Abdominal pain complicated 3 rd trimester pregnancy AUTHOR DR. PAULIN NG REVISED BY DR. WONG HO TUNG OCT, 2013 HKCEM College Tutorial

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

What are the DDx?

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

Now, a focused physical exam ▪ Abdomen ▪ Uterus-fetus ▪ Review of systems

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

What investigations would you like to request? ▪ Blood ▪ Urine ▪ Ultrasound

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

Thank You