ABDOMINAL PAIN IN PREGNANCY

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ABDOMINAL PAIN

IN PREGNANCY

MBBCh IV LECTURE

DR BRON MOORE

Consultant

Department of Obstetrics and Gynaecology Johannesburg Hospital

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Introduction:

Abdominal pain during pregnancy is a common complaint. This pain may be either physiological or pathological. Pathological conditions may be either related or unrelated to the pregnancy.

Abdominal Pain - Classification

Physiological:

Round ligament pain

Braxton Hicks contractions Miscellaneous

Heartburn, excesssive vomiting, constipation Pathological: Pregnancy Related Uterine: Miscarriage Leiomyomata Abruptio placenta Chorioamnionitis Preterm labour Uterine rupture Adnexal: Ectopic pregnancy Ovarian: Corpus luteum Cyst accidents

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Pregnancy Unrelated GIT:

Appendicitis

Cholecystitis and cholelithiasis Pancreatitis

Peptic ulcer disease

Intestinal obstruction Chron’s disease Urinary tract: Cystitis Pyelonephritis Urolithiasis Liver disease:

Acute fatty liver of pregnancy

Severe pre-eclampsia / Eclampsia

Other:

Sickle cell crisis Porphyria

Malaria TB

Of importance is that pregnancy may alter the presentation of many of these conditions and the clinician must be aware of this in order to make the diagnosis. Furthermore there is often a reluctance to perform

diagnostic and/or surgical procedures during pregnancy which often causes a delay in diagnosis and treatment, and which may in turn result in an increased morbidity and even mortality.

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1. Physiological causes of abdominal pain:

1.1 Round ligament pain:

Inc: 10-30%

When: End 1st T and 2nd T

Who: More common in multigravidas

Aet: ? due to stretching of the round ligaments but no evidence Nature: Cramp-like or stabbing

Worse with movement Radiates to the groin

Tenderness over round ligaments on palpation Risk: delay in diagnosis of pathological cause of pain Management: Reassurance

Decrease activity Simple analgesics

1.2 Braxton Hicks contractions:

Inc: Common – majority of women will experience these When: Latter half of pregnancy

Nature: Uterine contractions that are irregular and vary in intensity Painless in most women, some experience pain

Risk: Delay in diagnosis of true preterm labour if uterine activity is mistakenly labelled Braxton Hicks contractions

Management: Must exclude preterm labour; look for absence of a show, intact membranes and a high presenting part. Serial vaginal exam often necessary to confirm no cervical change. Once diagnosis made reassure

1.3Miscellaneous:

Including: Heartburn, excessive vomiting and constipation Inc: Common

When: Early pregnancy

Risk: Delay in diagnosis of pathology

Management: Symptomatic management including Heartburn: Avoid lying down after a meal

Elevate head of bed Alter diet

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Vomiting: Alter diet (excessive) Antiemetics

Admission for Hyperemesis gravidarum if

dehydrated (U&E), ketotic (urine dipstix) or protracted for fluids and antiemetics.

Exclude multiple pregnancy and molar pregnancy.

Constipation: Alter diet – fluids, fibre and fruit

Remember iron supplements aggravate Laxatives

Also: Discomfort due to abdominal distension, foetal movement and pressure from the foetus in later pregnency

2. Pathological causes of abdominal pain - Pregnancy Related

These conditions will be dealt with in depth in lectures dealing with each specific pathology. This is an overview only.

