Abdominal Pain in Pregnancy - Semantic Scholar

ABDOMINAL PAIN IN PREGNANCY*

By E. CHALMERS FAHMY, F.R.C.S.Ed., F.R.C.P.Ed., F.R.C.O.G.

PREGNANCY, being a physiological condition, should run its course

without the occurrence of either major or minor discomforts, yet many women suffer from various disturbances during some part of the

gestation period. One of the commonest disturbances is pain in the

abdomen, and it is my intention to discuss the causes of pain, especially in relation to diagnosis. Whether the pregnant woman feels pain more acutely than the non-pregnant is a doubtful point. Many writers

specify a heightened tension in the general nervous system, and claim that this can be demonstrated by the exaggerated response in simple reflex mechanisms. They infer that minor discomfort is translated

into pain, and mild pain into severe pain. Hamilton,1 the first Pro- fessor of Midwifery in this University, in the fourth edition of his

book published 150 years ago (1796), puts forward the view of his

day in a few words : " Alteration of spirits is merely the effect of uterine

irritability communicated to the nervous system ; for the mind, as

well as the body, is (in pregnancy) peculiarly susceptible to irritation." Others have written in similar strain down to the present day. Effect

on the autonomic system is clearly demonstrated by the frequency with which constipation and bowel distension occur as early as the ninth or tenth week of gestation. The over-anxious introspective woman is only too well known to us all ; if such a woman becomes

pregnant exaggeration of symptoms may be expected. But experience leads me to believe that the woman whose nervous reactions are at a

healthy normal level does not tend to exaggerate the discomforts of

pregnancy, and many of the nervous type maintain a more settled, even temperament than had been anticipated. In his classic work on Ante-Natal Care, F. J. Browne 2 states :

"

Fully 80 per cent, of women suffer from abdominal pain of greater or lesser degree during pregnancy, though its origin is often obscure or impossible to determine with certainty." Browne's figure is rather startling, and I know of no other writer who makes such a definite statement ; but I imagine that Browne's estimate is probably correct. In a widely read textbook on Obstetrics it is stated that " in a number of cases there is a

readily discernible cause (of pain) ; but there is a larger group of Patients, both in early and late pregnancy, who complain of severe abdominal pain, either continuously or in crises, in whom no physical signs of any kind can be found." With this statement I find it difficult to agree. The term " severe " is, perhaps rather vague ; but I venture t? suggest that pain without physical signs and of unknown origin

* A Honyman Gillespie Lecture delivered in the Royal Infirmary, Edinburgh, 0ri 2nd March 1944. vol. li. no. 5 229 P 2

230 E. CHALMERS FAHMY

of a degree commonly accounted severe is not, in fact, of very frequent occurrence. It is true that accurate diagnosis may be impossible in the first instance, but careful investigation will often disclose the

source of pain. I do not deny the occurrence of severe pain of obscure

origin ; my contention is that cases of this nature are in the minority. One example may be given here. A primigravida at the seventh

month of pregnancy was seized with acute pain just below and to the left of the umbilicus ; it came on while she was resting. When I saw

her there was no temperature, the pulse was 100, and the pain acute and of a sharp character. No rigidity could be felt, but there was

perhaps slight tenderness over the left side of the abdomen. There

was no vomiting and no pallor, and no sensation of faintness. The

patient could not move in bed without pain. No tender area in the

back or pelvic joints was discoverable. No urinary symptoms were

present and the urine was not infected. The pain lasted in lessening degree for three days, gradually passing off without any lesion of any kind being found to account for it. It did not recur, and observation

over the rest of the pregnancy failed to throw any light on the condition. The left kidney and ureter were suspected, but investigation proved negative. This is one example of acute pain of unknown

origin with no physical signs except perhaps slight tenderness. Causes of Pain.?I append a list of the causes of pain and indi-

cate the time in pregnancy when each is most likely to be operative, but of course the time-relation factor is by no means constant. The

list is not exhaustive, but it covers most of the conditions likely to be met in obstetric practice. I shall refer to some of these only briefly ;

others will be discussed more fully with special reference to differential diagnosis.

First Trimester.

Iliac fossa pain. Round ligament pain. Previous obstetric

trauma.

Ectopic gestation. Retroflexion of gravid

uterus.

Ovarian hsemorrhage. Angular pregnancy.

Second Trimester.

Hydatidiform mole. Acute hydramnios. Pyelitis.

Ureteral spasm.

Appendicitis.

Fibroid tumour.

Ovarian tumour.

Adhesions.

Intestinal pain.

Third Trimester.

Haematoma of rectus abdominis. Costal margin pain. Concealed accidental haemor-

rhage. Rupture of uterus. Rupture of vein on uterine wall.

Torsion of gravid uterus. Epigastric pain. Gall bladder pain. Pain of orthopaedic origin.

