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Baby Belly Aches: 7 Causes of Abdominal Pain in Pregnancy
Mark P. Brady, PA-C; Nicole Cimino-Fiallos, MD; Tejusve Rao, DO | June 17, 2021
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Ultrasonogram depicting appendicitis courtesy of Radiopaedia | Dr Chris O'Donnell.
Baby Belly Aches: 7 Causes of Abdominal Pain in Pregnancy
Mark P. Brady, PA-C; Nicole Cimino-Fiallos, MD; Tejusve Rao, DO | June 17, 2021 | Contributor Information
Appendicitis
Appendicitis develops in pregnant women with the same frequency as in nonpregnant women of the same age. It is the most common nonobstetric cause of an acute surgical abdomen in the pregnant patient. The anatomic position of the appendix changes during pregnancy, as does the localization of the abdominal pain, which can delay diagnosis.
Appendicitis is a surgical emergency; if undiagnosed, it can be fatal. Ruptured appendicitis is also associated with a 30% chance of fetal loss, versus a 3-5% risk without rupture.[1] Right lower quadrant pain is the most common presenting complaint of appendicitis during pregnancy.
Baby Belly Aches: 7 Causes of Abdominal Pain in Pregnancy
Mark P. Brady, PA-C; Nicole Cimino-Fiallos, MD; Tejusve Rao, DO | June 17, 2021 | Contributor Information
HELLP Syndrome
HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome can cause abdominal pain. Common symptoms include nausea, vomiting, and right upper quadrant abdominal pain. If the illness has progressed, the patient's mental status may be altered. Patients with this syndrome have high blood pressure and tenderness to palpation of the right upper abdominal quadrant.
Blood work demonstrates a high alanine transaminase/aspartate transaminase ratio, a low platelet count, and evidence of hemolysis (shown). Resuscitation with blood pressure control, seizure prevention, and correction of any coagulopathy is critical while preparing for cesarean section. If untreated, HELLP syndrome can progress to hepatic infarction and/or rupture.[2]
Image courtesy of Radiopaedia | Dr David Cuete.
Baby Belly Aches: 7 Causes of Abdominal Pain in Pregnancy
Mark P. Brady, PA-C; Nicole Cimino-Fiallos, MD; Tejusve Rao, DO | June 17, 2021 | Contributor Information
This ultrasonogram displays a large gallstone within the gallbladder.
Cholelithiasis
Women have twice the risk that men do for developing cholelithiasis. Hormonal changes during pregnancy increase the risk, as they cause decreased gallbladder contraction and bile stasis.[3,4]
Cholelithiasis is one of the most common abnormalities found on bedside ultrasonography, with ultrasonographic examination having a sensitivity of 95% in the diagnosis of gallstones. Symptomatic patients often experience biliary colic (ie, intermittent right upper quadrant abdominal pain with associated nausea and vomiting). Depending on symptoms and risk factors, patients may be monitored or undergo cholecystectomy.
Image courtesy of Radiopaedia | Dr Bruno Di Muzio.
Baby Belly Aches: 7 Causes of Abdominal Pain in Pregnancy
Mark P. Brady, PA-C; Nicole Cimino-Fiallos, MD; Tejusve Rao, DO | June 17, 2021 | Contributor Information
This computed tomography (CT) scan reveals a distended gallbladder (arrow) in a patient with acute cholecystitis.
Acute Cholecystitis
Acute cholecystitis is a sudden inflammation of the gallbladder that causes severe abdominal pain that is often associated with nausea and vomiting. In 90% of cases, acute cholecystitis results from gallstones.[4]
Management in pregnancy is initially conservative and includes antibiotic therapy. Surgical therapy, when indicated, should not be delayed; a planned intervention during the second trimester appears to offer a better outcome than surgery performed under emergent conditions. Pregnant patients who present with signs of sepsis, ileus, or perforation require emergent surgical intervention. Early intervention can reduce the rate of preterm delivery and life-threatening complications.
Image from Wikimedia Commons | BruceBlaus. [Creative Commons Attribution-Share Alike 4.0 International license (CC by-SA 4.0.]
Baby Belly Aches: 7 Causes of Abdominal Pain in Pregnancy
Mark P. Brady, PA-C; Nicole Cimino-Fiallos, MD; Tejusve Rao, DO | June 17, 2021 | Contributor Information
Urinary Tract Infections
Urinary tract infections such as symptomatic and asymptomatic bacteriuria are more common during pregnancy. Suprapubic abdominal pain with dysuria, urgency, and frequency often occurs. Untreated bacteriuria in pregnancy can lead to pyelonephritis, which is the leading cause of septic shock in pregnancy.[5]
Image from Wikimedia Commons | Mihajlo Andjelkovic [CC by-SA 3.0].
Baby Belly Aches: 7 Causes of Abdominal Pain in Pregnancy
Mark P. Brady, PA-C; Nicole Cimino-Fiallos, MD; Tejusve Rao, DO | June 17, 2021 | Contributor Information
Urolithiasis
Another urinary tract–related disorder, urolithiasis (in which urinary tract calculi form [shown]), is a relatively common cause of hospitalization for nonobstetric abdominal pain in pregnant women. Pregnancy-associated factors such as reduced ureteral peristalsis and physiologic hydronephrosis increase the risk of urolithiasis.[6]
First-line imaging for patients presenting with renal colic is renal and bladder ultrasonography. Initial care should include provision of adequate pain control and avoidance of dehydration. Active surgical treatment with a multidisciplinary team is required in the setting of signs of intractable pain, persistent vomiting, fever, obstetric complications, unilateral kidney, large ureteral stones, and worsening clinical condition.[7]
Image from Wikimedia Commons | Haitham Alfalah. [CC by-SA 3.0.]
