Abdominal Pain During Pregnancy?

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Abdominal Pain During Pregnancy?

• Dr.Samir Fouad AbdelAziz
• Assit.Professor Ob.Gyn.
• Al-Azhar University

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• Abdominal pain is a very common symptom in
  pregnant women. It may be due to pregnancy itself
  e.g red degeneration in a fibroid or may arise
  from some concomitant lesion such as
  appendicitis.
• It is convenient to divide the causes of pain due
  to pregnancy into those most commonly found in
  each of the three trimesters,though of course
  there is considerable overlap

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First Trimester

• Abortion
• Disturbed Ectopic pregnancy
• pregnancy in rudimentary horn
• Acute salpingitis
• Acute Retention of urine

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First Trimester pain

• Abortion
• Pain preceeded by vaginal bleeding,
• in the middle intermittent.
• Cervix,closed(threatened abortion)or open
  (inevitable)..U/S.gestational sac inside uterine
  cavity.

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First Trimester Pain

• Ectopic pregnancy
• Pain typically occur before bleeding and blood
  tend to be dark(prune juice)
• Pain tends to be limited initially to the
  affected side,though if interperitoneal bleeding
  occurs it become generalised the picture of
  acute abdomen may develop with shock

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First Trimester Pain

• Pregnancy in rudimentary horn
• pain resemble that of ectopic and usually the
  condition discovered during laparotomy
• If rupture occurs it usually in the midtrimester
  and of sudden onset with collapse

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First Trimester Pain

• Acute Salpingitis
• May develop up to the 10th.weeks after
  conception,due to gonococcal infection or
  infection at attempted attempted abortion
• Pain felt in both iliac fossae is continuous
• There is associated tenderness,tachycardia and
  elevated temperature,culture of discharge may
  reveal pathogens

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First Trimester Pain

• Acute retention of urine
• is usually due to enlargement of a cervical
  fibroid in response to pregnancy and may occur
  very early
• Severe lower abdominal wall, large tender bladder
  which may be mistaken for ov. Cyst
• Catheterisation causes immediate relief of pain

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Midtrimester Pain

• Acute retention of urine due to incarcerated RVF
  gravid uterus
• Red degeneration in a fibromyoma
• Rupture of rudimentary horn containing pregnancy
• Stretching of round ligament
• Abortion

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Midtrimester Pain

• Red degeneration of fibromyoma
• causes pain ranging from mild to severe over the
  fibroid.tenderness usually present over the
  fibroid.
• U/S usually detect the fibroid during first
  trimester
• There may be history of menorrhagia before
  pregnancy..TT..conservative with analgesic

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Midtrimester Pain

• Stretching of the round ligament may sometimes be
  a cause of mid-trimester pain
• Usually pain is continuous and there is
  tenderness over the affected ligament
• There is no constitutional symptoms.
• Reassurance and sometimes mild analgesia is
  required

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Third Trimester Pain

• Concealed haemorrhage
• Severe preeclampsia
• Red degeneration of fibromyoma
• Uterine rupture
• Contractions of labour

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Third Trimester Pain

• Concealed haemorrhage
• Pain is of acute onset is severe, with
  considerable shock and collapse.
• The abdominal ms. Are tense and the uterus may be
  larger than expected, hard tender with difficulty
  in palpating fetal parts
• Fetal heart is usually absent
• there may be vagina bleeding
• There may be hypertension before the event

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Third Trimester Pain

• Severe Pre-eclampsia
• Epigastric pain may occur is a sign of
  impending eclampsia.
• The characteristic signs of pre-eclampsia,
  hypertension, proteinuria and oedema are present
• The uterus is not tender fetal parts are
  palpable FHR usually present

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Third Trimester Pain

• Uterine rupture is a possibility in highly
  parous women those who have scarred uterus by
  CS,Myomectomy or perforation.
• Women usually feel a tearing sensation followed
  by constant pain..shock collapse. Vaginal
  bleeding is common.
• Fetal parts easily felt FHR is absent

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Third Trimester Pain

• Labour pains
• may occur prematurely or at term, they are
  intermittent gradually become stronger and more
  frequent.
• The characteristic show of early labour will be
  observed and on vaginal examination cervix will
  be taken up and perhaps dilated

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Incidental Causes of Pain

• Gastro-enteritis
• Pain is generalised over the abdomen and
  accompained by vomiting and diarrhoea.
• Temperature is elevated and abdomen is tender
  with no rigidity
• stool analysis show organism

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Incidental causes of Pain

• Acute Appendicitis and Pyelonephritis
• the appendix is displaced upward and laterally as
  pregnancy advances and its tip overly the tip of
  right kidney. Appendicitis may be confused with
  pyelonephritis

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• In pyelonephritis the pain is often of an aching
  character and felt only in the lumbar region,
  however, it may be felt only in the right side of
  abdomen in severe cases may be diffused over
  the whole abdomen
• in pyelonephritis the tenderness is usually
  localised in the right costovertebral angle

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• In pyelonephritis temperature tend to be high
  and pulse rate in relation to temperature tend to
  be lower than in case of appendecitis
• Even with sever cases the tongue is usually
  moist in cases of pyelonephritis,but usually dry
  with appendicitis.
• In case of doubt laparotomy is indicated, to
  avoid mortality with appendicitis

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Incidental causes(cont.)

• Renal and uretric calculi
• Pain may be confused as pyelitis and radiate to
  leg. Blood may be present in the urine and U/S
  may show stone in kidney or bladder.
• Acute cholycystitis..usually positive history
  present and pain over Rt.hypochondrium, radiate
  to Rt.shoulder.U/S may show stone in G.B

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Incidental causes of Pain

• Perforation of a hollow organ
• such as the stomach or duodenum, may occur with
  sudden pain, collapse and the rapid development
  of generalised peritonitis
• Usually history of peptic ulcer or gastric ulcer
  is present

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Incidental Causes of Pain

• Strangulated hernia should be born in mind and
  hernial sites should be examined
• Acute Pancreatitis the onset is sudden with
  severe upper abdominal pain vomiting.usually
  serum amylase and urinary diastase levels
  elevated.
• Treatment is usually conservative

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Incidental causes(cont.)

• Acute Hepatitis
• May occur in hyperemesis gravidarum, in sever
  pre-eclampsia/eclampsia or in acute infective
  hepatitis. In all these conditions there is pain
  tenderness over the liver jandice is usually
  soon manifest

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Incidental Causes (cont.)

• Acute intestinal obstruction
• Sometimes found in pregnancy usually there is
  history of laparotomy if there is band of
  adhesion the enlarged uterus displaces the
  intestine obstruction occurs.The onset is
  usually sudden,with vomiting. Distention
  vomiting with colicky pains are typical.

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Incidental Causes(cont.)

• Torsion of ovarian cyst may occur especially
  during first trimester. Pain is at first referred
  to one or other hypochondrium is acute in onset
  usually with vomiting.
• as peritonitis occur there is pain, tenderness
  rigidity over the tumor.there may be some
  pyrexia.
• U/S show the cyst

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Incidental Causes(cont.)

• Other causes
• Acute porphyeria
• Sickling crisis
• Diabetic ketoacidosis