ABDOMINAL PAIN IN PREGNANCY

1. ABDOMINAL PAIN IN PREGNANCY MR SUSHANTA BHADRA MD MRCOG WEXHAM PARK HOSPITALS SEPTEMBER 2004

2. A 22 yr old para 1 with 6-8 wks gestation presents with abdominal pain. WHAT ARE YOU THINKING OF ?

3. The history Localized one sided pain, no radiation, spasmodic to start with – now constant Mild bleeding p/v Some chest pain and shoulder tip pain Has been feeling faint Pregnancy test positive

4. THINK ECTOPIC VITAL SIGNS B HCG – QUANTITATIVE URGENT PELVIC USS REFER/ADMIT TO HOSPITAL

5. ECTOPIC PREGNANCYPit falls in diagnosis Wide variation in clinical presentation Pregnancy test can be negative at times of diagnosis. ( However it must have been positive at some time or another). TV USS even at the best of hands is only 50% accurate in picking up an ectopic pregnancy. B HCGs can double in very early ectopics Doubling time varies from 1.4 to 7.2 days depending on gestation

6. Mx of Ectopic Pregnancy Medical with Methotrexate with or without folinic acid. Surgical – laparotomy and laparoscopy salpingostomy and salpingiectomy Follow up and prognosis

7. IS IT OVARIAN ? Corpus luteum cysts and accidents Mild aching pain Usually asymptomatic Maternal pulse is not raised Hemorrhage inside cyst can cause severe pain

8. ADNEXAL TORSION More common in pregnancy ( 28%) Lateral lower quadrant pain- sudden onset Fever ,leucocytosis, nausea, vomiting UNRELIABLE IN PREGNANCY USS – no flow on colour mapping Surgery should not be delayed Miscarriage and preterm labour are common consequences Difficult to differentiate from ectopics and appendicitis

9. A 22 yr old para 1 with 6-8 wks amenorrhea presents with abdominal pain The history changes: Crampy lower abdominal Heavy bleeding p/v Speculum examination cx os closed cx os open

10. DIAGNOSIS - ? MISCARRIAGE Assess hemodynamic stability Arrange pelvic ultrasound Management depends on ultrasonographic findings. No role of Bhcgs Blood group, Rhesus and anti-D if necessary

11. SOME USS FINDINGS An intrauterine gestational sac seen 25X30 mm in diameters. No fetus visible. An IU gestational sac seen 20 X 20 mm in diameter. Fetal pole seen 4 mm CRL. No FH identified. An IU gestational sac seen 20X 20 mm in diameter ,FP seen 6 mm CRL. No FH An IU gestational sac seen 35X35 mm in diameters low down in the cavity. FP seen . FH seen but appears slow.

12. THE MANAGEMENT OF MISCARRIAGE Conservative Reassurance and TLC No role of bed rest ERPOC

13. 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

14. Lower abd pain with dysuria Acute cystitis occurs in 1-2% of pregnant women Acute pyelonephritis is a serious complication Usually happens in 2nd and 3rd trimester Asymptomatic bacteriuria is a predisposing factor May result in Preterm labour Urine testing is mandatory

15. UTERINE FIBROIDS 10 % of women with fibroid uterus experience abdominal pain Hemorrhagic infarction – red degeneration Localized pain – may mimic placental abruption or uterine rupture Maternal and fetal risks are due to incorrect diagnosis and delay in treatment

16. ROUND LIGAMENT PAIN 10-30% OF PREGNANCIES Commonly towards the beginning and the end of pregnancy More in multips Said to be due to stretching of round ligaments Cramplike or stabbing and made worse with movement Some tenderness in the lower quadrant and groin

17. CAUSES RELATED TO PREGNANCYA SUMMARY ECTOPIC PREGNANCY MISCARRIAGE URINARY TRACT INFECTION ADNEXAL MASSES AND TORSION ROUND LIGAMENT PAIN FIBROID DEGENERATION

18. A history 22 yrs old 1st pregnancy presents with right sided abdominal pain for about 2 days. It started with a vague pain in the epigastrium and is now constant on the rt side. She is about 26 wks pregnant and there is no vaginal bleeding. Her 20 wk scan was “normal”. WHAT ELSE WOULD YOU LIKE TO KNOW?

