Abdominal Pain in Pregnancy

REVIEW
Abdominal pain in signs of certain non-obstetric pathologies such as appendicitis.

Failure to recognize the altered presentation of these common
pregnancy: a rational pathologies (i.e. appendicitis) may result in delayed diagnosis,

leading to rupture and/or peritonitis and thereby, increasing
approach to management maternal morbidity and mortality.

A systematic and rational, multi-disciplinary approach is
essential to exclude both obstetric and non-obstetric causes of
Ana Pinas-Carrillo abdominal pain (Table 1) to avoid delays in diagnosis.
Edwin Chandraharan It is also important to bear in mind the gestational age whilst
assessing abdominal pain in pregnancy, as there are certain pa-
thologies which are specific to each trimester of pregnancy.
Abstract Whilst common causes of abdominal pain during the first
trimester include miscarriage or ectopic pregnancy, as the preg-
Abdominal pain is the most frequent complaint amongst pregnant
nancy advances, the most common obstetric causes are the onset
women throughout pregnancy and occurs in all three trimesters.
of uterine contractions (preterm or term labour, uterine irrita-
Although, most commonly it is secondary to the anatomical, physio-
bility secondary to chorioamnionitis), uterine rupture or a
logical, biochemical changes during pregnancy, it is essential to
placental abruption. Rarely, polyhydramnios may present with
approach every case in a systematic manner. It is essential to exclude
abdominal pain.
pathological causes of pain, both obstetric and non-obstetric, so as to
improve outcomes.
The challenges during pregnancy include the anatomical changes Obstetric causes of abdominal pain in early pregnancy
causing displacement of the intra-abdominal organs by the gravid
The most common obstetric causes of abdominal pain in early
uterus and consequently, the absence or modification of the “clas-
pregnancy include miscarriage, ectopic pregnancy and ovarian
sical” symptoms and signs as well as the physiological changes
hyperstimulation syndrome.
which alter the normal ranges of blood tests. In addition, anatomical
distortion secondary to a gravid uterus may lead to difficulties in inter-
Miscarriage
preting the results of radiological investigations, the presence of a
A miscarriage in the first trimester presents with a ‘period-like
fetus may pose a clinical dilemma with regard to performing tests
pain’ or ‘cramping’ pain, usually accompanied by spotting or
and investigations. This is because some investigations may have
frank vaginal bleeding.
an adverse impact on fetal wellbeing, and, any delay in performing
On vaginal examination, the cervical os may be open in an
these investigations in a timely manner so as to safeguard the fetus
inevitable or an incomplete miscarriage and products of
may increase the risks of complications to the mother.
conception can often be seen within the cervix or inside the
Keywords ectopic pregnancy; miscarriage; placental abruption; vagina. An ultrasound will help to diagnose the presence of an
preterm delivery; uterine rupture intrauterine pregnancy and its viability and hence, will help
differentiate between a missed, inevitable or complete miscar-
riage. If a complete miscarriage is diagnosed, generally no further
Introduction management is required. However, if there is an incomplete
Abdominal pain is the most frequent complaint during preg- miscarriage and ongoing heavy bleeding the patient may require
nancy. Although, often it may be related to anatomical, physio- emergency evacuation of the remaining retained products. A
logical, biochemical and positional changes during pregnancy, it missed miscarriage can be managed medically or surgically
is essential to rule out ‘pathological’ obstetric and non-obstetric depending on gestational age, clinical picture and patient’s
causes. preference.
The rapid expansion of the uterus results in the stretching of
the supporting ligaments (round ligaments) causing ‘physiolog- Ectopic pregnancy
ical’ abdominal pain. This expansion also causes displacement Ectopic pregnancy is defined as the presence of a pregnancy
and/or compression of several intra-abdominal organs (e.g. outside the uterine cavity (most commonly in the Fallopian
bowels, stomach, omentum and urinary tract). These changes in tubes). It may present with subtle symptoms such as mild
the anatomical location of these intra-abdominal organs may abdominal pain, typically unilateral associated with vaginal
result in the absence or variation of the ‘classical’ symptoms and spotting. On abdominal examination, there is unilateral iliac
fossa tenderness and occasionally, cervical excitation and
adnexal tenderness may be noted. A bimanual palpation may
suggest a uterine size that is less than the period of amenorrhoea.
Ana Pinas-Carrillo LMS is a Consultant Obstetrician at St. George’s If there is a ruptured ectopic pregnancy with haemoperitoneum,
University Hospitals NHS Foundation Trust, London, UK. Conflicts of the patient usually presents with a sharp, stabbing abdominal
interest: none declared. pain and varying degrees of haemodynamic instability, ranging
from changes in pulse rate or blood pressure to maternal
Edwin Chandraharan MBBS MS (Obs & Gyn) DFSRH DCRM FSLCOG FRCOG
is Labour Ward Lead Consultant at St. George’s University Hospitals collapse.
NHS Foundation Trust, London, UK. Conflicts of interest: none An empty uterine cavity on ultrasound with a b-hCG >1500
declared. IU/L should arouse a strong suspicion of an ongoing ectopic
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 27:4 112 Crown Copyright Ó 2017 Published by Elsevier Ltd. All rights reserved.
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REVIEW
Causes of acute and chronic abdominal pain and suggested investigations

