|Early pregnancy||Late pregnancy|
Ovarian cyst accident
Acute urinary retention
Degeneration of fibroids
Complications of invasive pre-natal diagnosisStretching of round ligaments
Liver pain associated with HELLP
Pressure from enlarging uterus
PolyhydramniosMusculoskeletal pain – especially pubic-symphysis dysfunction
(Adapted from Shervington J, Cox C. Abdominal pain in pregnancy: diagnosis, surgery and anaesthesia. TOG 2000;10:17-22).
It is important to remember that gynaecological and surgical causes of abdominal pain can still occur in the gravid woman. Initial assessment and ruling out of obstetric emergencies such as abruption or uterine rupture are important but other causes should not be overlooked. Pain may not present in the usual location as the gravid uterus will increasingly displace abdominal organs.
Examination may also be more complex in the pregnant woman. Physiological changes in pregnancy may mirror signs of sepsis or acute compromise (e.g. raised heart rate, relative hypotension, raised respiratory rate). For this reason observations should always be interpreted using modified obstetric warning scoring.
Investigations should be carried out as in the non-pregnant patient. Care should be taken as certain parameters will be raised due the physiological process of pregnancy, such as white cell count. Ultrasound is often useful to diagnose ovarian cysts, fibroids and visualise the upper abdominal organs. Although radiation imaging is relatively contra-indicated it may be necessary in certain cases.
Surgery and anaesthesia in pregnancy
Surgery is now increasingly performed in pregnancy. Laparoscopic cholecystectomy and appendicectomy are performed, where necessary, throughout pregnancy. Laparoscopic port site placement will be altered due to the gravid uterus. There is little evidence to suggest the commonly used anaesthetic drugs have any effect in pregnancy. The reduced physiological reserve in the pregnant woman may make their intra-operative and post-operative care more challenging.
|Acute appendicitis||1-2 in 1500 pregnancies|
|Acute cholecystitis||1-6 in 10 000 pregnancies|
|Acute intestinal obstruction||1 in 1500 pregnancies|
Appendicitis in Pregnancy
Acute appendicitis is the most common cause of acute abdomen in pregnancy. Symptoms may be atypical in pregnancy due to the displacement of the appendix by the uterus. They may also present with heartburn, constipation or general malaise. Rebound tenderness and guarding may be absent as the anterior abdominal wall and omentum are stretched away from the area of inflammation.
Women with acute appendicitis require surgery. This should not be delayed as the rate of foetal loss increases with worsening severity of inflammation (simple appendicitis 1.5%, appendicitis with peritonitis 6%, perforated appendix 36%). Evidence suggests that laparoscopic appendicectomy is an appropriate technique.