MCPC - Abdominal pain in later pregnancy and after childbirth

Section 2 - Symptoms

Abdominal pain in later pregnancy and after childbirth

PROBLEMS

The woman is experiencing abdominal pain after 22 weeks of pregnancy.
The woman is experiencing abdominal pain during the first 6 weeks after childbirth.

GENERAL MANAGEMENT

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. If appendicitis occurs in late pregnancy, the infection may be walled off by the gravid uterus. The size of the uterus rapidly decreases after delivery, allowing the infection to spill into the peritoneal cavity. In these cases, appendicitis presents as generalized peritonitis.

DIAGNOSIS

TABLE S-16

Diagnosis of abdominal pain in later pregnancy and after childbirth

Presenting Symptom and Other Symptoms and Signs Typically Present

Symptoms and Signs Sometimes Present

Probable Diagnosis

• Palpable contractions

• Blood-stained mucus discharge (show) or watery discharge before 37 weeks

• Cervical dilatation and effacement

• Light ^a vaginal bleeding

Possible preterm labour

^{a Light bleeding: takes longer than 5 minutes for a clean pad or cloth to be soaked.}

• Palpable contractions

• Blood-stained mucus discharge (show) or watery discharge at or after 37
weeks

• Cervical dilatation and effacement

• Light vaginal bleeding

Possible term labour

• Intermittent or constant abdominal pain

• Bleeding after 22 weeks gestation (may be retained in the uterus)

• Shock

• Tense/tender uterus

• Decreased/absent fetal movements

• Fetal distress or absent fetal heart sounds

Abruptio placentae

• Severe abdominal pain (may decrease after rupture)

• Bleeding (intra-abdominal and/or vaginal)

• Shock

• Abdominal distension/ free fluid

• Abnormal uterine contour

• Tender abdomen

• Easily palpable fetal parts

• Absent fetal movements and fetal heart sounds

• Rapid maternal pulse

Ruptured uterus

• Abdominal pain

• Foul-smelling watery vaginal discharge after 22 weeks gestation

• Fever/chills

• History of loss of fluid

• Tender uterus

• Rapid fetal heart rate

• Light vaginal bleeding

Amnionitis

• Abdominal pain

• Dysuria

• Increased frequency and urgency of urination

• Retropubic/suprapubic pain

Cystitis

• Dysuria

• Abdominal pain

• Spiking fever/chills

• Increased frequency and urgency of urination

• Retropubic/suprapubic pain

• Loin pain/tenderness

• Tenderness in rib cage

• Anorexia

• Nausea/vomiting

Acute pyelonephritis

• Lower abdominal pain

• Low-grade fever

• Rebound tenderness

• Abdominal distension

• Anorexia

• Nausea/vomiting

• Paralytic ileus

• Increased white blood cells

• No mass in lower abdomen

• Site of pain higher than expected

Appendicitis

• Lower abdominal pain

• Fever/chills

• Purulent, foul-smelling lochia

• Tender uterus

• Light vaginal bleeding

• Shock

Metritis

• Lower abdominal pain and distension

• Persistent spiking fever/ chills

• Tender uterus

• Poor response to antibiotics

• Swelling in adnexa or pouch of Douglas

• Pus obtained upon culdocentesis

Pelvic abscess

• Lower abdominal pain

• Low-grade fever/chills

• Absent bowel sounds

• Rebound tenderness

• Abdominal distension

• Anorexia

• Nausea/vomiting

• Shock

Peritonitis

• Abdominal pain

• Adnexal mass on vaginal examination

• Palpable, tender discrete mass in lower abdomen

• Light vaginal bleeding

Ovarian cyst^b

^b Ovarian cysts may be asymptomatic and are sometimes first detected on physical examination.

PRETERM LABOUR

Preterm delivery is associated with higher perinatal morbidity and mortality. Management of preterm labour consists of tocolysis (trying to stop uterine contractions) or allowing labour to progress. Maternal problems are chiefly related to interventions carried out to stop contractions (see below).

Make every effort to confirm the gestational age of the fetus.

TOCOLYSIS

This intervention aims to delay delivery until the effect of corticosteroids has been achieved (see below).

Attempt tocolysis if:

- gestation is less than 37 weeks;
- the cervix is less than 3 cm dilated;
- there is no amnionitis, pre-eclampsia or active bleeding;
- there is no fetal distress.

Confirm the diagnosis of preterm labour by documenting cervical effacement or dilatation over 2 hours.
If less than 37 weeks gestation, give corticosteroids to the mother to improve fetal lung maturity and chances of neonatal survival:

- betamethasone 12 mg IM, two doses 12 hours apart;
- OR dexamethasone 6 mg IM, four doses 6 hours apart.
Note: Do not use corticosteroids in the presence of frank infection.

Give a tocolytic drug (Table S-17) and monitor maternal and fetal condition (pulse, blood pressure, signs of respiratory distress, uterine contractions, loss of amniotic fluid or blood, fetal heart rate, fluid balance, blood glucose, etc.).

Note: Do not give tocolytic drugs for more than 48 hours.

If preterm labour continues despite use of tocolytic drugs, arrange for the baby to receive care at the most appropriate service with neonatal facilities.

Table S-17

Tocolytic drugs^a to stop uterine contractions

Drug

Initial Dose

Subsequent Dose

Side Effects and Precautions

Salbutamol

10 mg in 1 L IV fluids. Start IV infusion at 10 drops per minute.

If contractions persist, increase infusion rate by 10 drops per minute every 30 minutes until contractions stop or maternal pulse rate exceeds 120 per minute

If contractions stop, maintain the same infusion rate for at least 12 hours after the last contraction.

If maternal heart rate increases (more than 120 per minute), reduce infusion rate; If the woman is anaemic, use with caution.

If steroids and salbutamol are used, maternal pulmonary oedema may occur. Restrict fluids, maintain fluid balance and stop drug.

Indomethacin

100 mg loading dose by mouth or rectum

25 mg every 6 hours for 48 hours

If gestation is more than 32 weeks, avoid use to prevent

premature closure of fetal ductus arteriosus. Do not use for more than 48 hours.

^a Alternative drugs include terbutaline, nifedipine and ritodrine.

ALLOWING LABOUR TO PROGRESS

Allow labour to progress if:

- gestation is more than 37 weeks;
- the cervix is more than 3 cm dilated;
- there is active bleeding;
- the fetus is distressed, dead or has an anomaly incompatible with survival;
- there is amnionitis or pre-eclampsia.