1. ABDOMINAL PAIN IN
PREGNANCY
Rupali Shah

2. • Abdo pain is more complex in pregnant
women as uterine enlargement may hide
classical signs

3. Cause of pain
• Obstetric
• Gynaecological
• “Surgical”
• “Medical”
• Musculoskeletal
• Mainly going to focus on obs and gynae
pain

4. Obstetric causes 1
• Labour pain - premature labour or term.
• Pre-eclampsia or HELLP syndrome
– (Haemolysis, Elevated Liver Enzymes, Low plts)
– epigastric or right upper quadrant pain.
– This may be confused with heart burn
• Placental abruption:
– Separation of placenta from uterus wall before delivery
– Typically, sudden severe pain and a 'woody' hard, tender uterus;
fetal distress, ± vaginal bleeding.
– With posterior placenta, pain and shock may be less severe,
with pain felt in the back
– diagnose by pattern of fetal contractions (excessive and
frequent) with fetal heart pattern suggesting hypoxia.

5. Obstetric causes 2
• Uterine rupture:
– Integrity of myometrial wall is breached
– Constant pain, profound shock, fetal distress and vaginal
bleeding; usually presents during labour and with history of
uterine scar (eg c-section).
– Rarely, occurs without labour and without uterine scar.
• Chorioamnionitis:
– Infalammation of fetal membranes due to bact. infection
– This usually follows premature rupture of membranes, but can
occur with membranes intact.
• Acute fatty liver of pregnancy:
– Presents in the second half of pregnancy with abdominal pain,
nausea/vomiting, jaundice, malaise and headache.

6. Obstetric causes 3
• Acute polyhydramnios
– Excess amniotic fluid collects rapidly
• Severe uterine torsion - rare; may be due
to structural abnormalities in the pelvis.
– Presents in the second half of pregnancy with
variable symptoms, including severe
abdominal pain, tense uterus, retention of
urine ± shock and fetal distress; or, it may be
asymptomatic
– the fetus is at risk.

8. Gynaecological causes 1
• Ectopic pregnancy
– Usually presents between 5-9 weeks' gestation.
– Classical triad of bleeding, abdominal pain, and
amenorrhoea is not present in many women;
symptoms and signs are often nonspecific; the
diagnosis can only be confirmed in secondary care.
– Symptoms vary + include:
• syncope
• dysuria (including dipstick urine findings suggesting UTI)
• diarrhoea and vomiting
• subtle changes in vital signs
• adnexal tenderness may be absent
• a history of 'missed period' may be absent if vaginal bleeding
is mistaken for a normal period.

9. Gynaecological causes 2
• Miscarriage ± septic abortion.
• Torsion of the ovary or Fallopian tube.
– Sharp, unilateral lower abdo pain
• Ovarian cysts - torsion, haemorrhage or rupture.
• Fibroids - red degeneration or torsion.
– Hormones during pregnancy cause fibroids to grow
– They outgrow their blood supply
 lack of nutrients  break down and cause pain
– Can also cause miscarriage/early labour

10. Gynaecological causes 3
• Ovarian hyperstimulation syndrome:
– A complication of gonadotrophin-assisted
conception; can occur pre-conception or in
early pregnancy.
– Large ovarian cysts cause abdominal pain
and distention and, in severe cases, also fluid
shifts, ascites, pleural effusion and shock.
• Salpingitis
• Round ligament pain.

12. “Surgical” Causes
• Acute appendicitis.
– Presents with fever, anorexia, nausea, vomiting, right iliac fossa (RIF) pain.
– After the first trimester, the pain may shift upwards towards the right upper quadrant, but does not always
do so - and patients in all trimesters may have RIF pain.
– With retrocaecal appendix, may have back or flank pain.
• Cholecystitis and gallstones.
• Urinary tract - renal calculi, urinary tract obstruction (including acute urinary retention due to
retroverted gravid uterus).
• Intestinal obstruction - most often due to adhesions.
• Peritonitis from any cause.
• Abdominal trauma, including domestic violence.
• Mesenteric adenitis.
• Meckel's diverticulitis.
• Peptic ulcer.
• Inflammatory bowel disease.
• Abdominal wall - hernias, musculoskeletal pain, rupture of rectus abdominis muscle.
• Acute pancreatitis - rare and usually due to gallstones.
• Mesenteric venous thrombosis (rare) - most reported cases have occurred where dehydration
complicated an underlying hypercoagulable state.[2]
• Rupture of visceral artery aneurysm (rare).

13. “Medical” Problems
• UTI ± pyelonephritis.
• Constipation.
• Diabetic ketoacidosis.
• Sickle-cell anaemia crisis.
• Lower lobe pneumonia.
• Venous thromboembolism - deep vein thrombosis or
pulmonary embolus may cause lower or upper
abdominal pain respectively.
• Myocardial infarction.
• Gastroenteritis.
• Irritable bowel syndrome.

14. Musculoskeletal Causes
• Round ligament pain - low abdominal or groin
pain due to the uterus pulling on the round
ligament.
• General aches - due to uterine enlargement.
• Rectus muscle haematoma - due to rupture of
inferior epigastric vessels in late pregnancy:
– Presents with sudden severe abdominal pain, often
after coughing or trauma.
• Pelvic girdle pain:
– Symphysis pubis dehiscence.
– Osteomalacia may present in pregnancy due to
increasing vitamin D requirements.

16. History
• Pain history – SOCRATES
• Other abdominal symptoms - vaginal bleeding, bowel and urinary
symptoms; pre-eclampsia symptoms (eg headache, visual change,
nausea).
• Fetal movements.
• Obstetric history –
– last menstrual period (LMP)
– confirm whether the patient's last bleed was 'normal' for the patient
(ectopic pregnancy may have some bleeding which can be mistaken for
menstrual bleed)
– ask if there has been any difficult or assisted conception
– confirm use of any contraception (coil and progestogen-only pill (POP)
increase ectopic risk).
• Past medical and gynaecological history, medication, allergies, last
meal.

17. Examination
• General examination –
– well/ill, signs of sepsis, shock or haemorrhage, blood pressure, urine
dipstick protein and glucose.
• Assess the pregnancy and uterus:
– Palpate uterus for fundal height, contractions or hard uterus,
polyhydramnios, fetal position and presentation.
– Assess fetal wellbeing - movements or heartbeat (auscultate, Doppler
scan or CTG).
• Abdominal examination –
– distinguish extra-uterine from uterine tenderness,
– Peritoneal signs may be absent in pregnancy
– Note the changing positions of the intra-abdominal contents as the
pregnancy progresses.
• Consider whether vaginal and/or rectal examination is indicated:
– Never do vaginal examination if placenta praevia is suspected
– Suspected rupture of membranes requires sterile examination and
should be done in an obstetric unit.

18. Investigations
• Urine (dip stick and pregnancy if indicated)
• CTG
• Bloods (FBC, group and save, serum b-
HCG,)
• Ultrasound

19. Management
• Depends on cause