for 4th medical student

1. Abdominal pain inAbdominal pain in
pregnancypregnancy
Dr Hashmi HajrasiDr Hashmi Hajrasi
Consultant in OBS & GYNConsultant in OBS & GYN
MBBCH, DGO, MRCOGMBBCH, DGO, MRCOG

2. IntroductionIntroduction
 Abdominal pain in pregnancy is a commonAbdominal pain in pregnancy is a common
complaint.complaint.
 It’s management represents a challenge toIt’s management represents a challenge to
the clinician because the causes may bethe clinician because the causes may be
due to pregnancy or may be related todue to pregnancy or may be related to
pregnancy but not directly due to it or maypregnancy but not directly due to it or may
be unrelated to pregnancy at all.be unrelated to pregnancy at all.

3.  The incidence of the different causes ofThe incidence of the different causes of
abdominal pain in pregnancy is difficult toabdominal pain in pregnancy is difficult to
estimate . The is because classifying thisestimate . The is because classifying this
symptom into pregnancy & non-pregnancysymptom into pregnancy & non-pregnancy
related is often not possible until afterrelated is often not possible until after
delivery.delivery.
 The investigations that may be performedThe investigations that may be performed
outside pregnancy are difficult to justify inoutside pregnancy are difficult to justify in
pregnancy e.g laparoscopy because of it’spregnancy e.g laparoscopy because of it’s
potential complications after 1potential complications after 1stst
trimester.trimester.

4. The anatomy of painThe anatomy of pain
1- Uterine body: T10-L1 sensory afferent . These also1- Uterine body: T10-L1 sensory afferent . These also
supply the dermatomes from umbilicus tosupply the dermatomes from umbilicus to
symphysis. Laterally to iliac crests & posteriorly tosymphysis. Laterally to iliac crests & posteriorly to
lumber and sacral vertebralumber and sacral vertebra
2- Cervix: as above , plus additional sensory to S2-42- Cervix: as above , plus additional sensory to S2-4
3- Ovary: mainly sympathetic sensory afferent to T103- Ovary: mainly sympathetic sensory afferent to T10
4- The gynae sensory nerves overlap with other pelvic4- The gynae sensory nerves overlap with other pelvic
& abdominal structures so localization & diagnosis& abdominal structures so localization & diagnosis
may be difficult.may be difficult.

5. classifictionclassifiction
Pain directly related to pregnancyPain directly related to pregnancy

6. First trimesterFirst trimester
 AbortionAbortion
 Hydatidiform moleHydatidiform mole
 Ectopic pregnancyEctopic pregnancy

7. AbortionAbortion
 The pain is colicky in nature felt in theThe pain is colicky in nature felt in the
lower abdomen or pelvislower abdomen or pelvis
 commonly associated withcommonly associated with
amenorrhoea and vaginal bleedingamenorrhoea and vaginal bleeding
 In threatened & missed abortionsIn threatened & missed abortions
there may be mild or no painthere may be mild or no pain
 Diagnosis by BHCG,exam & USSDiagnosis by BHCG,exam & USS

8. Molar pregnancyMolar pregnancy
 Incidence is 1 in 1200 pregnanciesIncidence is 1 in 1200 pregnancies
 Pain when present is due to the uterusPain when present is due to the uterus
trying to expel the molar tissue (colicky)trying to expel the molar tissue (colicky)
 When severe may suggest intra-peritonealWhen severe may suggest intra-peritoneal
bleedingbleeding
 Uterus large for date ,watery blood stainedUterus large for date ,watery blood stained
dischargedischarge
 USS shows snow – storm appearanceUSS shows snow – storm appearance

9. Ectopic pregnancyEctopic pregnancy
 Incidence is 1 in 100 pregnancies inIncidence is 1 in 100 pregnancies in
UKUK
 Presents with pain & amenorrhoeaPresents with pain & amenorrhoea
 The pain is commonly in one of theThe pain is commonly in one of the
iliac fossa and may be referred to theiliac fossa and may be referred to the
tip of the shouldertip of the shoulder
 Most of cases are diagnosed byMost of cases are diagnosed by
BHCG,TVS and/or laparoscopyBHCG,TVS and/or laparoscopy

