Abdominal Pain In Pregnancy - A common phenomenon

Abdominal Pain In Pregnancy - A common phenomenon

1. ABDOMINAL PAIN IN
PREGNANCY
District 1 ACOG Medical Student
Teaching Module 2008

2. Challenge of Abdominal Pain During
Pregnancy
Multiple causes including essentially all
non pregnancy causes plus obstetric
causes
Clinical presentation & natural history
often altered with pregnancy
Diagnostic evaluation and treatment plans
altered & limited
Fetal wellbeing to be considered

3. Obstetric/Gynecologic Etiologies
Ruptured Ectopic
Pre-eclampsia/Eclampsia
Placental Abruption
Uterine Rupture
Ovarian Cyst Rupture
PID
Tubo-Ovarian Abscess
Uterine Leiomyomas
Abortion
Salpingitis
Endometriosis
Cancer of Cervix or Ovary

4. Common Non OB Etiologies
GERD/other bowel c/o
Intestinal Obstruction
Cholelithiasis/Cholecystitis
Pancreatitis
Pyelonephritis
Nephrolithiasis
Appendicitis

5. HISTORY
As with most things..history
essential to diagnosis:
-Location
-Character
-Radiation
-Aggravating/Relieving Factors

6. PHYSICAL EXAM
Uterus displaces abdominal organs
Moving omentum does not wall off
infection as well
Late pregnancy abdominal wall laxity may
mask rigid abdomen of peritonitis

7. GERD
Up to 80% in pregnancy
Gastric compression by uterus, hypotonic
LES, & gastrointestinal dysmotility
Epigastric discomfort, nausea, emesis,
anorexia, regurgitation, water brash
PUD decreases secondary to decreased
gastric secretion, decreased motility, &
increased mucus secretion

8. Treatment of GERD
Lifestyle modifications
H2 Blockers (Ranitidine)
PPI’s (Losec)
Consider deferring H Pylori eradication until PP
because of possible teratogenic effects of certain
medication regimes
Surgery for GERD best delayed until PP
Esophagogastroduodenoscopy for bleeding &
surgery if unstable as fetus tolerates maternal
hypotension poorly
In advanced pregnancy.. c/s before gastric
surgery for bleeding

9. Intestinal Obstruction
Second most common nonobstetrical
abdominal emergency (>1/1500)
Incidental or secondary to pregnancy
Large increase in #’s results from
increased #’s abdominal procedures, PID,
& # pregnancies in older women
Most common T3 b/c mechanical effects
large uterus, fetal head descent or
immediately PP because rapid change
uterine size
Adhesions (previous surgery) 60-70% SBO

10. Intestinal Obstruction cont …
AXR required to Dx & monitor despite risk
radiation to fetus
Surgery for complete/unremitting
Medical Tx for partial/intermittent
-iv fluid & lyte correction
-NG to suction
-Morbidity/mortality related to delay Dx
-Maternal < 6%
-Fetal 20-30%
-Maternal 13% in colonic volvulus

11. Cholelithiasis
Pregnancy increases bile lithogenicity &
sludge formation b/c estrogen increases
cholesterol synthesis and progesterone
impairs gallbladder motility
>12% pregnancy compared to 1-2%
controls
Pregnancy does not increase severity of
complications
Most gallstones are asymptomatic

12. Cholelithiasis
Symptoms:
-Biliary colic in epigastrium/RUQ
-May radiate to back, flank, or shoulders
-pain often associated with post prandial states
(especially fatty foods)
-Pain typically lasts 1 to several hours
-Diaphoresis, nausea, & emesis common
Physical exam often unremarkable apart from
occasional RUQ tenderness

13. Cholelithiasis
1/3 patients no additional episode X 2y
Complications of cholelithiasis include
cholecystitis, choledocholithiasis, jaundice,
cholangitis, biliary stricture, sepsis,
abscess, empyema, gallbladder
perforation, & gallstone pancreatitis

14. Cholecystitis
Inflammation usually caused by cystic duct
obstruction & supersaturated bile
3
rd
most common nonobstetric surgical
emergency
1-8/10,000
Same symptoms but pain more prolonged
Often get tachycardia, fever, R subcostal
tenderness, & Murphy’s sign
Leukocytosis common
Serum LFT’s may be slightly abnormal
Jaundice may suggest choledocholithiasis

15. Tx for Cholecystitis
Cholecystectomy
Pre-op NPO, iv fluid, abx
Abdominal surgery best in T2
T1 associated with fetal abortion & T3 with
premature labor
Cholecystectomy may be deferred in appropriate
cases
Lap chole safe in earlier pregnancy
Intraoperative cholangiography only for strong
indications
Maternal 7 fetal mortality < 5%