2.1 Uterine:

2.1.1 Miscarriage

Inc: Most common causes of pathological pain in 1st T 15 -20% of clinically diagnosed pregnancies Up to 60% of those diagnosed chemically When: By definition, before viability

WHO: 22 weeks (154days) or <500gm SA: 26weeks or <1000gm

Classification: (you must know how to differentiate) Threatened

Inevitable Incomplete Complete

Nature: Cramp like lower abdominal pain (LAP) Associated vaginal bleeding

Diagnosis: Clinical

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2.1.2 Leiomyomata

Inc: Leiomyomata (fibroids) are common

10% of women with fibroids have pain in preg Who: Increased incidence in black women

Increased incidence in older women When:May result in early pregnancy loss

May cause pain at any stage of pregnancy Nature: Localized pain and tenderness

May have low grade pyrexia and leukocytosis Aet: Due to red degeneration/haemorrhagic infarction

Occurs due to acute inadequacy of blood supply Pedunculated fibroids may undergo torsion

Diagnosis: Ultrasound will show fibroid in most Risks: Mimics abruptio placenta, uterine rupture

Incorrect diagnosis with unnecessary surgery Increased risk of preterm labour (>3cm) Increased malpresentation

Management: Conservative with analgesics Often have recurrent attacks

Avoid myomectomy during pregnancy and at

caesarean section due to risk of bleeding

2.1.3 Abruptio placenta

Inc: 0.5-1% of pregnancies When: Latter half of pregnancy

Who: Hypertensives, ip pregnancy induced HT Smokers

Multiple pregnancies

Women with a history of abruptio Nature: Sharp tearing pain

Continuous

Backache with a posterior placenta Diagnosis: LAP

Woody hard uterus which doesn’t relax

PVB – note that with a concealed abruptio there may be little or no bleeding

Foetal distress

Coagulopathy in severe cases usually associated with foetal death

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Risks: Maternal: shock due to severe haemorrhage, post partum haemorrhage, DIC, renal

failure, death

Foetal asphyxia which may lead to death Management: Resuscitate mother

Assess the foetus for gestational age, viability, distress

Plan mode of delivery depending on the maternal and foetal condition

Monitor post delivery until haemodynamically stable and blood parameters have

returned to normal

2.1.4 Chorioamnionitis

Inc: Related to incidence of premature rupture of membranes (ROM)

May precede ROM in some cases Diagnosis: Maternal pyrexia

Maternal and foetal tachycardia Abdominal pain, uterine tenderness Uterine irritability

Offensive liquor draining vaginally Increased WCC and CRP

Management: Broad spectrum antibiotics IV Delivery preferably vaginally if foetus not distressed and no other contraindications

2.1.5 Preterm labour

Inc: 10%

When: By definition, after viability (1000gm) but before 37 completed weeks

Who: Previous preterm labour – best predictor Cervical incompetence

Smokers

PROM, HT, APH all important causes Congenital abnormalities of the uterus Polyhydramnios

Etc,etc

Diagnosis: Regular painful uterine contractions with associated cervical change and descent of the presenting part

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Risks: Side effects of tocolytics Increased C/S rate

Prematurity

Management: Depends on gestational age, aetiology, maternal and foetal condition and

contraindications to tocolysis.

If gestation less than 34 weeks, mom stable, baby normal and not distressed and no

contraindications, then tocolyse and administer steroids to aid foetal lung maturity.

2.1.6 Uterine rupture

Inc: Uncommon

With previous lower segment incision 0.5-1% When: Unlikely to rupture an unscarred uterus prior

to labour

Scarred uterus may rupture before labour Rupture in labour more common in scarred

uterus, ip with prev classical C/S (2%) Who: Uterine abnormalities e.g. rudimentary horn Excessive oxytocin use

Obstructed labour High parity

Previous uterine surgery – C/S, myomectomy Risks: Maternal haemorrhage, shock, death

Foetal shock, hypoxia, death

Management: Deliver women with previous classical C/S by elective C/S

Careful monitoring of patients with previous C/S in labour

High index of suspicion in women at risk

2.2 Adnexal:

2.2.1 Ectopic pregnancy

Inc: Varies according to population

Who: PID, tubal surgery, assisted reproduction all inc Contraception decreases inc

When: Usually present at 6-10 weeks Nature: LAP – non-specific

PVB usually mild

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Diagnosis: consider in ALL women with LAP!!! History, examination, ßhCG, ultrasound Management: Conservative

