Abdominal Pain During Pregnancy

BY
ABHISHEK JAGUESSAR

 Abdominal pain is a very common symptom in pregnant women. It may be due to pregnancy itself e.g red degeneration in a fibroid or may arise from some concomitant lesion such as appendicitis. It is convenient to divide the causes of pain due to pregnancy into those most commonly found in each of the three trimesters,though of course there is considerable overlap

First Trimester
Abortion Disturbed Ectopic pregnancy pregnancy in rudimentary horn Acute salpingitis Acute Retention of urine

First Trimester pain

Abortion
Pain preceeded by vaginal bleeding, in the middle &intermittent. Cervix,closed(threatened abortion)or open (inevitable)..U/S.gestational sac inside uterine cavity.

First Trimester Pain

Ectopic pregnancy
Pain typically occur before bleeding and blood tend to be dark(prune juice) Pain tends to be limited initially to the affected side,though if interperitoneal bleeding occurs it become generalised & the picture of acute abdomen may develop with shock

First Trimester Pain

Pregnancy in rudimentary horn

pain resemble that of ectopic and usually the condition discovered during laparotomy If rupture occurs it usually in the midtrimester and of sudden onset with collapse

First Trimester Pain

Acute Salpingitis
May develop up to the 10th.weeks after conception,due to gonococcal infection or infection at attempted attempted abortion Pain felt in both iliac fossae & is continuous There is associated tenderness,tachycardia and elevated temperature,culture of discharge may reveal pathogens

First Trimester Pain

Acute retention of urine

is usually due to enlargement of a cervical fibroid in response to pregnancy and may occur very early Severe lower abdominal wall, large tender bladder which may be mistaken for ov. Cyst Catheterisation causes immediate relief of pain

Midtrimester Pain
Acute retention of urine due to incarcerated RVF gravid uterus Red degeneration in a fibromyoma Rupture of rudimentary horn containing pregnancy Stretching of round ligament Abortion

Midtrimester Pain
Red degeneration of fibromyoma
causes pain ranging from mild to severe over the fibroid.tenderness usually present over the fibroid. U/S usually detect the fibroid during first trimester There may be history of menorrhagia before pregnancy..TT..conservative with analgesic

Midtrimester Pain
Stretching of the round ligament may
sometimes be a cause of mid-trimester pain Usually pain is continuous and there is tenderness over the affected ligament There is no constitutional symptoms. Reassurance and sometimes mild analgesia is required

Third Trimester Pain

Concealed haemorrhage Severe preeclampsia Red degeneration of fibromyoma Uterine rupture Contractions of labour

Third Trimester Pain

Concealed haemorrhage
Pain is of acute onset & is severe, with considerable shock and collapse. The abdominal ms. Are tense and the uterus may be larger than expected, hard tender with difficulty in palpating fetal parts Fetal heart is usually absent there may be vagina bleeding

Third Trimester Pain

Severe Pre-eclampsia
Epigastric pain may occur & is a sign of impending eclampsia. The characteristic signs of pre-eclampsia, hypertension, proteinuria and oedema are present The uterus is not tender & fetal parts are palpable & FHR usually present

Third Trimester Pain

Uterine rupture is a possibility in
highly parous women & those who have scarred uterus by CS,Myomectomy or perforation. Women usually feel a tearing sensation followed by constant pain..shock & collapse. Vaginal bleeding is common. Fetal parts easily felt & FHR is absent

Third Trimester Pain

Labour pains
may occur prematurely or at term, they are intermittent & gradually become stronger and more frequent. The characteristic show of early labour will be observed and on vaginal examination cervix will be taken up and perhaps dilated

Incidental Causes of Pain

Gastro-enteritis
Pain is generalised over the abdomen and accompained by vomiting and diarrhoea. Temperature is elevated and abdomen is tender with no rigidity stool analysis show organism

Incidental causes of Pain

Acute Appendicitis and Pyelonephritis the appendix is displaced upward and laterally as pregnancy advances and its tip overly the tip of right kidney. Appendicitis may be confused with pyelonephritis

 *In pyelonephritis the pain is often of an aching character and felt only in the lumbar region, however, it may be felt only in the right side of abdomen & in severe cases may be diffused over the whole abdomen *in pyelonephritis the tenderness is usually localised in the right costovertebral angle

 *In pyelonephritis temperature tend to be high and pulse rate in relation to temperature tend to be lower than in case of appendecitis *Even with sever cases the tongue is usually moist in cases of pyelonephritis,but usually dry with appendicitis. In case of doubt laparotomy is indicated, to avoid mortality with appendicitis

Incidental causes(cont.)
Renal and uretric calculi
Pain may be confused as pyelitis and radiate to leg. Blood may be present in the urine and U/S may show stone in kidney or bladder. Acute cholycystitis..usually positive history present and pain over Rt.hypochondrium, radiate to Rt.shoulder.U/S may show stone in G.B

Incidental causes of Pain

Perforation of a hollow organ
such as the stomach or duodenum, may occur with sudden pain, collapse and the rapid development of generalised peritonitis Usually history of peptic ulcer or gastric ulcer is present

Incidental Causes of Pain

Strangulated hernia should be born in mind and hernial sites should be examined Acute Pancreatitis the onset is sudden with severe upper abdominal pain & vomiting.usually serum amylase and urinary diastase levels elevated. Treatment is usually conservative

Incidental causes(cont.)
Acute Hepatitis
May occur in hyperemesis gravidarum, in sever pre-eclampsia/eclampsia or in acute infective hepatitis. In all these conditions there is pain & tenderness over the liver & jandice is usually soon manifest

Incidental Causes (cont.)

Acute intestinal obstruction
Sometimes found in pregnancy & usually there is history of laparotomy & if there is band of adhesion the enlarged uterus displaces the intestine & obstruction occurs.The onset is usually sudden,with vomiting. Distention & vomiting with colicky pains are typical.

Incidental Causes(cont.)
Torsion of ovarian cyst may occur
especially during first trimester. Pain is at first referred to one or other hypochondrium & is acute in onset usually with vomiting. as peritonitis occur there is pain, tenderness & rigidity over the tumor.there may be some pyrexia. U/S show the cyst

Incidental Causes(cont.)
Other causes Acute porphyeria Sickling crisis Diabetic ketoacidosis