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Abdominal pain in pregnancy
Dr.Rupa Rajshekar MBBS, MD
Specialist in Obs & Gyne
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
• A 22 year old Para-1 with 6-8 weeks gestation presents with abdominal pain
What are you thinking of???
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
Think ectopic
• Vital signs• B-HCG – quantitative• Pelvic ultrasound• Admission
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
Treatment of ectopic pregnancy
• Medical with Methotrexate• Surgical – Laparotomy/Laparoscopy
» salphingostomy / salphingectomy
Is it Ovarian?
• Corpus luteum cysts:– Mild aching pain– Usually asymptomatic – Maternal pulse in not raised– Hemorrhage inside cyst can cause severe pain
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
First trimester pain
• Abortion• Pregnancy in rudimentary horn• Acute salpingitis• Acute retention of urine• Hydatidiform mole
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
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
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
The management of miscarriage
• Conservative• Reassurance and TLC• No role of bed rest• ERPOC
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
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
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
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
First trimester pain
• Hydatidiform mole• Pain in lower abdomen due to – Overdistention of uterus– Concealed haemorrhage– Perforation– Infection
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
Mid trimester pain
• Red degeneration of fibromyoma• Causes mild to severe pain. Tenderness
present over fibroid• USS detects fibroid• Conservative treatment with analgesics
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
Mid trimester pain
• Acute polyhydrominos• Pain due to over distention• Diagnosed clinically & by USS