16. Choledocholithiasis
Abdominal pressure & jaundice
Endoscopic u/s
Fever/chills, leukocytosis, n&v
ERCP & sphincterotomy with
cholecystectomy PP

17. Pyelonephritis
Renal alterations in 70-90%
More pronounced T2 & T3 when risk
pyelonephritis is greatest
Asymptomatic bacteriuria (ASB) in about
7%
Acute cystitis 2%
ASB treated to prevent pyelonephritis
(cephalosporins, nitrofurantoin …)
25-40% untreated ASB develop pyelo
30% retreatment

18. Pyelonephritis
Acute pyelo in 1-2% pregnancies
Symptoms & Signs:
-fever/chills
-N & V
-flank pain
-CVA tenderness
-Complications include sepsis, shock, ADRS,
Pulmonary edema, renal
insufficiency/abscess, & recurrent infection

19. Pyelonephritis
Tx is abx iv until patient clinically improves
and then po abx
Renal u/s if no improvement after 3 days
Associated with premature labor and
delivery

20. Nephrolithiasis
Symptomatic < 5/1000 pregnancies but
accounts for the most nonobstetric
hospitalizations
About 50% causes by hypercalcuria
Usually T2 or T3
Symptoms & Signs :
-abdominal/flank pain often radiating to
groin
-gross hematuria, urgency, frequency
-N&V, diaphoresis, fever/chills

21. Nephrolithiasis
Fluoroscopy relatively contraindicated
U/S initial test of choice
Tx includes hydration, analgesia, & abx if
infection –most responds well
Obstruction, sepsis requires ureteral stent
Surgery in refractory cases
Risk premature labor

22. Acute Pancreatitis
0.1-1% pregnancies
Most common T3 & PP
Gallstones cause > 70%
EtOH quite uncommon but other causes
include drugs, surgery, trauma, etc
Pregnancy does not affect
Epigastric pain most common complaint
Pain may radiate to back, shoulders, or
flanks
Nausea, emesis, fever common

23. Acute Pancreatitis cont …
Signs:
-midabdominal tenderness
-occasional rebound
-guarding
-hypoactive BS
-distension
-tympany

24. Acute Pancreatitis cont …
Elevated Amylase & Lipase
U/S for cholelithiasis & bile duct dilation
Endoscopic u/s for choledocholithiasis
Pancreatitis in pregnancy usually mild and
responds well to medical therapy
-NPO
-IV fluids
-Gastric acid suppression
-Analgesia (Meperidine)
-? NG suction

25. Acute Pancreatitis cont …
Severe pancreatitis with abscess, sepsis,
phlegmon requires ICU, Abx, TPN, &
possible radiologic/surgical intervention
Pregnancy should not delay CT or surgery
in these cases
Endoscopic spincterotomy can be
performed during pregnancy with minimal
fetal radiation exposure
Maternal mortality low with uncomplicated
but > 10% with complicated pancreatitis
T1 –fetal abortion ; T3 –premature labor

26. APPENDICITIS
Most common nonobstetric surgical
emergency (1/1000) in pregnancy
Appendicitis in 1/1500 (65%)
Slightly more likely during T2
Maternal mortality (highest in T3)
somewhat higher secondary to delayed dx
and decline of laparotomy (0.1% without
perforation & 4% with perforation)

27. Appendicitis cont …
Up to 25% develop appendiceal
perforation
Fetal complications mostly secondary to
premature labor (1-2% in uncomplicated
appendicitis and 30-40% with peritonitis)

28. Appendicitis cont …
Symptoms:
-Periumbilical (early visceral obstructive)
-RLL/RUQ (late parietal secondary
inflammation) –very focal
-N & V, anorexia, urinary frequency
Signs:
-Focal tenderness /guarding /rebound/
?peritoneal signs (omental displacement)

29. Appendicitis cont …
Investigations:
-leukocytosis normal in pregnancy
-U/S nonspecific but may show
appendiceal mural thickening &
periappendiceal fluid (mostly to help r/o
other etiologies)
-CT better but exposes fetus to radiation
-often confused with right
pyelonephritis/cholecystitis

30. Appendicitis Management
APPENDICITIS REQUIRES SURGERY
IV hydration & lytes correction
Abx (Penicillin, Cephalosporins, Clinda,
Gent)
Laparoscopy in T1 & ? T2 for
nonperforated
Laparotomy incision over pt of focal
tenderness
Appendectomy even if no appendicitis
Concomitant c/s not done