Masteralexis, JD, Department Head and Associate Professor, Mark H. McCormack Department of Sport Management, Isenberg School of Management, University of Massachusetts, Amherst. Presentation on theme: 'Abdominal Pain During Pregnancy Dr Muhammad El Hennawy Ob/gyn specialist 59 Street - Rass el barr – dumyat - egypt www.geocities.com/mmhennawy www.geocities.com/abc New Reports Alert Subscribe to any of nearly 200 specialized email or text alerts from WSDOT, including those covering research. Under Transportation Research, choose from a list of categories (or select all) and you'll be. View a directory of 10,288 public schools in California (CA), serving 6,215,029 students. Find school information, reviews and news. STUDENTS, please ask a teacher to update your password. Students passwords cannot be updated or reset via email, only teacher accounts.
Abdominal Pain During Pregnancy Dr Muhammad El Hennawy Ob/gyn specialist 5. Street - Rass el barr – dumyat - egypt www. There are three basic types of pain – Visceral, Somatic and referred. At the front and sides is the abdominal wall, of skin, fat and muscle, at the back, the spine (vertebral column) .
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It is completely filled with the abdominal organs: These are all covered by a thin membrane, continuous with that which also lines the inside of the abdominal wall (peritoneum). The abdominal cavity and its peritoneal lining are continuous below with those of the pelvis. If there is any doubt then immediate referral is required. Even if immediate referral is clearly not required, ensure the mother understands that she should seek further help if there is any deterioration, change or persistence of symptoms, or if there is any indication of fetal distress (reduced fetal movements). The underlying inflammation has no direct contact with the parietal peritoneum, which precludes any muscular response or guarding that would otherwise be expected The uterus can also obstruct and inhibit the movement of the omentum to an area of inflammation, distorting the clinical picture.
To help distinguish extrauterine tenderness from uterine tenderness, performing the examination with the patient in the right or left decubitus position, thus displacing the gravid uterus to one side, may prove helpful. When performing a physical examination of the gravid abdomen, it is essential to recall the changing positions of the intra- abdominal contents at different gestational ages.
For example, the appendix is located at the Mc. Burney point in patients in early pregnancy and in nonpregnant patients. After the first trimester, the appendix is progressively displaced upward and laterally, until it is closer to the gallbladder in late pregnancy Such alterations in physical assessment can delay diagnosis, and many authorities attribute the increased morbidity and mortality of acute abdomen in gravid patients to this delay. When evaluating the gravid patient, the clinician must evaluate 2 patients at the same time, the mother and the fetus. Before the gestational age at which independent viability (if delivery were to occur) is generally expected evaluation of the fetus can be limited to documentation of the presence or absence of fetal heart tones by Doppler or ultrasound. When the fetus is considered viable, a more thorough evaluation is required. The age of viability varies from institution to institution.
Monitor the fetal heart rate and uterine tone continuously throughout the period of evaluation. A nonreassuring tracing or evidence of fetal distress may suggest an obstetric etiology for the acute abdomen (eg, placental abruption, uterine rupture). A reassuring tracing allows the evaluation to continue at an appropriate pace. Monitoring for uterine contractions throughout the evaluation period and even after definitive treatment is important.
A strong correlation is observed between intra- abdominal infectious or inflammatory processes and preterm labor and delivery. These changes can make the initial evaluation process somewhat more difficult. Fetal monitoring Urinanalysis, MSU: infection, proteinuria in pre- eclampsia Full blood count: raised white cell count suggestive of infection, although the white cell count is normally slighty raised in pregnancy Liver function tests Ultrasound: may demonstrate ectopic pregnancy, abruption, miscarriage Magnetic resonance imaging : The intrinsic safety of MRI and its ability to accurately show abdominal and pelvic disease in pregnant patients make it highly useful in the evaluation of these patients. Laparoscopy to confirm ectopic pregnancy - Laparoscopy has become increasingly popular in the treatment and evaluation of acute abdomen. In the past, pregnancy was considered a contraindication for laparoscopy, Care must be taken to minimize manipulation of the uterus. Adjust the location of trocar placement based on uterine size.
Monitor fetal heart tones during the surgical procedure 1. Management of abdominal pain in pregnancy A thorough assessment of the wellbeing of the mother and fetus, as well as the possible underlying cause is required. Treatment of cause; urgent hospital referral if uncertain cause, and/or maternal or fetal distress. If surgery is required but is considered elective, waiting until after the pregnancy is completed is prudent.
