Abdominal pain in pregnancy

Abdominal pain is a common complaint in pregnancy , and the problem is in distinguishing pathological from physiological pain .

( A ) Non-pathological pain :
1. Ligaments streaching ( inguinal / round ligaments ) It is secondary to streaching of the ligaments as the uterus enlarge and become abdominal organ rather than pelvic organ .
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Occurs in late 1st & early 2nd trimester . It is dragging or cramp like sensation in the lower abdomen and Diagnosis by exclusion of other causes . Treatment : 2) 1) Reassurance . Physical activity .

radiated to the groin .

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3) sometimes local heat application . 4) Simple analgesia : as paracetamol . 2. Rib pain / costocondritis . 3. Exaggerated lumber lordosis & public symphysis pain . 4. Constipation : due to progesterone effect which will induce smooth muscle relaxation . 5. Heart burn ( reflux oesophagitis ) : more in late pregnancy , multiple pregnancy and poly hydramnios due to effect of progesterone push the distal oesophagus upward . - The pain is burning in sensation , - diagnosis and hiatus hernia . on lying flat , bending or straining . by history & should be differentiated from cholecystitis relaxation of the lower oesophageal sphincator , also by effect gravid uterus , which

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- Treatment

avoid lying flat , small frequent meals and ante acid .

6. Braxton Hicks contractions : During pregnancy spontaneous uterine contractions occur , these are initially painless & infrequent , but become more frequent as pregnancy advance . - Urinary tract infection and preterm labour should be excluded .

( B ) Pathological pain :
I . Pregnancy related pain : 1. Abortion : the commonest cause of pain in this period . - The pain usually preceded by vaginal bleeding . - It is intermittent in midline . 2. Eclopic pregnancy : The pain occurs usually before bleeding and follow a period of amenorrhoea the pain starts 1st on one side , then become generalized and radiating to the shoulder tip &/laparoscopy . 3. Acute urinary retention : Due to enlargement of cervical fibroid will press on urethral opening retention of urine , treated by catheterization . Acute abdomen . Diagnosis : By combination of Beta-HCG level and transvaginal u/s .

2nd trimester :
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1. Acute retention of urine : Due to retroverted gravid uterus at beginning of the 2nd-trimester will cause urine retention and pain . Diagnosis : By examination ,the cervix is pulled upward &foreward and the gravid uterus is posteriorly located ,treated by catheterization . 2. Red-degeneration of uterine fibroid : The fibroids contain estrogen receptors & the increasing circulating level of oestrogen during pregnancy stimulate their growth , while the most fibroids are asymptomatic , the enlarging fibroids will suffer from relative ischaemia pain . - The pain is constant & localized to the site of the fibroid & associated with tenderness . and low grade fever . Diagnosis : History and by u/s , leukocytosis . Treatment conservative - reassurance - potent analgesia 3. Ruptured of pregnant rudimentary horn : This occurs when there is bicornuate uterus , when the uterus is formed of 2 horns ( one functioning and other rudimentary ) if the pregnancy occurs in rudimentary horn internal bleeding ) . Treatment 5. Abortion Laprotomy + resection of that horn . ruptured . The pain is associated with nasea & vomiting fainting & shock ( due

4. Cornual or angular pregnancy

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6. Chorioamnionitis : With or without rupture of membranes .

Clinical features :
1. pain ( constant or intermittent ) . 2. offensive vaginal discharge . 3. fever . 4. Tachycardia ( Maternal & fetal ) . Treatment : Broad spectrum antibiotics . & expedition of delivery .

Third trimester :
1. Preterm labour : The pain felt in the back radiating to the front ,the pain is intermittent , gradually increases in frequency , intensity , duration & associated with cervical changes . 2. Placental abruption : Presented as pain with or without vaginal bleeding bleeding . The pain constant or intermittent oftenly mimicking labour pain . 3. Sever pre-eclampsia : epigastric pain ( subcapsular bleeding in the liver ) + signs of impending eclampsia . 4. Ruptured , scarred uterus ( especially by classical scar ) , myomectomy scar or previous perforation ,usually occur in grand multipara - The scar will be tender , the patient may feel tearing sensation followed by constant pain , Collapse & vaginal bleeding , maternal tachycardia , persistant fetal brady cardia . Treatment : resuscitation + Laprotomy .

II / Incidental causes of abdominal pain :

1. Gastro-enteritis : Pain associated with diarrhea & vomiting .

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2. Acute appendicitis : 1: 1500 pregnancies . - The pain may be located in the Rt-lumber region in early pregnancy or in the Rt-hypochondrium in late gestation . Diagnosis : need high index of suspension when the abdominal pain in Rtsided and associated with leukocytosis . - Treatment laprotomy & appendisectomy . - Maternal mortality 1 2 % . 3. Perforated peptic ulcer : sudden pain , collapse , signs of peritonitis . 4. Intestinal obstruction : Clinical features : Acute onset of pain , nasea & vomitting , constipation . Abdomibal X-ray Management Diagnosis loops of bowel with fluid level . laprotomy . serum amylase .

5. Acute pancreatitis : Sudden sever abdominal pain & vomitting . 6. Renal and ureteric calculus +/- infection : Clinical features : Lion pain , suprapubic pain frequency , dysuria , fever , tenderness over the renal angles . Treatment : libral fluid intake , potent , analgesia , anticholenergic drug , antibiotics , in sever infection ( pylonephritis ) - If renal obstruction persist need hospitalization . surgical removal will be indicated .

III . Pain from conditions which pregnancy predispose to :

1. Cholestasis of pregnancy . 2. Acute fatty liver of pregnancy . 3. Cholecystitis

4. Adenexal accident

Cyst rupture

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Cyst haemorrhage Torsion of overian cyst Torsion of pedunculated subserosal fibroid

Treatment :
- If the cyst not ruptured and the symptoms not getting worse : Conservative management is preferred option with frequent follow up and u/s examination . - If the cyst is large, or with features suggestive of malignancy (by u/s) surgical removal of the cyst or the affected overy will be the best management ( usually after 14 wks of gestation ) . - Torsion of overian cyst : The classical history will be intermittent abdominal pain which later become constant associated with nasea & vomitting , with low grade fever , WBCs count .

Treatment : Should not be delayed .

Laprotomy + cystectomy if the overy is viable or oo phrectomy if not viable .

Other rare causes of abdominal pain :

1. Haematoma of rectus abdominus muscle . The pain + tenderness are superficial and activity of the muscle aggreviate the pain , it subside spontaneously in few days . 2. 3. 4. 5. 6. 7. Rupture spleen . Sickle cell crisis . Porphyria . aneurysm . Malignancies . Psychological causes .

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Objective :
Abdominal pain in pregnancy is a common complaint . There are diverse obstetric , gynecologic , surgical , medical , A careful history and methodical physical examination aided

and psychiatric causes of abdominal pain .

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by selective investigations will usually reveal the causes of the pain in most cases . Physiologic changes that occurs in pregnancy may make A high index of suspicion together with a knowledge of the diagnosis more difficult . ways in which different pathologic conditions present in pregnancy is needed .

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