ABDOMINAL PAIN IN PREGNANCY (CONTINUED)

BY: REEM THEAB , SIXTH YEAR MEDICAL STUDENT.

Gynecological

Medical

Surgical

GYNECOLOGICAL CAUSES

• complications related to adnexal masses

• ovarian torsion

• Leiomyomas

(both have a higher incidence during pregnancy)

ADNEXAL MASS

• occur in approximately 2% of all pregnancies .

with 65% of these masses being asymptomatic and discovered incidentally on physical examination or

sonography(are not a usual cause of pain,)

• Functional cysts(The most common during pregnancy).

• Corpus luteum cyst in early pregnancy may bleed causing pain or rupture causing shock.

• Mostly diagnosed by ultrasound or bimanually if large.

• Managed mostly conservatively, but if they are large or showing abnormal pathology they should be

removed after 14 weeks.

OVARIAN TORSION

• Approximately 1 in 1800 pregnancies is complicated by adnexal torsion, typically between the

sixth and fourteenth weeks of gestation.

This increased frequency in pregnant women is likely due to greater laxity of the tissues

adjoining the ovaries and oviducts during pregnancy, as well as to enlargement of the ovary in

early pregnancy secondary to the corpus luteum cyst.

• typically presents with lateralized lower abdominal pain, frequently accompanied by nausea,

vomiting, low grade fever, and/or leukocytosis. (the pain may become constant indicating

ischemia).

A presumptive diagnosis of torsion can be in the presence of acute pelvic pain and an adnexal mass with a

sonographic appearance (including Doppler studies) consistent with torsion and after exclusion of other

conditions.

A definitive diagnosis requires direct visualization of a rotated ovary at the time of surgery for evaluation and

treatment (untwisting of the ovary).

Fibroid degeneration or torsion

The majority of fibroids remain asymptomatic in pregnancy.

Degeneration may occur, and is more common with leiomyomas >5 cm in diameter.

Most patients have only localized pain,

although mild leukocytosis, fever, peritoneal signs, and nausea and vomiting can occur.

Pedunculated fibroids are at risk of torsion; symptoms are similar to those with

degeneration.

Fibroids are readily

identified on ultrasound

examination. Pain after

ballottement by the

abdominal ultrasound

probe directly over the

fibroid supports the

diagnosis.

MEDICAL CAUSES

• Urinary tract infection

urinary tract changes in pregnancy predispose women to infection:

. Ureteral dilation is seen due to compression of the ureters from the gravid uterus

. Hormonal effects of progesterone also may cause smooth muscle relaxation.

- Organisms causing UTI in pregnancy are the same uropathogens which commonly cause

UTI in non-pregnant patients. Escherichia coli is the most common organism isolated

Signs and symptoms of a UTI include: burning or painful urination, suprapubic pain, frequent

urination ,fever

Treatment of asymptomatic bacteriuria in pregnant patients is important because of the

increased risk of urinary tract infection (UTI) and its associated sequelae, including

increased risk of pyelnonephritis, preterm delivery, and low birth weight.

Recurrent Cystitis: Pregnant women who have three

or more episodes of cystitis or bacteruria.

should be started on daily antibiotic prophylaxis for the

remainder of pregnancy.

Regimens includes: nitrofurantion 100 mg nightly, or

cephalexin 250-500 mg nightly.

ACUTE PYELONEPHRITIS

• This is one of the most common serious medical complications of pregnancy.

• Symptoms.: shaking chills, anorexia, nausea, vomiting, and flank pain.

Signs; Include high fever, tachycardia, and costovertebral angle tenderness (R>L)

• Severe cases are complicated by sepsis, anemia, Preterm labor and delivery can occur.

• Diagnosis.:Confirmed with a positive urine culture showing >100 K CFU of a single

organism

• Treatment:Hospital admission, generous IV hydration, parenteral antibiotics e.g., ceftriax-

one, and tocolysis as needed

Daily antibiotics should also be considered in pregnant women after one

episode of pyelonephritis.

HYDRONEPHROSIS

• Common physiologic condition in pregnancy , disappears rapidly after birth.

• Most commonly occurs after the 20th week of gestation , being more pronounced in

primigravidae.

• Dilation only seen above the linea terminalis , and is more frequently right sided.

• Compression of the ureters by the uterus (causing hydronephrosis) can result in acute

attacks of pain triggered by ureteral obstruction.

ACUTE FATTY LIVER

• This is a rare life-threatening complication of pregnancy that usually occurs in the third

trimester.