Medical

Surgical: open or laparoscopic

2.3Ovarian:

2.3.1 Corpus luteum

Inc: Uncertain When: 1st trimester

Nature: Most asymptomatic Dull aching pain of affected side Diagnosis: Ultrasound

Must exclude ectopic pregnancy Risks: Unnecessary surgery

Pregnancy loss if CL is ruptured or removed Management: Reassure

Conservative with serial ultrasound to document resolution

2.3.2 Cyst accidents

These include cyst rupture, haemorrhage into the cyst and torsion

Haemorrhage: This can be diagnosed on ultrasound. Management is conservative

Rupture: If rupture of the corpus luteum is diagnosed then progesterone to support the early

pregnancy should be given up to 10 weeks of amenorrhoea

Torsion:

When: Late 1st T & early 2nd T as uterus enters abdominal cavity

Who: any patient with adnexal mass Nature: Intermittent LAP

Pain is constant if infarction occurs Diagnosis: Nausea, vomiting

Tachycardia, low grade pyrexia, leucocytosis

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Risks: Miscarriage

Preterm labour

Adnexal infarction Management: Laparotomy

If adnexum is viable, cystectomy is done If adnexum is necrotic, adnexectomy is necessary

3.0 Pathological causes of abdominal pain - Pregnancy Unrelated

Any pathology that can occur outside of pregnancy can occur during pregnancy. Often the presentation is not typical thus delaying diagnosis and treatment.

3.1 GIT:

3.1.1 Appendicitis

Inc: 1:1500 pregnancies

No more frequent during pregnancy

Diagnosis: Difficult as many pregnant women have nausea, vomiting and anorexia

Also anatomic position of appendix changed Fever, leucocytosis

(Remember pregnancy increases WCC) Risks: Due to delay of diagnosis and treatment,

increased incidence of rupture with peritonitis and septicaemia

This increases miscarriage, preterm labour and foetal death

With rupture maternal mortality is 17%!!!! Less than 1% without

Management: High index of suspicion

Early surgery if diagnosis suspected

3.1.2 Cholecystitis and cholelithiasis

Inc: Increased in pregnancy due to physiological changes in the biliary system Many women have first attack in pregnancy Asymptomatic cholelithiasis 3.5% pregnancies Acute cholecystitis 1:1000 pregnancies

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Diagnosis: Sudden onset right upper quadrant pain Epigastric colicky pain or stabbing pain Nausea and vomiting

Fever, leucocytosis Ultrasound

Risks: Must differentiate from HELLP and severe pre-eclampsia

Preterm labour

Management: Initially conservative with analgesia, fluids and NGT

Surgery may be required, if possible best in second trimester

3.1.3 Pancreatitis

Inc: Rare 1:4000

May be more common during pregnancy due to increased gallstones

When: Late in pregnancy or soon postpartum Nature; severe central abdo pain, radiates to back Diagnosis: vomiting marked

Dehydration and shock

Gallstones on ultrasound in 50% Amylase increased

Risks: Significant maternal mortality Management: As for non pregnant patient

3.1.4 Peptic ulcer disease

Inc: Reduced risk during pregnancy Pre-existing disease improves

Diagnosis: Endoscopy in patients with suspected pathology

Management: As for non-pregnant patients

3.1.5 Intestinal obstruction

Inc: Is increasing due to more pregnant patients having had previous surgical procedures

Who: Patients with adhesions from previous surgery When: Early second trimester and immediately

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Diagnosis: Colicky abdo pain

Nausea, vomiting, abdo distension AXR to confirm

Risks: Delay in diagnosis and management common

Associated increase in morbidity and mortality Management: Initially conservative “drip and suck”

If suspect bowel necrosis or if conservative Mx fails, early surgery after correcting fluids and electrolytes