Type of onset Clinical conditions Suggested investigations (Based on
differential diagnosis)
Acute (within minutes Obstetric Imaging

or few hours) Placental abruption Obstetric ultrasound
Impending or actual scar rupture Abdominal ultrasound
Adnexal torsion MRI scan abdomen
Hepatic rupture (HELLP) Chest X-ray
Pregnancy associated sickle cell crisis Abdominal X-ray
Non-obstetric V/Q scan or CTPA
Gastro-intestinal Cardiac ECHO
Acute appendicitis Blood tests
Acute gastritis Full blood count
Perforated peptic ulcer CRP
Acute mesenteric infarction Urea & electrolytes
Strangulated hernia Renal function tests
Volvulus Liver function tests
Acute pancreatitis Serum amylase
Biliary colic Serum tryptase
Diverticulitis Blood gases
Urinary system Coagulation profile
Ureter colic Blood culture
Renal colic Others
Calculi High and low vaginal swabs
Vascular and extra-pelvic Urine (MSU) for microscopy and culture)
Ruptured thoracic/abdominal aortic aneurysm ECG
Pulmonary embolism CT chest
Acute myocardial infarction Consider multi-disciplinary input
Chronic (over few Obstetric Anaesthetists
hours/days) Chorioamnionitis Physicians
Threatened preterm labour Surgeons
Non-obstetric Cardio-thoracic
Appendicitis Hepatologists
Mesenteric lymphadenitis Gastroenterologists
Strangulated hernia Haematologists
Chronic pancreatitis
Chronic peptic ulcer disease
Inflammatory bowel disease
Chronic cystitis and urinary retention
Table 1
pregnancy, and a careful adnexal examination may show a tubal some cases oliguria. Severe cases can be life-threatening and
ectopic pregnancy on ultrasound. immediate senior input is required. In these cases, admission to
Management can be conservative or medical (methotrexate) if hospital is required and management is supportive with correc-
the patient is stable and there is no haemoperitoneum or signs of tion of intravascular dehydration, replacement of albumin, daily
haemodynamic instability. Surgical management is indicated in weight and thromboprophylaxis.
cases of ruptured ectopic pregnancy, maternal haemodynamic
instability or if an embryo and cardiac activity are seen on Complication of ovarian cyst
ultrasound.
Ovarian cysts may be found incidentally during the first trimester
Ovarian hyperstimulation syndrome (OHSS) ultrasound. They complicate in 1 in 1000 pregnancies and these
Ovarian hyperstimulation occurs in relation to assisted repro- cysts are most commonly benign (Figure 1). They often present
duction treatment, such as gonadotropins. It is a systemic con- with intermittent and unilateral abdominal pain. Other symp-
dition secondary to the production of vasoactive substances. toms include nausea, vomiting and general malaise. Ovarian
Symptoms include an acute abdominal pain and rapid abdominal torsion occurs more commonly on the right side due to the
distension (secondary to ascites), headache, vomiting and in presence of the sigmoid colon on the left side that limits the space
REVIEW
Figure 1 Note the simple ovarian cyst identified during an elective Figure 2 Torsion and subsequent degeneration of a pedunculated
caesarean section. fibroid during pregnancy which necessitated an emergency laparot-
omy and myomectomy.
for torsion. On abdominal examination, iliac fossa tenderness

