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Abdominal pain complicated 3 rd trimester pregnancy

HKCEM College Tutorial. Abdominal pain complicated 3 rd trimester pregnancy. Author Dr. Paulin Ng revised by Dr. WONG ho tung Oct, 2013. Triage note. Female, 30 G3P2 Gestation: 30 week C/O: diarrhea and abd pain for 4 hours Afebrile BP 120/80 mmHg; P 90/min. Triage Category IV.

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Abdominal pain complicated 3 rd trimester pregnancy

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  1. HKCEM College Tutorial Abdominal pain complicated 3rd trimester pregnancy Author Dr. Paulin Ng revised by Dr. WONG ho tung Oct, 2013

  2. Triage note • Female, 30 • G3P2 • Gestation: 30 week • C/O: diarrhea and abd pain for 4 hours • Afebrile • BP 120/80 mmHg; P 90/min Triage Category IV

  3. What are the DDx?

  4. DDx • OBGyn causes • Preterm labor, Preeclampsia, Abruptio placenta, Traction of round ligament • Surgical causes • acute appendicitis, cholecystitis (hydrop), renal colic • Medical causes • GE, pyelonephritis, hepatitis

  5. Now take a targeted history The nature of pain:PQRST Review GI, GU systems Antenatal history

  6. History • Uneventful antenatal history • Lower abd pain for 4 hours • Irregular, colicky, no radiation • Passing yellowish loose stool twice • No Nausea and Vomit • No group involvement or travel history • No PV bleeding or leaking • No dysuria or loin pain

  7. Abdomen Uterus-fetus Review of systems Now, a focused physical exam

  8. Physical Findings • Maternal • Afebrile, BP stable • Abdominal exam. • Soft, Mild tenderness over lower abd • No guarding or rebound tenderness • PR: no pelvic tenderness • Uterus_Fetal • Uterus palpation for several min to determine contraction • Fundal height • Fetal lie • Doptone fetal heart rate: 140/min Potential Pitfalls

  9. Potential pitfalls of Abd exam in pregnancy • Abnormal location of pain e.g. appendicitis with pain in RUQ • Peritoneal sign less obvious due to chronic stretching of abdomen • Bowel colic difficult to differentiate from uterine contraction

  10. Blood Urine Ultrasound What investigations would you like to request?

  11. Investigations • Blood work: • Hb (n), WCC (n) • Urinalysis • Protein (-), wbc (-) • USG • Fetal assessment: single viable fetus • Evidence of acute cholecystitis, dilated renal calyces, abruptio placenta: nil

  12. What are the management? • Bed rest • Monitor maternal and fetal vitals • Serial abdominal exam in observation ward • Cardiotocography (CTG) monitoring if preterm labor is suspected

  13. What is the Disposition? • Admit surgery • If there is evidence of acute abdomen • Admit Obstetric • If preterm labor or abruptio placenta is suspected • If abdominal pain persists after observation • Discharge Home • If pain subsides • Counsel on the risk and S/S of preterm labor • Seek medical care if pain recurs

  14. Progress • The patient had increasing frequency of abdominal pain compatible with uterine contraction in the “Observation” ward • She was admitted to Obstetric for further CTG monitoring and administration of tocolytics What is preterm labour? How does it present?

  15. Preterm Labour • < 37 weeks • regular uterine contraction+ cervical effacement; • contractions > 5-8/ hr • Nonspecific presentations • LBP • cramp • change in vaginal discharge

  16. Dx of Preterm labor • High index of suspicion • Presentations: • Uterine contraction • Backache • Bleeding • Leaking of fluid • Increased vaginal discharge

  17. Summary We have covered: • DDx of abd pain complicated preg • Important Dx to be R/O: surgical causes, pretern labor and concealed abruptio placenta • Evaluation of preg patient with abd pain • High index of suspicion in diagnosing preterm labor • CTG monitoring is advisable in suspected preterm labor

  18. Thank You

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