10. Second trimesterSecond trimester
* Abortion* Abortion
* Acute urinary retention in association with incarcerated* Acute urinary retention in association with incarcerated
retroverted gravid uterus typically at 12-14 weeksretroverted gravid uterus typically at 12-14 weeks
* Chorioamnionitis following PROM* Chorioamnionitis following PROM
* Retroplacental haemorrhage following amniocentesis* Retroplacental haemorrhage following amniocentesis
* Round ligament pain due to stretch classically at 18-22 wks* Round ligament pain due to stretch classically at 18-22 wks
* Red degeneration of the fibroid* Red degeneration of the fibroid

11. Incarcerated retrovertedIncarcerated retroverted
graved uterusgraved uterus
 Commonly occurs between 12-14wksCommonly occurs between 12-14wks
 Causes urethral obstruction with acuteCauses urethral obstruction with acute
urinary retention & painurinary retention & pain
 Indwelling urine cathter helps allow theIndwelling urine cathter helps allow the
uterus to become abdominaluterus to become abdominal

12. RetroplacentalRetroplacental
haemorrhage followinghaemorrhage following
amniocentesisamniocentesis
 Can complicate both diagnostic &Can complicate both diagnostic &
therapeutic amniocentesis especiallytherapeutic amniocentesis especially
when the needle insertedwhen the needle inserted
transplacentallytransplacentally
 Pain is felt a few hours after thePain is felt a few hours after the
procedureprocedure
 Constant & localised to the punctureConstant & localised to the puncture
sitesite

13. Prermature labour &Prermature labour &
chorioamnionitischorioamnionitis
 Presents with intermittent or constantPresents with intermittent or constant
abdominal painabdominal pain
 May be associated with vaginalMay be associated with vaginal
discharge, abdominal tenderness anddischarge, abdominal tenderness and
maternal & fetal tachycardiamaternal & fetal tachycardia
 Treatment with antibiotics andTreatment with antibiotics and
expediting deliveryexpediting delivery

14. Round ligament painRound ligament pain
 Occurs secondary to stretching of theOccurs secondary to stretching of the
ligament as the uterus enlarges into theligament as the uterus enlarges into the
abdomen (10-30% of pregnancy)abdomen (10-30% of pregnancy)
 Commonly occurs in the late 1Commonly occurs in the late 1stst
and early 2and early 2ndnd
trimestertrimester
 Felt as dragging, stabbing or cramp-likeFelt as dragging, stabbing or cramp-like
pain in the outer lower abdomen radiating topain in the outer lower abdomen radiating to
groingroin
 Diagnosis is made by excluding otherDiagnosis is made by excluding other
causescauses

15. Red degeneration ofRed degeneration of
fibroidfibroid
 Occurs due to infarction of the centre of theOccurs due to infarction of the centre of the
fibroid during mid –pregnancyfibroid during mid –pregnancy
 The fibroid suddenly enlarges & is painfulThe fibroid suddenly enlarges & is painful
and tendreand tendre
 The pain is ischaemic ,constant andThe pain is ischaemic ,constant and
localised to one side of the uterus butlocalised to one side of the uterus but
sometimes diffuse. Mild pyrexiasometimes diffuse. Mild pyrexia
leucocytosis. USS may be helpfulleucocytosis. USS may be helpful
 Treatment is conservativeTreatment is conservative

16. Third TrimesterThird Trimester

17. Fetal movements &Fetal movements &
Braxton-Hicks contractionsBraxton-Hicks contractions
 These are spontaneous uterine contractionsThese are spontaneous uterine contractions
becoming more frequent as pregnancybecoming more frequent as pregnancy
advances.advances.
 Initially painless but then perceived asInitially painless but then perceived as
vague backache which is minimallyvague backache which is minimally
uncomfortable but does not need analgesia,uncomfortable but does not need analgesia,
however can be sever requiring hospitalhowever can be sever requiring hospital
admission commonly in primigravidaadmission commonly in primigravida

