Abdominal pain and MEOWS Flashcards
What makes the assessment of abdominal pain more complex in pregnancy?
- Assessment of abdominal pain is more complex in pregnant women because uterine enlargement may hide classical signs.
- Peritoneal signs may be absent due to lifting of the abdominal wall.
Which diagnosis must you exclude first in a woman?
- Ectopic pregnancy
What does pregnancy do to abdominal organs?
• Abdominal organs can change position as the pregnancy progresses - for example, the appendix is displaced upwards and laterally towards the gallbladder after the first trimester.
Why is intra-abdominal infection or inflammation particularly bad in pregnancy?
Intra-abdominal infection or inflammation can be associated with premature labour or fetal loss and that acute conditions such as appendicitis carry higher risks in pregnancy.
What is the most common cause of acute abdomen during pregnancy?
Acute appendicitis
What are the obstetric causes of abdominal pain?
Labour pain- premature labour or term.
Pre-eclampsia or HELLP syndrome- epigastric or RUQ pain
Placental abruption- typically, sudden severe pain, fetal distress and vaginal bleeding.
Uterine rupture- constant pain, profound shock, fetal distress and vaginal bleeding; usually presents during labour and with history of uterine scar.
Chorioamnionitis- follows premature rupture of membranes
Acute fatty liver of pregnancy- presents in the second half of pregnancy with abdominal pain, nausea/vomiting, jaundice, malaise and headache.
Acute polyhydramnios
Rupture of utero-ovarian vessels
Severe uterine torsion
What are the gynaecological causes of abdominal pain?
- Ectopic pregnancy- usually presents between 5-9 weeks of gestation. The classical triad of bleeding, abdominal pain and amenorrhoea.
- Miscarriage and septic abortion
- Torsion of the ovary or Fallopian tube
- Ovarian cysts- torsion, haemorrhage or rupture
- Fibroids- red degeneration or torsion
- Salpingitis
- Round ligament pain
Surgical causes of abdominal pain
Acute appendicitis- presents with fever, anorexia, nausea, vomiting, RIF pain.
Cholecystitis and gallstones.
Urinary tract- renal calculi, urinary tract obstruction
Intestinal obstruction- most often due to adhesions.
Peritonitis from any cause
Abdominal trauma, including domestic violence
Mesenteric adenitis
Meckel’s diverticulitis
Peptic ulcer
IBD
Abdominal wall- hernias, musculoskeletal pain, rupture of rectus abdominis muscle.
Acute pancreatitis- rare and usually due to gallstones
Medical causes of abdominal pain
UTI and pyelonephritis Constipation DKA Sickle cell anaemia crisis Lower lobe pneumonia VTE- DVT or PE MI Gastroenteritis IBS
Musculoskeletal causes of abdominal pain
Round ligament pain- low abdominal or groin pain
General aches-due to uterine enlargement
Rectus muscle haematoma
Pelvic girdle pain- symphysis pubis dehiscence
What should you ask when taking an abdominal pain hx from a pregnant woman?
Pain hx- SOCRATES.
Other abdominal symptoms- vaginal bleeding, bowel and urinary symptoms; pre-eclampsia symptoms (e.g. headache, visual change, nausea)
Fetal movements
Obstetric hx- LMP
Past medical and gynaecological hx, medication, allergies, last meal.
Examination of a pregnant woman presenting with pain
General examination- well/ill, signs of sepsis, shock or haemorrhage, BP, urine dipstick protein and glucose.
Assess the pregnancy and uterus
Abdominal examination- to distinguish extra-uterine from uterine tenderness, peritoneal signs may be absent in pregnancy, as the uterus can lift the abdominal wall away from the area of inflammation.
Consider whether vaginal and/or rectal examination is indicated:
- Never do vaginal examination if placenta praevia is suspected.
- Suspected rupture of membranes requires sterile examination.
- For incomplete miscarriage with heavy bleeding, examine the cervical os.
Investigations for abdominal pain
• Bedside tests: Urine dipstick Urine pregnancy test Bedside glucose test Fetal CTG monitoring.
• Initial investigations:
o Blood tests
FBC
Group and save/crossmatch
Rhesus blood group (if not known)
Serum beta-hCG
Renal and liver function, glucose, calcium, amylase, hepatitis serology.
Clotting screen if haemorrhage, placental abruption or liver disease suspected.
Sickle cell screen
Blood film
o Urine tests:
Urine microscopy and culture
Urine protein for suspected pre-eclampsia
o ECG if atypical epigastric pain
o Ultrasound:
First trimester-can confirm whether pregnancy is intra-uterine and viable.
Second-third trimesters- gives information about fetal well-being, the uterus and placenta.
May assist surgical diagnosis- acute appendicitis, ovarian cysts, gallstones.
Management of abdominal pain in pregnancy
- This depends on the diagnosis
- Rhesus-negative women - give anti-D immunoglobulin if indicated.
- Combined management by an obstetrician, surgeon and/or physician may be needed.
- Indications for emergency surgery are similar to non-pregnant patients.
- If non-urgent surgery is required during pregnancy, the second trimester is preferred.
- Laparoscopy is increasingly used for diagnosis and treatment.
What are the urgent considerations in a pregnant woman presenting with abdominal pain?
o Shock or haemorrhage.
o Sepsis.
o Pregnancy-related problems - ectopic pregnancy, incomplete miscarriage with heavy bleeding, severe pre-eclampsia, HELLP syndrome (= Haemolysis, EL elevated liver) enzymes, LP (low platelet) count), placental abruption or placenta praevia, uterine rupture.
o Surgical problems - peritonitis, obstructed or ischaemic bowel.
o Medical problems - lower lobe pneumonia, pulmonary embolus, diabetic ketoacidosis, sickle cell crisis, myocardial infarction (may present with abdominal pain).
o Fetal distress.
