Dolore addominale in gravidanza

Ci sono articoli correlati separati su Dolore addominale e Addome acuto.

Introduzione

Il dolore addominale in gravidanza può essere difficile da diagnosticare. Spesso è necessaria una rapida consultazione ospedaliera, a meno che non si possa stabilire con certezza una causa benigna in assenza di disagio materno o fetale.

La valutazione del dolore addominale è più complessa nelle donne in gravidanza perché l'ingrossamento dell'utero può nascondere i segni classici. I segni peritoneali possono essere assenti a causa del sollevamento della parete addominale. Gli organi addominali possono cambiare posizione con il progredire della gravidanza - ad esempio, l'appendice viene spostata verso l'alto e lateralmente verso la cistifellea dopo il primo trimestre.

The assessment must consider both maternal and fetal well-being, bearing in mind that intra-abdominal infection or inflammation can be associated with premature labour or fetal loss and that acute conditions such as appendicitis carry higher risks in pregnancy. Patients may need joint assessment both by a gynaecological and/or obstetrics team and a surgical team. Where the diagnosis is unclear, the risks of exploratory surgery must be balanced against the risks of delayed diagnosis.

Acute appendicitis is the most common cause of an abdominal pain in pregnancy. Urinary tract infection (UTI) or stones and cholecystitis are also relatively common.

The following section lists the more likely causes of abdominal pain in pregnancy. For a more extensive list of non-pregnancy-related causes, see the separate Dolore addominale articolo.

Obstetric causes of abdominal pain in pregnancy

• Labour pain - un travaglio prematuro or at term.

• Pre-eclampsia o Sindrome HELLP - epigastric or right upper quadrant pain.

• Placental abruption:

  • Typically, sudden severe pain and a 'woody' hard, tender uterus; fetal distress ± vaginal bleeding.

  • With posterior placenta, pain and shock may be less severe, with pain felt in the back; diagnose by pattern of fetal contractions (excessive and frequent) with fetal heart pattern suggesting hypoxia.

• Uterine rupture:

  • Constant pain, profound shock, fetal distress and vaginal bleeding; usually presents during labour and with history of uterine scar.

  • Rarely, occurs without labour and without a uterine scar.

• Chorioamnionitis:

  • This usually follows premature rupture of membranes but can occur with membranes intact.

• Acute fatty liver of pregnancy:

  • Presents in the second half of pregnancy with abdominal pain, nausea and vomiting, jaundice, malaise and headache.

• Acuta polidramnios.

• Rupture of utero-ovarian vessels.

• Severe uterine torsion - rare; may be due to structural abnormalities in the pelvis:

  • Presents in the second half of pregnancy with variable symptoms, including severe abdominal pain, tense uterus, retention of urine ± shock and fetal distress; or, it may be asymptomatic; the fetus is at risk.

Gynaecological causes of abdominal pain in pregnancy

• Gravidanza ectopica:¹

  • Usually presents between 5-9 weeks of gestation.

  • The classical triad of bleeding, abdominal pain and amenorrhoea is not present in many women; symptoms and signs are often nonspecific; the diagnosis can only be confirmed in secondary care.

  • Symptoms vary and include: syncope, dysuria (including dipstick urine findings suggesting UTI), diarrhoea and vomiting, subtle changes in vital signs; adnexal tenderness may be absent; a history of 'missed period' may be absent if vaginal bleeding in early pregnancy is mistaken for a normal period.

• Aborto spontaneo ± septic abortion.

• Torsion of the ovary or Fallopian tube.

• Ovarian cysts - torsion, haemorrhage or rupture.

• Fibroids - red degeneration or torsion.

• Ovarian hyperstimulation syndrome:

  • A complication of gonadotrophin-assisted conception; can occur pre-conception or in early pregnancy.

  • Large ovarian cysts cause abdominal pain and distention and, in severe cases, also fluid shifts, ascites, pleural effusion and shock.