18. Placental abruptionPlacental abruption
 Presents with abdominal pain with orPresents with abdominal pain with or
without vaginal bleedingwithout vaginal bleeding
 Complicates up to 1% of pregnanciesComplicates up to 1% of pregnancies
 Abdominal pain could be mild constant orAbdominal pain could be mild constant or
intermittent (like labour pains)intermittent (like labour pains)
 When no vaginal bleeding, can be confusedWhen no vaginal bleeding, can be confused
with other causes of abdominal pain. A highwith other causes of abdominal pain. A high
index of suspicion is essentialindex of suspicion is essential

19. Sever Pre-eclampsia &Sever Pre-eclampsia &
eclampsiaeclampsia
 Incidence about 6% among primigravidaeIncidence about 6% among primigravidae
 Pain is mainly at the epigastrium & Rt upperPain is mainly at the epigastrium & Rt upper
quadrantquadrant
 It’s due to stretching of the liver capsuleIt’s due to stretching of the liver capsule
secondary to subcapsular haemorrhagesecondary to subcapsular haemorrhage
 Other symptoms & signs are often presentOther symptoms & signs are often present
 Treatment involves control & deliveryTreatment involves control & delivery

20. Uterine ruptureUterine rupture
 Unlikely to occur silently during pregnancyUnlikely to occur silently during pregnancy
but it can occur in women with previousbut it can occur in women with previous
classical C/S usually from early 3classical C/S usually from early 3rdrd
trimester.trimester.
 Others occur in labour in women who hadOthers occur in labour in women who had
c/s or perforated uterus during D/Cc/s or perforated uterus during D/C
 The abdominal pain typically acute,The abdominal pain typically acute,
associated with shock & shoulder tip painassociated with shock & shoulder tip pain
 The pain can penetrate through the epiduralThe pain can penetrate through the epidural
block. Laparotomy is required after resuscitblock. Laparotomy is required after resuscit

21. Pain not directly related toPain not directly related to
pregnancypregnancy

22. Gastrointestinal TractGastrointestinal Tract

23. Gastro-esophagealGastro-esophageal
refluxreflux
 A common cause of upper abdominalA common cause of upper abdominal
pain in pregnancy. Incidence 60-70%pain in pregnancy. Incidence 60-70%
 More common in late pregnancyMore common in late pregnancy
multiple pregnancy & polyhydramniosmultiple pregnancy & polyhydramnios
 Felt as burning sensation inFelt as burning sensation in
epigastrium & behind the sternumepigastrium & behind the sternum
 Caused by relaxation of gastro-Caused by relaxation of gastro-
esophageal sphincteresophageal sphincter

24. Peptic ulcerPeptic ulcer
 Uncommon during pregnancyUncommon during pregnancy
 Usually there is a pre-existing historyUsually there is a pre-existing history
 Pain typically in the epigasric & RtPain typically in the epigasric & Rt
hypochodrium worse with hunger & spicyhypochodrium worse with hunger & spicy
foodfood
 Perforation is rare but may occur especiallyPerforation is rare but may occur especially
after delivery. Presents with acute painafter delivery. Presents with acute pain
,collapse & peritonitis,collapse & peritonitis
 Gas under diaphragm on erect x-ray abdomGas under diaphragm on erect x-ray abdom

25. Hiatus herniaHiatus hernia
 Incidence 7-22% of all pregnanciesIncidence 7-22% of all pregnancies
 Present in 62% of cases of severPresent in 62% of cases of sever
heartburn in the 3heartburn in the 3rdrd
trimestertrimester
 Very severe cases present with severVery severe cases present with sever
vomiting & haematemesisvomiting & haematemesis
 Treatment as for reflux esophagitisTreatment as for reflux esophagitis

