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Abdominal Pain in Early Pregnancy: Causes, Evaluation, and Imaging

Learn about the common causes of abdominal pain in early pregnancy, when to be concerned, and appropriate evaluation and imaging methods.

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Abdominal Pain in Early Pregnancy: Causes, Evaluation, and Imaging

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  1. Spotlight Abdominal Pain in Early Pregnancy

  2. Source and Credits • This presentation is based on the September 2015AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Charlie C. Kilpatrick, MD, Associate Professor of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

  3. Objectives At the conclusion of this educational activity, participants should be able to: Recognize when nausea and vomiting in pregnancy is abnormal Identify the most common causes of non-obstetric abdominal pain and acute abdomen in early pregnancy Review the diagnosis of appendicitis in pregnancy Discuss a diagnostic imaging algorithm for pregnant women with suspected appendicitis

  4. Case: Abdominal Pain in Early Pregnancy A 34-year-old woman who was 14 weeks pregnant presented to the emergency department (ED) with 5 days of nonspecific abdominal pain, nausea, and vomiting. On examination, she appeared well with normal vital signs and had some mild diffuse abdominal tenderness. Her white blood cell count was 19,000 and a urinalysis was positive for nitrates and leukocyte esterase (indicating possible infection). She was diagnosed with a urinary tract infection and was discharged on antibiotic therapy. No imaging was performed at this initial visit.

  5. Case: Abdominal Pain in Early Pregnancy (2) The patient returned the following day with unchanged abdominal pain and more nausea and vomiting. A fetal ultrasound was performed and found normal fetal heart activity. No further testing was done, and she was discharged home with instructions to continue the antibiotics.

  6. Background • Abdominal pain is the most common reason for ED visits • More than 11% of all visits in 2008 • Many of these patients are women of childbearing age or pregnant • Providers evaluating such patients should be familiar with the common causes of abdominal pain in pregnant women

  7. Nausea and Vomiting in Pregnancy • Up to 80% of women experience nausea and vomiting during pregnancy • Symptoms and signs that may indicate another cause for nausea and vomiting: • Symptoms past 20 weeks • Associated with abdominal pain, fever, or diarrhea • In these instances, a more thorough evaluation is indicated

  8. Abdominal Pain in Pregnancy • Abdominal pain is also common in pregnancy • Warning signs that the cause may be nonpregnancy related: • Pain localized, abrupt, constant, or severe • Pain associated with nausea and vomiting, vaginal bleeding, or fever • If any of these are present, further investigation is warranted and consultation with an obstetric specialist is recommended

  9. Appropriate Evaluation • All women of childbearing age who present to the ED should have a urine pregnancy test • If pregnant, the location and gestational age of the pregnancy should be determined with ultrasound • Miscarriage and ectopic pregnancy are the most common causes of pain in early pregnancy • Both often also present with vaginal bleeding

  10. Non-obstetric Causes of Abdominal Pain • In general, the cause and incidence of non-obstetric abdominal pain in pregnancy varies little by gestational age of the fetus • The most common causes of acute abdominal pain in pregnancy are (with incidences): • Appendicitis (1/1500 pregnancies) • Cholecystitis (1/3000) • Nephrolithiasis (1/3000) • Pancreatitis (1/3000) • Small bowel obstruction (1/3000)

  11. Evaluation for Non-obstetric Causes • After a history, physical examination, pregnancy test, and ultrasound, certain laboratory tests may be helpful • Complete blood count • Liver and pancreatic enzymes • Urinalysis • If diagnosis is still uncertain, prompt imaging may be necessary

  12. Abdominal Imaging in Pregnancy • Imaging in pregnancy should begin with ultrasound or magnetic resonance imaging (MRI) • Neither has ionizing radiation • Neither has been linked to fetal harm • If diagnostic tests with ionizing radiation (e.g., computed tomography) are clinically necessary, they should not be withheld, even with concerns about fetal harm • Risk of harm to fetus is low, especially at lower radiation doses • The radiation delivered in a CT scan of the abdomen and pelvis is less than the dose known to cause fetal harm • As a rule, the smallest amount of ionizing radiation should be used • CT scan in this setting should only be obtained after obstetrical consultation