19. APPENDICITIS Most common cause of acute abdomen in pregnancy Challenging diagnosis Balance the risk of surgical delay associated morbidity with effects of surgery on mother and fetus Decision to operate on clinical grounds 20-35% rate of negative laparotomy

20. APPENDCITIS - DIAGNOSIS Appendix is progressively displaced upwards after 12 wks and reaches iliac crest at 24 wks. Single most reliable symptom in pregnancy is RIF pain Anorexia, vomiting, rebound , guarding are not specific in pregnancy Leucocytosis is NOT helpful. < 10,000 leucocyte may be reassuring

21. APPENDICITIS - DIAGNOSIS Graded compression ultrasonography accurate in 1st and 2nd trimesters , difficult in 3rd. 98% ACCURATE.

22. APPENDICITIS- CONSEQUENCES High fetal loss rate if perforation occurs (20%) Maternal mortality Mortality of delay Risk of perforation highest in 3rd trimester Premature labour esp in the 1st week after surgery

23. CHOLECYSTITIS 2nd most common cause of acute abdomen 1in 6000 pregnancies Cholelithiasis is the cause in >90% pts Unclear whether pregnancy predisposes to cholelithiasis

24. CHOLECSYTISTIS SIGNS AND SYMPTOMS Same as in non pregnant women. Nausea, vomiting, acute colicky pain at mid epigastrium or rightt upper abdomen Murphy’s sign is less common in pregnancy Jaundice is rare D/D – OC,AFLP & HELLP

25. CHOLECYSTITISDIAGNOSIS Elevated serum levels of bilirubin and transaminases Serum alkaline phosphatase less helpful Cholecystosonography- test of choice 95% accuracy

26. CHOLECYSTITISMANAGEMENT Medical - particularly in the 3rd trimester IV hydration, nasogastric suction,narcotics, antibiotics if sepsis Surgical indicated where medical treatment failed in 2-3 days Laparoscopic (open) better in terms of fetal survival and Premature labour.

27. BOWEL OBSTRUCTION 1 IN 2500 TO 3500 DELIVERIES The cause is adhesions in 70% of cases. Volvulus is responsible for 25 % of cases. Hernia and intesussceptions are rare Usually occurs in the 1st pregnancies and third trimester and postpartum Morbidity and mortality related to diagnostic and therapeutic delay.

28. BOWEL OBSTRUCTION Commonest misdiagnosis- Hyperemesis gravidarum in 2nd and 3rd trimesters Typical symptoms crampy abdominal pain obstipation vomiting In cases of high obstruction the period between attacks is short (4-5min) and is characterized by diffuse poorly localized upper abdominal pain Colonic obstruction may manifest as lower abdominal and perineal pain with longer time intervals

29. BOWEL OBSTRUCTIONCLINICAL FINDINGS Physical examination Tender distended abdomen Fever, leucocytosis and electrolyte imbalances increase the likelihood of intestinal strangulation Upright and flat abdominal films with or without contrast. Concern regarding the exposure of the fetus to radiation should be balanced against the risk if maternal mortality from a failed diagnosis

30. BOWEL OBSTRUCTIONMANAGEMENT Fluid and electrolyte replacement Nasogastric bowel decompression Timely surgery

31. ACUTE PANCREATITIS Rare Usually late in 3rd trimester or early postpartum Cholelithisasiis is the commonest cause Pregnancy contributes by an increased abdominal pressure on the biliary ducts Early recognition and treatment essential

32. ACUTE PANCREATITIS Signs and symptoms same as in the non pregnant state. Sudden severe epigastric pain radiating to the back with nausea and vomiting and fever. Hypoactive bowel sounds and diffusely tender abdomen Mimics preeclampsia, DKA,Hepatitis,Cholecystitis.

