Abdominal pain in pregnancy is a very common problem encountered in day to day practice. Although is can be benign at times great care should be exercised to dismiss as nothing significant.
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Rupa abdominal pain in pregnancy
1. Abdominal pain in pregnancy
Dr.Rupa Rajshekar MBBS, MD
Specialist in Obs & Gyne
2. 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
3. • A 22 year old Para-1 with 6-8 weeks gestation
presents with abdominal pain
What are you thinking of???
4. 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
6. 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
7. Treatment of ectopic pregnancy
• Medical with Methotrexate
• Surgical – Laparotomy/Laparoscopy
» salphingostomy / salphingectomy
8. Is it Ovarian?
• Corpus luteum cysts:
– Mild aching pain
– Usually asymptomatic
– Maternal pulse in not raised
– Hemorrhage inside cyst can cause severe pain
9. 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
10. First trimester pain
• Abortion
• Pregnancy in rudimentary horn
• Acute salpingitis
• Acute retention of urine
• Hydatidiform mole
11. 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
12. 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
13. 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
14. The management of miscarriage
• Conservative
• Reassurance and TLC
• No role of bed rest
• ERPOC
15. 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
16. 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
17. 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
18. 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
19. First trimester pain
• Hydatidiform mole
• Pain in lower abdomen due to
– Overdistention of uterus
– Concealed haemorrhage
– Perforation
– Infection
20. 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
21. Mid trimester pain
• Red degeneration of fibromyoma
• Causes mild to severe pain. Tenderness
present over fibroid
• USS detects fibroid
• Conservative treatment with analgesics
22. 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
23. Mid trimester pain
• Acute polyhydrominos
• Pain due to over distention
• Diagnosed clinically & by USS