Management of Severe Abdominal Pain at 32 Weeks Gestation Without Vaginal Bleeding
This is an obstetric emergency requiring immediate hemodynamic assessment, continuous fetal monitoring, and urgent evaluation for life-threatening conditions including placental abruption, uterine rupture, and surgical emergencies—with preparation for emergency cesarean delivery if maternal or fetal compromise is detected. 1
Immediate Critical Assessment (First 5-10 Minutes)
Check vital signs immediately to detect tachycardia, hypotension, or tachypnea, which signal serious maternal-fetal compromise requiring emergency intervention. 1
Initiate continuous fetal heart rate monitoring to detect fetal distress, which may indicate placental abruption or uterine rupture even without visible vaginal bleeding. 1
Establish large-bore IV access if any signs of instability are present, as this patient may require emergency surgery or resuscitation. 1
Assess for peritoneal signs including guarding, rigidity, and rebound tenderness—these indicate a surgical emergency requiring immediate intervention. 1
Specifically ask about pain exacerbated by fetal movement, as this is a characteristic early sign of uterine rupture. 2
Life-Threatening Obstetric Diagnoses to Rule Out First
Placental Abruption
Placental abruption is the most critical diagnosis in third-trimester severe abdominal pain and can present WITHOUT vaginal bleeding in 20% of cases. 1 The absence of bleeding does not exclude this diagnosis.
- Look for severe, constant abdominal pain, uterine tenderness, and a firm or "woody" uterus on palpation. 1
- Ultrasound has only 40-50% sensitivity for placental abruption, meaning normal imaging does NOT exclude this diagnosis. 1
- Clinical diagnosis based on pain severity, uterine tenderness, and fetal distress supersedes imaging findings. 1
- If clinical suspicion is high with fetal distress, proceed directly to emergency cesarean delivery. 1
Uterine Rupture
Uterine rupture must be considered in any patient with prior cesarean delivery or uterine surgery presenting with severe abdominal pain. 3, 4
- Severe pain exacerbated by fetal movement is a characteristic early sign of uterine rupture. 2
- Uterine rupture can occur in unscarred uteri, particularly with uterine torsion causing abruption. 4
- A 180-degree uterine torsion has been reported at 32 weeks presenting as severe abdominal pain with mild vaginal bleeding and placental abruption. 4
- Emergency cesarean section is required immediately if uterine rupture is suspected. 3, 4
Immediate Imaging Protocol
Perform obstetric ultrasound immediately to assess fetal viability, placental location, amniotic fluid volume, and look for signs of abruption (though negative ultrasound does not exclude it). 1, 5
If ultrasound is inconclusive and non-obstetric surgical pathology is suspected, proceed to MRI without contrast rather than delaying diagnosis. 1, 6
- MRI has 97% sensitivity and 95% specificity for diagnosing appendicitis in pregnancy. 7
- MRI was successful in assigning the correct diagnosis in 83.3% of pregnant patients with acute abdomen, compared to only 55% for ultrasound. 6
CT with IV contrast should be used if diagnosis cannot be made by ultrasound or MRI and maternal or fetal life is threatened, as benefits outweigh radiation risks in life-threatening situations. 1
Non-Obstetric Surgical Emergencies to Consider
Appendicitis
Appendicitis is the most common non-obstetric cause of acute abdomen requiring emergency surgery in pregnancy, presenting atypically due to anatomical displacement by the gravid uterus. 7, 1, 6
- Appendicitis and adhesive small bowel obstruction were the most common etiologies in pregnant patients requiring emergency surgery (30% and 15%, respectively). 6
- Do not delay surgical consultation if appendicitis is suspected, as laparoscopic surgery is safe in the third trimester. 7, 1
Internal Herniation and Bowel Obstruction
In patients with prior bariatric surgery, internal herniation requires immediate surgical consultation without delay, with maternal mortality of 9% and fetal mortality of 13.6%. 1
Adhesive small bowel obstruction should be kept in mind as an important etiology in patients with prior abdominal surgery. 6
Management Algorithm
If Obstetric Emergency Confirmed:
Proceed immediately to emergency cesarean delivery for placental abruption with fetal distress or suspected uterine rupture. 1, 3, 4
Position patient in left lateral tilt during procedures to avoid aortic/IVC compression by the gravid uterus. 1
If Surgical Non-Obstetric Pathology Diagnosed:
Do not delay surgical intervention—laparoscopic surgery is safe in the third trimester when feasible. 7, 1
Same-admission cholecystectomy or appendectomy reduces readmission rates and does not increase risk of premature delivery or abortion. 7
Elective surgery should ideally be performed in the second trimester, but emergency surgery should not be delayed regardless of gestational age. 7
If Initial Workup Is Reassuring:
This scenario is LESS likely given "severe pain," but if hemodynamics are stable, fetal monitoring is reassuring, and no peritoneal signs are present:
- Admit for continuous monitoring rather than discharge. 8, 9
- Repeat ultrasound within 24 hours to reassess. 8
- Maintain high suspicion and low threshold for intervention. 9
Critical Pitfalls to Avoid
Never attribute severe abdominal pain to "normal pregnancy changes" without excluding serious pathology first. 1
Never delay imaging or surgical consultation due to concerns about radiation—maternal and fetal outcomes worsen with delayed treatment, and the benefits of timely diagnosis outweigh radiation risks. 1, 9, 6
Never rely on negative ultrasound to exclude placental abruption—clinical judgment supersedes imaging when excluding this diagnosis. 1
Never perform digital bimanual examination before ultrasound excludes placenta previa in patients beyond first trimester, as this can precipitate catastrophic hemorrhage. 8
Do not assume absence of vaginal bleeding excludes placental abruption—20% of abruptions present without visible bleeding. 1