  13. In This Case The initial combination of abdominal pain, nausea, and vomiting appropriately raised concern for a nonpregnancy-related cause and triggered further investigations The patient should have had a pregnancy test and ultrasound at the first ED visit to establish the location and gestational age of the pregnancy Further imaging should have been considered because the combination of 5 days of pain, nausea and vomiting, tenderness on exam, and leukocytosis were not completely explained by a simple UTI

  14. In This Case (2) At the second visit, a limited ultrasound was performed solely for the purposes of documenting a normal pregnancy Given the severity and persistence of symptoms despite treatment, a complete abdominal ultrasound, looking for nonpregnancy-related intra-abdominal pathology, would have been appropriate

  15. Case: Abdominal Pain in Early Pregnancy (3) The patient again returned to the ED within 24 hours with persistent complaints. She now appeared more ill, with increased abdominal pain on examination. Magnetic resonance imaging of the abdomen was performed and revealed a ruptured appendix with signs of peritoneal inflammation. She was taken immediately to the operating room and found to have diffuse peritonitis secondary to the ruptured appendix. An emergent laparoscopic appendectomy was performed, which the patient tolerated well. Unfortunately, 3 hours after the operation, she had a spontaneous abortion and subsequent severe bleeding requiring multiple transfusions. She was discharged home days later.

  16. Clinical Presentation of Appendicitis • In early pregnancy, symptoms of appendicitis are identical to those seen in the nonpregnant state • Periumbilical pain that migrates to the right lower quadrant • Associated with anorexia, fever, nausea, and vomiting

  17. Clinical Presentation of Appendicitis (2) • With advancing gestational age, the diagnosis can become more challenging • As the uterus enlarges, the appendix can migrate and patients may actually present with right upper quadrant pain • Peritoneal signs may be masked as the distance from the appendix to the peritoneum increases • Yet, right lower quadrant pain remains the most common symptom of appendicitis in pregnant women

  18. Diagnostic Testing for Appendicitis Ultrasound is the best test for appendicitis in this setting Sometimes the appendix cannot be visualized by ultrasound The American College of Radiology recommends magnetic resonance imaging (MRI) as the second line test in pregnant patients If ultrasound is non-diagnostic and an MRI is not available, a CT scan with contrast is the best test

  19. Institutional Approaches Institutions should develop an algorithm for optimal imaging of pregnant patients with acute abdominal symptoms The goal should be to minimize ionizing radiation and fetal harm while maintaining diagnostic accuracy The use of the algorithm and clinical outcomes should be audited and reviewed

  20. Use of Checklists The use of a checklist may help remind clinicians to implement best practices Checklists in medicine have been associated with reduced morbidity and mortality, improved communication, and decreased adverse events A computerized checklist could review warning signs and symptoms in pregnant patients and prompt clinicians to consider other diagnoses

  21. This Case In the initial visit, pregnancy location and gestational age should have been documented Based on the patient's signs and symptoms, abdominal imaging was probably indicated An obstetric specialist should have been consulted A checklist highlighting key warning signs or an algorithm for appropriate and safe imaging may have led to an earlier diagnosis The error (delay in diagnosis) led to a catastrophic adverse event—the loss of the fetus

  22. Take-Home Points • Nausea and vomiting are common in early pregnancy, but symptoms that persist after 16−20 weeks or are accompanied by abdominal pain should be considered abnormal and evaluated • Initial imaging in evaluating abdominal pain in pregnant patients should begin with ultrasound or MRI, but ionizing imaging that is clearly indicated by the clinical situation should not be delayed or withheld due to concerns of fetal harm

  23. Take-Home Points (2) • ED physicians, in conjunction with obstetric specialists, should develop a diagnostic imaging algorithm for pregnant patients with abdominal pain, taking into account the availability and expertise of their radiologic staff • Consultation with an obstetric specialist should be strongly considered in pregnant patients with abdominal pain associated with nausea and vomiting • Appendicitis remains the most common cause of acute surgical abdomen in pregnancy, and a delay in diagnosis increases fetal mortality

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