Abdominal pain in pregnancy is a very common problem encountered in day to day practice. Although is can be benign at times great care should be exercised to dismiss as nothing significant.

1. Abdominal pain in pregnancy
Dr.Rupa Rajshekar MBBS, MD
Specialist in Obs & Gyne

2. Introduction
• Abdominal pain is a very common symptom in
pregnant women
• It is of varying degree, may be acute with
rapid onset or chronic that recurs or persists
for long time
• It is convenient to divide the cause of pain due
to pregnancy into those most commonly
encountered in each of the three trimesters

3. • A 22 year old Para-1 with 6-8 weeks gestation
presents with abdominal pain
What are you thinking of???

4. History
• Localized one sided pain, no radiation,
spasmodic to start with – now constant
• Mild p/v bleeding
• Some chest pain & shoulder tip pain
• Has been feeling faint
• Pregnancy test positive

5. Think ectopic
• Vital signs
• B-HCG – quantitative
• Pelvic ultrasound
• Admission

6. Ectopic pregnancy
Pitfalls in diagnosis
• Wide variations in clinical presentation
• Pregnancy test can be negative
• Trans vaginal ultrasound even in best hands is
only 50% accurate in early ectopics
• B-HCG can double in very early ectopics

7. Treatment of ectopic pregnancy
• Medical with Methotrexate
• Surgical – Laparotomy/Laparoscopy
» salphingostomy / salphingectomy

8. Is it Ovarian?
• Corpus luteum cysts:
– Mild aching pain
– Usually asymptomatic
– Maternal pulse in not raised
– Hemorrhage inside cyst can cause severe pain

9. Adnexal torsion
• More common in pregnancy (28%)
• Pain is sudden in onset in lateral lower quadrant
• Fever, leucocytosis, nausea, vomiting
• USS – shows cyst with no flow on color mapping
• At times difficult to differentiate from ectopics
and appendicitis
• Miscarriage & preterm are common
consequences
• Surgery should not be delayed

10. First trimester pain
• Abortion
• Pregnancy in rudimentary horn
• Acute salpingitis
• Acute retention of urine
• Hydatidiform mole

11. A 22 yr old para 1 with 6-8 weeks
amenorrhea presents with
abdominal pain
• The history changes:
– Crampy lower abdominal pain
– Heavy bleeding p/v
– Speculum examination
• Cx os closed
• Cx os open

12. Diagnosis - ? Miscarriage
• Assess hemodynamic stability
• Arrange pelvic ultrasound
• Management depends on ultrasonographic
findings
• No role of B-HCG
• Blood group, Rhesus and anti D if needed

13. Some USS findings
• An intrauterine gestational sac seen 25x30
mm in diameters. No fetus visible
• An IU gestational sac seen 20x20mm in
diameter, Fetal pole seen 6 mm CRL. No FH
• An IU gestational sac seen 35 x35 mm in
diameters low down in the cavity. Fetal pole
seen. FH seen but appears slow

14. The management of miscarriage
• Conservative
• Reassurance and TLC
• No role of bed rest
• ERPOC

15. Miscarriage
• Always confirm a possible complete
miscarriage by serial BHCGs
• This is specially true if there has been no scans
to prove an intrauterine gestational sac
• Pitfall: You might miss an ectopic

16. First trimester pain
• Pregnancy in rudimentary horn
• Pain resemble that of ectopic & usually the
condition discovered during laparotomy
• If rupture occurs it usually in the mid-
trimester & of sudden onset with collapse

17. First trimester pain
• Acute Salpingitis:
• May develop up to 10 wks after conception,
due to gonococcal infection or infection due to
attempted abortion
• Pain felt in both iliac fossae & is continous
• Associated tenderness, tachycardia & elevated
temperature, culture of discharge may reveal
pathogen

18. First trimester pain
• Acute retention of urine
• Due to enlargement of fibroid in response to
pregnancy
• Severe lower abdominal pain, large tender
bladder which may be mistaken for ovarian
cyst
• Catheterisation causes immediate pain relief

19. First trimester pain
• Hydatidiform mole
• Pain in lower abdomen due to
– Overdistention of uterus
– Concealed haemorrhage
– Perforation
– Infection

20. Mid trimester pain
• Red degeneration of fibromyoma
• Stretching of round ligament
• Acute polyhydromnios
• Rupture of rudimentary horn containing
pregnancy
• Acute retention of urine due to incarcerated
RVF gravid uterus

21. Mid trimester pain
• Red degeneration of fibromyoma
• Causes mild to severe pain. Tenderness
present over fibroid
• USS detects fibroid
• Conservative treatment with analgesics

22. Mid trimester pain
• Stretching of round ligament
• 10-30% of pregnancies
• More in multipara
• Cramp like or stabbing continuous pain, some
tenderness in the groin
• Reassurance & mild analgesics required

23. Mid trimester pain
• Acute polyhydrominos
• Pain due to over distention
• Diagnosed clinically & by USS