ABDOMINAL PAIN

IN PREGNANCY
BY
DR E.O .OBI-THOMAS
 INTRODUCTION

 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
 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
 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
 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
 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
 -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
 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
 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
 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
 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
 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
Thanks for
listening