If surgery is deemed necessary during pregnancy, perform it in the second trimester if possible; the risk of preterm labor and delivery is lower in the second trimester compared to the third, and the risk of spontaneous loss and risks due to medications such as anesthetic agents are lower in the second trimester compared to the first. A pregnancy in a woman with an intra- abdominal inflammatory disease will not be harmed by proper surgical treatment. The fetus is more likely to be damaged if the proper operation is delayed.
Laparotomy (or perhaps laparoscopy but not in late pregnancy) is indicated if the diagnosis is in doubt or if there is shock. If continuation of the pregnancy is expected to lead to maternal morbidity or mortality, delivery is indicated. If improvement of the maternal condition cannot be expected with delivery, treat the patient with the fetus in utero The prophylactic effect of tocolytics remains unproven in these patients. If used, tocolytics should be administered with care If preterm delivery is likely, glucocorticoids can be administered to the mother to decrease the risk of neonatal complications. Avoid glucocorticoids if the mother is at serious risk for significant infection 1.
Braxton Hicks contractions They are sporadic uterine contractions that actually start at about 6 weeks, although women won't be able to feel them that early. They get their name from John Braxton Hicks, an English doctor who first described them in 1. As pregnancy progresses, Braxton Hicks contractions tend to come somewhat more often, but they remain infrequent, irregular, and essentially painless.
Sometimes, though, Braxton Hicks are hard to distinguish from early signs of preterm labor By the time within weeks of labor, these contractions may get more intense and more frequent, and cause some discomfort. Unlike the earlier painless and sporadic Braxton Hicks contractions that caused no obvious cervical change, these may help cervix . Respond to anlgesics Cause women confusion as to whether or not they were going into actual labor.
They are thought to be part of the process of effacement, the thinning and dilation of the cervix 1. Labour (term or preterm) The evaluation of all pregnant women with abdominal discomfort must always include uterine contractions as an etiology. Pain from labor is generally intermittent, occurring at decreasing intervals. However, tetanic uterine contractions, often evidence of uterine irritability, may produce sustained pain. An accurate estimation of gestational age is crucial to distinguish the normal labor anticipated in a term pregnancy from preterm labor.
Preterm contractions are contractions that are painful and occur by definition before 3. When contractions are suspected as a cause of abdominal pain, a cervical examination should be performed to evaluate the cervix for dilation, effacement, and if possible the station of the presenting part. A digital cervical examination should not be performed in the face of vaginal bleeding if placenta previa has not been ruled out Patients who are at less than 3. While the majority of preterm labor is idiopathic, the clinician should remember that there are many conditions that may cause preterm uterine contractions and preterm labor, including placental abruption, chorioamnionitis, trauma, appendicitis, and pyelonephritis or other infection.
Rapid evaluation is essential as tocolysis or other obstetric interventions may be indicated depending on gestational age 1. Round Ligament Pain with advancing gestational age as the uterine size increases. The round ligaments, found on the right and left sides of the uterus, attach to the pubic bone and help support the placement of the uterus in the abdominal cavity.
Pain, either a sharp spasm or dull ache continuous, and may be described as a stretching or pulling sensation, is felt on one, or sometimes both, sides of the lower abdomen, often described as . This pain may be relieved by heat or acetaminophen, It is a benign and usually self- limiting occurrence that commonly causes discomfort in the second trimester 1. The most common complication is the syndrome of . Red Degeneration Of A Uterine Myoma (syndrome of painful myoma ) 1.
Uterine Tortion The uterus rotates axially 3. Rarely, it rotates > 9. Fibroids, adnexal masses, or congenital asymmetrical uterine anomalies are present in 9. Diagnosis is usually at laparotomy. Delivery is by caesarean section 1. Pressure symptoms Upper abdominal pressure - -- pain due to flaring of the ribs particularly in breech presentation - The ribcage expands enormously during pregnancy to help make room for the expanding uterus and to maintain adequate lung capacity.
Many pregnant women experience rib discomfort from this expansion, as well as the occasional little foot or knee of fetus that might habitually press against the ribs. Mid abdominal pressure - -- distension of the abdominal wall ( Twins, polyhydramnios ) Lower abdominal pressure - -engagement of the head 1. Liver congestion e. Rupture usually occurs close to term or immediately postpartum. Right upper quadrant pain and tendernes, hemorrhagic shock,distended abdomen Rupture of the liver capsule is thought to result from subcapsular bleeding and can be confirmed by sonography Correct any associated coagulopathy with recombinant factor VIIa.
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