Abdominal pain in
pregnancy
DR: Abir Mohiden Said
2012
physiology
-Pain is produced in different tissues and it is protective
mechanism for the body.
-It occurs whenever any tissues being damaged, and it
cause the individual to react to remove the stimulus.
-Three types of stimuli excite pain receptors:
-Mechanical
-Thermal.
-Chemical.
-It has been suggested that pain is chemically mediated
and that stimuli that provoke it have in common the
ability to liberate a chemical agents that stimulate nerve
endings.
-This chemical agent might be a kinin or histamine, both
of which cause pain on local injection.
Abdominal Pain In Pregnancy
Abdominal pain in pregnancy is often due to a benign cause but
may be very difficult to diagnose with certainty.
Unless a benign cause can be established with certainty in the
absence of maternal or fetal distress then urgent hospital
referral is usually indicated.
Causes of abdominal pain in pregnancy
1.Pregnancy related
 -Early pregnancy:
 1.ectopic pregnancy.
 2.miscarriage
-Later pregnancy:
1.labour (term or preterm).
2.placental abruption.
3.uterine rupture.
4.Acute Polyhydramnios
5.Choioamniotitis, usually precipitated by pre-term premature
rupture of membranes
2. gynecological causes:
1.Ovarian cysts or tumours, including rupture,
haemorrhage or torsion
2.Red degeneration of a fibroid
3.Uterine torsion
4.Round ligament pain: more common at the beginning
and end of pregnancy, more common in multips and pain
is aggravated by movement.
3.Non-gynecological causes
a. Abdominal wall, especially symphysis pubis and ligament strains.
b. Gastrointestinal causes:
1.Constipation
2.Appendicitis:
-affects 1 in 1500 pregnancies, less common than in non-pregnant women.
-Diagnosis is complicated by change in position of appendix which is carried high
and to the right and there may not be localization of pain.
-Nausea, vomiting, fever together with any right-sided abdominal pain are
suspicious of this.
-Leucocytosis is suggestive.
-Appendicitis is not diagnosed in 1 in 5 cases in pregnant women until the
appendix has ruptured causing peritonitis, which can cause premature labour
or abortion.
3.Perforated peptic ulcer, gastritis
4.Bowel obstruction, e.g. adhesions, volvulus
5.Gallstones, cholecystitis:
cholecystitis is relatively common in pregnancy
occurring usually late, 90% of cases have gallstones
most of which can be visualized under ultrasound.
Conventionally cholecystectomy is only necessary in
complicated cases such as obstruction, as can cause
15% perinatal mortality.
In advanced pregnancy, cholecystostomy may be is
possible.
ERCP and endoscopic retrograde sphincterotomy are
possible if exposure to radiation is minimized.
In early to middle of second trimester, laparoscopic
cholecystostomy carries few problems.
Most patients only require symptomatic relief.
-
6.Pancreatitis
7.Hepatic disorders: e.g.
-pre-eclampsia.
-acute fatty liver of pregnancy.
-HELLP syndrome.
c.Renal system, e.g. cystitis, Pyelonephritis and stones
d.Other uncommon causes include
-sickle cell crisis.
-malaria.
-porphyria and
-diabetic ketoacidosis.
e.Psychological: diagnosis by exclusion and must be very
careful not to miss a physical cause for the abdominal
pain.
Investigations
-Fetal monitoring
-Urine analysis, MSU: infection, proteinuria in
pre-eclampsia
-Full blood count: raised white cell count
suggestive of infection, although the white cell
count is normally slightly raised in pregnancy
-Liver function tests
-Ultrasound: may demonstrate ectopic pregnancy,
abruption, miscarriage
-Laparoscopy to confirm ectopic pregnancy
Management
A thorough assessment of the wellbeing of the mother and
fetus, as well as the possible underlying cause is required.
Treatment of cause; urgent hospital referral if uncertain cause,
and/or maternal or fetal distress.
Diagnosis of abdominal pain in later pregnancy and after
childbirth
• Palpable contractions
• Blood-stained mucus discharge (show) or watery
discharge before 37 weeks
• Cervical dilatation and effacement
• Light a vaginal bleeding
Possible preterm labour
a Light bleeding:
takes longer than 5 minutes for a clean pad or cloth to be
soaked.
• Palpable contractions
• Blood-stained mucus discharge (show) or watery discharge at
or after 37
weeks
• Cervical dilatation and effacement
• Light vaginal bleeding
Possible term labour
• Intermittent or constant abdominal pain
• Bleeding after 22 weeks gestation (may be retained in the
uterus)
• Shock
• Tense/tender uterus
• Decreased/absent fetal movements
• Fetal distress or absent fetal heart sounds. Abruptio
placentae
Severe abdominal pain (may decrease after rupture)
• Bleeding (intra-abdominal and/or vaginal)
• Shock
• Abdominal distension/ free fluid
• Abnormal uterine contour
• Tender abdomen
• Easily palpable fetal parts
• Absent fetal movements and fetal heart sounds
• Rapid maternal pulse
Possible Ruptured uterus
• Abdominal pain
• Foul-smelling watery vaginal discharge after 22
weeks gestation
• Fever/chills
• History of loss of fluid
• Tender uterus
• Rapid fetal heart rate
• Light vaginal bleeding
Possible Amnionitis
• Abdominal pain
• Dysuria
• Increased frequency and urgency of urination
• Retropubic/suprapubic pain
Possible Cystitis
• Dysuria
• Abdominal pain
• Spiking fever/chills
• Increased frequency and urgency of urination
• Retropubic/suprapubic pain
• Loin pain/tenderness
• Tenderness in rib cage
• Anorexia• Nausea/vomiting
Acute Pyelonephritis
• Lower abdominal pain
• Low-grade fever
• Rebound tenderness
• Abdominal distension
• Anorexia
• Nausea/vomiting
• Paralytic ileus
• Increased white blood cells
• No mass in lower abdomen
• Site of pain higher than expected
Possible Appendicitis
• Lower abdominal pain
• Fever/chills
• Purulent, foul-smelling lochia
• Tender uterus
• Light vaginal bleeding
• Shock
Endometritis
• Lower abdominal pain and distension
• Persistent spiking fever/ chills
• Tender uterus
• Poor response to antibiotics
• Swelling in adnexa or pouch of Douglas
• Pus obtained upon culdocentesis
Pelvic abscess
• Lower abdominal pain
• Low-grade fever/chills
• Absent bowel sounds
• Rebound tenderness
• Abdominal distension
• Anorexia
• Nausea/vomiting
• Shock
Peritonitis
• Abdominal pain
• Adnexal mass on vaginal examination
• Palpable, tender discrete mass in lower abdomen
• Light vaginal bleeding
Ovarian cyst
• Abdominal pain
• Light bleeding
• Closed cervix
• Uterus slightly larger than normal
• Uterus softer than normal
• Fainting
• Tender adnexal mass
• Amenorrhoea
• Cervical motion tenderness
Ectopic pregnancy
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