can be elicited in the first trimester but in late pregnancy, the subserous pedunculated fibroids and it presents with severe
ovary is pushed upwards into the upper abdomen, making the localized abdominal pain, nausea and vomiting, similar symp-
diagnosis more difficult. toms as a red degeneration. Ultrasound can help in the diagnosis
In early pregnancy, a laparoscopic approach is often possible, as in some cases, it is possible to identify signs of degenerative
however, in the second half of the pregnancy a midline or par- changes (cystic spaces). Management is conservative with
amedian laparotomy are recommended. adequate analgesia.
If there is any suspicion that the cyst may be malignant based on
the features observed on the ultrasound scan, referral to the Ruptured rudimentary horn
oncology team for further imagining and management is indicated. It is an extremely rare complication with dramatic consequences.
The reported incidence is 1 in 76,000 pregnancies, occurring
Gastritis and hyperemesis gravidarum most commonly in the second trimester. The patients present
Gastritis (acute inflammation of the gastric mucosae) and with acute and severe abdominal pain and different degree of
hyperemesis (severe nausea and vomiting in pregnancy) are haemodynamic instability secondary to the haemoperitoneum.
more common during the first trimester and up to the first 16 Ultrasound confirms the presence of intra-abdominal bleeding.
weeks of pregnancy. It usually responds well to fluid replace- Emergency laparotomy is indicated after stabilization of the pa-
ment, antiemetics and H2 blockers. Severe and persistent cases tient with removal of the products of conception and repair of the
can be complicated with MalloryeWeiss tears in the lower ruptured horn (Figure 3).
oesophagus leading to haematemesis and abdominal pain. In
these cases, referral to gastroenterology is indicated, as surgical Obstetric complications presenting with abdominal pain in
management may be needed. late pregnancy
An ultrasound to exclude twin pregnancy and molar preg-
nancy is recommended in cases of severe hyperemesis. Preterm labour
Preterm labour often presents with intermittent abdominal pain
Fibroid degeneration and uterine contractions, preceded or not by preterm rupture of
Complication of fibroids in the forms of torsion or degeneration membranes. On abdominal examination, uterine contractions
(Figure 2) can present during pregnancy. Torsion is possible in may be palpable and on vaginal examination cervical changes
REVIEW
Uterine scar dehiscence/rupture

