Abdominal in early pregnancy

PROBLEM
The woman is experiencing abdominal pain in the first 22 weeks of pregnancy. Abdominal pain may be the first presentation in serious complications such as abortion or ectopic pregnancy.
GENERAL MANAGEMENT
Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature).
If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately.
Note: Appendicitis should be suspected in any woman having abdominal pain. Appendicitis can be confused with other more common problems in pregnancy which cause abdominal pain (e.g. ectopic pregnancy, abruptio placentae, twisted ovarian cysts, pyelonephritis).

DIAGNOSIS
Table S-15
Diagnosis of abdominal pain in early pregnancy
Presenting Symptom and Other Symptoms and Signs TypicallyPresent
Symptoms and Signs Sometimes Present
Probable Diagnosis
• Abdominal pain
• Adnexal mass on vaginal examination
• Palpable, tender discrete mass in lower abdomen
• Lightb vaginal bleeding

Ovarian cystaaa
• Lower abdominal pain
• Low-grade fever
• Rebound tenderness
• Abdominal distension
• Anorexia
• Nausea/vomiting
• Paralytic ileus
sed white blood cells
• No mass in lower abdomen
• Site of pain higher than expected

Appendicitis
• Dysuria
• Increased frequency and urgency of urination
• Abdominal pain
• Retropubic/suprapubic pain

Cystitis
• Dysuria
• Spiking fever/chills
• Increased frequency and urgency of urination
• Abdominal pain
• Retropubic/suprapubic pain
• Loin pain/tenderness
• Tenderness in rib cage
• Anorexia
• Nausea/vomiting
Acute pyelonephritis
• Low-grade fever/chills
• Lower abdominal pain
• Absent bowel sounds
• Rebound tenderness
• Abdominal distension
• Anorexia
• Nausea/vomiting
• Shock

Peritonitis
• Abdominal pain
• Light bleeding
• Closed cervix
• Uterus slightly larger than normal
• Uterus softer than normal
• Fainting
• Tender adnexal mass
• Amenorrhoea
• Cervical motion tenderness

Ectopic
pregnancy
a Ovarian cysts may be asymptomatic and are sometimes first detected on physical examination.
b Light bleeding: takes longer than 5 minutes for a clean pad or cloth to be soaked.
MANAGEMENT
OVARIAN CYSTS
Ovarian cysts in pregnancy may cause abdominal pain due to torsion or rupture. Ovarian cysts most commonly undergo torsion and rupture during the first trimester.
If the woman is in severe pain, suspect torsion or rupture. Perform immediate laparotomy.
Note: If findings at laparotomy are suggestive of malignancy (solid areas in the tumour, growth extending outside the cyst wall), the specimen should be sent for immediate histological examination and the woman should be referred to a tertiary care centre for evaluation and management.
If the cyst is more than 10 cm and is asymptomatic:
- If it is detected during the first trimester, observe for growth or complications;
- If it is detected during the second trimester, remove by laparotomy to prevent complications.
If the cyst is between 5–10 cm, follow up. Laparotomy may be required if the cyst increases in size or fails to regress.
If the cyst is less than 5 cm, it will usually regress on its own and does not require treatment.
APPENDICITIS
Give a combination of antibiotics before surgery and continue until the woman is postoperative and fever-free for 48 hours:
- ampicillin 2 g IV every 6 hours;
- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;
- PLUS metronidazole 500 mg IV every 8 hours.
Perform an immediate surgical exploration (regardless of stage of gestation) and perform appendectomy, if required.
Note: Delaying diagnosis and treatment can result in rupture of the appendix which may lead to generalized peritonitis.
If there are signs of peritonitis (fever, rebound tenderness, abdominal pain), give antibiotics as for peritonitis.
Note: The presence of peritonitis increases the likelihood of abortion or preterm labour.
If the woman is in severe pain, give pethidine 1 mg/kg body weight (but not more than 100 mg) IM or IV slowly or give morphine 0.1 mg/kg body weight IM.
Tocolytic drugs may be needed to prevent preterm labour (Table S-17).