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.
12. 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.
13. Causes of abdominal pain In
Relation 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, splenic
artery aneurism.
(g) Abdominal Wall- epigastric hernia (strangulated).
14. Referred Pain to the
Epigastrium
Inferior Myocardial infarction.
Myocardial Ischemia.
Pericarditis.
Basal Pneumonia.
20. Cause of Abdominal pain in
Pregnancy.
Essentially the causes may be divided in to :
Those due to Pregnancy .
Those related to Reproductive system .
Other causes listed before .
21. Obstetrical / gynecological
causes of pain Abdomen
First 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 .
22. 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.
