Abdominal pain in Abdominal pain in pregnancy pregnancy

Dr Hashmi HajrasiDr Hashmi Hajrasi

Consultant in OBS & GYNConsultant in OBS & GYN

MBBCH, DGO, MRCOGMBBCH, DGO, MRCOG

IntroductionIntroduction

Abdominal pain in pregnancy is a Abdominal pain in pregnancy is a common complaint.common complaint.

It’s management represents a It’s management represents a challenge to the clinician because the challenge to the clinician because the causes may be due to pregnancy or causes may be due to pregnancy or may be related to pregnancy but not may be related to pregnancy but not directly due to it or may be unrelated directly due to it or may be unrelated to pregnancy at all. to pregnancy at all.

The incidence of the different causes of The incidence of the different causes of abdominal pain in pregnancy is difficult abdominal pain in pregnancy is difficult to estimate . The is because classifying to estimate . The is because classifying this symptom into pregnancy & non-this symptom into pregnancy & non-pregnancy related is often not possible pregnancy related is often not possible until after delivery.until after delivery.

The investigations that may be The investigations that may be performed outside pregnancy are performed outside pregnancy are difficult to justify in pregnancy e.g difficult to justify in pregnancy e.g laparoscopy because of it’s potential laparoscopy because of it’s potential complications after 1complications after 1stst trimester. trimester.

The anatomy of painThe anatomy of pain

1- Uterine body: T10-L1 sensory afferent . These 1- Uterine body: T10-L1 sensory afferent . These also supply the dermatomes from umbilicus to also supply the dermatomes from umbilicus to symphysis. Laterally to iliac crests & posteriorly symphysis. Laterally to iliac crests & posteriorly to lumber and sacral vertebrato lumber and sacral vertebra

2- Cervix: as above , plus additional sensory to S2-42- Cervix: as above , plus additional sensory to S2-4

3- Ovary: mainly sympathetic sensory afferent to 3- Ovary: mainly sympathetic sensory afferent to T10T10

4- The gynae sensory nerves overlap with other 4- The gynae sensory nerves overlap with other pelvic & abdominal structures so localization & pelvic & abdominal structures so localization & diagnosis may be difficult.diagnosis may be difficult.

classifictionclassifiction

Pain directly related to Pain directly related to pregnancypregnancy

First trimesterFirst trimester

AbortionAbortion

Hydatidiform moleHydatidiform mole

Ectopic pregnancyEctopic pregnancy

AbortionAbortion

The pain is colicky in nature felt in The pain is colicky in nature felt in the lower abdomen or pelvis the lower abdomen or pelvis

commonly associated with commonly associated with amenorrhoea and vaginal bleedingamenorrhoea and vaginal bleeding

In threatened & missed abortions In threatened & missed abortions there may be mild or no painthere may be mild or no pain

Diagnosis by BHCG,exam & USSDiagnosis by BHCG,exam & USS

Molar pregnancyMolar pregnancy

Incidence is 1 in 1200 pregnanciesIncidence is 1 in 1200 pregnancies Pain when present is due to the uterus Pain when present is due to the uterus

trying to expel the molar tissue trying to expel the molar tissue (colicky)(colicky)

When severe may suggest intra-When severe may suggest intra-peritoneal bleeding peritoneal bleeding

Uterus large for date ,watery blood Uterus large for date ,watery blood stained dischargestained discharge

USS shows snow – storm appearanceUSS shows snow – storm appearance

Ectopic pregnancyEctopic pregnancy

Incidence is 1 in 100 pregnancies Incidence is 1 in 100 pregnancies in UKin UK

Presents with pain & amenorrhoeaPresents with pain & amenorrhoea The pain is commonly in one of the The pain is commonly in one of the

iliac fossa and may be referred to iliac fossa and may be referred to the tip of the shoulderthe tip of the shoulder

Most of cases are diagnosed by Most of cases are diagnosed by BHCG,TVS and/or laparoscopy BHCG,TVS and/or laparoscopy

Second trimesterSecond trimester

* Abortion* Abortion

* Acute urinary retention in association with incarcerated * Acute urinary retention in association with incarcerated retroverted gravid uterus typically at 12-14 weeksretroverted gravid uterus typically at 12-14 weeks

* Chorioamnionitis following PROM* Chorioamnionitis following PROM

* Retroplacental haemorrhage following amniocentesis* Retroplacental haemorrhage following amniocentesis

* Round ligament pain due to stretch classically at 18-22 * Round ligament pain due to stretch classically at 18-22 wkswks

