Abdominal Pain


Dehydration

  • Labs: UA w/ micro & C/S, CBC, CMP
  • Exam: Vaginal exam to assess cervical change, EFM,
  • Tx: 1L IV LR bolus

Premature Labor

Regular uterine contractions + concurrent cervical change at < 37 weeks’ gestation
  • The 1° cause of neonatal morbidity and mortality.
  • Risk factors include:
    • Multiple gestation,
    • Infection
    • PROM
    • Trauma
    • Uterine anomalies
    • Previous preterm labor or delivery
    • Polyhydramnios
    • Placental abruption
    • Poor maternal nutrition, &
    • Low SES.
    • Most patients have no identifiable risk factors.

Hx / PE

  • Patients may have Menstrual-like cramps or Contractions, onset of Low back pain, Pelvic pressure, and New Vaginal DSischarge or Bleeding.

DIFFERENTIAL DIAGNOSIS
The differential should include premature labor, preterm rupture of membranes, preterm contractions (contractions prior to 37 wk gestation that do not result in cervical change), and abdominal pain or cramping secondary to other medical conditions. There are many conditions that may cause preterm contractions or premature labor. These include:

  • Infection
    • Chorioamnionitis
    • Genital tract infections, including bacterial vaginosis, gonorrhea, chlamydia
    • Urinary tract infections, including pyelonephritis, cystitis, or asymptomatic bacteruria
    • Gastroenteritis
  • Trauma
  • Placental abruption
  • Illicit drug use
  • Preterm premature rupture of membranes
  • Appendicitis
  • Nephrolithiasis
  • Pancreatitis
  • Cholelithiasis

Dx

  • Requires regular uterine contractions (≥ 3 contractions of 30 seconds each over a 30-minute period) and concurrent cervical change at < 37 weeks’ gestation.
  • Assess for contraindications to tocolysis (e.g., infection, nonreassuring fetal testing, placental abruption).

Workup

  • History and physical exam to rule out trauma, abuse, other causes of abdominal pain, and infection.
  • Fetal heart rate monitoring and tocometry to determine fetal status and contraction frequency.
  • Speculum exam to visually assess the cervix and assess for PROM, bleeding, infection, or advanced cervical dilation.
    • If the patient is , < 35 wk gestation, a Fetal Fibronectin (FFN) test should be collected prior to performing a digital exam or transvaginal ultrasound.
    • A FFN test can help predict preterm delivery if the patient has a cervical length on transvaginal ultrasound of < 30 mm.
  • Digital exam to determine cervical dilation and effacement, and fetal station.
  • LABS: CBC, Urine analysis and culture, Urine toxicology screen, Collect tests for GBS, gonorrhea, and Chlamydia, Perform a wet prep for yeast, bacterial vaginosis, and trichomonas, Fetal fibronectin, Consider PT, PTT, INR, CMP, amylase, and lipase, Amniocentesis may be performed if an intraamniotic infection is suspected.
  • IMAGING : A formal Ultrasound is indicated to determine estimated fetal weight, fetal presentation, amniotic fluid volume, placental location and appearance, and cervical length.

Treatment

  • Hydration and bed rest, Smoking cessation.
  • Deliver promptly if:  (+) Premature labor, (+) intraamniotic infection suspected or when they have cervical dilation > 5 cm, a persistently nonreassuring fetal heart rate tracing, intrauterine growth restriction, or vaginal bleeding concerning for placental abruption.
  • Unless contraindicated, begin Tocolytic therapy between 24 wk and 33 6/7 wk (β-mimetics, MgSO4, Ca2+ channel blockers, PGIs) and give Steroids to accelerate fetal lung maturation.
  • Give penicillin or ampicillin for GBS prophylaxis if preterm delivery is likely.
  • CHRONIC Rx
    • Patients with a history of prior spontaneous preterm birth may be candidates for prophylactic use of 17 alpha-hydroxyprogesterone caproate between 16 wk and 36 wk gestation.
    • Patients with a history of preterm birth and short cervix may also be candidates for prophylactic or rescue cerclage.
    • There is no evidence supporting the use of maintenance tocolytic therapy
  • REFERRAL
    • Women who present in preterm labor should be referred to an obstetrician and transferred to a facility with a neonatal intensive care unit.
    • For women who present for prenatal care with a history of preterm delivery, early referral to an obstetrician is also recommended.