• Salpingitis.

• Round ligament pain.

Surgical causes of abdominal pain in pregnancy

• Acuta appendicite:

  • Presents with fever, anorexia, nausea, vomiting, right iliac fossa (RIF) pain.

  • After the first trimester, the pain may shift upwards towards the right upper quadrant but does not always do so - patients in all trimesters may have RIF pain.

  • With retrocaecal appendix, the woman may have back or flank pain.

• Cholecystitis and gallstones.

• Urinary tract - renal calculi, urinary tract obstruction (including acute urinary retention due to retroverted gravid uterus).

• Intestinal obstruction - most often due to adhesions.

• Peritonitis from any cause.

• Abdominal trauma, including domestic violence.

• Adenite mesenterica.

• Diverticolite di Meckel.

• Ulcera peptica.

• Malattia infiammatoria intestinale.

• Abdominal wall - hernias, musculoskeletal pain, rupture of rectus abdominis muscle.

• Pancreatite acuta - rare and usually due to gallstones.

• Mesenteric venous thrombosis (rare) - most reported cases have occurred where dehydration complicated an underlying hypercoagulable state.

• Rupture of visceral artery aneurysm (rare).

'Medical' causes of abdominal pain in pregnancy

• UTI ± pyelonephritis.

• Costipazione.

• Chetosi diabetica.

• Sickle cell anaemia crisis.

• Lower lobe pneumonia.

• Venous thromboembolism - deep vein thrombosis or pulmonary embolus may cause lower or upper abdominal pain respectively.

• Infarto miocardico.

• Gastroenterite.

• Sindrome dell'intestino irritabile.

Musculoskeletal causes of abdominal pain in pregnancy

• Round ligament pain - low abdominal or groin pain due to the uterus pulling on the round ligament.

• General aches - due to uterine enlargement.

• Rectus muscle haematoma - due to rupture of inferior epigastric vessels in late pregnancy:

  • Presents with sudden severe abdominal pain, often after coughing or trauma.

• Pelvic girdle pain:

  • Symphysis pubis dehiscence.

  • Osteomalacia may present in pregnancy due to increasing vitamin D requirements.

Storia

• Pain history - nature, location and radiation, onset, exacerbating or relieving factors. These will give clues about the cause (see the separate Dolore addominale article for details).

• Other abdominal symptoms - vaginal bleeding, bowel and urinary symptoms; pre-eclampsia symptoms (for example, headache, visual change, nausea).

• Fetal movements.

• Obstetric history - last menstrual period (LMP); confirm whether the patient's last bleed was 'normal' for the patient (ectopic pregnancy may have some bleeding which can be mistaken for menstrual bleed); ascertain if there has been any difficult or assisted conception; confirm use of any contraception (coil and progestogen-only pill (POP) increase ectopic risk).

• In early pregnancy, check whether a scan has been done to confirm that the pregnancy is intrauterine. Remember that this does not 100% exclude an ectopic, as heterotopic pregnancies (where there is one foetus in the uterus and one as an ectopic) do occur. They are rare, with an incidence of 1 in 30,000 in naturally conceived pregnancies, but a potential incidence of as high as 1 in 100 in IVF pregnancies.²

• Past medical and gynaecological history, medication, allergies, last meal.

Esame

• If pain is reported via a phone call or electronic consult, consider whether bringing the woman to the GP surgery for an examination will change the need for a hospital assessment. If not, it may be appropriate to advise her to contact her obstetric team directly, or for you to refer to your local early pregnancy unit on the basis of a history taken over the phone.

• General examination - well/ill, signs of sepsis, shock or haemorrhage, blood pressure, urine dipstick protein and glucose.

• Assess the pregnancy and uterus:

  • Palpate uterus for fundal height, contractions or hard uterus, polyhydramnios, fetal position and presentation.

  • Assess fetal well-being - movements or heartbeat (auscultate, Doppler scan or cardiotocography (CTG)).

