Download - Abd Pain Pregnancy
ABDOMINAL PAIN IN ABDOMINAL PAIN IN PREGNANCYPREGNANCY
Augustinus BTAugustinus BT
A 22 yr old para 1 with 6-8 wks gestation A 22 yr old para 1 with 6-8 wks gestation presents with abdominal pain.presents with abdominal pain.
WHAT ARE YOU THINKING WHAT ARE YOU THINKING OF ?OF ?
The historyThe history
Localized one sided pain, no radiation, Localized one sided pain, no radiation, spasmodic to start with – now constantspasmodic to start with – now constant
Mild bleeding p/vMild bleeding p/v
Some chest pain and shoulder tip painSome chest pain and shoulder tip pain
Has been feeling faintHas been feeling faint
Pregnancy test positivePregnancy test positive
THINK ECTOPICTHINK ECTOPIC
VITAL SIGNSVITAL SIGNS
B HCG – QUANTITATIVEB HCG – QUANTITATIVE
URGENT PELVIC USSURGENT PELVIC USS
REFER/ADMIT TO HOSPITALREFER/ADMIT TO HOSPITAL
ECTOPIC PREGNANCYECTOPIC PREGNANCYPit falls in diagnosisPit falls in diagnosis
Wide variation in clinical presentationWide variation in clinical presentation
Pregnancy test can be negative at times of Pregnancy test can be negative at times of diagnosis. ( However it must have been positive diagnosis. ( However it must have been positive at some time or another).at some time or another).
TV USS even at the best of hands is only 50% TV USS even at the best of hands is only 50% accurate in picking up an ectopic pregnancy.accurate in picking up an ectopic pregnancy.
B HCGs can double in very early ectopicsB HCGs can double in very early ectopics
Doubling time varies from 1.4 to 7.2 days Doubling time varies from 1.4 to 7.2 days depending on gestationdepending on gestation
Mx of Ectopic PregnancyMx of Ectopic Pregnancy
Medical with Methotrexate with or without Medical with Methotrexate with or without folinic acid.folinic acid.
Surgical – laparotomy and laparoscopySurgical – laparotomy and laparoscopy
salpingostomy andsalpingostomy and
salpingiectomysalpingiectomy
Follow up and prognosisFollow up and prognosis
IS IT OVARIAN ?IS IT OVARIAN ?
Corpus luteum cysts and accidentsCorpus luteum cysts and accidents
Mild aching painMild aching pain
Usually asymptomaticUsually asymptomatic
Maternal pulse is not raisedMaternal pulse is not raised
Hemorrhage inside cyst can cause severe Hemorrhage inside cyst can cause severe painpain
ADNEXAL TORSIONADNEXAL TORSION
More common in pregnancy ( 28%)More common in pregnancy ( 28%)Lateral lower quadrant pain- sudden onsetLateral lower quadrant pain- sudden onsetFever ,leucocytosis, nausea, vomitingFever ,leucocytosis, nausea, vomiting
UNRELIABLE IN PREGNANCYUNRELIABLE IN PREGNANCYUSS – no flow on colour mappingUSS – no flow on colour mappingSurgery should not be delayedSurgery should not be delayedMiscarriage and preterm labour are common Miscarriage and preterm labour are common consequencesconsequencesDifficult to differentiate from ectopics and Difficult to differentiate from ectopics and appendicitisappendicitis
A 22 yr old para 1 with 6-8 wks amenorrhea A 22 yr old para 1 with 6-8 wks amenorrhea presents with abdominal painpresents with abdominal pain
The history changes:The history changes:
Crampy lower abdominalCrampy lower abdominal
Heavy bleeding p/vHeavy bleeding p/v
Speculum examinationSpeculum examination
cx os closedcx os closed
cx os opencx os open
DIAGNOSIS - ? MISCARRIAGEDIAGNOSIS - ? MISCARRIAGE
Assess hemodynamic stabilityAssess hemodynamic stability
Arrange pelvic ultrasoundArrange pelvic ultrasound
Management depends on Management depends on ultrasonographic findings.ultrasonographic findings.
