Abdominal Pain During Pregnancy Prof. M.C. Bansal MBBS.,MS. FICOG ., MICOG. Ex . Principal & controller Jhalawar Medical College & Hospital & M.G.M.C & Hospital . Sitapura ., Jaipur .
Incidence - 5-10 % pregnant women get admitted or seek medical consultation for acute pain abdomen other than labor pains in UK. Hospitals. About 30% of patients do not receive a specific diagnosis despite having a series of clinical investigations. Term Acute abdominal pain used to describe a patient with sudden onset of sever symptoms related to abdomen and its contents
Acute abdomen may be due to pathological changes & may require urgent surgical intervention. Pain may be visceral, somatic or referred, all of which may require different interventions..
Varieties of acute Abdominal pain :---(a) Somatic pain ,transmitted through the somatic nerve fibers from the parietal peritoneum , may be caused by physical or chemical irritation of the parietal peritoneum .The pain feels sharp ,very localized and constant until the cause is removed .
Varieties of Abdominal Pain--(b) Visceral pain is transmitted through autonomic nerves . Quality of perceived pain is different, being dull, some times described like cramps .It may be described by women ―just like before the start of a period.‖(c) Referred pain is arising from pathologically affected organ site other than abdominal organs also and is distributed according to somatic nerve distribution.
Clinical Approach Precise history may put a lot of pieces of diagnostic puzzle .quite often patient holds the key to the correct diagnosis , but needs to be given the chance to answer the right question. The history should include the timing , nature of its onset , radiating features plus any aggravating or relieving factors. Doctor needs to know whether patient has constant, intermittent or colicky pain.
Clinical Approach- A full Gynae-obstetrical history should be taken in order to know exact period of gestation ask for All medicines prescribed or taken including recreational drugs. Long term therapy with prednisolon should alert the clinician to the possibility of upper GI perforation. H/o all symptoms particular reference to the respiratory ,cardiac , alimentary and renal systems. It is always best to think beyond your own specialty. Always remember that common things happen more commonly.
Clinical examination Physical examination should have commenced through observation during history taking , noting any dyspnoea during conversation and seeing whether the patient stays still or is unable to get comfortable in any position. Note down all Vital Signs. Despite the abdominal pain examine heart and lungs, otherwise basal pneumonia, pleurisy and atrial fibrillation leading to mesenteric artery thrombosis may be missed . Look for any erythematous streaks / vesicles. Absent abdominal wall excursion with breathing is suggestive of peritonitis.
Clinical Examination- Abdominal palpation should commence distant to the most painful area (abdominal quadrant) . Abdominal rigidity/ Guarding / rebound tenderness and increased pain on coughing indicates peritonitis. All hernia sites are to be examined. Abdominal obstetrical examination should be done gentally to exclude Acute Hydraminose, accidental hemorrhage, Rupture uterus, rectus muscle hematoma, labor pains and rupture ectopic in early pregnancy.
Clinical Examination- Auscultation—It gives very vital information . Active bowel sounds with normal pitch often excludes active intra peritoneal disease. Such patient may have self limiting Gastroenteritis. High frequency bowel sounds in runs or clusters suggest bowel obstruction. Totally silent abdomen indicates paralytic ileus. FHS also needs recording.
Investigations Routine CVC,ABO Rh Grouping, Urine Analysis Imaging—USG / USG X Ray chest and Flat abdomen in erect standing position to see Air under diaphragm. (Exposure to radiation during pregnancy carries less risk than the intestinal perforation.) C T poses more radiation hazards.
Causes of abdominal pain InRelation to Site of symptoms :Abdominal Quadrants.Epigastrium(a) Stomach- dyspepsia, gastritis, gestro – oesophageal reflux ,gastric volvulus, ulcer , carcinoma(b) Small Bowel – duodenal ulcer.(c) Oesophagus-tear, rupture, ulcer,(d) Gall Bladder- Cholelithiasis, colic.(d) Pancreatitis- alcohol, gall bladder disease , bulimia(e) Giardiasis –(f ) Vascular- visceral ischemia , aortic aneurism, splenicartery aneurism.(g) Abdominal Wall- epigastric hernia (strangulated).
Referred Pain to theEpigastrium Inferior Myocardial infarction. Myocardial Ischemia. Pericarditis. Basal Pneumonia.
Cause of Abdominal pain inPregnancy. Essentially the causes may be divided in to : Those due to Pregnancy . Those related to Reproductive system . Other causes listed before .
Obstetrical / gynecologicalcauses of pain AbdomenFirst Trimester— Abortion ,Ectopic Pregnancy , vesicular mole , Epigastria pain / heart burn in Hyper emesis Gravidarum ,Twisted ruptured ovarian Cyst , Acute retention of urine , Septic induced abortion .Second Trimester— Sudden onset of poly hydramnios.Third Trimester— PROM ,Premature L.P. , True labor pains , Hellp syndrome , impending Eclampsia ,Premature placental separation with or without revealed Hemorrhage, threatened /rupture uterus .torsion of uterus , Red degeneration of fibroid ,Spontaneous rupture of uterine / infundibular- pelvic vessels (Rare) .Post natal Period- Post partum Eclampsia , Pelvic vein thrombosis ,sepsis of reproductive organs and peritonitis , Acute inversion of uterus , Infection /torsion of ovarian cyst or uterine fibroid .
Clinical management Relevant history , thorough clinical examination , necessary investigation and consultation with Physician and /or general surgeon will help in reaching the final diagnosis. Start anti shock therapy immediately, if it is present. Conservative or operative treatment should be started earliest so as to minimize immediate life threatening events to mother as well as fetus.