Complications

  • RDS, intraventricular hemorrhage, PDA, necrotizing enterocolitis, retinopathy of prematurity, bronchopulmonary dysplasia, death.

PROM

PROM:
< 34wk:

> 34 wks:

  • Pre-Term Labor? Contractions resulting in cervical change < 37 wks
  • Steril speculum to r/o PROM (Pooling, Nitrazine, Ferning)
    • PROM
      • Spontaneous ROM 1 hr before onset of labor regardless of gest. age.
      • Labs: Cath UA w/ micro & C/S, UDS, CBC, BMP, fetal fibronectin.
      • Exam: Vaginal exam to assess cervical change, EFM.
      • Tx: EFM, Immediately deliver for fetal distress of maternal infection.
    • PPROM
      • PROM that occurs < 37 wks.
      • Labs: Cath UA w/ micro & C/S, UDS, CBC, BMP, fetal fibronectin.
      • Exam: Vaginal exam to assess cervical change, EFM.
      • Tx: GBS proph, Steroids.

Placental Abruption

Pathophysiology:
  • Premature (before onset of labor) separation of normally implanted placenta.

Risk factors:

  • Hypertension,
  • Abdominal/pelvic trauma,
  • Tobacco or cocaine use,
  • Previous abruption,
  • Rapid decompression of over-distended uterus.

Symptoms:

  • PAINFUL, dark vaginal bleeding that does not spontaneously cease. Abdominal pain, uterine hypertonicity. Fetal distress.

Diagnosis:

  • Primarily clinical.
  • Transabdominal/Transvaginal ultrasound sensitivity is only 50%; look for retroplacental clot; most useful for ruling out previa.

Management:

  • Stabilize patients with mild abruption and a premature fetus.
  • Manage expectantly (hospitalize; start IV and fetal monitoring; type and cross blood; bed rest).
  • Moderate to severe abruption: Immediate delivery (vaginal delivery with amniotomy if mother and fetus are stable; C-section for maternal or fetal distress).

Complications:

  • Hemorrhagic shock.
  • Coagulopathy: DIC in 10%.
  • Recurrence risk is 5-16% and rises to 25% after two previous abruptions.
  • Fetal hypoxia.

Appendicitis

  • MCC of acute abdomen in pregnancy.
  • S/S: Acute RLQ tenderness, N/V, Low-grade fever, leukocytosis, Anorexia.
  • Dx: Ultrasound
  • DDx: UTI, Cholecystitis, renal & uretral stones, adnexal torsion, preterm labor, & placenta abruption.
  • Tx: Surgery, Ampicillin 2 g IV q6h + metronidazole 500 mg q6h + gentamicin 2.5mg/kg iv q8h.

Gall Bladder Disease

Biliary colic
  • S/S: Acute upper epigastric cramping, N/V, usually afebrile. RUQ tenderness. Pain may be constant and resolves in several hours.

Acute Cholecystitis

  • 2nd most frequent surgical acute abdomen in pregnancy.
  • S/S: Severe RUQ or epigastric pain radiating to R-shoulder or back, anorexia, N/V, fever, (+) Murphy's sign.
  • Labs: CBC, CMP ( leukocytosis w/ bands and elevated LFT)
  • Dx: GB Ultrasound
  • DDx: Severe pre-eclampsia, pancreatitis, appendicitis, pyelonephritis, peptic ulcer, or MI.
  • Tx: NPO, 1L IV LR bolus, Stadol 1mg IV/IM, Unasym 3g IV q6h + Rocephin 1g IV q24h OR cefotaxime 2g IV q8h.    
    • Surgery (lap. Cholecystectomy in preg. is associate w/ better maternal and fetal outcomes).

Pancreatitis

  • S/S: Upper epigastric pain w/ elevated Amylase/Lipase. Can be secondary to gallstones or alcoholism.
  • Labs: CBC, CMP, Amylase, Lipase,
  • Tx: NPO.  1L IV LR bolus, then NS  + 20mEq  KCH IV 100cc/hr.  Stadol 1mg IV/IM.