Abd Pain Pregnancy

ABDOMINAL PAIN IN ABDOMINAL PAIN IN PREGNANCYPREGNANCY

Augustinus BTAugustinus BT

A 22 yr old para 1 with 6-8 wks gestation A 22 yr old para 1 with 6-8 wks gestation presents with abdominal pain.presents with abdominal pain.

WHAT ARE YOU THINKING WHAT ARE YOU THINKING OF ?OF ?

The historyThe history

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

Mild bleeding p/vMild bleeding p/v

Some chest pain and shoulder tip painSome chest pain and shoulder tip pain

Has been feeling faintHas been feeling faint

Pregnancy test positivePregnancy test positive

THINK ECTOPICTHINK ECTOPIC

VITAL SIGNSVITAL SIGNS

B HCG – QUANTITATIVEB HCG – QUANTITATIVE

URGENT PELVIC USSURGENT PELVIC USS

REFER/ADMIT TO HOSPITALREFER/ADMIT TO HOSPITAL

ECTOPIC PREGNANCYECTOPIC PREGNANCYPit falls in diagnosisPit falls in diagnosis

Wide variation in clinical presentationWide variation in clinical presentation

Pregnancy test can be negative at times of Pregnancy test can be negative at times of diagnosis. ( However it must have been positive diagnosis. ( However it must have been positive at some time or another).at some time or another).

TV USS even at the best of hands is only 50% TV USS even at the best of hands is only 50% accurate in picking up an ectopic pregnancy.accurate in picking up an ectopic pregnancy.

B HCGs can double in very early ectopicsB HCGs can double in very early ectopics

Doubling time varies from 1.4 to 7.2 days Doubling time varies from 1.4 to 7.2 days depending on gestationdepending on gestation

Mx of Ectopic PregnancyMx of Ectopic Pregnancy

Medical with Methotrexate with or without Medical with Methotrexate with or without folinic acid.folinic acid.

Surgical – laparotomy and laparoscopySurgical – laparotomy and laparoscopy

salpingostomy andsalpingostomy and

salpingiectomysalpingiectomy

Follow up and prognosisFollow up and prognosis

IS IT OVARIAN ?IS IT OVARIAN ?

Corpus luteum cysts and accidentsCorpus luteum cysts and accidents

Mild aching painMild aching pain

Usually asymptomaticUsually asymptomatic

Maternal pulse is not raisedMaternal pulse is not raised

Hemorrhage inside cyst can cause severe Hemorrhage inside cyst can cause severe painpain

ADNEXAL TORSIONADNEXAL TORSION

More common in pregnancy ( 28%)More common in pregnancy ( 28%)Lateral lower quadrant pain- sudden onsetLateral lower quadrant pain- sudden onsetFever ,leucocytosis, nausea, vomitingFever ,leucocytosis, nausea, vomiting

UNRELIABLE IN PREGNANCYUNRELIABLE IN PREGNANCYUSS – no flow on colour mappingUSS – no flow on colour mappingSurgery should not be delayedSurgery should not be delayedMiscarriage and preterm labour are common Miscarriage and preterm labour are common consequencesconsequencesDifficult to differentiate from ectopics and Difficult to differentiate from ectopics and appendicitisappendicitis

A 22 yr old para 1 with 6-8 wks amenorrhea A 22 yr old para 1 with 6-8 wks amenorrhea presents with abdominal painpresents with abdominal pain

The history changes:The history changes:

Crampy lower abdominalCrampy lower abdominal

Heavy bleeding p/vHeavy bleeding p/v

Speculum examinationSpeculum examination

cx os closedcx os closed

cx os opencx os open

DIAGNOSIS - ? MISCARRIAGEDIAGNOSIS - ? MISCARRIAGE

Assess hemodynamic stabilityAssess hemodynamic stability

Arrange pelvic ultrasoundArrange pelvic ultrasound

Management depends on Management depends on ultrasonographic findings.ultrasonographic findings.

No role of BhcgsNo role of Bhcgs

Blood group, Rhesus and anti-D if Blood group, Rhesus and anti-D if necessarynecessary

SOME USS FINDINGSSOME USS FINDINGS

An intrauterine gestational sac seen 25X30 mm An intrauterine gestational sac seen 25X30 mm in diameters. No fetus visible.in diameters. No fetus visible.An IU gestational sac seen 20 X 20 mm in An IU gestational sac seen 20 X 20 mm in diameter. Fetal pole seen 4 mm CRL. No FH diameter. Fetal pole seen 4 mm CRL. No FH identified.identified.An IU gestational sac seen 20X 20 mm in An IU gestational sac seen 20X 20 mm in diameter ,FP seen 6 mm CRL. No FHdiameter ,FP seen 6 mm CRL. No FHAn IU gestational sac seen 35X35 mm in An IU gestational sac seen 35X35 mm in diameters low down in the cavity. FP seen . FH diameters low down in the cavity. FP seen . FH seen but appears slow.seen but appears slow.

