ABDOMINAL PAIN IN

PREGNANCY
District 1 ACOG Medical Student
Teaching Module 2008

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

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

Common Non OB Etiologies

GERD/other bowel c/o

Intestinal Obstruction
Cholelithiasis/Cholecystitis
Pancreatitis
Pyelonephritis
Nephrolithiasis
Appendicitis

HISTORY
As

with most things..history

essential to diagnosis:
-Location
-Character
-Radiation
-Aggravating/Relieving Factors

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

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

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

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

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

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

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

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

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

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%

Choledocholithiasis

Abdominal pressure & jaundice

Endoscopic u/s
Fever/chills, leukocytosis, n&v
ERCP & sphincterotomy with
cholecystectomy PP

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

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

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

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

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

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

Acute Pancreatitis cont

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

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

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

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)

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)

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)

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

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