ABDOMINAL PAIN IN PREGNANCY

Transcription

1 ABDOMINAL PAIN IN PREGNANCY MBBCh IV LECTURE DR BRON MOORE Consultant Department of Obstetrics and Gynaecology Johannesburg Hospital 1

2 Introduction: Abdominal pain during pregnancy is a common complaint. This pain may be either physiological or pathological. Pathological conditions may be either related or unrelated to the pregnancy. Abdominal Pain - Classification Physiological: Round ligament pain Braxton Hicks contractions Miscellaneous Heartburn, excesssive vomiting, constipation Pathological: Pregnancy Related Uterine: Miscarriage Leiomyomata Abruptio placenta Chorioamnionitis Preterm labour Uterine rupture Adnexal: Ectopic pregnancy Ovarian: Corpus luteum Cyst accidents 2

3 Pregnancy Unrelated GIT: Appendicitis Cholecystitis and cholelithiasis Pancreatitis Peptic ulcer disease Intestinal obstruction Chron s disease Urinary tract: Cystitis Pyelonephritis Urolithiasis Liver disease: Other: Acute fatty liver of pregnancy Severe pre-eclampsia / Eclampsia Sickle cell crisis Porphyria Malaria TB Of importance is that pregnancy may alter the presentation of many of these conditions and the clinician must be aware of this in order to make the diagnosis. Furthermore there is often a reluctance to perform diagnostic and/or surgical procedures during pregnancy which often causes a delay in diagnosis and treatment, and which may in turn result in an increased morbidity and even mortality. 3

4 1. Physiological causes of abdominal pain: 1.1 Round ligament pain: Inc: 10-30% When: End 1 st T and 2 nd T Who: More common in multigravidas Aet:? due to stretching of the round ligaments but no evidence Nature: Cramp-like or stabbing Worse with movement Radiates to the groin Tenderness over round ligaments on palpation Risk: delay in diagnosis of pathological cause of pain Management: Reassurance Decrease activity Simple analgesics 1.2 Braxton Hicks contractions: Inc: Common majority of women will experience these When: Latter half of pregnancy Nature: Uterine contractions that are irregular and vary in intensity Painless in most women, some experience pain Risk: Delay in diagnosis of true preterm labour if uterine activity is mistakenly labelled Braxton Hicks contractions Management: Must exclude preterm labour; look for absence of a show, intact membranes and a high presenting part. Serial vaginal exam often necessary to confirm no cervical change. Once diagnosis made reassure 1.3 Miscellaneous: Including: Heartburn, excessive vomiting and constipation Inc: Common When: Early pregnancy Risk: Delay in diagnosis of pathology Management: Symptomatic management including Heartburn: Avoid lying down after a meal Elevate head of bed Alter diet Antacids etc 4

5 Vomiting: Alter diet (excessive) Antiemetics Admission for Hyperemesis gravidarum if dehydrated (U&E), ketotic (urine dipstix) or protracted for fluids and antiemetics. Exclude multiple pregnancy and molar pregnancy. Constipation: Alter diet fluids, fibre and fruit Remember iron supplements aggravate Laxatives Also: Discomfort due to abdominal distension, foetal movement and pressure from the foetus in later pregnency 2. Pathological causes of abdominal pain - Pregnancy Related These conditions will be dealt with in depth in lectures dealing with each specific pathology. This is an overview only. 2.1 Uterine: Miscarriage Inc: Most common causes of pathological pain in 1 st T 15-20% of clinically diagnosed pregnancies Up to 60% of those diagnosed chemically When: By definition, before viability WHO: 22 weeks (154days) or <500gm SA: 26weeks or <1000gm Classification: (you must know how to differentiate) Threatened Inevitable Incomplete Complete Nature: Cramp like lower abdominal pain (LAP) Associated vaginal bleeding Diagnosis: Clinical Ultrasound to confirm 5

6 2.1.2 Leiomyomata Inc: Leiomyomata (fibroids) are common 10% of women with fibroids have pain in preg Who: Increased incidence in black women Increased incidence in older women When:May result in early pregnancy loss May cause pain at any stage of pregnancy Nature: Localized pain and tenderness May have low grade pyrexia and leukocytosis Aet: Due to red degeneration/haemorrhagic infarction Occurs due to acute inadequacy of blood supply Pedunculated fibroids may undergo torsion Diagnosis: Ultrasound will show fibroid in most Risks: Mimics abruptio placenta, uterine rupture Incorrect diagnosis with unnecessary surgery Increased risk of preterm labour (>3cm) Increased malpresentation Management: Conservative with analgesics Often have recurrent attacks Avoid myomectomy during pregnancy and at caesarean section due to risk of bleeding Abruptio placenta Inc: 0.5-1% of pregnancies When: Latter half of pregnancy Who: Hypertensives, ip pregnancy induced HT Smokers Multiple pregnancies Women with a history of abruptio Nature: Sharp tearing pain Continuous Backache with a posterior placenta Diagnosis: LAP Woody hard uterus which doesn t relax PVB note that with a concealed abruptio there may be little or no bleeding Foetal distress Coagulopathy in severe cases usually associated with foetal death 6