• Prevalence is 1 in 15,000. Maternal mortality rate is 20%.

• It is thought to be caused by a disordered metabolism of fatty acids by mitochondria in

the fetus, caused by deficiency in the long-chain 3-hydroxyacyl-coenzyme A

dehydrogenase (LCHAD) enzyme.

Findings: Symptom onset is gradual, with nonspecific flu-like symptoms including nausea, vomiting,

anorexia, and epigastric pain

.• Jaundice and fever may occur in as many as 70% of patients

.• Hypertension, proteinuria, and edema can mimic preeclampsia

.• This may progress to involvement of additional systems, including acute renal failure,

pancreatitis, hepatic encephalopathy, and coma.

Laboratory findings : -moderate elevation of liver enzymes (e.g., ALT, AST, GGT), hyperbilirubinemia, DIC

.-Hypoglycemia and increased serum ammonia are unique laboratory abnormalities

Management: Intensive care unit stabilization with acute IV hydration and monitoring is essential

Prompt delivery is indicated.

Resolution follows delivery if mother survives.

DIABETIC KETOACIDOSIS

• Nausea or vomiting, Abdominal pain, Polyuria or polydipsia ,Change in mental status Hyperventilation

(Kussmaul breathing,Abnormal fetal heart tracing.

• Investigation:

• Positive serum/urine ketones,hyperglycaemia (≥ 11.0 mmol), but DKP can occur at lower glucose levels

Low serum bicarbonate (<15 mEq/l) ,Arterial pH ≤7.30 Anion gap >12 Elevated base deficit ≥4 mEq/l

Potassium level may be falsely normal/elevated

• Approach:IV fluid therapy, IV insulin therapy, Electrolyte correction,Evaluation of the need for

bicarbonate administration,

Identification and treatment of any precipitating factors

Monitoring of maternal and fetal responses

GERD

• Most pregnant women have symptoms of gastroesophageal reflux disease (GERD),

• More common in late pregnancy ,multiple pregnancy , polyhydraminois

• Due to hormonal effects(relaxing lower esophageal sphincter). And as the uterus grows,

it pushes on the stomach. This can sometimes force stomach acid up into the esophagus.

• Change eating habits(eat several small meals instead of two or three large meals),

Medications: cimetidine, ranitidine, omeprazole or lansoprazole.

SURGICAL CAUSES

• Acute appendicitis

• Incidence of appendicitis for pregnant is the same for the non-pregnant

• Appendicitis is the most common cause of the acute surgical abdomen during pregnancy.

• Symptoms and signs may be atypical.

• Pain may be in the right lumbar region in early gestationor in the right hypochondrium in late

pregnancy due to displacement of cecum and appendix by the gravid uterus.

• Accompanied by nausea , vomiting ,anorexia , fever (however these may be absent in late

pregnancy)

Leukocytosis is an important sign but due to physiologic leukocytosis in pregnancy , serial count is

more useful.

Pyrexia , tenderness , guarding over right abdomen may be the only signs present.

Graded compression ultrasonography is the first-line modality.

The primary goal of imaging is to reduce delays in surgical intervention due to diagnostic

uncertainty. A secondary goal is to reduce, but not eliminate, the negative appendectomy rate.

Once necessary, never postpone appendectomy.

In pregnancy the appendix position is atypical so its confused with right ovarian torsion .

The inflamed appendix may induce preterm labor.

GALL STONES DISEASE

• Pregnancy predisposes to formation of gallstone(due to biliary stasis and increased

cholesterol).

• Most women are asymptomatic.

• Ultrasonography is the most reliable method for making the diagnosis of gallstones and acute

or chronic cholecystitis.

• Pyrexia differentiates acute cholecystitis from biliary pain

tx: conservative , laproscopic surgery can be done in early pregnancy

ACUTE PANCREATITIS

• Acute pancreatitis is a rare complication of pregnancy; most cases are related to gallstone

disease. Almost all patients have acute and persistent upper abdominal pain, which may

radiate to the back, may be relieved with leaning forward, and may be accompanied by

fever and postprandial nausea and vomiting

• The range of normal serum amylase and lipase levels are similar in healthy pregnant and

nonpregnant women; significantly elevated values should be considered pathologic.

Ultrasound can be used to look for choledocholithiasis and pseudocyst formation. If

further imaging is needed, MR may be helpful

Tx: iv fluid , electrolyte correction , analgesics