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Abdominal Pain in Pregnancy

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Abdominal Pain in Pregnancy

  1. 1. ABDOMINAL PAIN IN PREGNANCY Rupali Shah
  2. 2. • Abdo pain is more complex in pregnant women as uterine enlargement may hide classical signs
  3. 3. Cause of pain • Obstetric • Gynaecological • “Surgical” • “Medical” • Musculoskeletal • Mainly going to focus on obs and gynae pain
  4. 4. Obstetric causes 1 • Labour pain - premature labour or term. • Pre-eclampsia or HELLP syndrome – (Haemolysis, Elevated Liver Enzymes, Low plts) – epigastric or right upper quadrant pain. – This may be confused with heart burn • Placental abruption: – Separation of placenta from uterus wall before delivery – Typically, sudden severe pain and a 'woody' hard, tender uterus; fetal distress, ± vaginal bleeding. – With posterior placenta, pain and shock may be less severe, with pain felt in the back – diagnose by pattern of fetal contractions (excessive and frequent) with fetal heart pattern suggesting hypoxia.
  5. 5. Obstetric causes 2 • Uterine rupture: – Integrity of myometrial wall is breached – Constant pain, profound shock, fetal distress and vaginal bleeding; usually presents during labour and with history of uterine scar (eg c-section). – Rarely, occurs without labour and without uterine scar. • Chorioamnionitis: – Infalammation of fetal membranes due to bact. infection – This usually follows premature rupture of membranes, but can occur with membranes intact. • Acute fatty liver of pregnancy: – Presents in the second half of pregnancy with abdominal pain, nausea/vomiting, jaundice, malaise and headache.
  6. 6. Obstetric causes 3 • Acute polyhydramnios – Excess amniotic fluid collects rapidly • Severe uterine torsion - rare; may be due to structural abnormalities in the pelvis. – Presents in the second half of pregnancy with variable symptoms, including severe abdominal pain, tense uterus, retention of urine ± shock and fetal distress; or, it may be asymptomatic – the fetus is at risk.
  7. 7. Gynaecological causes 1 • Ectopic pregnancy – Usually presents between 5-9 weeks' gestation. – Classical triad of bleeding, abdominal pain, and amenorrhoea is not present in many women; symptoms and signs are often nonspecific; the diagnosis can only be confirmed in secondary care. – Symptoms vary + include: • syncope • dysuria (including dipstick urine findings suggesting UTI) • diarrhoea and vomiting • subtle changes in vital signs • adnexal tenderness may be absent • a history of 'missed period' may be absent if vaginal bleeding is mistaken for a normal period.
  8. 8. Gynaecological causes 2 • Miscarriage ± septic abortion. • Torsion of the ovary or Fallopian tube. – Sharp, unilateral lower abdo pain • Ovarian cysts - torsion, haemorrhage or rupture. • Fibroids - red degeneration or torsion. – Hormones during pregnancy cause fibroids to grow – They outgrow their blood supply  lack of nutrients  break down and cause pain – Can also cause miscarriage/early labour
  9. 9. Gynaecological causes 3 • Ovarian hyperstimulation syndrome: – A complication of gonadotrophin-assisted conception; can occur pre-conception or in early pregnancy. – Large ovarian cysts cause abdominal pain and distention and, in severe cases, also fluid shifts, ascites, pleural effusion and shock. • Salpingitis • Round ligament pain.
  10. 10. “Surgical” Causes • Acute appendicitis. – Presents with fever, anorexia, nausea, vomiting, right iliac fossa (RIF) pain. – After the first trimester, the pain may shift upwards towards the right upper quadrant, but does not always do so - and patients in all trimesters may have RIF pain. – With retrocaecal appendix, may have back or flank pain. • Cholecystitis and gallstones. • Urinary tract - renal calculi, urinary tract obstruction (including acute urinary retention due to retroverted gravid uterus). • Intestinal obstruction - most often due to adhesions. • Peritonitis from any cause. • Abdominal trauma, including domestic violence. • Mesenteric adenitis. • Meckel's diverticulitis. • Peptic ulcer. • Inflammatory bowel disease. • Abdominal wall - hernias, musculoskeletal pain, rupture of rectus abdominis muscle. • Acute pancreatitis - rare and usually due to gallstones. • Mesenteric venous thrombosis (rare) - most reported cases have occurred where dehydration complicated an underlying hypercoagulable state.[2] • Rupture of visceral artery aneurysm (rare).
  11. 11. “Medical” Problems • UTI ± pyelonephritis. • Constipation. • Diabetic ketoacidosis. • Sickle-cell anaemia crisis. • Lower lobe pneumonia. • Venous thromboembolism - deep vein thrombosis or pulmonary embolus may cause lower or upper abdominal pain respectively. • Myocardial infarction. • Gastroenteritis. • Irritable bowel syndrome.
  12. 12. Musculoskeletal Causes • Round ligament pain - low abdominal or groin pain due to the uterus pulling on the round ligament. • General aches - due to uterine enlargement. • Rectus muscle haematoma - due to rupture of inferior epigastric vessels in late pregnancy: – Presents with sudden severe abdominal pain, often after coughing or trauma. • Pelvic girdle pain: – Symphysis pubis dehiscence. – Osteomalacia may present in pregnancy due to increasing vitamin D requirements.
  13. 13. History • Pain history – SOCRATES • Other abdominal symptoms - vaginal bleeding, bowel and urinary symptoms; pre-eclampsia symptoms (eg headache, visual change, nausea). • Fetal movements. • Obstetric history – – last menstrual period (LMP) – confirm whether the patient's last bleed was 'normal' for the patient (ectopic pregnancy may have some bleeding which can be mistaken for menstrual bleed) – ask if there has been any difficult or assisted conception – confirm use of any contraception (coil and progestogen-only pill (POP) increase ectopic risk). • Past medical and gynaecological history, medication, allergies, last meal.
  14. 14. Examination • General examination – – well/ill, signs of sepsis, shock or haemorrhage, blood pressure, urine dipstick protein and glucose. • Assess the pregnancy and uterus: – Palpate uterus for fundal height, contractions or hard uterus, polyhydramnios, fetal position and presentation. – Assess fetal wellbeing - movements or heartbeat (auscultate, Doppler scan or CTG). • Abdominal examination – – distinguish extra-uterine from uterine tenderness, – Peritoneal signs may be absent in pregnancy – Note the changing positions of the intra-abdominal contents as the pregnancy progresses. • Consider whether vaginal and/or rectal examination is indicated: – Never do vaginal examination if placenta praevia is suspected – Suspected rupture of membranes requires sterile examination and should be done in an obstetric unit.
  15. 15. Investigations • Urine (dip stick and pregnancy if indicated) • CTG • Bloods (FBC, group and save, serum b- HCG,) • Ultrasound
  16. 16. Management • Depends on cause

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