26. constipationconstipation
 May present as sever or chronicMay present as sever or chronic
abdominal painabdominal pain
 Caused by slow peristalsisCaused by slow peristalsis
(progeterone effect)(progeterone effect)
 Felt as dull, constant & sometimesFelt as dull, constant & sometimes
colicky pain in the iliac fossae (Ltcolicky pain in the iliac fossae (Lt
 Treatment with high fibre diet &Treatment with high fibre diet &
laxativeslaxatives

27. Acute appendicitisAcute appendicitis
 Complicates 1 in 1500-2500Complicates 1 in 1500-2500
pregnancies (as in non-pregnants)pregnancies (as in non-pregnants)
 Symptoms & signs may be atypical.Symptoms & signs may be atypical.
 Pain may be in the Rt lumber region inPain may be in the Rt lumber region in
early gestation or in the Rtearly gestation or in the Rt
hypochondrium in late pregnancy duehypochondrium in late pregnancy due
to displacement of caecum & appedixto displacement of caecum & appedix
by the gravid uterusby the gravid uterus

28.  The pain in early pregnancy startsThe pain in early pregnancy starts
around the umbilicus then settles inaround the umbilicus then settles in
the RIFthe RIF
 Accompanied by nausea, vomitingAccompanied by nausea, vomiting
anorexia & fever however, theseanorexia & fever however, these
symptoms may be absent in latesymptoms may be absent in late
pregnancypregnancy

29.  Leucocytosis is an important sign butLeucocytosis is an important sign but
due to physiological leucocytosis indue to physiological leucocytosis in
pregnancy, serial count is more usefulpregnancy, serial count is more useful
 Pyrexia, tenderness & guarding overPyrexia, tenderness & guarding over
the Rt abdomen may be the only signsthe Rt abdomen may be the only signs
presentpresent
 The inflammed appendix may induceThe inflammed appendix may induce
preterm labourpreterm labour

30. Treatment of acute appendicitisTreatment of acute appendicitis
 In early pregnancy laparoscopicIn early pregnancy laparoscopic
appendectomy can be done or throughappendectomy can be done or through
the classical McBurney incisionthe classical McBurney incision
 If laparotomy is necessary, a para-If laparotomy is necessary, a para-
median incision over the area of maxmedian incision over the area of max
tenderness allows the best access iftenderness allows the best access if
extension is neededextension is needed

31. Complications of appendicitis inComplications of appendicitis in
pregnancypregnancy
 RuptureRupture
 Peritonitis: organ displacementPeritonitis: organ displacement
prevents walling- off of the inflammedprevents walling- off of the inflammed
appendixappendix
 PROM & preterm labourPROM & preterm labour

32. Bowel obstructionBowel obstruction
 Is a rare cause of acute abdominalIs a rare cause of acute abdominal
pain in pregnancy (1 in 2500-3500 )pain in pregnancy (1 in 2500-3500 )
 Incidence appears to be increasingIncidence appears to be increasing
due to increased abdomino –pelvicdue to increased abdomino –pelvic
surgery causing adhesion bandssurgery causing adhesion bands
 Rarely caused by strangulated femoralRarely caused by strangulated femoral
or inguinal herniae & volvulus.or inguinal herniae & volvulus.

33. Bowel obstruction ..contBowel obstruction ..cont
 The pain is colicky with exaggerated bowelThe pain is colicky with exaggerated bowel
sounds & constipation. Abdominalsounds & constipation. Abdominal
distension may be difficult to detect indistension may be difficult to detect in
advanced pregnancyadvanced pregnancy
 Treatment is conservative with N/S tubing,Treatment is conservative with N/S tubing,
fluid & electrolyte replacementfluid & electrolyte replacement
it usually settle within few hours otherwiseit usually settle within few hours otherwise
laparotomy is required to divide adhesionslaparotomy is required to divide adhesions

34. Gallstones &Gallstones &
cholecystitischolecystitis
 Pregnancy predisposes to gallstonesPregnancy predisposes to gallstones
due to biliary stasis and raiseddue to biliary stasis and raised
cholesterol in pregnancycholesterol in pregnancy
 Incidence about 3.5%Incidence about 3.5%
 Most women are asymptomaticMost women are asymptomatic
 Symptomatic Pt’s present with suddenSymptomatic Pt’s present with sudden
onset of colicky abdominal painonset of colicky abdominal pain
radiating to the back in Rt hypochodriuradiating to the back in Rt hypochodriu