THE MANAGEMENT OF THE MANAGEMENT OF MISCARRIAGEMISCARRIAGE

ConservativeConservative

Reassurance and TLCReassurance and TLC

No role of bed restNo role of bed rest

ERPOCERPOC

MISCARRIAGEMISCARRIAGE

ALWAYS CONFIRM A POSSIBLE ALWAYS CONFIRM A POSSIBLE COMPLETE MISCARRIAGE BY SERIAL COMPLETE MISCARRIAGE BY SERIAL BHCGS.BHCGS.

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

PITFALL : You might miss an ECTOPICPITFALL : You might miss an ECTOPIC

Lower abd pain with dysuriaLower abd pain with dysuria

Acute cystitis occurs in 1-2% of pregnant Acute cystitis occurs in 1-2% of pregnant womenwomenAcute pyelonephritis is a serious Acute pyelonephritis is a serious complicationcomplicationUsually happens in 2Usually happens in 2ndnd and 3 and 3rdrd trimester trimesterAsymptomatic bacteriuria is a Asymptomatic bacteriuria is a predisposing factorpredisposing factorMay result in Preterm labourMay result in Preterm labourUrine testing is mandatoryUrine testing is mandatory

UTERINE FIBROIDSUTERINE FIBROIDS

10 % of women with fibroid uterus 10 % of women with fibroid uterus experience abdominal painexperience abdominal pain

Hemorrhagic infarction – red degenerationHemorrhagic infarction – red degeneration

Localized pain – may mimic placental Localized pain – may mimic placental abruption or uterine ruptureabruption or uterine rupture

Maternal and fetal risks are due to Maternal and fetal risks are due to incorrect diagnosis and delay in treatmentincorrect diagnosis and delay in treatment

ROUND LIGAMENT PAINROUND LIGAMENT PAIN

10-30% OF PREGNANCIES10-30% OF PREGNANCIES

Commonly towards the beginning and the end of Commonly towards the beginning and the end of pregnancypregnancy

More in multipsMore in multips

Said to be due to stretching of round ligamentsSaid to be due to stretching of round ligaments

Cramplike or stabbing and made worse with Cramplike or stabbing and made worse with movementmovement

Some tenderness in the lower quadrant and Some tenderness in the lower quadrant and groingroin

CAUSES RELATED TO CAUSES RELATED TO PREGNANCYPREGNANCYA SUMMARYA SUMMARY

ECTOPIC PREGNANCYECTOPIC PREGNANCY

MISCARRIAGEMISCARRIAGE

URINARY TRACT INFECTIONURINARY TRACT INFECTION

ADNEXAL MASSES AND TORSIONADNEXAL MASSES AND TORSION

ROUND LIGAMENT PAINROUND LIGAMENT PAIN

FIBROID DEGENERATIONFIBROID DEGENERATION

A historyA history

22 yrs old 122 yrs old 1stst pregnancy presents with right pregnancy presents with right sided abdominal pain for about 2 days. It sided abdominal pain for about 2 days. It started with a vague pain in the started with a vague pain in the epigastrium and is now constant on the rt epigastrium and is now constant on the rt side. She is about 26 wks pregnant and side. She is about 26 wks pregnant and there is no vaginal bleeding. Her 20 wk there is no vaginal bleeding. Her 20 wk scan was “normal”.scan was “normal”.

WHAT ELSE WOULD YOU LIKE TO WHAT ELSE WOULD YOU LIKE TO KNOW?KNOW?

APPENDICITISAPPENDICITIS

Most common cause of acute abdomen in Most common cause of acute abdomen in pregnancypregnancy

Challenging diagnosisChallenging diagnosis

Balance the risk of surgical delay Balance the risk of surgical delay associated morbidity with effects of associated morbidity with effects of surgery on mother and fetussurgery on mother and fetus

Decision to operate on clinical groundsDecision to operate on clinical grounds

20-35% rate of negative laparotomy20-35% rate of negative laparotomy

APPENDCITIS - DIAGNOSISAPPENDCITIS - DIAGNOSIS

Appendix is progressively displaced Appendix is progressively displaced upwards after 12 wks and reaches iliac upwards after 12 wks and reaches iliac crest at 24 wks.crest at 24 wks.Single most reliable symptom in Single most reliable symptom in pregnancy is RIF painpregnancy is RIF painAnorexia, vomiting, rebound , guarding are Anorexia, vomiting, rebound , guarding are not specific in pregnancynot specific in pregnancyLeucocytosis is NOT helpful.Leucocytosis is NOT helpful.< 10,000 leucocyte may be reassuring< 10,000 leucocyte may be reassuring

APPENDICITIS - DIAGNOSISAPPENDICITIS - DIAGNOSIS

Graded compression ultrasonographyGraded compression ultrasonography

accurate in 1accurate in 1stst and 2 and 2ndnd trimesters , difficult trimesters , difficult in 3in 3rdrd..

