Ambreen Anwer.
Abdominal Pain in Pregnancy.
J Coll Physicians Surg Pak Jan ;10(11):430-2.

Abdominal pain and surgical problems in pregnancy pose particular diagnostic and management challenges. Here is a group of three case reports highlighting this fact. First was a case of uterine rupture, treated as gastroenteritis, second, a case of subphrenic abscess, treated as a renal colic thus delaying drainage and third case was HELPP syndrome where initially abdominal pain was ignored as a significant symptom.

Case No. 1: Thirty-two years old gravida seven para one with history of five abortions (G7P1+A5) reported at 26 weeks of gestation mild bleeding per vaginum and pain in lower abdomen. She had her previous delivery by an emergency lower segment cesarean section (LSCS) at 32 weeks due to antepartum hemorrhage. Prior to that she had five midtrimester miscarriages. Ultrasound examination revealed a normally situated placenta and an active alive fetus. McDonald`s stitch was removed immediately and patient was admitted for observation. Both symptoms settled by next morning. Vital signs remained within normal limits was afebrile. A provisional diagnosis of paralytic illeus was made. On the third day of admission, she complained of abdominal pain and loose motions. Pain was dull and aching in character and diffusely distributed over whole abdomen. No positive feature was found on examination. She was prescribed antispasmodics and oral rehydration salts (ORS). By next morning there was increasing tachycardia, her blood pressure dropped to 90/50 mmHg and she started having cold sweats. Abdominal distension was now significant. Ultrasonography revealed a dead fetus in the abdominal cavity with a well retracted uterus lying by the side and free fluid in pouch of douglas as well as upper abdomen. A diagnosis of uterine rupture was made. It was the slow tearing of the uterine scar that caused her the , abdominal pain which was neglected initially and was not correlated with her previous scar, leading to this emergent situation. Emergency laparotomy revealed approximately two liters of collected blood and a uterine tear extending posteriorly on the right side tearing away the ipsilateral cardinal ligament. Total abdominal hysterectomy with bilateral ovarian conservation was performed as a life saving measure. Patient received six pints of whole blood intra-operatively.She made an uneventful recovery and was discharged on the 10th postoperative day after detailed counselling.

Case No. 2: Twenty-nine year old gravida four para three (G4P3) reported at 39 weeks of gestation with pain in the right lumber region, vomiting and low-grade fever. She gave a vague history of frequency and dysuria as well. Total leucocyte count was raised, however, ultrasonography, X-ray, KUB and urine routine examination was unremarkable. Her pain improved with analgesics and antibiotics though her malaise and general feeling of being unwell persisted. She reported an early labour after a week. Emergency lower segment cesarean section had to be performed for fetal distress. On fifth postoperative day she developed vomiting and abdominal distension. She was having tachycardia but made and she was started on conservative management. However, patient`s condition deteriorated over the next 24 hours and temperature spikes were added. Her white cell count got raised to 23000/1. X-ray plain abdomen revealed fluid level under right hemidiaphragm, atelectasis right lung and plural thickening over the right lobe. The findings raised a suspicion of right subphrenic abscess and laparotomy was planned. About 200 ml pus was drained from the hepatorenal pouch. Primary source was found to be an appendicular abscess. Appendix was located abnormally high in this case being further pushed up by the gravid uterus. Patient was discharged next week symptom free.

Case No. 3: Thirty-two years old gravida three para two (G3P2) reported at term with abdominal pain vaguely distributed in the right upper quadrant. She was not booked with us for antenatal care. She was normotensive and her urine albumin by dipstick was found positive. On examination the only positive feature was epigastric tenderness. Her Bishop score was recorded 8. The baseline investigations were within normal limits. Her abdominal pain was attributed to early labour. She delivered spontaneously next day uneventfully except the persistent vague upper abdominal pain. On her first postnatal day she reported having nausea and was passing dark coloured urine. The liver enzymes were raised three times and platelet count had dropped to 30umm. Her blood pressure was 140/90mmHg but urine albumin was very high (+4). It was only then that her initial symptom of abdominal pain was linked to the now biochemically confirmed hemolysis elevated liver enzymes and low platelets (HELLP) syndrome. She was immediately shifted to the intensive care unit. Haematologist was involved in the management and transfusion of fresh frozen plasma, platelets and packed red cells was started, calculated on the basis of her derranged coagulation profile. Regular six hourly assessment of her hepatic, renal and coagulation function was continued. Patient was shifted back to the postnatal ward on sixth postpartum day remarkably improved.

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