causes and differentials

1. ABDOMINAL PAIN IN
PREGNANCY
Associate Professor Dr Hanifullah Khan

2. CAUSES OF ABDOMINAL PAIN DURING PREGNANCY
• A. Pregnancy Related Pain: • B.Conditions associated with
Early pregnancy pregnancy
o Abortion: Inevitable, UTI
incomplete or septic Vaginal Infections
abortions • C. Non-Pregnancy Related
o Vesicular mole: when Pain
expulsion starts.
• Gastrointestinal
o Ectopic pregnancy: pain
precedes bleeding. o Acute appendicitis
Later pregnancy o Peptic ulcer
o Braxton-Hicks Contraction o AGE
o Placental abruption HepatoBliary
o Pre-eclampsia , HELLP o Biliary Stones
o Chorioamnionitis Genitourinary
o Labor ( Term , Preterm ) o Ureteral calculus
o Acute pyelonephritis
o Acute cystitis
Other
o Abdominal trauma

3. Urinary tract infection
• Acute cystitis acute pyelonephritis and urolithiasis
• Acute cystitis
- occurs in 1-2% of cases
-2/3th of cases have cystitis in spite of their sterile
urine at booking
Experience urinary symptoms and abdominal
discomfort

4. Braxton Hicks contractions∗
• Sporadic uterine contractions - actually start
at about 6 weeks,
– although women won't be able to feel them that
early.
– Usually noticeable only after midpregnancy,
• Increase in frequency as pregnancy progresses
– But they remain infrequent, irregular, and
essentially painless.
• Sometimes, though, hard to distinguish from
early signs of preterm labor
• May get more intense and more frequent, and
cause some discomfort.
∗ John Braxton Hicks, 1872.

5. False labour pain
( Late Braxton Hicks contractions )
• Irregular,
• Not progressively increasing
• Not associated with bulging of forebag of water or
dilatation of the cervix.
• Respond to anlgesics
• Cause women confusion as to whether or not they were
going into actual labor.
• They are thought to be part of the process of effacement,
the thinning and dilation of the cervix

6. Abortion
Miscarrage
– Common in the first trimester
– Vaginal bleeding
– Cramp like pain
– Dealt with under bleeding in pregnancy

7. Ectopic Pregnancy
• Most common obstetric cause of acute
abdomen
• Pain usually one-sided initially
– Can be confused with appendix if on the right
• May be sharp initially
• Later, may be diffuse and dull
• Shoulder tip pain

8. Placental Abruption
• Premature separation of the placenta from the
uterus,
– resulting in bleeding from the site of placental
attachment (concealed , revealed . Combined )
• The triad of abdominal pain, uterine rigidity, and
vaginal bleeding
– Suggests abruption
– Also fetal tachycardia
• A tender uterus is highly suggestive
• Prepare for DIC, which complicates 33% -50% of
severe cases,
• Beware PPH, which is also common

9. Site: Contraction occurs at the uterus Radiating: Pain at uterus, which
sometimes radiates to the back
Onset: Spontaneously
Associated symptoms: Leaking of liquor,
Character:
Show
•Intermittent
Time: 20-60 seconds per contraction
(comes in an irregular which then
becomes regular pattern over time with
one to several pain-free minutes in Exacerbating factors: -
between them)
•Increasing in frequency Severity: mild, moderte, severe
(Contractions almost always start off mild
and gradually grow longer, stronger, and
closer together)
•Spasmodic
(on and off)
HISTORY OF LABOUR
•Self-limiting
PAIN
(rarely takes more than 24 hours)

10. Preterm labour
•Definition
•Classification of preterm labour
•Causes of preterm labour
•History and examination findings
•Investigations

11. Definition of preterm labor
Defined as the presence of uterine contractions of sufficient
frequency and intensity to effect progressive effacement and
dilation of the cervix prior to term gestation (between 24+0
and 36+6 weeks)
http://emedicine.medscape.com/article/260998-overview

12. • Extremely preterm birth: 24+0
Classification of to 27+6 weeks (incidence 0.4%)
preterm labour
• Very preterm birth: 28+0 to 31+6
weeks (incidence 0.7%)
• Mildly preterm birth: 32+0 to
36+6 weeks (incidence 5.5%)

13. Extremely
Very preterm Mildly preterm
preterm
28+0 to 31+6) (32+0 to 36+6)
(24+0 to 27+6)

14. Causes of preterm labour
• Infections (chorioamnitis)
• Over distension (multiple pregnancy, polyhydramnios)
• Vascular causes (eclampsia)
• Intercurrent illness (pyelonephritis)
• Cervical weakness

15. POSSIBLE
CAUSES

16. History
• Ask about age of gestation, history of leaking or bleeding
• Pain
-cramp-like pain, low backache
-radiates to the back
-increase in intensity and frequency
-spontaneous onset
-not relieved by posture/ medications
-associate with liquor/show/blood
• Pelvic pressure
• Increase of vagina discharge
• Vaginal bleeding

17. Physical examination
• Uterus: tender (abruption/ chorioamnionitis)
• Speculum examination revealed:
-pooling of amniotic fluid
-abnormal discharge/ blood