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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 


Section 2 - Symptoms

Abdominal in early pregnancy


  • 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.


  • 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).


Table S-15 

Diagnosis of abdominal pain in early pregnancy

Presenting Symptom and Other Symptoms and Signs Typically

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


• Dysuria

• Increased frequency and urgency of urination

• Abdominal pain

• Retropubic/suprapubic pain


• 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


• Abdominal pain

• Light bleeding

• Closed cervix

• Uterus slightly larger than normal

• Uterus softer than normal

• Fainting 

• Tender adnexal mass

• Amenorrhoea

• Cervical motion tenderness



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.




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.


- 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.

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).

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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support


General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages



Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems


Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia


External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section


Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy


Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy



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