Baby Belly Aches: 7 Causes of Abdominal Pain in Pregnancy
Mark P. Brady, PA-C; Nicole Cimino-Fiallos, MD; Tejusve Rao, DO | June 17, 2021 | Contributor Information
The above image shows a small-bowel obstruction with compromised blood flow, resulting in a color change.
Small-Bowel Obstruction
Small-bowel obstructions, including intussusception, are among the leading nonobstetric causes of abdominal pain in pregnant patients. Many different causes of small-bowel obstruction have been identified. For example, the increased popularity of Roux-en-Y gastric bypass surgery has contributed to the increased incidence of intestinal blockages. However, up to 20% of obstructions are idiopathic.
Practitioners must have a high level of suspicion for small-bowel obstruction and should not hesitate to obtain imaging if there is any concern for bowel ischemia. The vomiting associated with a small-bowel obstruction is sometimes mistaken for hyperemesis gravidarum.[8]
Data from McCollough CH, Schueler BA, Atwell TD, et al. Radiographics. 2007;27(4):909-17. PMID: 17620458.
Baby Belly Aches: 7 Causes of Abdominal Pain in Pregnancy
Mark P. Brady, PA-C; Nicole Cimino-Fiallos, MD; Tejusve Rao, DO | June 17, 2021 | Contributor Information
Imaging Modalities
Ultrasonography and magnetic resonance imaging
Ultrasonography is the most frequently used radiologic modality for evaluating the pregnant abdomen. Extensive evidence documents the safety of ultrasonography in pregnancy; however, it should be used only to answer clinically relevant questions. The maternal gallbladder, pancreas, and kidneys can be evaluated easily. Ultrasonography is also used with graded compression as a diagnostic aid for appendicitis.
Because magnetic resonance imaging (MRI) avoids exposure to ionizing radiation, it is the preferred second-line diagnostic modality when ultrasonography is inconclusive.[9] Gadolinium should not be used with MRI during pregnancy, as this contrast agent has been shown to cross the placental barrier and is thought to be teratogenic.[10]
Image from Wikimedia Commons | Mikael Häggström, MD. [Creative Commons CC0 1.0 Universal Public Domain Dedication (CC0 1.0).]
Baby Belly Aches: 7 Causes of Abdominal Pain in Pregnancy
Mark P. Brady, PA-C; Nicole Cimino-Fiallos, MD; Tejusve Rao, DO | June 17, 2021 | Contributor Information
This CT scan shows a pregnancy at 37 weeks' gestational age.
Computed tomography in pregnancy
The use of ionizing radiation in the pregnant patient with abdominal pain is a source of anxiety for patients and their physicians, but limited radiation exposure does not result in harmful fetal effects. If multiple diagnostic procedures are needed, remember that exposure to less than 50 mGy of radiation has not been associated with an increase in fetal anomalies or pregnancy loss.
During pregnancy, it is important to perform medically indicated diagnostic radiographic procedures when needed, but consider other imaging modalities when possible. Many adverse effects have been reported from diagnostic delays resulting from physician hesitation, secondary to concerns about radiation, to order the appropriate tests.[11,12]
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Contributor Information
Authors
Mark P Brady, PA-C
Adjunct Faculty and Preceptor
Physician Assistant Program
University of New England;
Physician Assistant
Department of Emergency Medicine
Cambridge Hospital, Cambridge Health Alliance
Cambridge, MA
Disclosure: Mark P Brady, PA-C, has disclosed no relevant financial relationships.
Nicole Cimino-Fiallos, MD
Emergency Medicine
Meritus Medical Center;
Assistant Medical Director
US Acute Care Solutions
Hagerstown, MD
Disclosure: Nicole Cimino-Fiallos, MD, has disclosed no relevant financial relationships.
Tejusve Rao, DO
Emergency Medicine Physician
University of Maryland Capital Region Health
Cheverly, MD
Disclosure: Tejusve Rao, DO, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
Associate Professor
Department of Diagnostic Radiology
Duke University Medical Center
Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
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References
Tase A, Kamarizan MFA, Swarnkar K. Appendicitis in pregnancy: difficulties in diagnosis and management. Guidance for the emergency general surgeon: a systematic review. Int J Surg Open. 2017;6:5-11.
Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A review. BMC Pregnancy Childbirth. 2009 Feb 26;9:8. PMID: 19245695
Pedro RN, Das K, Buchholz N. Urolithiasis in pregnancy. Int J Surg. 2016 Dec;36(pt D):688-92. PMID: 27816709
Vaynshtein J, Guetta O, Replyansky I. Abdominal pain in pregnancy. JAMA Surg. 2019 Feb 1;154(2):176-7. PMID: 30383119
Bouyou J, Gaujoux S, Marcellin L, et al. Abdominal emergencies during pregnancy. J Visc Surg. 2015 Dec;152(6 suppl):S105-15. PMID: 26527261
Ali A, Beckett K, Flink C. Emergent MRI for acute abdominal pain in pregnancy—review of common pathology and imaging appearance. Emerg Radiol. 2020 Apr;27(2):205-14. PMID: 31902010
Bailey AA, Twickler DM, Rofsky NM, Pedrosa I. MR imaging of abdominal and pelvic pain in pregnancy. Appl Radiol. 2012 Aug 28;42(9):16-24.
Diegelmann L. Nonobstetric abdominal pain and surgical emergencies in pregnancy. Emerg Med Clin North Am. 2012 Nov;30(4):885-901. PMID: 23137401
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