• Abdominal examination - see the separate Esame addominale article but note the differences in pregnant patients:

  • To distinguish extrauterine from uterine tenderness, lay the patient on her side, thus displacing the uterus.

  • Clinical signs may be less distinct.

  • Peritoneal signs may be absent in pregnancy, as the uterus can lift the abdominal wall away from the area of inflammation.

  • Note the changing positions of the intra-abdominal contents as the pregnancy progresses. The appendix is located at McBurney's point in patients in the first trimester but then moves upward and laterally towards the gallbladder. The bowel can be displaced into the upper abdomen.

• Consider whether vaginal and/or rectal examination is indicated:

  • Never do a vaginal examination if placenta praevia is suspected (vaginal bleeding in the second half of a pregnancy) - it could cause a massive bleed. Similarly, if you suspect an ectopic pregnancy, do not palpate for an abdominal mass as this could rupture an undiagnosed ectopic. The National Institute for Health and Care Excellence (NICE) CKS recommends carrying out a 'gentle pelvic examination', however if this will not change your decision to refer then it may not be appropriate.

  • Suspected rupture of membranes requires sterile examination and should be done in an obstetric unit.

  • For incomplete miscarriage with heavy bleeding, examine the cervical os. Products in the os may cause heavy bleeding and also bradycardia/shock due to vagal stimulation. Remove products in the os (using sponge forceps) to reduce bleeding and pain.

Bedside tests

• Urine dipstick.

• Urine pregnancy test. It is very unlikely that a woman with a negative pregnancy test has an ectopic pregnancy, given the sensitivity of modern tests, however if you have strong reason to suspect this then it may be appropriate to refer for same-day hospital assessment, where a serum HCG can be more easily accessed.

• Bedside glucose test.

• Fetal CTG monitoring.
  

Indagini iniziali

• Blood tests - depending on the clinical scenario, the following tests might be done in secondary care:

  • FBC.

  • Group and save/cross-match.

  • Rhesus blood group (if not known).

  • Serum beta-hCG - can aid diagnosis/management decisions regarding suspected ectopic pregnancy or miscarriage.

  • Biochemistry: renal and liver function, glucose, calcium, amylase, hepatitis serology.

  • Clotting screen if haemorrhage, placental abruption or liver disease suspected.

  • Sickle cell screen.

  • Blood film (for evidence of haemolysis, if HELLP syndrome is suspected).

• Urine tests:

  • Urine microscopy and culture.

  • Urine protein quantification for suspected pre-eclampsia.

• ECG if atypical epigastric pain.

• Ultrasound:

  • First trimester - can confirm whether pregnancy is intrauterine and viable. From 5+ weeks a sac is visible and from six weeks the fetal heartbeat is seen. Free fluid in the pelvis suggests ectopic pregnancy. Transvaginal ultrasound is more sensitive in early pregnancy.

  • Second-third trimesters - gives information about fetal well-being, the uterus and placenta.

  • May assist surgical diagnosis - for example, acute appendicitis, ovarian cysts, gallstones.

Ulteriori indagini

• CXR, if required, involves negligible radiation dose to the fetus.

• Swabs and/or blood cultures if there is suspected infection/sepsis.

• MRI (if feasible) can be used to evaluate pregnant patients with acute lower abdominal pain where an extrauterine cause is suspected.

• CT scans have been used in the second and third trimesters but involve significant radiation.

• Diagnostic laparoscopy or laparotomy may be required. Laparoscopy is feasible and useful in pregnancy.

This depends on the diagnosis but some general points are:

• Rhesus-negative women - give anti-D immunoglobulin if indicated.

• Combined management by an obstetrician, surgeon and/or physician may be needed.

• Indications for emergency surgery are similar to non-pregnant patients.

• If non-urgent surgery is required during pregnancy, the second trimester is preferred.

• Laparoscopy is increasingly used for diagnosis and treatment.