35. Gallbladder ..contGallbladder ..cont
 Nausea, vomiting & vasovagal attacksNausea, vomiting & vasovagal attacks
 Tenderness & positive murphy’s signTenderness & positive murphy’s sign
may be the only positive clinical signsmay be the only positive clinical signs
 Diagnosis can be made by ultrasoundDiagnosis can be made by ultrasound
 Treatment is coservativeTreatment is coservative
 Surgery can be performed in earlySurgery can be performed in early
pregnancy laparoscopicallypregnancy laparoscopically

36. Gallbladder..contGallbladder..cont
 Open surgery can be done inOpen surgery can be done in
advanced pregnancy but risks areadvanced pregnancy but risks are
ascending cholangitis which may leadascending cholangitis which may lead
to septicaemia & preterm labourto septicaemia & preterm labour

37. Gallbladder..contGallbladder..cont
 Acute cholecystitis is uncommon inAcute cholecystitis is uncommon in
pregnancypregnancy
 Presents with acute Rt hypochonderialPresents with acute Rt hypochonderial
pain, nausea, vomiting & pyrexiapain, nausea, vomiting & pyrexia
 Pyrexia differentiating it from gallstonePyrexia differentiating it from gallstone
 Incidence 1 in 1000 pregnanciesIncidence 1 in 1000 pregnancies
 Treatment with antibiotics & analgesiaTreatment with antibiotics & analgesia

38. pancreatitispancreatitis
 Uncommon in pregnancy (1 in 5000)Uncommon in pregnancy (1 in 5000)
 More common in pregnants than nonMore common in pregnants than non
 High mortality rate (>10%)High mortality rate (>10%)
 Presents with central or upperPresents with central or upper
abdominal pain radiating to the backabdominal pain radiating to the back
 There may be nausea, vomiting &There may be nausea, vomiting &
shock. Few with juandice when thereshock. Few with juandice when there
is obstructed biliary systemis obstructed biliary system

39. Pancreatitis.. contPancreatitis.. cont
 Diagnosis confirmed by raised serumDiagnosis confirmed by raised serum
amylaseamylase
 Ultrasound shows gallstones in 50% ofUltrasound shows gallstones in 50% of
casescases
 Treatment is conservative with iv fluidTreatment is conservative with iv fluid
& electrolyte replacement, pethidine,& electrolyte replacement, pethidine,
steroids, antibiotics cimitidine &steroids, antibiotics cimitidine &
glucgoneglucgone

40. Renal tractRenal tract

41. Acute pyelonephritisAcute pyelonephritis
 Is the most common renal cause ofIs the most common renal cause of
abdominal pain in pregnancy (1-2%)abdominal pain in pregnancy (1-2%)
 Most cases present in the 2Most cases present in the 2ndnd
& 3& 3rdrd
trimesters with sever abdominal paintrimesters with sever abdominal pain
in the lumbar region radiating to thein the lumbar region radiating to the
iliac fossa or vulvailiac fossa or vulva
 Nausea, vomiting, pyrexia, rigors &Nausea, vomiting, pyrexia, rigors &
tachycardia with loin tendernesstachycardia with loin tenderness

42. Pyelonephritis..contPyelonephritis..cont
 Associated with increased risk ofAssociated with increased risk of
preterm labourpreterm labour
 Diagnosis by MSU for R/E & C/SDiagnosis by MSU for R/E & C/S
 E. Coli is the most common causeE. Coli is the most common cause
 If recurrent exclude renal anomaliesIf recurrent exclude renal anomalies
USS during preg. Or IVP 3-4 monthsUSS during preg. Or IVP 3-4 months
after delivery.after delivery.

