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ABDOMINAL PAIN DURING PREGNANCY
s.k.s
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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
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A 22 yr old para 1 with 6-8 wks gestation presents with abdominal pain.
WHAT ARE YOU THINKING OF ?
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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.
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THINK ECTOPIC
VITAL SIGNS
B HCG – QUANTITATIVE
URGENT PELVIC USS
REFER/ADMIT TO HOSPITAL
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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.
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Mx of Ectopic Pregnancy
Medical with Methotrexate with or without folinic acid.
Surgical – laparotomy and laparoscopy salpingostomy and salpingiectomy
Follow up and prognosis
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First Trimester
1. Abortion
2. pregnancy in rudimentary horn
3. Acute salpingitis
4. Acute Retention of urine
5. Hydatidiform mole
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First Trimester pain
Abortion
Pain preceeded by vaginal bleeding.
Cervix, closed (threatened abortion)or open (inevitable)..U/S.gestational sac inside uterine cavity.
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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.
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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
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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.
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First Trimester Pain
Hydatidiform molePain in lower abdomen.
Pain due to Overdistention of uterus
Concealed haemorrhage
Perforation
Infection
Uterine contraction for expulsion
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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
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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
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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.
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THE MANAGEMENT OF MISCARRIAGE
Incomplete Abortin,Inevitable abortion,Missed abortion-Termination
ERPOC
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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
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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
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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
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Mid Trimester Pain
Acute polyhydramniosPain is due to over distention.
It can be differentiated from. pregnancy by absence of foetal heart sound.
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Third Trimester Pain1. Concealed haemorrhage
2. Severe preeclampsia
3. Uterine rupture
4. Contractions of labour
5. Abruptio placentae
6. Red degeneration of fibromyoma
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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.
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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
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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..
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Third Trimester Pain
Labour painsPrematurely or at term. I
Intermittent & gradually become stronger and more frequent.
Cervical dilatation. & effacement
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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
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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”.
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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.
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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.
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APPENDICITIS - DIAGNOSIS
Graded compression ultrasonography
accurate in 1st and 2nd trimesters , difficult in 3rd.
98% ACCURATE.
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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
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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.
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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
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Incidental causes of Pain
USG
RFT
UrineAnalysis
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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.
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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
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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.
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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.
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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
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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.
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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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THANK YOU …