No role of BhcgsNo role of Bhcgs
Blood group, Rhesus and anti-D if Blood group, Rhesus and anti-D if necessarynecessary
SOME USS FINDINGSSOME USS FINDINGS
An intrauterine gestational sac seen 25X30 mm An intrauterine gestational sac seen 25X30 mm in diameters. No fetus visible.in diameters. No fetus visible.An IU gestational sac seen 20 X 20 mm in An IU gestational sac seen 20 X 20 mm in diameter. Fetal pole seen 4 mm CRL. No FH diameter. Fetal pole seen 4 mm CRL. No FH identified.identified.An IU gestational sac seen 20X 20 mm in An IU gestational sac seen 20X 20 mm in diameter ,FP seen 6 mm CRL. No FHdiameter ,FP seen 6 mm CRL. No FHAn IU gestational sac seen 35X35 mm in An IU gestational sac seen 35X35 mm in diameters low down in the cavity. FP seen . FH diameters low down in the cavity. FP seen . FH seen but appears slow.seen but appears slow.
THE MANAGEMENT OF THE MANAGEMENT OF MISCARRIAGEMISCARRIAGE
ConservativeConservative
Reassurance and TLCReassurance and TLC
No role of bed restNo role of bed rest
ERPOCERPOC
MISCARRIAGEMISCARRIAGE
ALWAYS CONFIRM A POSSIBLE ALWAYS CONFIRM A POSSIBLE COMPLETE MISCARRIAGE BY SERIAL COMPLETE MISCARRIAGE BY SERIAL BHCGS.BHCGS.
This is specially true if there has been no This is specially true if there has been no scans to prove an intrauterine gestational scans to prove an intrauterine gestational sacsac
PITFALL : You might miss an ECTOPICPITFALL : You might miss an ECTOPIC
Lower abd pain with dysuriaLower abd pain with dysuria
Acute cystitis occurs in 1-2% of pregnant Acute cystitis occurs in 1-2% of pregnant womenwomenAcute pyelonephritis is a serious Acute pyelonephritis is a serious complicationcomplicationUsually happens in 2Usually happens in 2ndnd and 3 and 3rdrd trimester trimesterAsymptomatic bacteriuria is a Asymptomatic bacteriuria is a predisposing factorpredisposing factorMay result in Preterm labourMay result in Preterm labourUrine testing is mandatoryUrine testing is mandatory
UTERINE FIBROIDSUTERINE FIBROIDS
10 % of women with fibroid uterus 10 % of women with fibroid uterus experience abdominal painexperience abdominal pain
Hemorrhagic infarction – red degenerationHemorrhagic infarction – red degeneration
Localized pain – may mimic placental Localized pain – may mimic placental abruption or uterine ruptureabruption or uterine rupture
Maternal and fetal risks are due to Maternal and fetal risks are due to incorrect diagnosis and delay in treatmentincorrect diagnosis and delay in treatment
ROUND LIGAMENT PAINROUND LIGAMENT PAIN
10-30% OF PREGNANCIES10-30% OF PREGNANCIES
Commonly towards the beginning and the end of Commonly towards the beginning and the end of pregnancypregnancy
More in multipsMore in multips
Said to be due to stretching of round ligamentsSaid to be due to stretching of round ligaments
Cramplike or stabbing and made worse with Cramplike or stabbing and made worse with movementmovement
Some tenderness in the lower quadrant and Some tenderness in the lower quadrant and groingroin
CAUSES RELATED TO CAUSES RELATED TO PREGNANCYPREGNANCYA SUMMARYA SUMMARY
ECTOPIC PREGNANCYECTOPIC PREGNANCY
MISCARRIAGEMISCARRIAGE
URINARY TRACT INFECTIONURINARY TRACT INFECTION
ADNEXAL MASSES AND TORSIONADNEXAL MASSES AND TORSION
ROUND LIGAMENT PAINROUND LIGAMENT PAIN
FIBROID DEGENERATIONFIBROID DEGENERATION
A historyA history
22 yrs old 122 yrs old 1stst pregnancy presents with right pregnancy presents with right sided abdominal pain for about 2 days. It sided abdominal pain for about 2 days. It started with a vague pain in the started with a vague pain in the epigastrium and is now constant on the rt epigastrium and is now constant on the rt side. She is about 26 wks pregnant and side. She is about 26 wks pregnant and there is no vaginal bleeding. Her 20 wk there is no vaginal bleeding. Her 20 wk scan was “normal”.scan was “normal”.
