ABDOMINAL PAIN IN PREGNANCY District 1 ACOG Medical Student Teaching Module 2011.

ABDOMINAL PAIN ABDOMINAL PAIN IN PREGNANCYIN PREGNANCY

District 1 ACOG Medical District 1 ACOG Medical Student Teaching Module Student Teaching Module

20112011

Challenge of Abdominal Pain Challenge of Abdominal Pain During PregnancyDuring Pregnancy

Multiple causes including essentially Multiple causes including essentially all non pregnancy causes plus all non pregnancy causes plus obstetric causesobstetric causes

Clinical presentation & natural Clinical presentation & natural history often altered with pregnancyhistory often altered with pregnancy

Diagnostic evaluation and treatment Diagnostic evaluation and treatment plans altered & limitedplans altered & limited

Fetal wellbeing to be consideredFetal wellbeing to be considered

Obstetric/Gynecologic Obstetric/Gynecologic EtiologiesEtiologies

Ruptured EctopicRuptured Ectopic Pre-eclampsia/EclampsiaPre-eclampsia/Eclampsia Placental AbruptionPlacental Abruption Uterine RuptureUterine Rupture Ovarian Cyst RuptureOvarian Cyst Rupture PIDPID Tubo-Ovarian AbscessTubo-Ovarian Abscess Uterine LeiomyomasUterine Leiomyomas AbortionAbortion SalpingitisSalpingitis EndometriosisEndometriosis Cancer of Cervix or OvaryCancer of Cervix or Ovary

Common Non OB Common Non OB EtiologiesEtiologies

GERD/other bowel c/oGERD/other bowel c/o Intestinal ObstructionIntestinal Obstruction Cholelithiasis/CholecystitisCholelithiasis/Cholecystitis PancreatitisPancreatitis PyelonephritisPyelonephritis NephrolithiasisNephrolithiasis AppendicitisAppendicitis

HISTORYHISTORY As with most things, history As with most things, history

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

FactorsFactors

PHYSICAL EXAMPHYSICAL EXAM Uterus displaces abdominal organsUterus displaces abdominal organs Moving omentum does not wall off Moving omentum does not wall off

infection as wellinfection as well Late pregnancy abdominal wall laxity Late pregnancy abdominal wall laxity

may mask rigid abdomen of may mask rigid abdomen of peritonitisperitonitis

GERDGERD Up to 80% in pregnancyUp to 80% in pregnancy Gastric compression by uterus, Gastric compression by uterus,

hypotonic LES, & gastrointestinal hypotonic LES, & gastrointestinal dysmotilitydysmotility

Epigastric discomfort, nausea, emesis, Epigastric discomfort, nausea, emesis, anorexia, regurgitation, water brashanorexia, regurgitation, water brash

PUD decreases secondary to decreased PUD decreases secondary to decreased gastric secretion, decreased motility, & gastric secretion, decreased motility, & increased mucus secretionincreased mucus secretion

Treatment of GERDTreatment of GERD Lifestyle modificationsLifestyle modifications H2 Blockers (Ranitidine)H2 Blockers (Ranitidine) PPI’s (Losec)PPI’s (Losec) Consider deferring H Pylori eradication Consider deferring H Pylori eradication

until PP because of possible teratogenic until PP because of possible teratogenic effects of certain medication regimes effects of certain medication regimes

Surgery for GERD best delayed until PPSurgery for GERD best delayed until PP Esophagogastroduodenoscopy (EGD) for Esophagogastroduodenoscopy (EGD) for

bleeding & surgery if unstable as fetus bleeding & surgery if unstable as fetus tolerates maternal hypotension poorlytolerates maternal hypotension poorly

In advanced pregnancy, c/s before gastric In advanced pregnancy, c/s before gastric surgery for bleedingsurgery for bleeding

Intestinal ObstructionIntestinal Obstruction Second most common nonobstetrical Second most common nonobstetrical

abdominal emergency (>1/1500)abdominal emergency (>1/1500) Incidental or secondary to pregnancyIncidental or secondary to pregnancy Large increase in #’s results from Large increase in #’s results from

increased #’s abdominal procedures, increased #’s abdominal procedures, PID, & # pregnancies in older womenPID, & # pregnancies in older women