7 Risks: Maternal: shock due to severe haemorrhage, post partum haemorrhage, DIC, renal failure, death Foetal asphyxia which may lead to death Management: Resuscitate mother Assess the foetus for gestational age, viability, distress Plan mode of delivery depending on the maternal and foetal condition Monitor post delivery until haemodynamically stable and blood parameters have returned to normal Chorioamnionitis Inc: Related to incidence of premature rupture of membranes (ROM) May precede ROM in some cases Diagnosis: Maternal pyrexia Maternal and foetal tachycardia Abdominal pain, uterine tenderness Uterine irritability Offensive liquor draining vaginally Increased WCC and CRP Management: Broad spectrum antibiotics IV Delivery preferably vaginally if foetus not distressed and no other contraindications Preterm labour Inc: 10% When: By definition, after viability (1000gm) but before 37 completed weeks Who: Previous preterm labour best predictor Cervical incompetence Smokers PROM, HT, APH all important causes Congenital abnormalities of the uterus Polyhydramnios Etc,etc Diagnosis: Regular painful uterine contractions with associated cervical change and descent of the presenting part 7

8 Risks: Side effects of tocolytics Increased C/S rate Prematurity Management: Depends on gestational age, aetiology, maternal and foetal condition and contraindications to tocolysis. If gestation less than 34 weeks, mom stable, baby normal and not distressed and no contraindications, then tocolyse and administer steroids to aid foetal lung maturity Uterine rupture Inc: Uncommon With previous lower segment incision 0.5-1% When: Unlikely to rupture an unscarred uterus prior to labour Scarred uterus may rupture before labour Rupture in labour more common in scarred uterus, ip with prev classical C/S (2%) Who: Uterine abnormalities e.g. rudimentary horn Excessive oxytocin use Obstructed labour High parity Previous uterine surgery C/S, myomectomy Risks: Maternal haemorrhage, shock, death Foetal shock, hypoxia, death Management: Deliver women with previous classical C/S by elective C/S Careful monitoring of patients with previous C/S in labour High index of suspicion in women at risk 2.2 Adnexal: Ectopic pregnancy Inc: Varies according to population Who: PID, tubal surgery, assisted reproduction all inc Contraception decreases inc When: Usually present at 6-10 weeks Nature: LAP non-specific PVB usually mild May have associated dizzinedd and nausea 8

9 2.3 Ovarian: Diagnosis: consider in ALL women with LAP!!! History, examination, ßhCG, ultrasound Management: Conservative Medical Surgical: open or laparoscopic Corpus luteum Inc: Uncertain When: 1 st trimester Nature: Most asymptomatic Dull aching pain of affected side Diagnosis: Ultrasound Must exclude ectopic pregnancy Risks: Unnecessary surgery Pregnancy loss if CL is ruptured or removed Management: Reassure Conservative with serial ultrasound to document resolution Cyst accidents These include cyst rupture, haemorrhage into the cyst and torsion Haemorrhage: This can be diagnosed on ultrasound. Management is conservative Rupture: If rupture of the corpus luteum is diagnosed then progesterone to support the early pregnancy should be given up to 10 weeks of amenorrhoea Torsion: When: Late 1 st T & early 2 nd T as uterus enters abdominal cavity Who: any patient with adnexal mass Nature: Intermittent LAP Pain is constant if infarction occurs Diagnosis: Nausea, vomiting Tachycardia, low grade pyrexia, leucocytosis 9

10 Risks: Miscarriage Preterm labour Adnexal infarction Management: Laparotomy If adnexum is viable, cystectomy is done If adnexum is necrotic, adnexectomy is necessary 3.0 Pathological causes of abdominal pain - Pregnancy Unrelated Any pathology that can occur outside of pregnancy can occur during pregnancy. Often the presentation is not typical thus delaying diagnosis and treatment. 3.1 GIT: Appendicitis Inc: 1:1500 pregnancies No more frequent during pregnancy Diagnosis: Difficult as many pregnant women have nausea, vomiting and anorexia Also anatomic position of appendix changed Fever, leucocytosis (Remember pregnancy increases WCC) Risks: Due to delay of diagnosis and treatment, increased incidence of rupture with peritonitis and septicaemia This increases miscarriage, preterm labour and foetal death With rupture maternal mortality is 17%!!!! Less than 1% without Management: High index of suspicion Early surgery if diagnosis suspected Cholecystitis and cholelithiasis Inc: Increased in pregnancy due to physiological changes in the biliary system Many women have first attack in pregnancy Asymptomatic cholelithiasis 3.5% pregnancies Acute cholecystitis 1:1000 pregnancies 10