WHAT ELSE WOULD YOU LIKE TO WHAT ELSE WOULD YOU LIKE TO KNOW?KNOW?
APPENDICITISAPPENDICITIS
Most common cause of acute abdomen in Most common cause of acute abdomen in pregnancypregnancy
Challenging diagnosisChallenging diagnosis
Balance the risk of surgical delay Balance the risk of surgical delay associated morbidity with effects of associated morbidity with effects of surgery on mother and fetussurgery on mother and fetus
Decision to operate on clinical groundsDecision to operate on clinical grounds
20-35% rate of negative laparotomy20-35% rate of negative laparotomy
APPENDCITIS - DIAGNOSISAPPENDCITIS - DIAGNOSIS
Appendix is progressively displaced Appendix is progressively displaced upwards after 12 wks and reaches iliac upwards after 12 wks and reaches iliac crest at 24 wks.crest at 24 wks.Single most reliable symptom in Single most reliable symptom in pregnancy is RIF painpregnancy is RIF painAnorexia, vomiting, rebound , guarding are Anorexia, vomiting, rebound , guarding are not specific in pregnancynot specific in pregnancyLeucocytosis is NOT helpful.Leucocytosis is NOT helpful.< 10,000 leucocyte may be reassuring< 10,000 leucocyte may be reassuring
APPENDICITIS - DIAGNOSISAPPENDICITIS - DIAGNOSIS
Graded compression ultrasonographyGraded compression ultrasonography
accurate in 1accurate in 1stst and 2 and 2ndnd trimesters , difficult trimesters , difficult in 3in 3rdrd..
98% ACCURATE.98% ACCURATE.
APPENDICITIS- APPENDICITIS- CONSEQUENCESCONSEQUENCES
High fetal loss rate if perforation occurs High fetal loss rate if perforation occurs (20%)(20%)
Maternal mortalityMaternal mortality
Mortality of delayMortality of delay
Risk of perforation highest in 3Risk of perforation highest in 3rdrd trimester trimester
Premature labour esp in the 1st week after Premature labour esp in the 1st week after surgerysurgery
CHOLECYSTITISCHOLECYSTITIS
22ndnd most common cause of acute most common cause of acute abdomenabdomen
1in 6000 pregnancies1in 6000 pregnancies
Cholelithiasis is the cause in >90% ptsCholelithiasis is the cause in >90% pts
Unclear whether pregnancy predisposes Unclear whether pregnancy predisposes to cholelithiasisto cholelithiasis
CHOLECSYTISTIS CHOLECSYTISTIS SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS
Same as in non pregnant women.Same as in non pregnant women.
Nausea, vomiting, acute colicky pain at Nausea, vomiting, acute colicky pain at mid epigastrium or rightt upper abdomenmid epigastrium or rightt upper abdomen
Murphy’s sign is less common in Murphy’s sign is less common in pregnancypregnancy
Jaundice is rareJaundice is rare
D/D – OC,AFLP & HELLPD/D – OC,AFLP & HELLP
CHOLECYSTITISCHOLECYSTITISDIAGNOSISDIAGNOSIS
Elevated serum levels of bilirubin and Elevated serum levels of bilirubin and transaminasestransaminases
Serum alkaline phosphatase less helpfulSerum alkaline phosphatase less helpful
Cholecystosonography- test of choiceCholecystosonography- test of choice
95% accuracy95% accuracy
CHOLECYSTITISCHOLECYSTITISMANAGEMENTMANAGEMENT
MedicalMedical- particularly in the 3- particularly in the 3rdrd trimester trimesterIV hydration, nasogastric IV hydration, nasogastric suction,narcotics, antibiotics if sepsissuction,narcotics, antibiotics if sepsis
SurgicalSurgical indicated where medical treatment failed indicated where medical treatment failed in 2-3 daysin 2-3 daysLaparoscopic (open) better in terms of Laparoscopic (open) better in terms of fetal survival and Premature labour.fetal survival and Premature labour.