98% ACCURATE.98% ACCURATE.

APPENDICITIS- APPENDICITIS- CONSEQUENCESCONSEQUENCES

High fetal loss rate if perforation occurs High fetal loss rate if perforation occurs (20%)(20%)

Maternal mortalityMaternal mortality

Mortality of delayMortality of delay

Risk of perforation highest in 3Risk of perforation highest in 3rdrd trimester trimester

Premature labour esp in the 1st week after Premature labour esp in the 1st week after surgerysurgery

CHOLECYSTITISCHOLECYSTITIS

22ndnd most common cause of acute most common cause of acute abdomenabdomen

1in 6000 pregnancies1in 6000 pregnancies

Cholelithiasis is the cause in >90% ptsCholelithiasis is the cause in >90% pts

Unclear whether pregnancy predisposes Unclear whether pregnancy predisposes to cholelithiasisto cholelithiasis

CHOLECSYTISTIS CHOLECSYTISTIS SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS

Same as in non pregnant women.Same as in non pregnant women.

Nausea, vomiting, acute colicky pain at Nausea, vomiting, acute colicky pain at mid epigastrium or rightt upper abdomenmid epigastrium or rightt upper abdomen

Murphy’s sign is less common in Murphy’s sign is less common in pregnancypregnancy

Jaundice is rareJaundice is rare

D/D – OC,AFLP & HELLPD/D – OC,AFLP & HELLP

CHOLECYSTITISCHOLECYSTITISDIAGNOSISDIAGNOSIS

Elevated serum levels of bilirubin and Elevated serum levels of bilirubin and transaminasestransaminases

Serum alkaline phosphatase less helpfulSerum alkaline phosphatase less helpful

Cholecystosonography- test of choiceCholecystosonography- test of choice

95% accuracy95% accuracy

CHOLECYSTITISCHOLECYSTITISMANAGEMENTMANAGEMENT

MedicalMedical- particularly in the 3- particularly in the 3rdrd trimester trimesterIV hydration, nasogastric IV hydration, nasogastric suction,narcotics, antibiotics if sepsissuction,narcotics, antibiotics if sepsis

SurgicalSurgical indicated where medical treatment failed indicated where medical treatment failed in 2-3 daysin 2-3 daysLaparoscopic (open) better in terms of Laparoscopic (open) better in terms of fetal survival and Premature labour.fetal survival and Premature labour.

BOWEL OBSTRUCTIONBOWEL OBSTRUCTION

1 IN 2500 TO 3500 DELIVERIES1 IN 2500 TO 3500 DELIVERIES

The cause is adhesions in 70% of cases. The cause is adhesions in 70% of cases. Volvulus is responsible for 25 % of cases. Volvulus is responsible for 25 % of cases. Hernia and intesussceptions are rareHernia and intesussceptions are rare

Usually occurs in the 1Usually occurs in the 1stst pregnancies and pregnancies and third trimester and postpartumthird trimester and postpartum

Morbidity and mortality related to Morbidity and mortality related to diagnostic and therapeutic delay.diagnostic and therapeutic delay.


Commonest misdiagnosis- Hyperemesis gravidarum Commonest misdiagnosis- Hyperemesis gravidarum in 2in 2ndnd and 3 and 3rdrd trimesters trimestersTypical symptoms Typical symptoms

crampy abdominal paincrampy abdominal pain obstipationobstipation vomitingvomiting In cases of high obstruction the period between In cases of high obstruction the period between

attacks is short (4-5min) and is characterized by attacks is short (4-5min) and is characterized by diffuse poorly localized upper abdominal paindiffuse poorly localized upper abdominal pain

Colonic obstruction may manifest as lower abdominal Colonic obstruction may manifest as lower abdominal and perineal pain with longer time intervalsand perineal pain with longer time intervals

BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONCLINICAL FINDINGSCLINICAL FINDINGS

Physical examination Physical examination

Tender distended abdomenTender distended abdomen

Fever, leucocytosis and electrolyte imbalances Fever, leucocytosis and electrolyte imbalances increase the likelihood of intestinal strangulationincrease the likelihood of intestinal strangulation

Upright and flat abdominal films with or without Upright and flat abdominal films with or without contrast.contrast.