11 Diagnosis: Sudden onset right upper quadrant pain Epigastric colicky pain or stabbing pain Nausea and vomiting Fever, leucocytosis Ultrasound Risks: Must differentiate from HELLP and severe preeclampsia Preterm labour Management: Initially conservative with analgesia, fluids and NGT Surgery may be required, if possible best in second trimester Pancreatitis Inc: Rare 1:4000 May be more common during pregnancy due to increased gallstones When: Late in pregnancy or soon postpartum Nature; severe central abdo pain, radiates to back Diagnosis: vomiting marked Dehydration and shock Gallstones on ultrasound in 50% Amylase increased Risks: Significant maternal mortality Management: As for non pregnant patient Peptic ulcer disease Inc: Reduced risk during pregnancy Pre-existing disease improves Diagnosis: Endoscopy in patients with suspected pathology Management: As for non-pregnant patients Intestinal obstruction Inc: Is increasing due to more pregnant patients having had previous surgical procedures Who: Patients with adhesions from previous surgery When: Early second trimester and immediately postpartum when uterus moves abdo organs 11

12 3.2 Urinary tract: Diagnosis: Colicky abdo pain Nausea, vomiting, abdo distension AXR to confirm Risks: Delay in diagnosis and management common Associated increase in morbidity and mortality Management: Initially conservative drip and suck If suspect bowel necrosis or if conservative Mx fails, early surgery after correcting fluids and electrolytes Cystitis Inc: 1-2% of pregnant women Diagnosis: Frequency, urgency and abdo discomfort Dysuria most specific Risks: Pyelonephritis pregnancy lowers maternal immunity Preterm labour Management: Send urine for MC&S Single dose antibiotic regimens NOT appropriate Pyelonephritis Inc: One of the most common serious medical conditions in pregnancy 1-2% of pregnant women When: Due to stasis and obstruction, occurs in 2 nd & 3 rd T Who: Women with untreated asymptomatic bacteriuria are at increased risk Nature: Renal angle tenderness(rat) and LAP Diagnosis: Pyrexia Raised WCC Nausea, vomiting, loss of appetite LAP, RAT Dipstix and MC&S Management: IV antibiotics 12

13 3.2.3 Urolithiasis 3.3 Liver disease: Inc: Not increased in pregnancy, despite increased stasis, infection and calcium excretion Increase in flow, alkalinity and substances which counter calcium stone formation % of pregnancies Who: Multiparous patients Known stone formers When: 2 nd & 3 rd T Risks: UTI, pyelonephritis, septicaemia Renal dysfunction Premature labour Diagnosis: Pain UTI, haematuria Ultrasound IVP only if strongly suspect Dx & U/S negative Management: Conservative initially 50-75% will pass stone I.E. bedrest, fluids, analgesia, treat infection Aggressive management if U&E deteriorates, persistent infection, complete obstuction, recurrent preterm labour Acute fatty liver of pregnancy Inc: Rare 1:10000 to 1:15000 pregnancies When: late 3 rd T Nature: Sudden onset of nausea, vomiting, pain and jaundice Diagnosis: Raised bilirubin Abnormal liver enzymes Leukocytosis Thrombocytopaenia Hypoglycaemia Abnormal clotting profile Management: Supportive (fluid, electrolytes, blood products) Prompt delivery Risks: Delay in management sig increases maternal and perinatal morbidity and mortality 13

14 3.3.2 Severe pre-eclampsia / Eclampsia 3.4 Other: Inc: Liver involvement in 10% of severe PE When: Late 2 nd and 3 rd T Diagnosis: HT Proteinuria Rt hypochondrial and epigastric pain Nausea and vomiting Sickle cell crisis Inc: Depends on population group Nature: Severe constant or colicky abdo pain Diagnosis: Haemoglobin electrophoresis Suspect in known patient with infection, dehydration etc Management: Prompt treatment Fluids, oxygen, screen for infection May need exchange transfusion Porphyria Inc: Rare disorder of haeme metabolism Diagnosis: Abdo pain, GIT symptoms, autonomic system disturbances Attack may be precipitate by pregnancy Management: As in non-pregnant patient Malaria Inc: Depends on population and travel Pregnant women more likely to acquire malaria Diagnosis: Travel history Anaemia, thrombocytopaenia, renal failure Confusion, decreased LOC Jaundice, splenomegaly Positive smear Management: Supportive care often ICU if severe Quinine is drug of choice, avoid doxycycline 14

15 3.4.4 TB Risks: Miscarriage, foetal death Premature labour More aggressive and severe infection in pregnancy with increased organ failure Inc: Pregnancy is an immunocompromised state Increasing HIV also important Disseminated disease with peritoneal involvement can present with abdominal pain APPROACH TO A PATIENT WITH ABDOMINAL PAIN IN PREGNANCY As in all patients presenting to a doctor a structured logical approach to the complaint must be followed to avoid missing the diagnosis. HISTORY: The nature, site and duration of the pain are important. Associated symptoms such as nausea, vomiting and diarrhoea must be asked about. Relieving and aggravating factors may be important Previous episodes of similar pain may help in making the diagnosis. Past medical and surgical history is vital. EXAMINATION: SIDE WARD TESTS: LABORATORY INVESTIGATIONS: SPECIAL INVESTIGATIONS: 15