BOWEL OBSTRUCTIONBOWEL OBSTRUCTION
1 IN 2500 TO 3500 DELIVERIES1 IN 2500 TO 3500 DELIVERIES
The cause is adhesions in 70% of cases. The cause is adhesions in 70% of cases. Volvulus is responsible for 25 % of cases. Volvulus is responsible for 25 % of cases. Hernia and intesussceptions are rareHernia and intesussceptions are rare
Usually occurs in the 1Usually occurs in the 1stst pregnancies and pregnancies and third trimester and postpartumthird trimester and postpartum
Morbidity and mortality related to Morbidity and mortality related to diagnostic and therapeutic delay.diagnostic and therapeutic delay.
BOWEL OBSTRUCTIONBOWEL OBSTRUCTION
Commonest misdiagnosis- Hyperemesis gravidarum Commonest misdiagnosis- Hyperemesis gravidarum in 2in 2ndnd and 3 and 3rdrd trimesters trimestersTypical symptoms Typical symptoms
crampy abdominal paincrampy abdominal pain obstipationobstipation vomitingvomiting In cases of high obstruction the period between In cases of high obstruction the period between
attacks is short (4-5min) and is characterized by attacks is short (4-5min) and is characterized by diffuse poorly localized upper abdominal paindiffuse poorly localized upper abdominal pain
Colonic obstruction may manifest as lower abdominal Colonic obstruction may manifest as lower abdominal and perineal pain with longer time intervalsand perineal pain with longer time intervals
BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONCLINICAL FINDINGSCLINICAL FINDINGS
Physical examination Physical examination
Tender distended abdomenTender distended abdomen
Fever, leucocytosis and electrolyte imbalances Fever, leucocytosis and electrolyte imbalances increase the likelihood of intestinal strangulationincrease the likelihood of intestinal strangulation
Upright and flat abdominal films with or without Upright and flat abdominal films with or without contrast.contrast.
Concern regarding the exposure of the fetus to Concern regarding the exposure of the fetus to radiation should be balanced against the risk if radiation should be balanced against the risk if maternal mortality from a failed diagnosismaternal mortality from a failed diagnosis
BOWEL OBSTRUCTIONBOWEL OBSTRUCTIONMANAGEMENTMANAGEMENT
Fluid and electrolyte replacementFluid and electrolyte replacement
Nasogastric bowel decompressionNasogastric bowel decompression
Timely surgeryTimely surgery
ACUTE PANCREATITISACUTE PANCREATITIS
RareRare
Usually late in 3Usually late in 3rdrd trimester or early trimester or early postpartumpostpartum
Cholelithisasiis is the commonest causeCholelithisasiis is the commonest cause
Pregnancy contributes by an increased Pregnancy contributes by an increased abdominal pressure on the biliary ductsabdominal pressure on the biliary ducts
Early recognition and treatment essentialEarly recognition and treatment essential
ACUTE PANCREATITISACUTE PANCREATITIS
Signs and symptoms same as in the non Signs and symptoms same as in the non pregnant state.pregnant state.Sudden severe epigastric pain radiating to Sudden severe epigastric pain radiating to the back with nausea and vomiting and the back with nausea and vomiting and fever.fever.Hypoactive bowel sounds and diffusely Hypoactive bowel sounds and diffusely tender abdomentender abdomenMimics preeclampsia, Mimics preeclampsia, DKA,Hepatitis,Cholecystitis.DKA,Hepatitis,Cholecystitis.