Most common T3 b/c mechanical Most common T3 b/c mechanical effects large uterus, fetal head effects large uterus, fetal head descent or immediately PP because descent or immediately PP because rapid change uterine sizerapid change uterine size

Adhesions (previous surgery) 60-70% Adhesions (previous surgery) 60-70% SBOSBO

Intestinal Obstruction cont Intestinal Obstruction cont ……

AXR required to dx & monitor despite risk AXR required to dx & monitor despite risk radiation to fetusradiation to fetus

Surgery for complete/unremittingSurgery for complete/unremitting Medical tx for partial/intermittentMedical tx for partial/intermittent

-IV fluid & lyte correction-IV fluid & lyte correction

-NGT to suction-NGT to suction

-Morbidity/mortality related to delayed dx-Morbidity/mortality related to delayed dx

-Maternal < 6%-Maternal < 6%

-Fetal 20-30%-Fetal 20-30%

-Maternal 13% in colonic volvulus-Maternal 13% in colonic volvulus

Cholelithiasis Cholelithiasis Pregnancy increases bile lithogenicity Pregnancy increases bile lithogenicity

& sludge formation b/c estrogen & sludge formation b/c estrogen increases cholesterol synthesis and increases cholesterol synthesis and progesterone impairs gallbladder progesterone impairs gallbladder motilitymotility

>12% pregnancy compared to 1-2% >12% pregnancy compared to 1-2% controlscontrols

Pregnancy does not increase severity Pregnancy does not increase severity of complicationsof complications

Most gallstones are asymptomaticMost gallstones are asymptomatic

Cholelithiasis Cholelithiasis Symptoms:Symptoms: -Biliary colic in epigastrium/RUQ-Biliary colic in epigastrium/RUQ -May radiate to back, flank, or shoulders-May radiate to back, flank, or shoulders -pain often associated with post prandial -pain often associated with post prandial

states (especially fatty foods)states (especially fatty foods) -Pain typically lasts 1 to several hours-Pain typically lasts 1 to several hours -Diaphoresis, nausea, & emesis common-Diaphoresis, nausea, & emesis common

Physical exam often unremarkable apart Physical exam often unremarkable apart from occasional RUQ tendernessfrom occasional RUQ tenderness

Cholelithiasis Cholelithiasis 1/3 patients no additional episode X 1/3 patients no additional episode X

2 yrs2 yrs Complications of cholelithiasis Complications of cholelithiasis

include cholecystitis, include cholecystitis, choledocholithiasis, jaundice, choledocholithiasis, jaundice, cholangitis, biliary stricture, sepsis, cholangitis, biliary stricture, sepsis, abscess, empyema, gallbladder abscess, empyema, gallbladder perforation, & gallstone pancreatitisperforation, & gallstone pancreatitis

CholecystitisCholecystitis Inflammation usually caused by cystic duct Inflammation usually caused by cystic duct

obstruction & supersaturated bileobstruction & supersaturated bile 33rdrd most common nonobstetric surgical most common nonobstetric surgical

emergencyemergency 1-8/10,0001-8/10,000 Same symptoms but pain more prolonged Same symptoms but pain more prolonged Often get tachycardia, fever, R subcostal Often get tachycardia, fever, R subcostal

tenderness, & Murphy’s signtenderness, & Murphy’s sign Leukocytosis commonLeukocytosis common Serum LFT’s may be slightly abnormalSerum LFT’s may be slightly abnormal Jaundice may suggest choledocholithiasisJaundice may suggest choledocholithiasis

Tx for CholecystitisTx for Cholecystitis CholecystectomyCholecystectomy Pre-op NPO, IV fluid, abxPre-op NPO, IV fluid, abx Abdominal surgery best in T2Abdominal surgery best in T2 T1 associated with fetal abortion & T3 with T1 associated with fetal abortion & T3 with

premature laborpremature labor Cholecystectomy may be deferred in Cholecystectomy may be deferred in

appropriate casesappropriate cases Lap chole safe in earlier pregnancyLap chole safe in earlier pregnancy Intraoperative cholangiography only for Intraoperative cholangiography only for

strong indicationsstrong indications Maternal & fetal mortality < 5%Maternal & fetal mortality < 5%

