What is the treatment for abdominal pain in a pregnant female?

Treatment of Abdominal Pain in Pregnancy

The treatment of abdominal pain in pregnancy depends entirely on identifying the underlying cause through systematic evaluation, with ultrasound as the first-line imaging modality followed by MRI if needed, and management ranging from conservative measures for benign causes to urgent surgical intervention for life-threatening conditions. 1

Initial Diagnostic Approach

Immediate Assessment Priorities

• Check vital signs immediately - tachycardia, hypotension, and tachypnea signal serious maternal-fetal compromise requiring urgent intervention 1, 2
• Perform continuous fetal heart rate monitoring to detect fetal distress, which may indicate placental abruption or uterine rupture 2
• Assess for peritoneal signs (guarding, rigidity, rebound tenderness) as these suggest surgical emergency 2
• Evaluate for vaginal bleeding, a key indicator of placental abruption or other obstetric hemorrhage 2
• Obtain β-hCG measurement in early pregnancy to narrow differential diagnosis and guide imaging decisions 3

Essential Laboratory Studies

• Complete blood count, coagulation profile, and urinalysis are essential initial tests 1, 4
• Establish IV access immediately if any signs of instability are present 2

Imaging Strategy

First-Line: Ultrasound

• Ultrasound is the primary imaging modality for all pregnant patients with abdominal pain - it avoids radiation exposure and can evaluate both obstetric and non-obstetric causes 3, 1
• Transvaginal or transabdominal pelvic ultrasound is recommended when gynecologic etiology is suspected or β-hCG is positive 3
• Critical limitation: Ultrasound sensitivity for placental abruption is only 40-50%, meaning normal imaging does not exclude this diagnosis 4, 2

Second-Line: MRI Without Contrast

• MRI should be the next step after inconclusive ultrasound - it provides excellent soft tissue detail without radiation exposure 3, 1
• MRI has 97% sensitivity and 95% specificity for diagnosing appendicitis in pregnancy 3, 4, 2
• MRI is useful for evaluating gastrointestinal, hepatobiliary, genitourinary, vascular, and gynecologic causes of pain 5

Last Resort: CT With IV Contrast

• Reserve CT for life-threatening situations only when diagnosis cannot be made by ultrasound or MRI and immediate intervention is needed 1, 2
• A single-acquisition CT of abdomen/pelvis delivers <25 mGy, which poses minimal fetal risk 1
• Do not delay CT when maternal or fetal life is threatened - benefits outweigh radiation risks in emergencies 2

Treatment Based on Etiology

Life-Threatening Obstetric Emergencies

Placental Abruption

• Emergency cesarean delivery is required immediately for placental abruption with fetal distress 2
• Clinical diagnosis based on severe pain, uterine tenderness, and fetal distress often supersedes imaging 2

Ectopic Pregnancy

• Ectopic pregnancy is a critical diagnosis in early pregnancy with abdominal pain, especially with vaginal bleeding 1
• Requires immediate surgical or medical management based on hemodynamic stability 1

Non-Obstetric Surgical Emergencies

Appendicitis

• Appendicitis is the most common cause of abdominal pain requiring emergency surgery in pregnancy 1, 4, 2
• Do not delay surgical intervention - maternal and fetal outcomes worsen with delayed treatment 1, 2
• Laparoscopic surgery is safe in the second and third trimester and preferred over open surgery when feasible 1, 2
• Position patient in left lateral tilt during procedures to avoid aortic/IVC compression by the gravid uterus 1, 2

Post-Bariatric Surgery Complications

• Internal herniation requires immediate surgical consultation without delay - maternal mortality is 9% and fetal mortality is 13.6% when treatment is delayed beyond 48 hours 1, 2

Other Surgical Conditions

• Ovarian torsion, cholecystitis, and bowel obstruction require surgical intervention when diagnosed 1, 2
• Urgent surgery to manage complications should not be delayed solely due to pregnancy 3

Medical Management of Specific Conditions

Inflammatory Bowel Disease (IBD)

• Continue 5-ASA therapy throughout pregnancy for patients on maintenance therapy 3
• Continue thiopurine therapy throughout pregnancy for patients on maintenance therapy 3
• Continue anti-TNF therapy for patients on maintenance therapy 3
• For mild to moderate UC flare, optimize combination 5-ASA oral and rectal therapy 3
• For disease flare on optimal 5-ASA or thiopurine therapy, treat with systemic corticosteroids or anti-TNF therapy 3
• For corticosteroid-resistant flare, start anti-TNF therapy 3
• For perianal sepsis in Crohn's disease, use metronidazole and/or ciprofloxacin 3
• Provide anticoagulant thromboprophylaxis during hospitalization 3

Urinary Tract Infections and Urolithiasis

• These are common causes requiring antibiotic therapy and supportive care 1, 4

Conservative Management for Benign Causes

Physiological Pain

• Uterine stretching, ligament pain, and gastrointestinal changes are common benign causes 1
• Constipation-related pain can be managed with magnesium hydroxide after consulting a healthcare provider 6
• Acetaminophen can be used for pain relief after consulting a healthcare professional 7

Critical Pitfalls to Avoid

• Never attribute severe abdominal pain to "normal pregnancy changes" without excluding serious pathology first 1, 2
• Do not delay imaging or surgical consultation due to radiation concerns - maternal and fetal outcomes worsen with delayed treatment 2
• Clinical judgment should supersede negative imaging when excluding placental abruption - ultrasound misses 50-60% of cases 2
• Pain location may not follow typical patterns due to anatomical changes of pregnancy 1

Multidisciplinary Consultation Requirements

• Consult with obstetrician, preferably one affiliated with high-risk obstetrics program, for active or complicated conditions 3
• Transfer to tertiary center with access to gastroenterologist and high-risk obstetrician if hospitalization is required 3
• Immediate surgical consultation for patients with fever and peritoneal signs 1