ACUTE PANCREATITISACUTE PANCREATITIS
Serum amylase and lipase levels increase Serum amylase and lipase levels increase spontaneously in pregnancyspontaneously in pregnancy
Calculation of amylase to creatinine ratio Calculation of amylase to creatinine ratio is more useful in pregnancy.is more useful in pregnancy.
The ratio is usually low in pregnancyThe ratio is usually low in pregnancy
USS is may be neccessaryUSS is may be neccessary
ACUTE PANCREATITIS ACUTE PANCREATITIS MANAGEMENTMANAGEMENT
Classic triad of medical management Classic triad of medical management consists of bowel rest , fluid and consists of bowel rest , fluid and electrolyte management and pain relief.electrolyte management and pain relief.
ERCP and papillotomy are safeERCP and papillotomy are safe
Cholecystectomy after inflammation Cholecystectomy after inflammation subsidessubsides
NONOBSTETRICAL CAUSESNONOBSTETRICAL CAUSES
APPENDICITISAPPENDICITIS
CHOLECYSTITISCHOLECYSTITIS
BOWEL OBSTRUCTIONBOWEL OBSTRUCTION
PANCREATITISPANCREATITIS
LIVER PROBLEMSLIVER PROBLEMS
MISCELLANEOUSMISCELLANEOUS
LIVER DISORDERSLIVER DISORDERS
Acute fatty liver of pregnancyAcute fatty liver of pregnancyUnknown causeUnknown cause1in 10000- 1 in 15000 pregnancies1in 10000- 1 in 15000 pregnanciesLate in 3Late in 3rdrd trimester trimesterConsiderable overlap with HELLP syndromeConsiderable overlap with HELLP syndromeClinical presentation with abd pain, jaundice and Clinical presentation with abd pain, jaundice and HYPEREMESISHYPEREMESISHepatic encephalopathy and coagulopathyHepatic encephalopathy and coagulopathyFetal demiseFetal demise
ACUTE FATTY LIVER OF ACUTE FATTY LIVER OF PREGNANCYPREGNANCY
Early diagnosis essentialEarly diagnosis essential
Cannot be predictedCannot be predicted
Maintain awarenessMaintain awareness
DO AN LFT in a pt presenting with abdominal DO AN LFT in a pt presenting with abdominal painpain
PREECLAMPSIA AND HELLPPREECLAMPSIA AND HELLP
Complication of severe PETComplication of severe PETHemolysis, Elevated liver enzymes, low platelet Hemolysis, Elevated liver enzymes, low platelet countscountsPeriportal hemorrhagic necrosis with Periportal hemorrhagic necrosis with subcapsular hematomasubcapsular hematomaDiagnosis: rt upper quadrant painDiagnosis: rt upper quadrant pain
nausea and vomitingnausea and vomitingheadacheheadacheDBP > 110 mmHgDBP > 110 mmHgProteinuria 2+Proteinuria 2+
HELLPHELLP
Serious complication of PETSerious complication of PETCan manifest at any time but rare before 20 wksCan manifest at any time but rare before 20 wksOccurs more in whites,mutips and >35 yrsOccurs more in whites,mutips and >35 yrsPoor prognosisPoor prognosisIncidence of about 10 % in PETIncidence of about 10 % in PETRecurrence risk of 25%Recurrence risk of 25%Can also develop postnatallyCan also develop postnatallyManaged as severe PETManaged as severe PETPlasma vol exp, thrombolysis, exchange Plasma vol exp, thrombolysis, exchange plasmapheresis, dialysis, steroidsplasmapheresis, dialysis, steroids
A case historyA case history
A 36 yr old para 4 at 38 wks of gestation A 36 yr old para 4 at 38 wks of gestation presents to you with abdominal pain presents to you with abdominal pain mainly near the umbilicus. The pain came mainly near the umbilicus. The pain came on suddenly and is described as sharp on suddenly and is described as sharp and constant. There is some bleeding pv and constant. There is some bleeding pv and she has not felt the baby move for the and she has not felt the baby move for the last 6 hrs.An examination reveals a tender last 6 hrs.An examination reveals a tender area near the umbilicus.area near the umbilicus.
