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)
Potential pre-term labour symptoms
Vague symptoms:
- back ache
- vaginal discharge
- pressure
- ruptured membranes
Causes of pre-term labour
- some women will present with classic symptoms of labour (with dilated cervix)
- often unclear
common: UTI, ascending infection, systemic illness
Do we need to examine every woman that is 20weeks pregnant or more and presents with abdominal pain?
Yes. We need to do speculum and bimanual
This is because we need to check for premature labour (e.g. cervical dilatation)
Obstetric cholestasis
- clinical picture
Obstetric cholestasis
- pruritis limbs, trunk, palms and soles
- no rash
- dark urine, pale stool
- no pain
- elevated transaminases -> liver impairment
Obstetric cholecystitis
- possible complications
- liver impairment
- foetal compromise is difficult to predict
- small risk of foetal death
- risk of PPH
Obstetric cholestasis
- causes
- the clear cause is unknown
- potentially due to raise in hormonal levels -> highest in 3rd trimester
- twin and triplet pregnancies -> have higher levels of hormones = higher incidence of obstetric cholestasis
Investigations in obstetric cholestasis
- bile acids
- transaminases
- USS
- viral screen (to exclude infection)
- autoantibodies (to exclude autoimmune causes)
Management of obstetric cholestasis
- induce at 37 weeks
- vitamin K - if clotting function is affected (to lower the risk of haemorrhage at delivery)
- chlorphenamine
- ursodeoxycholic acid
Acute fatty liver of pregnancy
- risk factors
- pre-eclampsia (coexisting)
- multiple pregnancies
- 30 weeks +
- more common with male foetus
Acute fatty liver of pregnancy
- clinical signs and symptoms
- malaise (feeling unwell) and anorexia
- vomiting and abdo pain
- jaundice
- ascites
- liver flap (encephalopathy)
Acute fatty liver of pregnancy
- how do the results of investigations look like?
- very abnormal LFTs
- DIC (90%)
- hypoglycaemia
- fatty infiltration of hepatocytes
What result on investigation helps to distinguish between HELLP syndrome and Acute Fatty liver of the pregnancy?
in Acute fatty liver of the pregnancy, we will see hypoglycaemia
Management of Acute Fatty Liver of the pregnancy
- delivery when stabilised
- MDT
- liaison with the liver unit
- ITU
- aggressive correction of coagulopathy
Risk factors for placental abruption in the pregnancy?
What is its complication?
Placental abruption
- Risks: smoking, IUGR, hypertension, cocaine use
- complication: foetal death due to hypoxia
The classic clinical picture of placental abruption
- severe sudden onset of abdo pain
- high uterus
- woody hard uterus (due to bleeding tracking into the myometrium -> uterus cannot contract in normal way -> tonic contraction/ no normal relaxation)
- concealed or revealed bleed
- DIC
Management of placental abruption
- blood replacement
- clotting factors
- delivery when mum is stable (vaginal preferred but often CS happen)
- ITU
- thromboprophylaxis
*abruption may trigger the labour, assess if the cervix is dilated, vaginal delivery may be quicker
