemodynamic stability

Arrange pelvic ultrasound

Management depends on ultrasonographic findings.

No role of Bhcgs

Blood group, Rhesus and anti-D if necessary

SOME USS FINDINGS

An intrauterine gestational sac seen 25X30 mm in diameters. No fetus visible.An IU gestational sac seen 20 X 20 mm in diameter. Fetal pole seen 4 mm CRL. No FH identified.An IU gestational sac seen 20X 20 mm in diameter ,FP seen 6 mm CRL. No FH.An IU gestational sac seen 35X35 mm in diameters low down in the cavity. FP seen . FH seen but appears slow.

THE MANAGEMENT OF MISCARRIAGE

Incomplete Abortin,Inevitable abortion,Missed abortion-Termination

ERPOC

Mid Trimester Pain1. Red degeneration in a fibromyoma

2. Stretching of round ligament

3. Acute polyhydramnios

4. Rupture of rudimentary horn containing pregnancy

5. Acute retention of urine due to incarcerated RVF gravid uterus

Mid Trimester Pain

Red degeneration of fibromyomacauses mild to severe pain. Fibroid tenderness usually present over the fibroid.

U/S usually detect the fibroid during first trimester

There may be history of menorrhagia before pregnancy..TT..conservative with analgesic

Mid Trimester Pain

Stretching of the round ligament 10-30% of pregnanciesMore in multiparaCramp like or stabbing continuous pain and made worse with movementSome tenderness in the lower quadrant and groinThere is no constitutional symptoms.Reassurance and sometimes mild analgesia is required

Mid Trimester Pain

Acute polyhydramniosPain is due to over distention.

It can be differentiated from. pregnancy by absence of foetal heart sound.

Third Trimester Pain1. Concealed haemorrhage

2. Severe preeclampsia

3. Uterine rupture

4. Contractions of labour

5. Abruptio placentae

6. Red degeneration of fibromyoma

Third Trimester Pain

Concealed haemorrhagePain is of acute onset & is severe, with considerable shock and collapse.

The abdominal mass are tense and the uterus may be larger than expected, hard tender with difficulty in palpating fetal parts.

Fetal heart is usually absent.

There may be vagina bleeding.

There may be hypertension before the event.

Third Trimester Pain

Severe Pre-eclampsiaEpigastric pain may occur & is a sign of impending eclampsia.

The characteristic signs of pre-eclampsia, hypertension, proteinuria and oedema are present

The uterus is not tender & fetal parts are palpable & FHR usually present

Third Trimester Pain

Uterine rupture

is a possibility in highly parous women & those who have scarred uterus.

Women usually feel a tearing sensation followed by constant pain.

Shock & collapse.

Vaginal bleeding is common.

Fetal parts easily felt & FHR is usually absent or distress is seen..

Third Trimester Pain

Labour painsPrematurely or at term. I

Intermittent & gradually become stronger and more frequent.

Cervical dilatation. & effacement

Third Trimester Pain

True labour pain

False labour pain

Contraction Regular interval Irregular interval

Intervals Shorter Longer

Intensity Gradually increases

Unchanged

Discomfort In back and abdomen

In lower abdomen

Cervical dilatation

Present Absent

With sedation Not relieved relieved

A History

22 yrs old 1st pregnancy presents with right sided abdominal pain for about 2 days. It starteds with a vague pain in the epigastrium and is now constant on the rt side. She is about 26 wks pregnant and there is no vaginal bleeding. Her 20 wk scan was “normal”.

APPENDICITIS

Most common cause of acute abdomen in pregnancy

Tenderness over McBurney’s point.

Low grade fever.

DD-Rupture ectopic pregnancy,Bilat.salphingoopheritis,Renal colic,Placental abruption,Degn.of uterine myoma.

APPENDCITIS - DIAGNOSIS

Appendix is progressively displaced upwards after 12 wks and reaches iliac crest at 24 wks.Single most reliable symptom in pregnancy is Refferred painAnorexia, vomiting, rebound , guarding are not specific in pregnancyLeucocytosis is NOT helpful.

APPENDICITIS - DIAGNOSIS

Graded compression ultrasonography

accurate in 1st and 2nd trimesters , difficult in 3rd.

98% ACCURATE.

APPENDICITIS- CONSEQUENCES

High fetal loss rate if perforation occurs (20%)

Maternal mortality

Mortality of delay

Risk of perforation highest in 3rd trimester

Premature labour esp in the 1st week after surgery

Incidental Causes of Pain

Gastro-enteritisPain is generalized over the abdomen and accompanied by vomiting and diarrhoea and tenesmus.Due to irritant effect of gastric acid on peritonium. Temperature is elevated and abdomen is tender with no rigidity.stool analysis show organism.

Incidental causes of Pain

Acute Appendicites

Acute Pyelonephritis

Site varies with advancing pregnancy

Site remains the same

Colicky pain Aching pain

McBurney’s point tenderness

Right costovertebral angle tenderness

Fever lowgrade High grade

Incidental causes of Pain

USG

RFT

UrineAnalysis

Incidental causes of Pain

Renal and uretric calculiPain may be confused as pyelitis.

pain radiates to leg and worse on movement.

Blood may be present in the urine and U/S may show stone in kidney or bladder.

Incidental causes of Pain

CholecystitisRight subcostal pain lower border of 9th rib, radiating to back and shoulder.

May radiate to chest .

Usually severe and lasts only for mins or hrs.

Starts at night and wakes the patient.

USG

Incidental causes of Pain

Perforation of a hollow organsuch as the stomach or duodenum, may occur with sudden pain, collapse and the rapid development of generalized peritonitis.Usually history of peptic ulcer or gastric ulcer is present.CXR-Gas shadow under the diaphragm.

Incidental causes of Pain

Strangulated hernia Should be born in mind and hernial sites should be examined.

Acute Pancreatitis the onset is sudden with severe upper abdominal pain & vomiting.usually serum amylase and urinary diastase levels elevated.Treatment is usually symptomatic.

Incidental causes of Pain

Acute HepatitisMay occur in hyperemesis gravidarum, in sever pre-eclampsia/eclampsia or in acute infective hepatitis. In all these conditions there is pain & tenderness over the rt.hypochondrium.Jaundice

Incidental causes of Pain

Acute intestinal obstructionSometimes found in pregnancy & usually there is history of laparotomy & obstipation.

The onset is usually sudden, with vomiting. Distention & vomiting with colicky pains are typical.

Incidental causes of Pain

Torsion of ovarian cyst may occur especially during first trimester. Pain is at first referred to one or other hypochondrium & is acute in onset usually with vomiting.as peritonitis occur there is pain, tenderness & rigidity over the tumor. There may be some pyrexia.TVS show the cyst.

Doppler

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