1. Abdominal Pain DuringPregnancyProf. M.C. Bansal MBBS.,MS. FICOG ., MICOG.Ex . Principal & controller Jhalawar Medical College & Hospital & M.G.M.C & Hospital . Sitapura ., Jaipur .

2. Incidence - 5-10 % pregnant women get admitted or seek medical consultation for acute pain abdomenother than labor pains in UK. Hospitals.About 30% of patients do not receive a specific diagnosis despite having a series of clinical investigations. Term Acute abdominal pain used to describe apatient with sudden onset of sever symptomsrelated to abdomen and its contents 3. Acute abdomen may be due to pathological changes& may require urgent surgical intervention. Pain may be visceral, somatic or referred, all of whichmay require different interventions.. 4. Varieties of acute Abdominal pain :---(a) Somatic pain ,transmitted through the somaticnerve fibers from the parietal peritoneum , may becaused by physical or chemical irritation of theparietal peritoneum .The pain feels sharp ,verylocalized and constant until the cause is removed . 5. Varieties of Abdominal Pain--(b) Visceral pain is transmitted through autonomicnerves . Quality of perceived pain is different, beingdull, some times described like cramps .It may bedescribed by women just like before the start of aperiod.(c) Referred pain is arising from pathologically affected organ site other than abdominal organs also and is distributed according to somatic nerve distribution. 6. Clinical Approach Precise history may put a lot of pieces of diagnosticpuzzle .quite often patient holds the key to the correctdiagnosis , but needs to be given the chance to answerthe right question. The history should include the timing , nature of its onset, radiating features plus any aggravating or relievingfactors. Doctor needs to know whether patient has constant,intermittent or colicky pain. 7. Clinical Approach- A full Gynae-obstetrical history should be taken in orderto know exact period of gestationask for All medicines prescribed or taken includingrecreational drugs. Long term therapy with prednisolon should alert theclinician to the possibility of upper GI perforation. H/o all symptoms particular reference to the respiratory,cardiac , alimentary and renal systems. It is always best to think beyond your own specialty. Always remember that common things happen morecommonly. 8. Clinical examination Physical examination should have commenced throughobservation during history taking , noting any dyspnoea duringconversation and seeing whether the patient stays still or isunable to get comfortable in any position. Note down all Vital Signs. Despite the abdominal pain examine heart and lungs, otherwisebasal pneumonia, pleurisy and atrial fibrillation leading tomesenteric artery thrombosis may be missed . Look for anyerythematous streaks / vesicles. Absent abdominal wall excursion with breathing is suggestive ofperitonitis. 9. Clinical Examination- Abdominal palpation should commence distant to themost painful area (abdominal quadrant) . Abdominal rigidity/ Guarding / rebound tendernessand increased pain on coughing indicatesperitonitis. All hernia sites are to be examined. Abdominal obstetrical examination should be donegentally to exclude Acute Hydraminose, accidentalhemorrhage, Rupture uterus, rectus musclehematoma, labor pains and rupture ectopic in earlypregnancy. 10. Clinical Examination- AuscultationIt gives very vital information . Active bowel sounds with normal pitch often excludes active intra peritoneal disease. Such patient may have self limiting Gastroenteritis. High frequency bowel sounds in runs or clusters suggest bowel obstruction. Totally silent abdomen indicates paralytic ileus. FHS also needs recording. 11. Investigations Routine CVC,ABO Rh Grouping, Urine Analysis ImagingUSG / USG X Ray chest and Flat abdomen in erect standing position to see Air under diaphragm. (Exposure to radiation during pregnancy carries less risk than the intestinal perforation.) C T poses more radiation hazards. 