* Red degeneration of the fibroid * Red degeneration of the fibroid

Incarcerated Incarcerated retroverted graved retroverted graved uterusuterus

Commonly occurs between 12-Commonly occurs between 12-14wks14wks

Causes urethral obstruction with Causes urethral obstruction with acute urinary retention & pain acute urinary retention & pain

Indwelling urine cathter helps Indwelling urine cathter helps allow the uterus to become allow the uterus to become abdominal abdominal

Retroplacental Retroplacental haemorrhage following haemorrhage following amniocentesisamniocentesis Can complicate both diagnostic & Can complicate both diagnostic &

therapeutic amniocentesis therapeutic amniocentesis especially when the needle especially when the needle inserted transplacentallyinserted transplacentally

Pain is felt a few hours after the Pain is felt a few hours after the procedure procedure

Constant & localised to the Constant & localised to the puncture site puncture site

Prermature labour & Prermature labour & chorioamnionitischorioamnionitis Presents with intermittent or Presents with intermittent or

constant abdominal pain constant abdominal pain May be associated with vaginal May be associated with vaginal

discharge, abdominal tenderness discharge, abdominal tenderness and maternal & fetal tachycardiaand maternal & fetal tachycardia

Treatment with antibiotics and Treatment with antibiotics and expediting delivery expediting delivery

Round ligament painRound ligament pain

Occurs secondary to stretching of the Occurs secondary to stretching of the ligament as the uterus enlarges into ligament as the uterus enlarges into the abdomen (10-30% of pregnancy)the abdomen (10-30% of pregnancy)

Commonly occurs in the late 1Commonly occurs in the late 1stst and and early 2early 2ndnd trimester trimester

Felt as dragging, stabbing or cramp-Felt as dragging, stabbing or cramp-like pain in the outer lower abdomen like pain in the outer lower abdomen radiating to groinradiating to groin

Diagnosis is made by excluding other Diagnosis is made by excluding other causes causes

Red degeneration of Red degeneration of fibroidfibroid

Occurs due to infarction of the centre Occurs due to infarction of the centre of the fibroid during mid –pregnancyof the fibroid during mid –pregnancy

The fibroid suddenly enlarges & is The fibroid suddenly enlarges & is painful and tendrepainful and tendre

The pain is ischaemic ,constant and The pain is ischaemic ,constant and localised to one side of the uterus but localised to one side of the uterus but sometimes diffuse. Mild pyrexia sometimes diffuse. Mild pyrexia leucocytosis. USS may be helpful leucocytosis. USS may be helpful

Treatment is conservative Treatment is conservative

Third TrimesterThird Trimester

Fetal movements & Fetal movements & Braxton-Hicks Braxton-Hicks contractionscontractions

These are spontaneous uterine These are spontaneous uterine contractions becoming more frequent contractions becoming more frequent as pregnancy advances.as pregnancy advances.

Initially painless but then perceived as Initially painless but then perceived as vague backache which is minimally vague backache which is minimally uncomfortable but does not need uncomfortable but does not need analgesia, however can be sever analgesia, however can be sever requiring hospital admission commonly requiring hospital admission commonly in primigravida in primigravida

Placental abruptionPlacental abruption

Presents with abdominal pain with or Presents with abdominal pain with or without vaginal bleedingwithout vaginal bleeding

Complicates up to 1% of pregnanciesComplicates up to 1% of pregnancies Abdominal pain could be mild constant Abdominal pain could be mild constant

or intermittent (like labour pains)or intermittent (like labour pains) When no vaginal bleeding, can be When no vaginal bleeding, can be

confused with other causes of confused with other causes of abdominal pain. A high index of abdominal pain. A high index of suspicion is essential suspicion is essential

Sever Pre-eclampsia & Sever Pre-eclampsia & eclampsiaeclampsia Incidence about 6% among primigravidaeIncidence about 6% among primigravidae Pain is mainly at the epigastrium & Rt Pain is mainly at the epigastrium & Rt

upper quadrantupper quadrant It’s due to stretching of the liver capsule It’s due to stretching of the liver capsule

secondary to subcapsular haemorrhagesecondary to subcapsular haemorrhage Other symptoms & signs are often Other symptoms & signs are often

presentpresent Treatment involves control & delivery Treatment involves control & delivery

Uterine ruptureUterine rupture

Unlikely to occur silently during pregnancy Unlikely to occur silently during pregnancy but it can occur in women with previous but it can occur in women with previous classical C/S usually from early 3classical C/S usually from early 3rdrd trimester.trimester.

