ABDOMINAL PAIN IN PREGNANCY

n Multiple causes including essentially all non pregnancy causes plus obstetric causes
n Clinical presentation & natural history often altered with pregnancy
n Diagnostic evaluation and treatment plans altered & limited
n Fetal wellbeing to be considered



Obstetric/Gynecologic Etiologies
n Ruptured Ectopic
n Pre-eclampsia/Eclampsia
n Placental Abruption
n Uterine Rupture
n Ovarian Cyst Rupture
n PID
n Tubo-Ovarian Abscess
n Uterine Leiomyomas
n Abortion
n Salpingitis
n Endometriosis
n Cancer of Cervix or Ovary


Common Non OB Etiologies
n GERD/other bowel c/o
n Intestinal Obstruction
n Cholelithiasis/Cholecystitis
n Pancreatitis
n Pyelonephritis
n Nephrolithiasis
n Appendicitis


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


PHYSICAL EXAM
n Uterus displaces abdominal organs
n Moving omentum does not wall off infection as well
n Late pregnancy abdominal wall laxity may mask rigid abdomen of peritonitis


GERD
n Up to 80% in pregnancy
n Gastric compression by uterus, hypotonic LES, & gastrointestinal dysmotility
n Epigastric discomfort, nausea, emesis, anorexia, regurgitation, water brash
n PUD decreases secondary to decreased gastric secretion, decreased motility, & increased mucus secretion

Treatment of GERD
n Lifestyle modifications
n H2 Blockers (Ranitidine)
n PPI’s (Losec)
n Consider deferring H Pylori eradication until PP because of possible teratogenic effects of certain medication regimes
n Surgery for GERD best delayed until PP
n Esophagogastroduodenoscopy for bleeding & surgery if unstable as fetus tolerates maternal hypotension poorly
n In advanced pregnancy.. c/s before gastric surgery for bleeding


Intestinal Obstruction
n Second most common nonobstetrical abdominal emergency (>1/1500)
n Incidental or secondary to pregnancy
n Large increase in #’s results from increased #’s abdominal procedures, PID, & # pregnancies in older women
n Most common T3 b/c mechanical effects large uterus, fetal head descent or immediately PP because rapid change uterine size
n Adhesions (previous surgery) 60-70% SBO
n AXR required to Dx & monitor despite risk radiation to fetus
n Surgery for complete/unremitting
n 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

n Pregnancy increases bile lithogenicity & sludge formation b/c estrogen increases cholesterol synthesis and progesterone impairs gallbladder motility n >12% pregnancy compared to 1-2% controls
n Pregnancy does not increase severity of complications
n Most gallstones are asymptomatic


n 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
n 1/3 patients no additional episode X 2y
n Complications of cholelithiasis include cholecystitis, choledocholithiasis, jaundice, cholangitis, biliary stricture, sepsis, abscess, empyema, gallbladder perforation, & gallstone pancreatitis


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

Tx for Cholecystitis
n Cholecystectomy
n Pre-op NPO, iv fluid, abx
n Abdominal surgery best in T2
n T1 associated with fetal abortion & T3 with premature labor
n Cholecystectomy may be deferred in appropriate cases
n Lap chole safe in earlier pregnancy
n Intraoperative cholangiography only for strong indications
n Maternal 7 fetal mortality < 5% Choledocholithiasis n Abdominal pressure & jaundice n Endoscopic u/s n Fever/chills, leukocytosis, n&v n ERCP & sphincterotomy with cholecystectomy


Pyelonephritis
n Renal alterations in 70-90% n More pronounced T2 & T3 when risk pyelonephritis is greatest
n Asymptomatic bacteriuria (ASB) in about 7% n Acute cystitis 2%
n ASB treated to prevent pyelonephritis (cephalosporins, nitrofurantoin …)
n 25-40% untreated ASB develop pyelo
n 30% retreatment Pyelonephritis
n Acute pyelo in 1-2% pregnancies

n Symptoms & Signs:

-fever/chills -N & V -flank pain -CVA tenderness -Complications include sepsis, shock, ADRS, Pulmonary edema, renal insufficiency/abscess, & recurrent infection Pyelonephritis
n Tx is abx iv until patient clinically improves and then po abx n Renal u/s if no improvement after 3 days
n Associated with premature labor and delivery

Nephrolithiasis
n Symptomatic < 5/1000 pregnancies but accounts for the most nonobstetric hospitalizations

n About 50% causes by hypercalcuria
n Usually T2 or T3
n Symptoms & Signs : -abdominal/flank pain often radiating to groin -gross hematuria, urgency, frequency -N&V, diaphoresis, fever/chills

 Fluoroscopy relatively contraindicated
n U/S initial test of choice
n Tx includes hydration, analgesia, & abx if infection – most responds well
n Obstruction, sepsis requires ureteral stent
n Surgery in refractory cases n Risk premature labor


Acute Pancreatitis

n 0.1-1% pregnancies
n Most common T3 & PP n Gallstones cause > 70%
n EtOH quite uncommon but other causes include drugs, surgery, trauma, etc
n Pregnancy does not affect
n Epigastric pain most common complaint
n Pain may radiate to back, shoulders, or flanks
n Nausea, emesis, fever common

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

n Elevated Amylase & Lipase
n U/S for cholelithiasis & bile duct dilation
n Endoscopic u/s for choledocholithiasis

n Pancreatitis in pregnancy usually mild and responds well to medical therapy
-NPO
-IV fluids
-Gastric acid suppression
-Analgesia (Meperidine)
-? NG suction

n Severe pancreatitis with abscess, sepsis, phlegmon requires ICU, Abx, TPN, & possible radiologic/surgical intervention
n Pregnancy should not delay CT or surgery in these cases
n Endoscopic spincterotomy can be performed during pregnancy with minimal fetal radiation exposure
n Maternal mortality low with uncomplicated but > 10% with complicated pancreatitis
n T1 – fetal abortion ; T3 – premature labor


APPENDICITIS
n Most common nonobstetric surgical emergency (1/1000) in pregnancy
n Appendicitis in 1/1500 (65%)
n Slightly more likely during T2
n Maternal mortality (highest in T3) somewhat higher secondary to delayed dx and decline of laparotomy (0.1% without perforation & 4% with perforation)

n Up to 25% develop appendiceal perforation
n Fetal complications mostly secondary to premature labor (1-2% in uncomplicated appendicitis and 30-40% with peritonitis)

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 …
n 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
n APPENDICITIS REQUIRES SURGERY
n IV hydration & lytes correction
n Abx (Penicillin, Cephalosporins, Clinda, Gent)
n Laparoscopy in T1 & ? T2 for nonperforated
n Laparotomy incision over pt of focal tenderness
n Appendectomy even if no appendicitis
n Concomitant c/s not done