Concern regarding the exposure of the fetus to Concern regarding the exposure of the fetus to radiation should be balanced against the risk if radiation should be balanced against the risk if maternal mortality from a failed diagnosismaternal mortality from a failed diagnosis

BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONMANAGEMENTMANAGEMENT

Fluid and electrolyte replacementFluid and electrolyte replacement

Nasogastric bowel decompressionNasogastric bowel decompression

Timely surgeryTimely surgery

ACUTE PANCREATITISACUTE PANCREATITIS

RareRare

Usually late in 3Usually late in 3rdrd trimester or early trimester or early postpartumpostpartum

Cholelithisasiis is the commonest causeCholelithisasiis is the commonest cause

Pregnancy contributes by an increased Pregnancy contributes by an increased abdominal pressure on the biliary ductsabdominal pressure on the biliary ducts

Early recognition and treatment essentialEarly recognition and treatment essential


Signs and symptoms same as in the non Signs and symptoms same as in the non pregnant state.pregnant state.Sudden severe epigastric pain radiating to Sudden severe epigastric pain radiating to the back with nausea and vomiting and the back with nausea and vomiting and fever.fever.Hypoactive bowel sounds and diffusely Hypoactive bowel sounds and diffusely tender abdomentender abdomenMimics preeclampsia, Mimics preeclampsia, DKA,Hepatitis,Cholecystitis.DKA,Hepatitis,Cholecystitis.


Serum amylase and lipase levels increase Serum amylase and lipase levels increase spontaneously in pregnancyspontaneously in pregnancy

Calculation of amylase to creatinine ratio Calculation of amylase to creatinine ratio is more useful in pregnancy.is more useful in pregnancy.

The ratio is usually low in pregnancyThe ratio is usually low in pregnancy

USS is may be neccessaryUSS is may be neccessary

ACUTE PANCREATITIS ACUTE PANCREATITIS MANAGEMENTMANAGEMENT

Classic triad of medical management Classic triad of medical management consists of bowel rest , fluid and consists of bowel rest , fluid and electrolyte management and pain relief.electrolyte management and pain relief.

ERCP and papillotomy are safeERCP and papillotomy are safe

Cholecystectomy after inflammation Cholecystectomy after inflammation subsidessubsides

NONOBSTETRICAL CAUSESNONOBSTETRICAL CAUSES

APPENDICITISAPPENDICITIS

CHOLECYSTITISCHOLECYSTITIS


PANCREATITISPANCREATITIS

LIVER PROBLEMSLIVER PROBLEMS

MISCELLANEOUSMISCELLANEOUS

LIVER DISORDERSLIVER DISORDERS

Acute fatty liver of pregnancyAcute fatty liver of pregnancyUnknown causeUnknown cause1in 10000- 1 in 15000 pregnancies1in 10000- 1 in 15000 pregnanciesLate in 3Late in 3rdrd trimester trimesterConsiderable overlap with HELLP syndromeConsiderable overlap with HELLP syndromeClinical presentation with abd pain, jaundice and Clinical presentation with abd pain, jaundice and HYPEREMESISHYPEREMESISHepatic encephalopathy and coagulopathyHepatic encephalopathy and coagulopathyFetal demiseFetal demise

ACUTE FATTY LIVER OF ACUTE FATTY LIVER OF PREGNANCYPREGNANCY

Early diagnosis essentialEarly diagnosis essential

Cannot be predictedCannot be predicted

Maintain awarenessMaintain awareness

DO AN LFT in a pt presenting with abdominal DO AN LFT in a pt presenting with abdominal painpain

PREECLAMPSIA AND HELLPPREECLAMPSIA AND HELLP

Complication of severe PETComplication of severe PETHemolysis, Elevated liver enzymes, low platelet Hemolysis, Elevated liver enzymes, low platelet countscountsPeriportal hemorrhagic necrosis with Periportal hemorrhagic necrosis with subcapsular hematomasubcapsular hematomaDiagnosis: rt upper quadrant painDiagnosis: rt upper quadrant pain

nausea and vomitingnausea and vomitingheadacheheadacheDBP > 110 mmHgDBP > 110 mmHgProteinuria 2+Proteinuria 2+