Uterine rupture has an incidence of 0.5e1% in the presence of a
previous uterine scar. The classic symptoms include a sudden
onset of an acute abdominal pain, often persisting in between
contractions, vaginal bleeding or haematuria if there is involve-
ment of the bladder, easily palpable fetal parts if the fetus has
extruded into the peritoneal cavity and signs of hypovolemic
shock. However, the presence of all the classical symptoms in the
same patient is rare. Although it is more common during estab-
lished labour, in rare cases, it can occur antenatally or even in
the immediate postnatal period.
The earliest sign of uterine rupture is commonly the presence
of abnormal patterns on the CTG such as variable decelerations if
there is a prolapse of the umbilical cord through the dehisced
uterine scar or late or a prolonged deceleration if there is com-
plete rupture and placental separation.
Management includes maternal resuscitation and immediate
delivery followed by repair of the uterus.
Chorioamnionitis
The presence of chorioamnionitis is typically associated with a
history of prolonged rupture of membranes, however it can also
happen with intact amniotic membranes.
The woman usually presents with abdominal pain associated
with systemic symptom and signs of infection such as maternal
tachycardia, pyrexia and offencive vaginal discharge. In severe
cases, signs of septic shock may be present (fever, tachycardia,
tachypnoea, nausea and vomiting, confusion, diarrhoea, hypo-
tension, altered kidney and liver function and high or low white
Figure 3 Rupture of a rudimentary horn which presented with an acute cell count).
abdominal pain and sudden maternal collapse at 16 weeks of Management includes immediate treatment with broad spec-
gestation. trum intravenous antibiotics, fluid resuscitation and expedite
delivery to remove the source of infection. If there are signs of
septic shock, appropriate treatment in a high dependency unit
confirm the suspected diagnosis. Management includes exclusion setting (HDU) should be given including correction of metabolic
of premature rupture of membranes and infection as a cause of acidosis, oxygen, vasopressors, inotropes, corticosteroids and
preterm labour, tocolysis and administration of steroids for fetal mechanical ventilation if required.
lung maturity from 24 to 35 weeks.
Acute polyhydramnios
Placental abruption A sudden increase in amniotic fluid causes uterine distension and
Placental abruption is defined as premature placental separation the patient refers it as a tense abdomen causing breathlessness.
of a normally inserted placenta. The classical symptoms are On examination, the symphysio-fundal height is increased for the
acute and severe abdominal pain, sustained uterine contraction, given gestational age and the abdomen is often ‘tense’. Ultra-
Couvelaire uterus (secondary to the presence of blood into the sound examination confirms the presence of polyhydramnios
myometrium) and vaginal bleeding. However, if there is a con- and in selected cases an amnio-drainage may be indicated to
cealed abruption, vaginal bleeding may be absent. In severe relieve symptoms and to reduce the risk of preterm labour and
cases, the patient can present with signs of hypovolemic shock. placental abruption. The cause of the polyhydramnios needs to
Fetal heart rate may be absent in severe cases due to acute be identified, if possible. Fetal congenital abnormalities, fetal
placental insufficiency caused by the complete separation of the infection and diabetes need to be excluded. Polyhydramnios is
placenta from the uterine wall. Management includes maternal also one of the features of twin-to-twin transfusion syndrome and
resuscitation, correction of hypovolaemia and possible coagula- laser ablation of vascular anastomoses may be required.
tion abnormalities. Immediate delivery should be accomplished
if there is fetal compromise. HELLP syndrome
If intrauterine death is confirmed, induction of vaginal labour HELLP syndrome is a complication of preeclampsia, defined as
is possible if the mother is haemodynamically stable, otherwise, haemolysis, Elevated Liver enzymes and low platelets. The pa-
immediate uterine evacuation is needed to reduce maternal tient may present with severe epigastric and right upper quadrant
morbidity and mortality. Massive postpartum haemorrhage may pain secondary to the oedema of the capsule of the liver. Other
occur due to the entry of blood into the myometrium separating classical symptoms of preeclampsia can be present such as
and dispersing the muscle fibres (‘Couvelaire’ uterus). headache, visual disturbances, nausea and vomiting, irritability
REVIEW
and altered consciousness. Investigations demonstrate haemol- uncommon but can be found if diagnosis and treatment are
ysis (raised lactate dehydrogenase and bilirubin), raised liver delayed or in immuno-compromised patients such as diabetics.