3.2 Urinary tract:

3.2.1 Cystitis

Inc: 1-2% of pregnant women

Diagnosis: Frequency, urgency and abdo discomfort Dysuria most specific

Risks: Pyelonephritis – pregnancy lowers maternal immunity

Preterm labour

Management: Send urine for MC&S

Single dose antibiotic regimens NOT appropriate

3.2.2 Pyelonephritis

Inc: One of the most common serious medical conditions in pregnancy

1-2% of pregnant women

When: Due to stasis and obstruction, occurs in 2nd & 3rd T

Who: Women with untreated asymptomatic bacteriuria are at increased risk

Nature: Renal angle tenderness(RAT) and LAP Diagnosis: Pyrexia

Raised WCC

Nausea, vomiting, loss of appetite LAP, RAT

Dipstix and MC&S Management: IV antibiotics

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3.2.3 Urolithiasis

Inc: Not increased in pregnancy, despite increased stasis, infection and calcium excretion

Increase in flow, alkalinity and substances

which counter calcium stone formation 0.03-0.5% of pregnancies

Who: Multiparous patients Known stone formers

When: 2nd & 3rd T

Risks: UTI, pyelonephritis, septicaemia Renal dysfunction

Premature labour Diagnosis: Pain

UTI, haematuria Ultrasound

IVP only if strongly suspect Dx & U/S negative Management: Conservative initially – 50-75% will

pass stone

I.E. bedrest, fluids, analgesia, treat infection

Aggressive management if U&E deteriorates, persistent infection, complete obstuction, recurrent preterm labour

3.3 Liver disease:

3.3.1 Acute fatty liver of pregnancy

Inc: Rare 1:10000 to 1:15000 pregnancies When: late 3rd T

Nature: Sudden onset of nausea, vomiting, pain and jaundice

Diagnosis: Raised bilirubin Abnormal liver enzymes Leukocytosis

Thrombocytopaenia Hypoglycaemia

Abnormal clotting profile

Management: Supportive (fluid, electrolytes, blood products)

Prompt delivery

Risks: Delay in management sig increases maternal and perinatal morbidity and mortality

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3.3.2 Severe pre-eclampsia / Eclampsia

Inc: Liver involvement in 10% of severe PE When: Late 2nd and 3rd T

Diagnosis: HT Proteinuria

Rt hypochondrial and epigastric pain Nausea and vomiting

3.4 Other:

3.4.1 Sickle cell crisis

Inc: Depends on population group

Nature: Severe constant or colicky abdo pain Diagnosis: Haemoglobin electrophoresis

Suspect in known patient with infection, dehydration etc

Management: Prompt treatment Fluids, oxygen, screen for infection May need exchange transfusion

3.4.2 Porphyria

Inc: Rare disorder of haeme metabolism

Diagnosis: Abdo pain, GIT symptoms, autonomic system disturbances

Attack may be precipitate by pregnancy Management: As in non-pregnant patient

3.4.3 Malaria

Inc: Depends on population and travel

Pregnant women more likely to acquire malaria Diagnosis: Travel history

Anaemia, thrombocytopaenia, renal failure Confusion, decreased LOC

Jaundice, splenomegaly Positive smear

Management: Supportive care often ICU if severe Quinine is drug of choice, avoid doxycycline

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Risks: Miscarriage, foetal death Premature labour

More aggressive and severe infection in pregnancy with increased organ failure

3.4.4 TB

Inc: Pregnancy is an immunocompromised state Increasing HIV also important

Disseminated disease with peritoneal

involvement can present with abdominal pain

APPROACH TO A PATIENT WITH ABDOMINAL PAIN

IN PREGNANCY

As in all patients presenting to a doctor a structured logical approach to the complaint must be followed to avoid missing the diagnosis.

HISTORY:

The nature, site and duration of the pain are important.

Associated symptoms such as nausea, vomiting and diarrhoea must be asked about.

Relieving and aggravating factors may be important

Previous episodes of similar pain may help in making the diagnosis. Past medical and surgical history is vital.

EXAMINATION: SIDE WARD TESTS:

LABORATORY INVESTIGATIONS: SPECIAL INVESTIGATIONS:

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