CholedocholithiasisCholedocholithiasis Abdominal pressure & jaundiceAbdominal pressure & jaundice Endoscopic u/sEndoscopic u/s Fever/chills, leukocytosis, n&vFever/chills, leukocytosis, n&v ERCP & sphincterotomy with ERCP & sphincterotomy with

cholecystectomy PPcholecystectomy PP

PyelonephritisPyelonephritis Renal alterations in 70-90%Renal alterations in 70-90% More pronounced T2 & T3 when risk More pronounced T2 & T3 when risk

pyelonephritis is greatestpyelonephritis is greatest Asymptomatic bacteriuria (ASB) in Asymptomatic bacteriuria (ASB) in

about 7%about 7% Acute cystitis 2%Acute cystitis 2% ASB treated to prevent pyelonephritis ASB treated to prevent pyelonephritis

(cephalosporins, nitrofurantoin …)(cephalosporins, nitrofurantoin …) 25-40% untreated ASB develop pyelo25-40% untreated ASB develop pyelo 30% retreatment30% retreatment

PyelonephritisPyelonephritis Acute pyelo in 1-2% pregnanciesAcute pyelo in 1-2% pregnancies Symptoms & Signs:Symptoms & Signs: -Fever/chills-Fever/chills -N & V-N & V -Flank pain-Flank pain -CVA tenderness-CVA tenderness

-Complications include sepsis, shock, -Complications include sepsis, shock, ADRS, Pulmonary edema, renal ADRS, Pulmonary edema, renal insufficiency/abscess, & recurrent insufficiency/abscess, & recurrent infectioninfection

PyelonephritisPyelonephritis

Tx is IV abx until patient clinically Tx is IV abx until patient clinically improves and then PO abximproves and then PO abx

Renal u/s if no improvement after 3 Renal u/s if no improvement after 3 daysdays

Associated with preterm labor and Associated with preterm labor and deliverydelivery

NephrolithiasisNephrolithiasis Symptomatic < 5/1000 pregnancies but Symptomatic < 5/1000 pregnancies but

accounts for the most nonobstetric accounts for the most nonobstetric hospitalizationshospitalizations

About 50% causes by hypercalciuriaAbout 50% causes by hypercalciuria Usually T2 or T3Usually T2 or T3 Symptoms & SignsSymptoms & Signs : :

-Abdominal/flank pain often radiating to -Abdominal/flank pain often radiating to

groingroin

-Gross hematuria, urgency, frequency-Gross hematuria, urgency, frequency

-N&V, diaphoresis, fever/chills-N&V, diaphoresis, fever/chills

NephrolithiasisNephrolithiasis Fluoroscopy relatively contraindicatedFluoroscopy relatively contraindicated U/S initial test of choiceU/S initial test of choice

Tx includes hydration, analgesia, & Tx includes hydration, analgesia, & abx if infection – most responds wellabx if infection – most responds well

Obstruction, sepsis requires ureteral Obstruction, sepsis requires ureteral stentstent

Surgery in refractory casesSurgery in refractory cases Risk premature laborRisk premature labor

Acute PancreatitisAcute Pancreatitis 0.1-1% pregnancies0.1-1% pregnancies Most common T3 & PPMost common T3 & PP Gallstones cause > 70%Gallstones cause > 70% EtOH quite uncommon but other causes EtOH quite uncommon but other causes

include drugs, surgery, trauma, etcinclude drugs, surgery, trauma, etc Pregnancy does not affectPregnancy does not affect Epigastric pain most common complaintEpigastric pain most common complaint Pain may radiate to back, shoulders, or Pain may radiate to back, shoulders, or

flanksflanks Nausea, emesis, fever commonNausea, emesis, fever common

Acute Pancreatitis cont Acute Pancreatitis cont …… Signs:Signs:

-Midabdominal tenderness-Midabdominal tenderness

-Occasional rebound-Occasional rebound

-Guarding-Guarding

-Hypoactive BS-Hypoactive BS

-Distension-Distension

-Tympany-Tympany

Acute Pancreatitis cont …Acute Pancreatitis cont … Elevated Amylase & Lipase Elevated Amylase & Lipase U/S for cholelithiasis & bile duct dilationU/S for cholelithiasis & bile duct dilation Endoscopic u/s for choledocholithiasisEndoscopic u/s for choledocholithiasis

