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Abdominal Pain in Pregnancy

Answer: C.

Abdominal pain in the pregnant patient is a diagnostic challenge because both benign and emergent conditions overlap in symptoms and signs.  Normal benign conditions include discomfort due to an enlarging uterus, fetal movement, Braxton-Hicks contractions, constipation, and round ligament pain.  Unfortunately due to changes in anatomy (uterus becomes an abdominal organ at 12 weeks; parietal wall and peritoneum are displaced and peritoneal signs may be absent) and physiology (progesterone effect on colonic motility, bile emptying, esophageal and ureteral tone), the history and physical normally elicited is unreliable in a pregnant patient.

To simplify the approach, abdominal pain in a pregnant patient can be divided into three categories: obstetric, gynecologic, and non-Ob/GYN causes.

Obstetric
Early (< 24 weeks)
Round ligament strain
Threatened, incomplete, or inevitable miscarriage
Rupture of corpus luteum cyst
Ectopic pregnancy 
Septic abortion with or without peritonitis
Acute urinary retention

Late (>24 weeks)
Preterm labor
Placental abruption
Placenta accreta/increta/percreta
Acute polyhydramnios

Gynecologic
Rupture of ovarian cyst
Adnexal torsion
Fibroids and degenerating myoma
Severe pre-eclampsia and HELLP syndrome
Uterine rupture
Chorioamnionitis


Non-OB/GYN
Differential is the same as a non-pregnant patient.
However, the most common causes of an acute abdomen in pregnancy are:
Acute appendicitis (#1)
Acute cholecystitis (#2) ...Now what?  Stay tuned for next week's revealing season finale...


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