Others occur in labour in women who had Others occur in labour in women who had c/s or perforated uterus during D/Cc/s or perforated uterus during D/C

The abdominal pain typically acute, The abdominal pain typically acute, associated with shock & shoulder tip painassociated with shock & shoulder tip pain

The pain can penetrate through the The pain can penetrate through the epidural block. Laparotomy is required epidural block. Laparotomy is required after resuscit after resuscit

Pain not directly related Pain not directly related to pregnancyto pregnancy

Gastrointestinal Gastrointestinal TractTract

Gastro-esophageal Gastro-esophageal refluxreflux A common cause of upper abdominal A common cause of upper abdominal

pain in pregnancy. Incidence 60-70%pain in pregnancy. Incidence 60-70% More common in late pregnancy More common in late pregnancy

multiple pregnancy & multiple pregnancy & polyhydramniospolyhydramnios

Felt as burning sensation in Felt as burning sensation in epigastrium & behind the sternumepigastrium & behind the sternum

Caused by relaxation of gastro-Caused by relaxation of gastro-esophageal sphincteresophageal sphincter

Peptic ulcerPeptic ulcer

Uncommon during pregnancyUncommon during pregnancy Usually there is a pre-existing historyUsually there is a pre-existing history Pain typically in the epigasric & Rt Pain typically in the epigasric & Rt

hypochodrium worse with hunger & hypochodrium worse with hunger & spicy foodspicy food

Perforation is rare but may occur Perforation is rare but may occur especially after delivery. Presents with especially after delivery. Presents with acute pain ,collapse & peritonitisacute pain ,collapse & peritonitis

Gas under diaphragm on erect x-ray Gas under diaphragm on erect x-ray abdomabdom

Hiatus herniaHiatus hernia

Incidence 7-22% of all pregnanciesIncidence 7-22% of all pregnancies Present in 62% of cases of sever Present in 62% of cases of sever

heartburn in the 3heartburn in the 3rdrd trimester trimester Very severe cases present with Very severe cases present with

sever vomiting & haematemesissever vomiting & haematemesis Treatment as for reflux esophagitisTreatment as for reflux esophagitis

constipationconstipation

May present as sever or chronic May present as sever or chronic abdominal painabdominal pain

Caused by slow peristalsis Caused by slow peristalsis (progeterone effect)(progeterone effect)

Felt as dull, constant & sometimes Felt as dull, constant & sometimes colicky pain in the iliac fossae (Ltcolicky pain in the iliac fossae (Lt

Treatment with high fibre diet & Treatment with high fibre diet & laxativeslaxatives

Acute appendicitisAcute appendicitis

Complicates 1 in 1500-2500 Complicates 1 in 1500-2500 pregnancies (as in non-pregnants)pregnancies (as in non-pregnants)

Symptoms & signs may be atypical.Symptoms & signs may be atypical. Pain may be in the Rt lumber region Pain may be in the Rt lumber region

in early gestation or in the Rt in early gestation or in the Rt hypochondrium in late pregnancy hypochondrium in late pregnancy due to displacement of caecum & due to displacement of caecum & appedixappedix

by the gravid uterusby the gravid uterus

The pain in early pregnancy starts The pain in early pregnancy starts around the umbilicus then settles around the umbilicus then settles in the RIFin the RIF

Accompanied by nausea, Accompanied by nausea, vomiting anorexia & fever vomiting anorexia & fever however, these symptoms may however, these symptoms may be absent in late pregnancy be absent in late pregnancy

Leucocytosis is an important sign Leucocytosis is an important sign but due to physiological but due to physiological leucocytosis in pregnancy, serial leucocytosis in pregnancy, serial count is more usefulcount is more useful

Pyrexia, tenderness & guarding Pyrexia, tenderness & guarding over the Rt abdomen may be the over the Rt abdomen may be the only signs presentonly signs present

The inflammed appendix may The inflammed appendix may induce preterm labourinduce preterm labour

Treatment of acute Treatment of acute appendicitisappendicitis

In early pregnancy laparoscopic In early pregnancy laparoscopic appendectomy can be done or appendectomy can be done or through the classical McBurney through the classical McBurney incisionincision

If laparotomy is necessary, a para- If laparotomy is necessary, a para- median incision over the area of median incision over the area of max tenderness allows the best max tenderness allows the best access if extension is needed access if extension is needed

Complications of appendicitis in Complications of appendicitis in pregnancypregnancy

RuptureRupture Peritonitis: organ displacement Peritonitis: organ displacement

prevents walling- off of the prevents walling- off of the inflammed appendix inflammed appendix

PROM & preterm labourPROM & preterm labour

Bowel obstructionBowel obstruction

Is a rare cause of acute abdominal Is a rare cause of acute abdominal pain in pregnancy (1 in 2500-3500 )pain in pregnancy (1 in 2500-3500 )

Incidence appears to be increasing Incidence appears to be increasing due to increased abdomino –pelvic due to increased abdomino –pelvic surgery causing adhesion bandssurgery causing adhesion bands

Rarely caused by strangulated femoral Rarely caused by strangulated femoral or inguinal herniae & volvulus.or inguinal herniae & volvulus.