enzymes (alanine transaminase >70 units/L) and low platelets
(<10,000/mm3). Acute cholecystitis
Management includes stabilizing blood pressure, prophylaxis Cholecystitis refers to the inflammation of the gall bladder. The
of eclampsia, correction of coagulopathy if present and delivery incidence is about 0.1%. During pregnancy, the hormonal
in an HDU setting. changes predispose to this pathology due to the biliary stasis and
A rare complication of HELLP syndrome is hepatic rupture increased synthesis of cholesterol. There is also an increased
secondary to the distension of the Glisson’s capsule of the liver, prevalence of asymptomatic gall stones during pregnancy. It is
immediate laparotomy is indicated to repair the liver laceration. estimated that about 2% of women develop asymptomatic gall
stones during pregnancy.
The classical clinical symptoms are right upper quadrant pain,
Conditions associated with pregnancy
nausea and vomiting, jaundice and fever. On examination,
Acute fatty liver icterus may be apparent and tenderness over the right hypo-
Acute fatty liver is a rare complication in late pregnancy (most chondrium. The classic ‘Murphy’s sign’ (tenderness over the tip
commonly on the third trimester) occurring in 1 in 10,000 to 1 in of the right costal margin on deep inspiration) may be absent
15,000 pregnancies. The exact aetiology remains unknown but it during pregnancy. Laboratory investigations show leucocytosis
is believed that is secondary to biochemical and endocrine and raised alkaline phosphatase but normal alanine trans-
changes or to an altered immune response occurring during aminase that can help differentiate cholecystitis from other liver
pregnancy. It has a high fetal and maternal mortality (47 and pathology. Ultrasound can demonstrate distension of the gall
18% respectively). Patients may present with an acute abdom- bladder and the presence of gall stones.
inal pain, generally on the right upper quadrant, nausea and Management includes intravenous fluids, analgesia, intrave-
vomiting, general malaise, jaundice and fever. Investigations nous fluids and nasogastric suction in more severe cases. Occa-
show impaired liver function (raised conjugated bilirubin, alka- sionally, if there are recurrent episodes or complications such as
line phosphate and alanine transaminase), prolonged pro- empyema or perforation, surgical treatment may be required.
thrombin time leucocytosis and thrombocytopenia. Although
acute fatty liver is a clinical diagnosis, ultrasound can help Complications not related to pregnancy
exclude biliary tract pathology. CT scan and MRI are not indi- Acute appendicitis
cated as they have limited value. The clinical picture can rapidly The incidence in pregnancy is 1 in 2000 pregnancies and it is the
deteriorate with hypoglycemia, renal failure, intravascular most common non-obstetric surgical emergency in pregnancy.
disseminated coagulopathy and hepatic encephalopathy. Care The morbidity and mortality are increased mainly due to delayed
should be provided on an HDU setting and in severe cases, ITU diagnosis resulting from the absence of the ‘classical’ signs
admission may be needed with management from a specialized during pregnancy.
liver team. Women usually present with abdominal pain on the right
Treatment is aimed at correcting the metabolic and coagula- flank, nausea and vomiting, anorexia and constipation. On ex-
tion abnormalities followed by delivery. amination, the abdomen is tender over the right side and rigidity
and guarding may be present, however it is essential to
Urinary tract infections (UTI) remember that the appendix and caecum are displaced upwards
The hormonal and anatomical changes occurring during preg- by the gravid uterus and therefore pain over the McBurney point
nancy predispose to urinary tract infections. The relaxing effect may be absent.
of the progesterone and the compression of the ureters produce Investigations show leucocytosis with neutrophilia, raised C-
dilatation of the pelvicalyceal system resulting in stasis of the reactive protein (CRP) and serum amylase. Ultrasound and
urine and infection. Escherichia coli is responsible of 70e90% of abdominal X-ray have limited use. If there is clinical suspicion,
uncomplicated UTIs in pregnancy. Although asymptomatic surgical management is indicated due to the risk of perforation
bacteriuria is frequent, 20e30% of them evolve to acute and peritonitis. Laparoscopic appendicectomy has been
pyelonephritis. described during pregnancy. If the exact cause has not been
An uncomplicated cystitis presents frequently in the form of determined, a midline or paramedian laparotomy is recom-
suprapubic pain, difficulty to empty the bladder and increased mended. Alternatively, an incision at the point of maximum