12. Causes of abdominal pain InRelation to Site of symptoms :Abdominal Quadrants.Epigastrium(a) Stomach- dyspepsia, gastritis, gestro oesophageal reflux ,gastric volvulus, ulcer , carcinoma(b) Small Bowel duodenal ulcer.(c) Oesophagus-tear, rupture, ulcer,(d) Gall Bladder- Cholelithiasis, colic.(d) Pancreatitis- alcohol, gall bladder disease , bulimia(e) Giardiasis (f ) Vascular- visceral ischemia , aortic aneurism, splenicartery aneurism.(g) Abdominal Wall- epigastric hernia (strangulated). 13. Referred Pain to theEpigastrium Inferior Myocardial infarction. Myocardial Ischemia. Pericarditis. Basal Pneumonia. 14. Central / Umbilical Bowel Irritable bowel syndrome (IBS), Initialappendicitis-pain, Obstruction, Crohns disease. Pancreatitis. Vascular-mesentery artery thrombosis , aorticaneurism. Abdominal Wall umbilical hernia. 15. Left Upper Quadrant /Hypochondrium( a) Stomach-gastritis ,ulcer , carcinoma.( b) Pancreas-pancreatitis , carcinoma.( c ) Large bowel- perforation , diverticulitis( D )Spleen leukemia , lymphoma , infarct,rupture ,infectious mono nucleosus ,malaria ,kalajar( E ) Kidney pyelonephritis ,hydro nephrosis,calculi .( F ) Viral Herpes Zosters( g ) Referred----lungLeft lower lobe pneumonia, pulmonary embolism. Cardiac-ischemia or infarction. 16. Right Upper Quadrant/hypochondrium. (a ) Gall Bladder-billiary colic ,cholicystits , carcinoma. ( B )Liver right heart failure ,hepatic veinthrombosis,carcinoma ,abscess , Hellp syndrome ( c ) Small bowel ulcer Perforation . ( D) Large bowel Crohn disease. ( E ) Pancreas-=pancreatitis ,carcinoma. ( F ) Kidney- pyelonephritis ,hydronephrosis , calculi . ( G ) Viral-hrepes Zoster . ( H ) Referred from-right lower lobe pneumonia ,pulmonary embolism ,cardiac ischemia or infarction . 17. Iliac Fosse Bowel constipation ,gastroenteritis , colitis ,IBS ,obstruction , carcinoma , perforation . Reproductiveectopic pregnancy ,ovarian cystsaccident ,PID ,mittlesmerz. Abdominal wall- hernia : inguinal femoral , psoasabscess. Urological-cystitis ,ureteric colic . Vascular aneurism . Viral herpes zoster. 18. Medical Causes of diffuse /generalized Abdominal Pain . Pneumonia. Diabetic Ketoacidosis . Henochs Purpura. Sickle cell crisis . Acute intermittent porphyria. Familial Meditterrean Fever Paroxysmal peritonitis . Lead poisoning . Infection- malaria , Typhoid Fever ,Cholera , giardiasis. Drugs-Heroin withdrawal . 19. Cause of Abdominal pain inPregnancy. Essentially the causes may be divided in to : Those due to Pregnancy . Those related to Reproductive system . Other causes listed before . 20. Obstetrical / gynecologicalcauses of pain AbdomenFirst Trimester Abortion ,Ectopic Pregnancy , vesicular mole , Epigastria pain / heart burn in Hyper emesis Gravidarum ,Twisted ruptured ovarian Cyst , Acute retention of urine , Septic induced abortion .Second Trimester Sudden onset of poly hydramnios.Third Trimester PROM ,Premature L.P. , True labor pains , Hellp syndrome , impending Eclampsia ,Premature placental separation with or without revealed Hemorrhage, threatened /rupture uterus .torsion of uterus , Red degeneration of fibroid ,Spontaneous rupture of uterine / infundibular- pelvic vessels (Rare) .Post natal Period- Post partum Eclampsia , Pelvic vein thrombosis ,sepsis of reproductive organs and peritonitis , Acute inversion of uterus , Infection /torsion of ovarian cyst or uterine fibroid . 21. Clinical management Relevant history , thorough clinical examination ,necessary investigation and consultation withPhysician and /or general surgeon will help inreaching the final diagnosis. Start anti shock therapy immediately, if it is present. Conservative or operative treatment should bestarted earliest so as to minimize immediate lifethreatening events to mother as well as fetus. 22. Thank you