What is the best course of action for an 8-month pregnant woman with a breech presentation and severe abdominal pain?

Immediate Obstetric Emergency Requiring Urgent Evaluation and Likely Cesarean Delivery

An 8-month pregnant woman with breech presentation and severe abdominal pain requires immediate assessment for life-threatening complications including placental abruption, uterine rupture, and internal herniation (if post-bariatric surgery), with urgent obstetric ultrasound and preparation for emergency cesarean delivery if indicated.

Critical Initial Assessment

Immediate Priorities

• Check hemodynamic stability immediately by assessing vital signs, as tachycardia, hypotension, and tachypnea signal serious maternal-fetal compromise 1, 2
• Perform continuous fetal heart rate monitoring to detect fetal distress, which may indicate placental abruption or uterine rupture 1
• Assess for peritoneal signs (guarding, rigidity, rebound tenderness) which suggest surgical emergency 1, 2
• Evaluate for vaginal bleeding, a key indicator of placental abruption or other obstetric hemorrhage 1, 2
• Establish IV access immediately if any signs of instability are present 3

Essential Laboratory Studies

• Complete blood count to assess for anemia from concealed hemorrhage 1
• Coagulation profile to evaluate for disseminated intravascular coagulation 1
• Blood type and Rh status for potential transfusion needs 1, 3

Life-Threatening Obstetric Diagnoses to Rule Out

Placental Abruption

• This is the most critical diagnosis in third-trimester severe abdominal pain, presenting with pain, vaginal bleeding, and uterine tenderness 1
• Ultrasound sensitivity is only 40-50%, meaning normal imaging does NOT exclude this diagnosis 1
• Clinical diagnosis based on pain severity, uterine tenderness, and fetal distress often supersedes imaging 1

Uterine Rupture

• Extremely high risk given breech presentation and severe pain, particularly if prior cesarean section history 1, 4
• Presents with severe abdominal pain, abdominal wall retraction during contractions, loss of fetal station, and maternal shock 4
• Requires immediate surgical intervention to prevent maternal and fetal death 1

Abdominal Pregnancy (Rare but Possible)

• Should be considered with breech presentation, severe abdominal pain, and oligohydramnios 5
• Diagnosis often made intraoperatively but can be life-threatening 5

Non-Obstetric Surgical Emergencies

Internal Herniation (Post-Bariatric Surgery Patients)

• All maternal and perinatal deaths occurred when treatment was delayed beyond 48 hours after symptom onset 6
• Presents with abdominal pain, nausea, and vomiting in third trimester 6
• Maternal mortality 9% and fetal mortality 13.6% in case series 6
• Requires immediate surgical consultation without delay 6

Appendicitis

• Most common cause of non-obstetric abdominal pain requiring emergency surgery in pregnancy 6, 1, 2, 3
• Presents atypically due to anatomical displacement by gravid uterus 1
• MRI has 97% sensitivity and 95% specificity for diagnosis 1, 2

Imaging Algorithm

First-Line: Obstetric Ultrasound

• Perform transvaginal and transabdominal ultrasound immediately to assess fetal viability, placental location, amniotic fluid, and fetal anatomy 1, 2, 3
• Evaluate for free fluid in abdomen suggesting hemorrhage or rupture 1
• Remember ultrasound has poor sensitivity for placental abruption, so clinical suspicion overrides negative imaging 1

Second-Line: MRI Without Contrast

• Use MRI if ultrasound is inconclusive and non-obstetric surgical pathology is suspected 6, 2, 3
• Provides excellent soft tissue detail without radiation exposure 2
• Particularly useful for appendicitis, bowel obstruction, or internal herniation 6, 1

Third-Line: CT with IV Contrast (Life-Threatening Situations Only)

• Reserve for situations requiring timely intervention when diagnosis cannot be made by ultrasound or MRI 6, 1, 2
• In 36% of pregnant patients with severe abdominal pain, CT showed findings explaining pain, with appendicitis being most common 6
• Benefits outweigh radiation risks when maternal or fetal life is threatened 6, 1, 2

Management Strategy

If Obstetric Emergency Confirmed

• Proceed immediately to emergency cesarean delivery for placental abruption with fetal distress or uterine rupture 1, 4
• Breech presentation is NOT a contraindication to emergency delivery—maternal and fetal survival is the priority 7
• Do not attempt external cephalic version in the setting of severe abdominal pain, as this could worsen underlying pathology 7

If Surgical Non-Obstetric Pathology

• Do not delay surgical intervention when appendicitis, internal herniation, or bowel obstruction is diagnosed 6, 2, 3
• Laparoscopic surgery is safe in third trimester when feasible 2
• Position patient in left lateral tilt during procedures to avoid aortic/IVC compression by gravid uterus 2, 3

If Diagnosis Remains Unclear After Initial Workup

• Admit for continuous monitoring with serial abdominal exams and fetal heart rate monitoring 8
• Obtain multidisciplinary consultation involving obstetrics, general surgery, and maternal-fetal medicine 8
• Reassess within 24-48 hours with repeat imaging if symptoms persist or worsen 3

Critical Pitfalls to Avoid

• Never attribute severe abdominal pain to "normal pregnancy changes" without excluding serious pathology first 2
• Do not delay imaging or surgical consultation due to concerns about radiation—maternal and fetal outcomes worsen with delayed treatment 6, 2
• Do not assume breech presentation alone explains the pain—it may be coincidental to a more serious underlying condition 5, 9
• Do not rely solely on ultrasound to exclude placental abruption—clinical judgment supersedes negative imaging 1