HKCEM College Tutorial Abdominal pain complicated 3rd trimester pregnancy Author Dr. Paulin Ng revised by Dr. WONG ho tung Oct, 2013
Triage note • Female, 30 • G3P2 • Gestation: 30 week • C/O: diarrhea and abd pain for 4 hours • Afebrile • BP 120/80 mmHg; P 90/min Triage Category IV
DDx • OBGyn causes • Preterm labor, Preeclampsia, Abruptio placenta, Traction of round ligament • Surgical causes • acute appendicitis, cholecystitis (hydrop), renal colic • Medical causes • GE, pyelonephritis, hepatitis
Now take a targeted history The nature of pain:PQRST Review GI, GU systems Antenatal history
History • Uneventful antenatal history • Lower abd pain for 4 hours • Irregular, colicky, no radiation • Passing yellowish loose stool twice • No Nausea and Vomit • No group involvement or travel history • No PV bleeding or leaking • No dysuria or loin pain
Abdomen Uterus-fetus Review of systems Now, a focused physical exam
Physical Findings • Maternal • Afebrile, BP stable • Abdominal exam. • Soft, Mild tenderness over lower abd • No guarding or rebound tenderness • PR: no pelvic tenderness • Uterus_Fetal • Uterus palpation for several min to determine contraction • Fundal height • Fetal lie • Doptone fetal heart rate: 140/min Potential Pitfalls
Potential pitfalls of Abd exam in pregnancy • Abnormal location of pain e.g. appendicitis with pain in RUQ • Peritoneal sign less obvious due to chronic stretching of abdomen • Bowel colic difficult to differentiate from uterine contraction
Blood Urine Ultrasound What investigations would you like to request?
Investigations • Blood work: • Hb (n), WCC (n) • Urinalysis • Protein (-), wbc (-) • USG • Fetal assessment: single viable fetus • Evidence of acute cholecystitis, dilated renal calyces, abruptio placenta: nil
What are the management? • Bed rest • Monitor maternal and fetal vitals • Serial abdominal exam in observation ward • Cardiotocography (CTG) monitoring if preterm labor is suspected
What is the Disposition? • Admit surgery • If there is evidence of acute abdomen • Admit Obstetric • If preterm labor or abruptio placenta is suspected • If abdominal pain persists after observation • Discharge Home • If pain subsides • Counsel on the risk and S/S of preterm labor • Seek medical care if pain recurs
Progress • The patient had increasing frequency of abdominal pain compatible with uterine contraction in the “Observation” ward • She was admitted to Obstetric for further CTG monitoring and administration of tocolytics What is preterm labour? How does it present?
Preterm Labour • < 37 weeks • regular uterine contraction+ cervical effacement; • contractions > 5-8/ hr • Nonspecific presentations • LBP • cramp • change in vaginal discharge
Dx of Preterm labor • High index of suspicion • Presentations: • Uterine contraction • Backache • Bleeding • Leaking of fluid • Increased vaginal discharge
Summary We have covered: • DDx of abd pain complicated preg • Important Dx to be R/O: surgical causes, pretern labor and concealed abruptio placenta • Evaluation of preg patient with abd pain • High index of suspicion in diagnosing preterm labor • CTG monitoring is advisable in suspected preterm labor