43. Renal stonesRenal stones
 Affects 0.03-0.05% of pregnant women (asAffects 0.03-0.05% of pregnant women (as
in non-pregnants)in non-pregnants)
 Pregnancy does not predispose to stonePregnancy does not predispose to stone
formation . In fact small stones may passedformation . In fact small stones may passed
unnoticed due to ureteric dilatationunnoticed due to ureteric dilatation
 Presents with loin pain radiating to thePresents with loin pain radiating to the
suprapubic region the pain may besuprapubic region the pain may be
excruciating & associated with shockexcruciating & associated with shock

44. Renal stones...contRenal stones...cont
 Renal tenderness may be the only clinicalRenal tenderness may be the only clinical
sign USS may show dilated renal tract or asign USS may show dilated renal tract or a
stonestone
 Treatment mostly conservative with potentTreatment mostly conservative with potent
analgesic & liberal fluid intakeanalgesic & liberal fluid intake
 If obstruction persist surgery is indicatedIf obstruction persist surgery is indicated
 There is a risk of precipitating pretermThere is a risk of precipitating preterm
labourlabour

45. Acute retention of urineAcute retention of urine
 More likely to occur in the 1More likely to occur in the 1stst
trimestertrimester
and in the puerperium.and in the puerperium.
 Causes include:Causes include:
- incarcerated R/v gravid uterus- incarcerated R/v gravid uterus
- pelvic mass (ovarian or fibroid)- pelvic mass (ovarian or fibroid)
- acute herpes infection- acute herpes infection
- vulval haematoma- vulval haematoma

46. Urine retention..contUrine retention..cont
 Presents with sudden onset of severPresents with sudden onset of sever
pain with distended bladder on exampain with distended bladder on exam
 Catherterization for 24-48hrs &Catherterization for 24-48hrs &
analgesia are very helpful and allowanalgesia are very helpful and allow
the gravid uterus to becomethe gravid uterus to become
abdominalabdominal

47. Adenxal accidentsAdenxal accidents
 Corpus luteum cyst in early pregnancy mayCorpus luteum cyst in early pregnancy may
bleed causing pain or rupture causing shockbleed causing pain or rupture causing shock
 Mostly diagnosed by USS or bimanually ifMostly diagnosed by USS or bimanually if
they are largethey are large
 Managed mostly conservatively but if theyManaged mostly conservatively but if they
are large or showing abnormal pathologyare large or showing abnormal pathology
they should be removed after 14 wksthey should be removed after 14 wks

48. Adenxal accidents..contAdenxal accidents..cont
 Torsion of a pre-existing ovarian cystTorsion of a pre-existing ovarian cyst
(benign or malignant) presents with(benign or malignant) presents with
intermittent abdominal pain which laterintermittent abdominal pain which later
becomes constant (indicatingbecomes constant (indicating
ischaemia). There may be nausea,ischaemia). There may be nausea,
vomiting, low grade fever andvomiting, low grade fever and
leucocytosis .If ignored the ovary mayleucocytosis .If ignored the ovary may
become gangrenousbecome gangrenous

49. Adnexal accidents..contAdnexal accidents..cont
 Laparotomy with oophorectomy orLaparotomy with oophorectomy or
fixing the ovary if viablefixing the ovary if viable
 Torsion of a pedunculated fibroid mayTorsion of a pedunculated fibroid may
present in a similar way to tortedpresent in a similar way to torted
ovarian cyst. They need to beovarian cyst. They need to be
removed at laparotomy. Don’t try toremoved at laparotomy. Don’t try to
remove subserous, intramural fibroidremove subserous, intramural fibroid
as it may end by hysterectomyas it may end by hysterectomy

50. Miscellaneous causeMiscellaneous cause
 Musculoskeletal :Musculoskeletal :
- exaggerated lumbar lordosis- exaggerated lumbar lordosis
- sumphyseal diasthesis- sumphyseal diasthesis
* sickle cell crisis* sickle cell crisis
* rectus sheath haematoma* rectus sheath haematoma
* porphyria* porphyria
* Aortic aneurysm* Aortic aneurysm