Abdominal Pain In Pregnancy

ABDOMINAL PAIN IN PREGNANCY BY DR E.O .OBI-THOMAS

INTRODUCTION 

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All pregnancies demonstrate pain in one form or the other be it in the 1st, 2nd and 3rd trimester. Pain may result from -physiological effect of pregnancy -pathological conditions related to pregnancy - pathological conditions unrelated to pregnancy.

Anatomy of pelvic pain -from pelvic organ sensory afferent plus sympathetic nerves T10 - L1 -Degree of pain expression varies with individuals. PHYSIOLOGICAL CONDITIONS IN PREGNANCY Round ligament pain - occurs in 10-30% - commonly in the end of 1st and 2nd trimester -usually mistaken for appendicitis, ovarian cyst accident, preterm uterine contraction and placenta abruption 

Severe uterine torsion pain -normally rotate no more than 400(mild) -rotation beyond 900 (severe) -common later half of pregnancy - predisposing factors include uterine fibroid, congenital anomaly, adnexae mass or hx of pelvic surgery -shock and fetal asphyxia Mgt include excluding pathological causes of pain ,bed rest and analgesia -correct torsion -c/section

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Braxton Hicks contraction Common in later half of pregnancy  Irregular in frequency , inconsistent in intensity  Painless in majority of women, painful in some  Could be confused with preterm labour  Usually no ‘’show’’ ,no membrane rupture and presenting part is high.  Usually transient  reassurance 

Other physiological causes 

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Heartburn- give anti-acids or H2 antagonist if severe Excessive vomiting –dietary adjustment ,infusion and antiemetics Constipation –dietary adjustment, avoid iron therapy and give laxatives

Pathological conditions in pregnancy Divided into : -related to uterus -related to adnexae RELATED TO UTERUS -Miscarriage, fibroid, placenta abruption, chorioamnitis,preterm labour and uterine rupture 

Miscarrage  Common in the first trimester  Vaginal bleeding  Cramp like pain  Could be confirmed using ultrasound Uterine fibroid -usually asymptomatic -occasionally complicate pregnancy -may interfere with conception and maintenance of pregnancy -10% of women with uterine fibroid experience abdominal pain due to red degeneration or carneous degeneration -Pain and tenderness are usually localized -low grade fever and leucocytosis

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During labour degeneration can mimick placenta abruption Pain can be from torsion of pedunculated fibroid Can lead to obstructed labour, abdominal lie Avoid unnecessary operations Mgt is conservative: analgesia ,bed rest c/section Caeserean myomectomy ( controversial)

Placenta abruption  

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Acute pain in later pregnancy Associated commonly with HBP, smoking multiple pregnancy,uterine myomas Could be concealed or overt Mgt is variable based on presentation,fetal viability maternal stability, cervical status Chorioamnnits, preterm labour cause pain

Uterine rupture     

Rupture of unscarred uterus prior to labour is uncommon Occurs commonly in malformed uterus,excessive oxytocin doses, obstructed labour high parity Rupture of scarred uterus may occur either before or during labour Maternal hypovolemia is associated risk Mgt –careful evaluation, resusciatation, exploratory laparotomy and sterilization

Related to adnexae

Ectopic pregnancy  Ovarian pathology Ectopic pregnancy -must be considered in any woman in the 1st trimester with lower abdominal pain -Usually associated with some bleeding per vagina -Pain is typically unrelenting especially with ruptured type -Serial BhcG assays ,transvaginal sonography and laparoscopy are of value in early diagnosis 

Ovarian pathology   

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-corpus luteum, ovarian cyst haemorrhage and ovarian cyst torsion. Most ovarian cysts in pregnancy are presumably corpus luteum cysts Persistence and growth of cl causes aching pelvic pain particularly in the first trimester Torsion of an ovarian cyst -presents with pain ,vomitting ,nausea pyrexia tachycardia  Leucocytosis  Mimicks ectopic pregnancy acut appendicitis 

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Mgt Laparotomy is essential -if adnexae appear necrotic or vessels appear thrombosed avoid untwisting the pedicle.Risk of embolization If corpus luteum is removed in the 1st eight weeks give progesterone up to 10 weeks of amenorrhoea

Pathological conditions  

These are treated –GIT, UT, LIVER DX ,OTHERS GIT -acute appendicitis ,intestinal obtruction,acute cholecystitis and cholelithiasis crohn’s dx peptic ulcer dx and acute pancreatitis

Acute appendicitis

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Complicates 1:1500 pregnancies Can present with anorexia, nausea vomiting Anatomical location of appendix in pregnancy varies along RIF and RLR Acute appendicitis can be confused with endometriosis of the appendix Preterm labour ,abruptio placenta,carneous fibroids ,ruptured adnexal cyst or torsion mimics acute appendicitis Presentation is atypical Delay can lead to rupture Mgt- rescusitation,laparotomy with R paramedian incision at the site of maximal tenderness Tocolysis antibiotics

Urinary tract infection Acute cystitis acute pyelonephritis and urolithiasis  Acute cystitis - occurs in 1-2% of cases -2/3th of cases have cystitis in spite of their sterile urine at booking Experience urinary symptoms and abdominal discomfort 

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Liver dx -Include acute fatty liver of pregnancy and severe pre-eclampsia and eclampsia Others include rectus haematoma, sickle cell crisis porphyxia, malaria, arteriovenous haemorrhage ,tuberculosis and psychological

5. Abdominal pregnancy (ectopic pregnancy) -advanced abdominal pregnancy is rare  Common amongst low socioeconomic group, hx of infertility and previous hx of pelvic infection  Abd pregnancy could be primary or secondary  Presents with abdominal pain 

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GIT symptoms Closed uneffaced cervix Non palpable uterine contractions to oxytocin Increase maternal serum alpha fetoprotein Uss reveals -fetus and placenta outside uterus -no uterine wall b/w fetus and urinary bladder -Fetal parts close to maternal abdominal wall

Radiography -no uterine shadow around fetus -maternal intestine intermingle with fetal parts -Maternal spine overlaps fetal small parts. MRI -Very sensitive -no ionizing radiation -Carries high morbidity and mortality rate Mgt includes: -timing of intervention, nature of intervention or mgt of placenta 

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Is optimal approach If placenta cannot be removed ,leave it behind Ligate cord close to placenta Ligate placenta blood supply and remove pelvic organ on which placenta implants Use of methotrexate

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