Abdominal pain in pregnancy

Dr.Rupa Rajshekar MBBS, MD

Specialist in Obs & Gyne

Introduction

• Abdominal pain is a very common symptom in pregnant women

• It is of varying degree, may be acute with rapid onset or chronic that recurs or persists for long time

• It is convenient to divide the cause of pain due to pregnancy into those most commonly encountered in each of the three trimesters

• A 22 year old Para-1 with 6-8 weeks gestation presents with abdominal pain

What are you thinking of???

History

• Localized one sided pain, no radiation, spasmodic to start with – now constant

• Mild p/v bleeding• Some chest pain & shoulder tip pain• Has been feeling faint• Pregnancy test positive

Think ectopic

• Vital signs• B-HCG – quantitative• Pelvic ultrasound• Admission

Ectopic pregnancy Pitfalls in diagnosis

• Wide variations in clinical presentation• Pregnancy test can be negative• Trans vaginal ultrasound even in best hands is

only 50% accurate in early ectopics• B-HCG can double in very early ectopics

Treatment of ectopic pregnancy

• Medical with Methotrexate• Surgical – Laparotomy/Laparoscopy

» salphingostomy / salphingectomy

Is it Ovarian?

• Corpus luteum cysts:– Mild aching pain– Usually asymptomatic – Maternal pulse in not raised– Hemorrhage inside cyst can cause severe pain

Adnexal torsion

• More common in pregnancy (28%)• Pain is sudden in onset in lateral lower quadrant• Fever, leucocytosis, nausea, vomiting• USS – shows cyst with no flow on color mapping• At times difficult to differentiate from ectopics and

appendicitis • Miscarriage & preterm are common consequences • Surgery should not be delayed

First trimester pain

• Abortion• Pregnancy in rudimentary horn• Acute salpingitis• Acute retention of urine• Hydatidiform mole

A 22 yr old para 1 with 6-8 weeks amenorrhea presents with

abdominal pain• The history changes:– Crampy lower abdominal pain– Heavy bleeding p/v– Speculum examination• Cx os closed• Cx os open

Diagnosis - ? Miscarriage

• Assess hemodynamic stability • Arrange pelvic ultrasound• Management depends on ultrasonographic

findings• No role of B-HCG• Blood group, Rhesus and anti D if needed

Some USS findings

• An intrauterine gestational sac seen 25x30 mm in diameters. No fetus visible

• An IU gestational sac seen 20x20mm in diameter, Fetal pole seen 6 mm CRL. No FH

• An IU gestational sac seen 35 x35 mm in diameters low down in the cavity. Fetal pole seen. FH seen but appears slow

The management of miscarriage

• Conservative• Reassurance and TLC• No role of bed rest• ERPOC

Miscarriage

• Always confirm a possible complete miscarriage by serial BHCGs

• This is specially true if there has been no scans to prove an intrauterine gestational sac

• Pitfall: You might miss an ectopic

First trimester pain

• Pregnancy in rudimentary horn• Pain resemble that of ectopic & usually the

condition discovered during laparotomy• If rupture occurs it usually in the mid-

trimester & of sudden onset with collapse

First trimester pain

• Acute Salpingitis:• May develop up to 10 wks after conception,

due to gonococcal infection or infection due to attempted abortion

• Pain felt in both iliac fossae & is continous• Associated tenderness, tachycardia & elevated

temperature, culture of discharge may reveal pathogen

First trimester pain

• Acute retention of urine• Due to enlargement of fibroid in response to

pregnancy• Severe lower abdominal pain, large tender

bladder which may be mistaken for ovarian cyst

• Catheterisation causes immediate pain relief

First trimester pain

• Hydatidiform mole• Pain in lower abdomen due to – Overdistention of uterus– Concealed haemorrhage– Perforation– Infection

Mid trimester pain

• Red degeneration of fibromyoma• Stretching of round ligament• Acute polyhydromnios• Rupture of rudimentary horn containing

pregnancy• Acute retention of urine due to incarcerated

RVF gravid uterus

Mid trimester pain

• Red degeneration of fibromyoma• Causes mild to severe pain. Tenderness

present over fibroid• USS detects fibroid• Conservative treatment with analgesics

Mid trimester pain

• Stretching of round ligament• 10-30% of pregnancies• More in multipara• Cramp like or stabbing continuous pain, some

tenderness in the groin• Reassurance & mild analgesics required

Mid trimester pain

• Acute polyhydrominos• Pain due to over distention• Diagnosed clinically & by USS