HELLPHELLP

Serious complication of PETSerious complication of PETCan manifest at any time but rare before 20 wksCan manifest at any time but rare before 20 wksOccurs more in whites,mutips and >35 yrsOccurs more in whites,mutips and >35 yrsPoor prognosisPoor prognosisIncidence of about 10 % in PETIncidence of about 10 % in PETRecurrence risk of 25%Recurrence risk of 25%Can also develop postnatallyCan also develop postnatallyManaged as severe PETManaged as severe PETPlasma vol exp, thrombolysis, exchange Plasma vol exp, thrombolysis, exchange plasmapheresis, dialysis, steroidsplasmapheresis, dialysis, steroids

A case historyA case history

A 36 yr old para 4 at 38 wks of gestation A 36 yr old para 4 at 38 wks of gestation presents to you with abdominal pain presents to you with abdominal pain mainly near the umbilicus. The pain came mainly near the umbilicus. The pain came on suddenly and is described as sharp on suddenly and is described as sharp and constant. There is some bleeding pv and constant. There is some bleeding pv and she has not felt the baby move for the and she has not felt the baby move for the last 6 hrs.An examination reveals a tender last 6 hrs.An examination reveals a tender area near the umbilicus.area near the umbilicus.

WHAT COULD THIS BE?WHAT COULD THIS BE?

WHAT ARE YOU THINKING OF ?WHAT ARE YOU THINKING OF ?

PLACENTAL ABRUPTIONPLACENTAL ABRUPTION

What would you like to know ?What would you like to know ?

Placental position on USS.Placental position on USS.

History of hypertensionHistory of hypertension

Maternal ageMaternal age

MultiparityMultiparity

SmokingSmoking

Overdistension of uterusOverdistension of uterus

traumatrauma

PLACENTAL ABRUPTIONPLACENTAL ABRUPTION

In late pregnancyIn late pregnancy

0.5- 1 % of all pregnancies0.5- 1 % of all pregnancies

Associated with hypertension, smoking Associated with hypertension, smoking multiple pregnancies, myomasmultiple pregnancies, myomas

Unrelenting pain- sharp or tearingUnrelenting pain- sharp or tearing

Vaginal bleeding may or may not be Vaginal bleeding may or may not be presentpresent

Coagulopathy and fetal death is commonCoagulopathy and fetal death is common

LABOUR PAINSLABOUR PAINS

Uterine contractionsUterine contractions

Regular intervalsRegular intervals

Intervals gradually shortenIntervals gradually shorten

Associated with bac discomfortAssociated with bac discomfort

Associated with cervical changesAssociated with cervical changes

Discomfort not stopped by sedationDiscomfort not stopped by sedation

UTERINE TORSIONUTERINE TORSION

Mild dextrorotation is common(<40 deg)Mild dextrorotation is common(<40 deg)Rarely may progress beyond 90 dextro Rarely may progress beyond 90 dextro produce acute torsion of uterusproduce acute torsion of uterusUsually in the latter half of pregnancyUsually in the latter half of pregnancyFibroids, congenital anomalies, adnexal Fibroids, congenital anomalies, adnexal mass may predisposemass may predisposeMaternal shock and fetal asphyxiaMaternal shock and fetal asphyxiaMx – conservative or laparotomy to correct Mx – conservative or laparotomy to correct torsiontorsion

CHORIOAMNIONITISCHORIOAMNIONITIS

Usually precipitated by PPROMUsually precipitated by PPROM

Other clinical and laboratory featuresOther clinical and laboratory features

ARTERIOVENOUS HGEARTERIOVENOUS HGE

Rupture of uteroovarian veinsRupture of uteroovarian veins

Rupture of aneurysms – splenic, hepatic, Rupture of aneurysms – splenic, hepatic, renal, aorticrenal, aortic

Rapidly progressing shockRapidly progressing shock

PSYCHOLOGICALPSYCHOLOGICAL

Diagnosis of exclusionDiagnosis of exclusion

Commoner in women with known Commoner in women with known psychosocial problemspsychosocial problems

Reporting a high number of ailments Reporting a high number of ailments during antenatal care is commonduring antenatal care is common

Rectus sheath hematomaRectus sheath hematoma

Rupture of inferior epigastric arteryRupture of inferior epigastric artery

May follow a bout of coughing or May follow a bout of coughing or abdominal trauma usually in late abdominal trauma usually in late pregnancypregnancy

Large unilateral painful swellingLarge unilateral painful swelling

Confused with abruptionConfused with abruption

Superficial locationSuperficial location

MISCELLANEOUS CAUSESMISCELLANEOUS CAUSES

SICKLE CELL CRISISSICKLE CELL CRISIS

MALARIAMALARIA

PORPHYRIAPORPHYRIA

DIABETIC KETOACIDOSISDIABETIC KETOACIDOSIS

THANKTHANK

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Abd Pain Pregnancy

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