frequency. If the infection involves the upper urinary tract (kid- tenderness may be used.
neys and ureters), the severity of the symptoms is greater with
acute abdominal pain (loin to groin), fever, nausea and vomiting. Acute pancreatitis
On examination, tenderness over the renal flank can be Pancreatitis is infrequent during pregnancy but it can be poten-
identified. Other investigations include a mid stream urine and tially life-threatening. The reported incidence varies from 1 in
blood sample for cultures and antibiotic sensitivity and renal 1000 to 1 in 10,000 pregnancies. Risk factors include gall stones,
ultrasound to assess the presence of hydronephrosis, renal stones chronic alcohol use, hyperlipidaemia, viral infection and less
or renal abscess. frequently abdominal trauma. The classical signs of epigastric
If there is clinical suspicion of pyelonephritis, immediate pain radiating to the back, nausea and vomiting, jaundice and
treatment with intravenous antibiotics should be started as se- low-grade fever are present. On examination, signs of peritoneal
vere cases can progress to septicaemia. Renal abscesses are irritation are rare due to the gravid uterus. Investigations show
REVIEW
raised amylase. Ultrasound can demonstrate gall stones and help are dehydration and stress. Patients refer acute abdominal pain,
exclude other causes of epigastric pain. Management includes breathlessness, low-grade fever, joint pain and jaundice. Treat-
intravenous fluids, correction of the electrolyte imbalance, ment is mainly supportive with correction of the fluid and elec-
hyperglycaemia, and hypocalcaemia and keeping the patient nil trolyte imbalance, oxygen administration, adequate analgesia
by mouth. In severe cases, nasogastric suction and total paren- and keeping the patient warm. Thromboprophylaxis is essential
teral nutrition may be needed. to prevent thromboembolism. In severe cases, a blood exchange
transfusion may be required to obtain a post-transfusion Hae-
Acute hepatitis moglobin of 10e11 g/dL and an HbS level of around 50%. Early
Acute hepatitis can be present with abdominal pain, jaundice, involvement of the Anaesthesia and Haematology teams should
malaise, nausea and vomiting and low-grade fever. A detailed be sought.
history should be taken to identify aetiology (viral or drug-
induced, history of travel, blood transfusion, medications Case history
including homoeopathy). On examination, tenderness over the
A 35 year-old woman in her first pregnancy was admitted with a
right upper quadrant is elicited. Laboratory investigations show
history of right-sided abdominal pain at 34 weeks þ3 days of
raised liver enzymes and hepatitis serology can confirm if it is
gestation. She had an uneventful antenatal period with normal
viral in origin. Treatment is supportive and involvement of the
first trimester and anomaly ultrasound scans. She described that
gastric team should be sought.
the pain was “dull and aching” in nature and was not associated
with fever, chills or rigours. Apart from constipation she did not
Peptic ulcer disease
have any other bowel or urinary symptoms. She did not
Peptic ulcer is uncommon in pregnancy and some patients with
complain of any painful uterine contractions or abnormal vaginal
preexisting disease experience an improvement of the symptoms
bleeding or discharge and perceived good fetal movements.
due to the protective effect of the prostaglandins during pregnancy.
On clinical examination, there was mild tenderness in the
Presentation is usually with epigastric pain rather than symptoms
right iliac region and rebound tenderness. The patient refers the
of complications such as haemorrhage or perforation. Gastroin-
pain irradiates to the upper quadrant. On speculum examination,
testinal endoscopy is safe in pregnancy and may be needed to
no abnormal vaginal bleeding or discharge were noted. An
investigate severe epigastric pain after exclusion of other causes.
abdominal ultrasound scan was performed with normal findings.
Treatment includes antacids, sucralfate and histamine-
Cardiotocography (CTG) trace was normal with no evidence of
receptor blockers and eradication of Helicobacter pylori if there
ongoing hypoxia or infection. No obstetric cause was found for
is confirmation of infection. Misoprostol, a prostaglandin
her non-specific, non-acute right-sided abdominal pain.
analogue, is contraindicated because of the risk of miscarriage/
Her haematological and biochemical investigations were
preterm labour.
normal, except for the normal leucocytosis of pregnancy (i.e.
More common, especially in late pregnancy, is the presence of
14.5 109/L). Due to the abdominal pain without any obvious
gastric reflux secondary to the increased intra-abdominal pres-
cause, the patient was initially referred to the medical team, who
sure, the displacement of the gastro-oesophageal junction and
