Abdominal Pain During Pregnancy

Abdominal Pain During Pregnancyِ Dr.Samir Fouad AbdelAziz Assit.Professor Ob.Gyn. Al-Azhar University • 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 First Trimester • • • • • Abortion Disturbed Ectopic pregnancy pregnancy in rudimentary horn Acute salpingitis Acute Retention of urine 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. 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 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 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 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 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 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 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 Third Trimester Pain • • • • • Concealed haemorrhage Severe preeclampsia Red degeneration of fibromyoma Uterine rupture Contractions of labour 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 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 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 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 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 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 • *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 • *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 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 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 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 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 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. 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 Incidental Causes(cont.) • • • • Other causes Acute porphyeria Sickling crisis Diabetic ketoacidosis