ABDOMINAL PAIN IN PREGNANCY

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ABDOMINAL PAIN IN PREGNANCY

• District 1 ACOG Medical Student Teaching Module
  2008

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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

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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

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Common Non OB Etiologies

• GERD/other bowel c/o
• Intestinal Obstruction
• Cholelithiasis/Cholecystitis
• Pancreatitis
• Pyelonephritis
• Nephrolithiasis
• Appendicitis

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HISTORY

• As with most things..history essential to
  diagnosis
• -Location
• -Character
• -Radiation
• -Aggravating/Relieving Factors

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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

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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

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Treatment of GERD

• Lifestyle modifications
• H2 Blockers (Ranitidine)
• PPIs (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

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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

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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
• -Fetal 20-30
• -Maternal 13 in colonic volvulus

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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

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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

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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

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Cholecystitis

• Inflammation usually caused by cystic duct
  obstruction supersaturated bile
• 3rd most common nonobstetric surgical emergency
• 1-8/10,000
• Same symptoms but pain more prolonged
• Often get tachycardia, fever, R subcostal
  tenderness, Murphys sign
• Leukocytosis common
• Serum LFTs may be slightly abnormal
• Jaundice may suggest choledocholithiasis

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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

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Choledocholithiasis

• Abdominal pressure jaundice
• Endoscopic u/s
• Fever/chills, leukocytosis, nv
• ERCP sphincterotomy with cholecystectomy PP

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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

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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

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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

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Nephrolithiasis

• Symptomatic 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
• -NV, diaphoresis, fever/chills

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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

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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

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Acute Pancreatitis cont

• Signs
• -midabdominal tenderness
• -occasional rebound
• -guarding
• -hypoactive BS
• -distension
• -tympany

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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

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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

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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)

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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)

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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)

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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/cholecys
  titis

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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