excluded hepatic, renal and pancreatic causes of abdominal pain.
the relaxation of the oesophageal sphincter due to the effect of
As the pain gradually increased over the following 24 hours
the progesterone.
requiring opiates, the patient was referred to the surgical team
who requested a CT scan of the abdomen, also reported as
Intestinal obstruction
normal with no evidence of appendicitis.
The reported incidence of intestinal obstruction during preg-
The patient developed mild guarding and rebound tenderness
nancy varies between 1 in 2500 and 1 in 3500 deliveries. The
four days after admission and in view of deteriorating clinical
anatomical changes producing displacement of the bowel into
condition, she was counselled regarding management options
the upper abdomen are thought to be responsible. There is
and was recommended to have a laparotomy and caesarean
increased risk in patients with bowel disease (Crohn’s, ulcerative
section. During laparotomy, yellowish-brown exudate and frank
colitis) or previous abdominal surgery with presence of
pus were noted within the right para-colic gutter and the
adhesions.
omentum plastered on the anterior wall of the uterus, completely
The episode presents with acute abdominal pain, vomiting
separating the upper abdomen. Baby was delivered in good
(small bowel), constipation (large bowel) and distension. Pa-
condition. Surgical team was requested to attend and identified a
tients can present severely ill with electrolyte imbalance and
caecal perforation secondary to the torsion of the ileo-caecal
sepsis if the obstruction is complicated with perforation. On ex-
junction, which was managed surgically. There was a matted
amination, there is abdominal distension, tenderness, different
mass firmly adherent to the posterior aspect of the uterus. The
degrees of rigidity and guarding and bowel sounds may be ab-
surgical team repaired the perforation. The patient made a good
sent. Further investigations reveal raised serum amylase, leuco-
post-operative recovery and was discharged home five days later.
cytosis and classical signs of obstruction on abdominal X-ray.
Management consists of electrolyte imbalance correction and
Discussion
surgical approach if volvulus or perforation are suspected.
This clinical case highlights the importance of recognizing “non-
Sickle cell crisis obstetric” causes of abdominal pain during pregnancy. Bowel
The incidence of sickle cell crisis can increase during pregnancy pathology may be difficult to identify as the symptoms and signs
as it is a pro-coagulable state. Amongst the predisposing factors may not be present in the expected quadrant of the anterior
REVIEW
abdominal wall. The ileocaecal junction as well as the appendix recognizing worsening clinical condition instead of solely relying
may be pushed upwards by the enlarging gravid uterus towards on diagnostic imaging during pregnancy. The presence of a
the right hypochondrium. In addition, secondary to the immu- gravid uterus containing a fetus with amniotic fluid may interfere
nological changes which take place in pregnancy, signs of with the quality and interpretation of the images and may mask
inflammation and infection may also be less marked until very an underlying bowel pathology. In addition, the role of multi-
late in the disease process when a rapid deterioration suddenly disciplinary input to improve the outcome cannot be
occurs. This is because maternal immune response is altered overemphasized.
during pregnancy to facilitate the growth and survival of the fetus A delay in diagnosis in such cases may lead to peritonitis and
in-utero. This may blunt the usual immune response a woman serious maternal and fetal morbidity and mortality. Young and fit
would mount against an infection. Unfortunately, due to adher- pregnant women may maintain their vital parameters until the
ence of the perforated ileocaecal junction behind the gravid ‘critical tipping point’ or “CTP” and may rapidly deteriorate
uterus, even the CT scan was unable to show any evidence of thereafter. Hence, it is essential to exercise a high index of clin-
perforation of the bowel in this case. ical suspicion based on observed clinical parameters and to
The decision to perform an emergency caesarean section by involve the patient in the decision making process by appropri-
the obstetric team was solely made based on deteriorating clin- ately keeping her appraised regarding the evolving clinical pic-
ical condition, after appropriate counselling and a multi- ture and the management options. This case highlights the fact
disciplinary discussion. This highlights the importance of that even the technological advances in imaging may not always
Abdominal pain in pregnancy: differential diagnosis according to localization of abdominal pain
Table 2
REVIEW
according to the findings and the differential diagnosis. Radio-