Bowel Bowel obstruction ..contobstruction ..cont The pain is colicky with exaggerated The pain is colicky with exaggerated

bowel sounds & constipation. bowel sounds & constipation. Abdominal distension may be difficult Abdominal distension may be difficult to detect in advanced pregnancy to detect in advanced pregnancy

Treatment is conservative with N/S Treatment is conservative with N/S tubing, fluid & electrolyte replacementtubing, fluid & electrolyte replacement

it usually settle within few hours it usually settle within few hours otherwise laparotomy is required to otherwise laparotomy is required to divide adhesions divide adhesions

Gallstones & Gallstones & cholecystitischolecystitis Pregnancy predisposes to Pregnancy predisposes to

gallstones due to biliary stasis and gallstones due to biliary stasis and raised cholesterol in pregnancyraised cholesterol in pregnancy

Incidence about 3.5%Incidence about 3.5% Most women are asymptomaticMost women are asymptomatic Symptomatic Pt’s present with Symptomatic Pt’s present with

sudden onset of colicky abdominal sudden onset of colicky abdominal pain radiating to the back in Rt pain radiating to the back in Rt hypochodriu hypochodriu

Gallbladder ..contGallbladder ..cont

Nausea, vomiting & vasovagal attacksNausea, vomiting & vasovagal attacks Tenderness & positive murphy’s sign Tenderness & positive murphy’s sign

may be the only positive clinical signsmay be the only positive clinical signs Diagnosis can be made by ultrasoundDiagnosis can be made by ultrasound Treatment is coservativeTreatment is coservative Surgery can be performed in early Surgery can be performed in early

pregnancy laparoscopicallypregnancy laparoscopically

Gallbladder..contGallbladder..cont

Open surgery can be done in Open surgery can be done in advanced pregnancy but risks are advanced pregnancy but risks are ascending cholangitis which may ascending cholangitis which may lead to septicaemia & preterm lead to septicaemia & preterm labourlabour

Gallbladder..contGallbladder..cont

Acute cholecystitis is uncommon in Acute cholecystitis is uncommon in pregnancypregnancy

Presents with acute Rt hypochonderial Presents with acute Rt hypochonderial pain, nausea, vomiting & pyrexiapain, nausea, vomiting & pyrexia

Pyrexia differentiating it from gallstonePyrexia differentiating it from gallstone Incidence 1 in 1000 pregnanciesIncidence 1 in 1000 pregnancies Treatment with antibiotics & analgesiaTreatment with antibiotics & analgesia

pancreatitispancreatitis

Uncommon in pregnancy (1 in 5000)Uncommon in pregnancy (1 in 5000) More common in pregnants than nonMore common in pregnants than non High mortality rate (>10%)High mortality rate (>10%) Presents with central or upper Presents with central or upper

abdominal pain radiating to the backabdominal pain radiating to the back There may be nausea, vomiting & There may be nausea, vomiting &

shock. Few with juandice when there shock. Few with juandice when there is obstructed biliary system is obstructed biliary system

Pancreatitis.. contPancreatitis.. cont

Diagnosis confirmed by raised Diagnosis confirmed by raised serum amylaseserum amylase

Ultrasound shows gallstones in Ultrasound shows gallstones in 50% of cases50% of cases

Treatment is conservative with iv Treatment is conservative with iv fluid & electrolyte replacement, fluid & electrolyte replacement, pethidine, steroids, antibiotics pethidine, steroids, antibiotics cimitidine & glucgone cimitidine & glucgone

Renal tractRenal tract

Acute pyelonephritisAcute pyelonephritis

Is the most common renal cause Is the most common renal cause of abdominal pain in pregnancy (1-of abdominal pain in pregnancy (1-2%)2%)

Most cases present in the 2Most cases present in the 2ndnd & 3 & 3rdrd trimesters with sever abdominal trimesters with sever abdominal pain in the lumbar region radiating pain in the lumbar region radiating to the iliac fossa or vulvato the iliac fossa or vulva

Nausea, vomiting, pyrexia, rigors Nausea, vomiting, pyrexia, rigors & tachycardia with loin tenderness& tachycardia with loin tenderness

Pyelonephritis..contPyelonephritis..cont

Associated with increased risk of Associated with increased risk of preterm labourpreterm labour

Diagnosis by MSU for R/E & C/SDiagnosis by MSU for R/E & C/S E. Coli is the most common causeE. Coli is the most common cause If recurrent exclude renal If recurrent exclude renal

anomalies USS during preg. Or anomalies USS during preg. Or IVP 3-4 months after delivery.IVP 3-4 months after delivery.

