Abdominal pain in pregnancy Flashcards
Abdo pain in 1st trimester of pregnancy - differentials
- ectopic pregnancy (always considered unless proven otherwise)
- threatened miscarriage (1 in 5 pregnancies below 10 weeks)
- hormone related (especially in the first pregnancy, as the uterus is still small and then expands massively) - stretching pain of uterine growth
- morning sickness
- hyperemesis gravidarum
- UTI
- ovarian cyst
Is nausea and vomiting normal in pregnancy?
Nausea and vomiting are normal in pregnancy - particularly in 1st trimester (50%)
When are nausea and vomiting pathological in pregnancy?
Hyperemesis gravidarum in <1%
Is admission required in hyperemesis gravidarum? Why?
Admission is required if significant dehydration
Typical progression of hyperemesis gravidarum
- usually settles with advanced gestation (as pregnancy hormones will subside)
- rarely requires enteral feeding
What may happen in hyperemesis gravidarum
*what’s the rare complication
- significant weight loss and malnutrition
- tear in the oesophagus
- dehydration
*Wernicke’s encephalopathy (due to loss of vitamin B)
Medical treatment of hyperemesis gravidarum
- Antihistamines (cyclizine)
We start with cyclizine and then we add other meds to it:
- Antiemetics:
- IV, SC, IM, PO
- phenothiazides (prochlorperazine)
- dopamine antagonists (metoclopromide)
- ginger
- Rehydration:
- saline (IV fluids)
- thiamine
Dietary advice in women with hyperemesis gravidarum
Poorly tolerated food:
- acidic
- fatty/oily
Good tolerated:
- dry carbohydrates (salty/plain crackers)
*try to sip small amounts of fluid everyday
*try to keep some veggies/fruits
- cooking smells, coffee, hot food - maybe difficult to deal with as may trigger emesis
Why UTI in pregnancy is more common?
- short urethra
- delayed bladder emptying (urinary stasis - the risk of bacterial infection)
- frequency
*30 % may progress to pyelonephritis
*UTI can present a bit atypically in a pregnancy - may present with pyelonephritis (fever, loin pain) but may not have dysuria -> therefore regular midwife checks
Treatment of UTIs in the pregnancy
- how long
- antibiotics used and what to avoid
- 7-day course - as more urinary stasis therefore longer infection
Antibiotics:
A. Cefalexin - but careful if penicillin allergy crossover
B. Nitrofurantoin - avoid at term due to haemolytic anaemia of newborn
C. Trimethoprim - avoid in first 20 weeks
Specimen:
- clean catch midstream
Causes of constipation in the pregnancy:
- pelvic mass
- delayed gastric emptying
- decreased colonic motility
Management of constipation in the pregnancy - lifestyle advice
- reassurance (it is common 40% pregnant women)
- increase fluid intake (may drink hot water and lemon in the morning to help)
- temporary stopping iron supplementation - but that depends on gestation time (how much they need iron)
Management of constipation in the pregnancy - medication (laxatives - types and names)
A. Bulk-forming:
- ispaghula husk
- barn
B. Stimulant
- senna
- glycerol
C. Softeners:
- docusate sodium
D. Osmotic:
- lactulose
GORD in the pregnancy
- how common
- associated symptoms/problems
GORD
Common: 60% of 3rd trimester
Associated problems: heartburn, epigastric pain, N&V, haematemesis, Mallory- Weiss tears
Advice in GORD in the pregnancy
- general
- medication
- sleep position - but tricky as advised to sleep on L side (to minimise compression to SVC) + elevate head
meds:
- antiacids - gaviscon
- H2 blockers - ranitidine
- gastric motility stimulant - metoclopramide
- PPI - omeprazole
Unsuspected/uncommon causes of abdo pain in the pregnancy
A. Adhesions - due to pelvic infections (previously not significant may become significant due to changes in anatomy in the pregnancy)
B. Appendicitis - pain will be higher when localises due to changes in the position of the appendix (non-specific, generalised for longer in the pregnancy)
C. Bowel related
D. Pancreatitis
E. Acute cholecystitis
What may happen to the fibroid during pregnancy?
Fibroids in the pregnancy
- very common 20%
*but most would not cause problems
- can enlarge during pregnancy (due to oestrogen)
- red degeneration -> acute, severe pain
*Red degeneration of the fibroid: fibroid grows so much -> cut off blood supply -> ischaemia, necrosis
Management: supportive care, analgesics (morphine)
*once fibroid dies off then a woman continues to have a normal pregnancy
IBD in the pregnancy
- what do we need to find out
- prognosis
- what’s needed once pregnancy is ended?
- History: how the disease is normally? What meds are they on?
- IBD (and most other inflammatory conditions) -> quiet/ better in the pregnancy due to hormonal changes
- once pregnancy ended -> possible increase in treatment as the conditions may flare up
When do we need to consider elective CS in a woman with IBD?
- Possibly, if their condition is quite complicated and if they have stoma in place
This is because we need to avoid an emergency CS (if the need arises) as the lady has lots of adhesion in her abdomen already and we want to have access to bowel surgeon if we need
- If the patient has fistulas, tears -> they may have healing issues so we do not want to risk difficult vaginal delivery
What do we need to consider if IBD is active in a woman during pregnancy?
It may cause foetal growth restriction -> monitor for it
Management of IBD in the pregnancy
- do we manage it differently?
- what meds? are they safe?
- other considerations (delivery mode)
IBD in pregnancy
- we aim to manage as normal
- Meds: Mesalazine, azathioprine, biologics and steroids -> all safe (but advice from bowel specialist)
- folate supplementation
Try to aim for vaginal delivery (as may already have adhesions or strictures)
Definition of labour
- regular (2:10 mins) painful uterine contractions
- last 30-45 seconds
- increasing frequency 4-5 in 10 mins
- cervical dilatation 3-4 cm
What examination we do if we suspect the labour?
- vaginal examination -> to assess cervical dilatation
- we ask about the frequency of the contractions
What’s Braxton-Hicks?
What to do?
Braxton-Hicks: (usually) painless uterine contractions (tight muscles, the belly is hard to touch) - uterine muscles are practising for labour
*usually in 2nd half of pregnancy
* assess cervix for dilatation
* there should be no contraction progression (e.g. increase in the frequency or association with membrane rupture)
