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Abdominal pain and pregnancy

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  • 1. 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 .
  • 2. 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
  • 3.  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..
  • 4. 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 .
  • 5. 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.
  • 6. 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.
  • 7. 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.
  • 8. 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.
  • 9. 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.
  • 10. 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.
  • 11. 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.
  • 12. 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).
  • 13. Referred Pain to theEpigastrium  Inferior Myocardial infarction.  Myocardial Ischemia.  Pericarditis.  Basal Pneumonia.
  • 14. Central / Umbilical Bowel –Irritable bowel syndrome (IBS), Initial appendicitis-pain, Obstruction, Crohn’s disease. Pancreatitis. Vascular-mesentery artery thrombosis , aortic aneurism. Abdominal Wall –umbilical hernia.
  • 15. Left Upper Quadrant /Hypochondrium ( a) Stomach-gastritis ,ulcer , carcinoma. ( b) Pancreas-pancreatitis , carcinoma. ( c ) Large bowel- perforation , diverticulitis ( D )Spleen – leukemia , lymphoma , infarct ,rupture ,infectious mono nucleosus ,malaria , kalajar ( E ) Kidney – pyelonephritis ,hydro nephrosis ,calculi . ( F ) Viral – Herpes Zosters ( g ) Referred----lung—Left lower lobe pneumonia , pulmonary embolism. Cardiac-ischemia or infarction.
  • 16. Right Upper Quadrant/hypochondrium. (a ) Gall Bladder-billiary colic ,cholicystits , carcinoma. ( B )Liver –right heart failure ,hepatic vein thrombosis,carcinoma ,abscess , Hellp syndrome ( c ) Small bowel –ulcer –Perforation . ( D) Large bowel –Crohn‖ disease. ( E ) Pancreas-=pancreatitis ,carcinoma. ( F ) Kidney- pyelonephritis ,hydronephrosis , calculi . ( G ) Viral-hrepes Zoster . ( H ) Referred from-right lower lobe pneumonia , pulmonary embolism ,cardiac ischemia or infarction .
  • 17. Iliac Fosse Bowel –constipation ,gastroenteritis , colitis ,IBS , obstruction , carcinoma , perforation . Reproductive—ectopic pregnancy ,ovarian cyst’s accident ,PID ,mittlesmerz. Abdominal wall- hernia : inguinal femoral , psoas abscess. Urological-cystitis ,ureteric colic . Vascular –aneurism . Viral – herpes zoster.
  • 18. Medical Causes of diffuse /generalized Abdominal Pain . Pneumonia. Diabetic Ketoacidosis . Henoch‖s Purpura. Sickle cell crisis . Acute intermittent porphyria. Familial Meditterrean Fever –Paroxysmal peritonitis . Lead poisoning . Infection- malaria , Typhoid Fever ,Cholera , giardiasis . Drugs-Heroin withdrawal .
  • 19. 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 .
  • 20. 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 .
  • 21. 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.
  • 22. Thank you

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