33. ACUTE PANCREATITIS Serum amylase and lipase levels increase spontaneously in pregnancy Calculation of amylase to creatinine ratio is more useful in pregnancy. The ratio is usually low in pregnancy USS is may be neccessary

34. ACUTE PANCREATITIS MANAGEMENT Classic triad of medical management consists of bowel rest , fluid and electrolyte management and pain relief. ERCP and papillotomy are safe Cholecystectomy after inflammation subsides

35. NONOBSTETRICAL CAUSES APPENDICITIS CHOLECYSTITIS BOWEL OBSTRUCTION PANCREATITIS LIVER PROBLEMS MISCELLANEOUS

36. LIVER DISORDERS Acute fatty liver of pregnancy Unknown cause 1in 10000- 1 in 15000 pregnancies Late in 3rd trimester Considerable overlap with HELLP syndrome Clinical presentation with abd pain, jaundice and HYPEREMESIS Hepatic encephalopathy and coagulopathy Fetal demise

37. ACUTE FATTY LIVER OF PREGNANCY Early diagnosis essential Cannot be predicted Maintain awareness DO AN LFT in a pt presenting with abdominal pain

38. PREECLAMPSIA AND HELLP Complication of severe PET Hemolysis, Elevated liver enzymes, low platelet counts Periportal hemorrhagic necrosis with subcapsular hematoma Diagnosis: rt upper quadrant pain nausea and vomiting headache DBP > 110 mmHg Proteinuria 2+

39. HELLP Serious complication of PET Can manifest at any time but rare before 20 wks Occurs more in whites,mutips and >35 yrs Poor prognosis Incidence of about 10 % in PET Recurrence risk of 25% Can also develop postnatally Managed as severe PET Plasma vol exp, thrombolysis, exchange plasmapheresis, dialysis, steroids

40. A case history A 36 yr old para 4 at 38 wks of gestation presents to you with abdominal pain mainly near the umbilicus. The pain came on suddenly and is described as sharp and constant. There is some bleeding pv and she has not felt the baby move for the last 6 hrs.An examination reveals a tender area near the umbilicus. WHAT COULD THIS BE?

41. WHAT ARE YOU THINKING OF ? PLACENTAL ABRUPTION

42. What would you like to know ? Placental position on USS. History of hypertension Maternal age Multiparity Smoking Overdistension of uterus trauma

43. PLACENTAL ABRUPTION In late pregnancy 0.5- 1 % of all pregnancies Associated with hypertension, smoking multiple pregnancies, myomas Unrelenting pain- sharp or tearing Vaginal bleeding may or may not be present Coagulopathy and fetal death is common

44. LABOUR PAINS Uterine contractions Regular intervals Intervals gradually shorten Associated with bac discomfort Associated with cervical changes Discomfort not stopped by sedation

45. UTERINE TORSION Mild dextrorotation is common(<40 deg) Rarely may progress beyond 90 dextro produce acute torsion of uterus Usually in the latter half of pregnancy Fibroids, congenital anomalies, adnexal mass may predispose Maternal shock and fetal asphyxia Mx – conservative or laparotomy to correct torsion

46. CHORIOAMNIONITIS Usually precipitated by PPROM Other clinical and laboratory features

47. ARTERIOVENOUS HGE Rupture of uteroovarian veins Rupture of aneurysms – splenic, hepatic, renal, aortic Rapidly progressing shock

48. PSYCHOLOGICAL Diagnosis of exclusion Commoner in women with known psychosocial problems Reporting a high number of ailments during antenatal care is common

49. Rectus sheath hematoma Rupture of inferior epigastric artery May follow a bout of coughing or abdominal trauma usually in late pregnancy Large unilateral painful swelling Confused with abruption Superficial location

50. MISCELLANEOUS CAUSES SICKLE CELL CRISIS MALARIA PORPHYRIA DIABETIC KETOACIDOSIS

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