Renal stonesRenal stones

Affects 0.03-0.05% of pregnant women Affects 0.03-0.05% of pregnant women (as in non-pregnants)(as in non-pregnants)

Pregnancy does not predispose to Pregnancy does not predispose to stone formation . In fact small stones stone formation . In fact small stones may passed unnoticed due to ureteric may passed unnoticed due to ureteric dilatationdilatation

Presents with loin pain radiating to the Presents with loin pain radiating to the suprapubic region the pain may be suprapubic region the pain may be excruciating & associated with shockexcruciating & associated with shock

Renal stones...contRenal stones...cont

Renal tenderness may be the only Renal tenderness may be the only clinical sign USS may show dilated clinical sign USS may show dilated renal tract or a stonerenal tract or a stone

Treatment mostly conservative with Treatment mostly conservative with potent analgesic & liberal fluid intakepotent analgesic & liberal fluid intake

If obstruction persist surgery is If obstruction persist surgery is indicatedindicated

There is a risk of precipitating preterm There is a risk of precipitating preterm labour labour

Acute retention of Acute retention of urineurine

More likely to occur in the 1More likely to occur in the 1stst trimester and in the puerperium.trimester and in the puerperium.

Causes include:Causes include:

- incarcerated R/v gravid uterus- incarcerated R/v gravid uterus

- pelvic mass (ovarian or fibroid)- pelvic mass (ovarian or fibroid)

- acute herpes infection- acute herpes infection

- vulval haematoma - vulval haematoma

Urine retention..contUrine retention..cont

Presents with sudden onset of Presents with sudden onset of sever pain with distended bladder sever pain with distended bladder on examon exam

Catherterization for 24-48hrs & Catherterization for 24-48hrs & analgesia are very helpful and analgesia are very helpful and allow the gravid uterus to become allow the gravid uterus to become abdominalabdominal

Adenxal accidentsAdenxal accidents

Corpus luteum cyst in early pregnancy Corpus luteum cyst in early pregnancy may bleed causing pain or rupture may bleed causing pain or rupture causing shockcausing shock

Mostly diagnosed by USS or Mostly diagnosed by USS or bimanually if they are largebimanually if they are large

Managed mostly conservatively but if Managed mostly conservatively but if they are large or showing abnormal they are large or showing abnormal pathology they should be removed pathology they should be removed after 14 wks after 14 wks

Adenxal Adenxal accidents..contaccidents..cont Torsion of a pre-existing ovarian cystTorsion of a pre-existing ovarian cyst

(benign or malignant) presents with (benign or malignant) presents with intermittent abdominal pain which intermittent abdominal pain which later becomes constant (indicating later becomes constant (indicating ischaemia). There may be nausea, ischaemia). There may be nausea, vomiting, low grade fever and vomiting, low grade fever and leucocytosis .If ignored the ovary leucocytosis .If ignored the ovary may become gangrenousmay become gangrenous

Adnexal Adnexal accidents..contaccidents..cont Laparotomy with oophorectomy Laparotomy with oophorectomy

or fixing the ovary if viableor fixing the ovary if viable Torsion of a pedunculated fibroid Torsion of a pedunculated fibroid

may present in a similar way to may present in a similar way to torted ovarian cyst. They need to torted ovarian cyst. They need to be removed at laparotomy. Don’t be removed at laparotomy. Don’t try to remove subserous, try to remove subserous, intramural fibroidintramural fibroid

as it may end by hysterectomy as it may end by hysterectomy

Miscellaneous causeMiscellaneous cause

Musculoskeletal : Musculoskeletal :

- exaggerated lumbar lordosis- exaggerated lumbar lordosis

- sumphyseal diasthesis- sumphyseal diasthesis

* sickle cell crisis* sickle cell crisis

* rectus sheath haematoma* rectus sheath haematoma

* porphyria* porphyria

* Aortic aneurysm* Aortic aneurysm