Pancreatitis in pregnancy usually mild and Pancreatitis in pregnancy usually mild and responds well to medical therapyresponds well to medical therapy

-NPO-NPO -IV fluids-IV fluids -Gastric acid suppression-Gastric acid suppression -Analgesia (Meperidine)-Analgesia (Meperidine) -? NGT suction-? NGT suction

Acute Pancreatitis cont …Acute Pancreatitis cont … Severe pancreatitis with abscess, Severe pancreatitis with abscess,

sepsis, phlegmon requires ICU, Abx, sepsis, phlegmon requires ICU, Abx, TPN, & possible radiologic/surgical TPN, & possible radiologic/surgical interventionintervention

Pregnancy should not delay CT or Pregnancy should not delay CT or surgery in these casessurgery in these cases

Endoscopic spincterotomy can be Endoscopic spincterotomy can be performed during pregnancy with performed during pregnancy with minimal fetal radiation exposureminimal fetal radiation exposure

Maternal mortality low with Maternal mortality low with uncomplicated but > 10% with uncomplicated but > 10% with complicated pancreatitiscomplicated pancreatitis

T1 – fetal abortion ; T3 – preterm laborT1 – fetal abortion ; T3 – preterm labor

APPENDICITISAPPENDICITIS

Most common nonobstetric surgical Most common nonobstetric surgical emergency (1/1000) in pregnancyemergency (1/1000) in pregnancy

Appendicitis in 1/1500 (65%)Appendicitis in 1/1500 (65%) Slightly more likely during T2Slightly more likely during T2 Maternal mortality (highest in T3) Maternal mortality (highest in T3)

somewhat higher secondary to somewhat higher secondary to delayed dx and decline of delayed dx and decline of laparotomy (0.1% without laparotomy (0.1% without perforation & 4% with perforation)perforation & 4% with perforation)

Appendicitis cont …Appendicitis cont …

Up to 25% develop appendiceal Up to 25% develop appendiceal perforationperforation

Fetal complications mostly secondary Fetal complications mostly secondary to preterm labor (1-2% in to preterm labor (1-2% in uncomplicated appendicitis and 30-uncomplicated appendicitis and 30-40% with peritonitis)40% with peritonitis)

Appendicitis cont …Appendicitis cont …

Symptoms:Symptoms: -Periumbilical (early visceral obstructive)-Periumbilical (early visceral obstructive) -RLL/RUQ (late parietal secondary -RLL/RUQ (late parietal secondary inflammation) – very focalinflammation) – very focal -N & V, anorexia, urinary frequency-N & V, anorexia, urinary frequency

Signs:Signs: -Focal tenderness/guarding /rebound/ ?-Focal tenderness/guarding /rebound/ ?

peritoneal signs (omental displacement)peritoneal signs (omental displacement)

Appendicitis cont …Appendicitis cont … Investigations:Investigations:

-Leukocytosis normal in pregnancy-Leukocytosis normal in pregnancy

-U/S nonspecific but may show -U/S nonspecific but may show

appendiceal mural thickening & appendiceal mural thickening &

periappendiceal fluid (mostly to help r/o periappendiceal fluid (mostly to help r/o other other

etiologies)etiologies)

-CT better but exposes fetus to radiation-CT better but exposes fetus to radiation

-Often confused with right -Often confused with right

pyelonephritis/cholecystitispyelonephritis/cholecystitis

Appendicitis ManagementAppendicitis Management APPENDICITIS REQUIRES SURGERYAPPENDICITIS REQUIRES SURGERY IV hydration & lytes correctionIV hydration & lytes correction Abx (Penicillin, Cephalosporins, Abx (Penicillin, Cephalosporins,

Clinda, Gent)Clinda, Gent) Laparoscopy in T1 & ? T2 for Laparoscopy in T1 & ? T2 for

nonperforatednonperforated Laparotomy incision over pt of focal Laparotomy incision over pt of focal

tendernesstenderness Appendectomy even if no appendicitisAppendectomy even if no appendicitis Concomitant c/s not doneConcomitant c/s not done