Estimated fetal exposure from some common Radiologic logical investigations should be requested if appropriate, even in
procedures (ACOG, 1995) the presence of a fetus, as the risk of radiation is low (Table 3).
Procedure Fetal exposure Multidisciplinary input should be sought in early stages of
diagnosis if a non-obstetric cause is suspected. Women should be
Chest radiograph (two views) 0.02e0.07 mrad informed of the importance of timely diagnosis and management
Abdominal film (single view) 100 mrad to optimize maternal and fetal outcomes during counselling. A
Intravenous pyelography 1 rad
Mammography 7e20 mrad
FURTHER READING
Barium enema or small bowel series 2e4 rad
Chandraharan E, Arulkumaran S. Acute abdomen and abdominal pain
CT scan head or chest <1 rad
in pregnancy. Obstet Gynaecol Reprod Med 2008; 18: 205e12.
CT scan abdomen and lumbar spine 3.5 rad
Green-top Guideline 64a. Bacterial sepsis in pregnancy. RCOG, April
CT pelvimetry (Key e 1 rad ¼ 0.01 Gy) 250 mrad
2012.
Table 3 Guidelines for diagnostic imaging during pregnancy. ACOG Commit-
tee Opinion No. 299. American College of Obstetricians and Gy-
necologists. Obstet Gynecol 2004; 104: 647e51.
be useful in diagnosing intra-abdominal pathology during preg- Krishna A, Chandraharan E. Abdominal pain in pregnancy. Obstetric
nancy and it is vital to exercise clinical acumen and ensure a and intrapartum emergencies: a practical guide to management.
multi-disciplinary input in formulating a management plan. Cambridge University Press, October 2012. ISBN:
9780521268271.
Conclusion on behalf of MBRRACE- UK. In: Knight M, Kenyon S, Brocklehurst P,
Although the vast majority of patients who present with an Neilson J, Shakespeare J, Kurinczuk JJ, eds. Saving lives,
abdominal pain during pregnancy do so due to the normal improving mothers’ care e lessons learned to inform future ma-
physiological changes in pregnancy, it is essential to maintain a ternity care from the UK and Ireland con dential enquiries into
systematic approach (Table 2). This includes taking a thorough maternal deaths and morbidity 2009e12. Oxford: National Perinatal
history of the current episode as well as past medical, surgical Epidemiology Unit, University of Oxford, 2014.
and family history, appropriate abdominal examination, taking Pedrosa I, Levine D, Eyvazzadeh AD, Siewert B, Ngo L, Rofsky NM.
into account the modified anatomy during pregnancy and a MR imaging evaluation of acute appendicitis in pregnancy. Radi-
vaginal examination, if indicated. It is crucial to consider ob- ology Mar 2006; 238: 891e9.
stetric and non-obstetric causes and to request additional tests

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REVIEW

Abdominal pain in signs of certain non-obstetric pathologies such as appendicitis.

pregnancy: a rational pathologies (i.e. appendicitis) may result in delayed diagnosis,

approach to management maternal morbidity and mortality.

Causes of acute and chronic abdominal pain and suggested investigations

Acute (within minutes Obstetric Imaging

for torsion. On abdominal examination, iliac fossa tenderness

Uterine scar dehiscence/rupture

Abdominal pain in pregnancy: differential diagnosis according to localization of abdominal pain

according to the findings and the differential diagnosis. Radio-

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