WHAT COULD THIS BE?WHAT COULD THIS BE?
WHAT ARE YOU THINKING OF ?WHAT ARE YOU THINKING OF ?
PLACENTAL ABRUPTIONPLACENTAL ABRUPTION
What would you like to know ?What would you like to know ?
Placental position on USS.Placental position on USS.
History of hypertensionHistory of hypertension
Maternal ageMaternal age
MultiparityMultiparity
SmokingSmoking
Overdistension of uterusOverdistension of uterus
traumatrauma
PLACENTAL ABRUPTIONPLACENTAL ABRUPTION
In late pregnancyIn late pregnancy
0.5- 1 % of all pregnancies0.5- 1 % of all pregnancies
Associated with hypertension, smoking Associated with hypertension, smoking multiple pregnancies, myomasmultiple pregnancies, myomas
Unrelenting pain- sharp or tearingUnrelenting pain- sharp or tearing
Vaginal bleeding may or may not be Vaginal bleeding may or may not be presentpresent
Coagulopathy and fetal death is commonCoagulopathy and fetal death is common
LABOUR PAINSLABOUR PAINS
Uterine contractionsUterine contractions
Regular intervalsRegular intervals
Intervals gradually shortenIntervals gradually shorten
Associated with bac discomfortAssociated with bac discomfort
Associated with cervical changesAssociated with cervical changes
Discomfort not stopped by sedationDiscomfort not stopped by sedation
UTERINE TORSIONUTERINE TORSION
Mild dextrorotation is common(<40 deg)Mild dextrorotation is common(<40 deg)Rarely may progress beyond 90 dextro Rarely may progress beyond 90 dextro produce acute torsion of uterusproduce acute torsion of uterusUsually in the latter half of pregnancyUsually in the latter half of pregnancyFibroids, congenital anomalies, adnexal Fibroids, congenital anomalies, adnexal mass may predisposemass may predisposeMaternal shock and fetal asphyxiaMaternal shock and fetal asphyxiaMx – conservative or laparotomy to correct Mx – conservative or laparotomy to correct torsiontorsion
CHORIOAMNIONITISCHORIOAMNIONITIS
Usually precipitated by PPROMUsually precipitated by PPROM
Other clinical and laboratory featuresOther clinical and laboratory features
ARTERIOVENOUS HGEARTERIOVENOUS HGE
Rupture of uteroovarian veinsRupture of uteroovarian veins
Rupture of aneurysms – splenic, hepatic, Rupture of aneurysms – splenic, hepatic, renal, aorticrenal, aortic
Rapidly progressing shockRapidly progressing shock
PSYCHOLOGICALPSYCHOLOGICAL
Diagnosis of exclusionDiagnosis of exclusion
Commoner in women with known Commoner in women with known psychosocial problemspsychosocial problems
Reporting a high number of ailments Reporting a high number of ailments during antenatal care is commonduring antenatal care is common
Rectus sheath hematomaRectus sheath hematoma
Rupture of inferior epigastric arteryRupture of inferior epigastric artery
May follow a bout of coughing or May follow a bout of coughing or abdominal trauma usually in late abdominal trauma usually in late pregnancypregnancy
Large unilateral painful swellingLarge unilateral painful swelling
Confused with abruptionConfused with abruption
Superficial locationSuperficial location
MISCELLANEOUS CAUSESMISCELLANEOUS CAUSES
SICKLE CELL CRISISSICKLE CELL CRISIS
MALARIAMALARIA
PORPHYRIAPORPHYRIA
DIABETIC KETOACIDOSISDIABETIC KETOACIDOSIS
THANKTHANK
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