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Abdominal Pain In Pregnancy

Abdominal pain in pregnancy is often due to a benign cause but may be very difficult to diagnose with certainty. Unless a benign cause can be established with certainty in the absence of maternal or fetal distress then urgent hospital referral is usually indicated.

Causes of abdominal pain in pregnancy

Pregnancy related

• Early pregnancy: ectopic pregnancy, miscarriage
• Later pregnancy: labour (term or preterm), abruption, uterine rupture
• Acute polyhydramnios
• Gestational trophoblastic disease
• Choioamniotitis, usually precipitated by pre-term premature rupture of membranes

Other gynaecological causes

• Ovarian cysts or tumours, including rupture, haemorrhage or torsion
• Red degeneration of a fibroid
• Uterine torsion
• Round ligament pain: more common at the beginning and end of pregnancy, more common in multips and pain is aggravated by movement

Non-gynaecological causes

• Abdominal wall, especially symphysis pubis and ligament strains
• Constipation
• Appendicitis: affects 1 in 1500 pregnancies, less common than in non-pregnant women. ³ Diagnosis is complicated by change in position of appendix which is carried high and to the right and there may not be localisation of pain. Nausea, vomiting, fever together with any right-sided abdominal pain are suspicious of this. Leucocytosis is suggestive. Appendicitis is not diagnosed in 1 in 5 cases in pregnant women until the appendix has ruptured causing peritonitis, which can cause premature labour or abortion.
• Perforated peptic ulcer, gastritis
• Bowel obstruction, e.g. adhesions, volvulus
• Gallstones, cholecystitis: cholecystitis is relatively common in pregnancy occurring usually late, 90% of cases have gallstones most of which can be visualised under ultrasound. Conventionally cholecystectomy is only necessary in complicated cases such as obstruction, as can cause 15% perinatal mortality. In advanced pregnancy, cholecystostomy and lithotomy may be all that is possible. ERCP and endoscopic retrograde sphincterotomy are possible if exposure to radiation is minimised. In early to middle of second trimester, laparoscopic cholecystostomy carries few problems. ⁴. Most patients only require symptomatic relief.
• Pancreatitis
• Liver congestion, e.g. pre-eclampsia; acute fatty liver of pregnancy; HELLP syndrome
• Renal, e.g. urinary tract infection, stones
• Other uncommon causes include sickle cell crisis, malaria, porphyria and diabetic ketoacidosis
• Psychological: diagnosis of exclusion and must be very careful not to miss a physical cause for the abdominal pain

Presentation

• Often presents with localised discomfort and no sign of maternal or fetal distress. If there is any doubt then immediate referral is required.
• Even if immediate referral is clearly not required, ensure the mother understands that she should seek further help if there is any deterioration, change or persistence of symptoms, or if there is any indication of fetal distress (reduced fetal movements).

Investigations

• Fetal monitoring
• Urinanalysis, MSU: infection, proteinuria in pre-eclampsia
• Full blood count: raised white cell count suggestive of infection, although the white cell count is normally slighty raised in pregnancy
• Liver function tests
• Ultrasound: may demonstrate ectopic pregnancy, abruption, miscarriage
• Laparoscopy to confirm ectopic pregnancy

Management A thorough assessment of the wellbeing of the mother and fetus, as well as the possible underlying cause is required. Treatment of cause; urgent hospital referral if uncertain cause, and/or maternal or fetal distress.

References Used

1. Langdon MB in Obstetric Syndromes and Conditions. O'Grady JP and Burkman RT. Parthenon Publishing
2. Professional Guide to Signs & Symptoms 3^rd Edition. Springhouse Corp 2001.
3. Andersson RE, Lambe M; Incidence of appendicitis during pregnancy.;Int J Epidemiol 2001 Dec;30(6):1281-5.
4. Allmendinger N, Hallisey MJ, Ohki SK, et al; Percutaneous cholecystostomy treatment of acute cholecystitis in pregnancy.;Obstet Gynecol 1995 Oct;86(4 Pt 2):653-4.

Acknowledgements EMIS is grateful to Dr Colin Tidy for updating this article from an original by doctoronline.nhs. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2006.

Last issued 30 Aug 2006