The causes of pain are numerous, and we find marked variation m character and in intensity. Colicky, cramp-like, cutting, tearing, sickening, twisting aching, dragging, stretching-all these descrip- tions may be heard from the lips of sufferers at various stages of preg-

?

nancy. Further, some pains are persistent, others intermittent It is

not enough to note than an individual has pain ; attention must be

paid to the type of pain and to the region of the abdomen in which

ABDOMINAL PAIN IN PREGNANCY 231

the pain was first noticed. One other point may be referred to here, namely pyrexia. Of the various uterine causes of pain there are

practically none associated with pyrexia in the early stage of illness. One exception to this rule is that due to criminal abortion, in which

pyrexia may precede uterine pain, and in these cases the true history of the case is often suppressed. The only other exception is that of

a degenerating fibroid tumour ; but pyrexia in such a case is, in fact, uncommon, and only of slight degree when present. The importance of this clinical fact is clear?abdominal pain associated with pyrexia at the onset or very shortly afterwards, is due to some condition out-

side the pregnant uterus ; but the absence of early pyrexia does not of course exclude extra-uterine lesions, either obstetrical or surgical.

The First Trimester of Pregnancy

Iliac Fossa Pain.?Mild or moderate pain in this region is not

uncommonly experienced, in the absence of any definite lesion, between the second and third months and after. The site of the pain is usually above the middle of the inguinal ligament ; it is generally sharp in

character, sometimes fleeting, sometimes more prolonged, but never

persistent. Swelling is absent, and tenderness, if present, is slight. No constitutional signs accompany it. Possibly because no clear

origin is discernible, the round ligament is apt to bear the blame.

Adair and Stieglitz 3 suggest that 50 per cent, of primigravidae suffer

from pain of this nature early in pregnancy ; and because nausea and

vomiting (due to pregnancy) may be present, appendicular disturbance may be suspected. These authors say that the pain ceases when the uterus rises out of the pelvis, but in fact it does not always do so.

Browne 2 states that the round ligament, by stretching, may definitely cause pain, and may do so up to the fifth month. Many other writers support this view, and Montgomery 4 a hundred years ago referred to it. It is difficult to understand why the round ligaments should so commonly cause pain, for they are soft structures and become softer still with the vascularity of pregnancy ; nor are the ligaments attached firmly to neighbouring tissues as they run their course to the labia. If the genital branch of the genito-femoral nerve, which runs with the ligament in the inguinal canal, is pressed upon or stretched pain should be referred to the supra-pubic area and to the labium, and it

is not so referred. Similar pain, too, may occur in the parous woman in whom the ligaments have been previously stretched. I do not

myself feel satisfied that the common pain referred to can be so generally attributable to the round ligament, but it is difficult to offer an

adequate explanation. Its frequency is worth bearing in mind, for

appendicitis occasionally and ectopic pregnancy frequently are sus-

pected on account of this iliac fossa pain. Further, pain above the

inguinal ligament is not uncommon apart from pregnancy, and experi-


ence demonstrates how difficult it may be to find a definite lesion to

account for it ; but in such instances acute symptoms are absent. But pain due to the round ligament may unquestionably arise

should pregnancy follow shortly after the commonly performed Gilliam

operation for retroversion of the uterus. The pain, often quite acute, is strictly localised to the point where the ligament is stitched to the rectus sheath?the patient can put the tip of the finger on the exact

spot where the sutured ligament may be palpated. This pain dis-

appears after mid-term of pregnancy. Its recognition is important, for it has been mistaken for the pain of appendicitis, especially when the nausea and vomiting of pregnancy are still evident. Only last month I saw a rather stout woman who had been operated on under the erroneous diagnosis of appendicitis five to six months after a

Gilliam operation. The pain due to the latter is very localised, never alters in character or position, and is unassociated with pyrexia.

In parous women pain of aching character in the iliac fossa may arise from a degree of prolapse, from the result of previous trauma and infection, and possibly from varicosities in the broad ligament. None of these conditions lead to symptoms of an acute nature.

Ectopic Gestation.?Though this condition is well recognised as a cause of lower abdominal pain, it is relatively seldom that an

unruptured or unaborted tubal pregnancy is operated on. The mild

occasional pain is not considered seriously by the patient, unless there is evidence of vaginal bleeding. It is when severe pain is experienced that advice is generally sought. Such pain means that either tubal abortion or rupture has occurred. Prior to rupture, slight pain, usually colicky, and tenderness on examination over one or other tubal area raises suspicion ; the suspicion is strengthened if intermittent, scanty vaginal bleeding is present. The tender enlarged tube may be felt. But we must remember that the ovary itself may be tender in early pregnancy and does, I think, cause pain of either sharp or aching nature low in the iliac fossa, especially if cystic change or haemorrhage into the ovary has taken place. Such a tender ovary may well be mistaken for a tubal gestation. In cases of doubt between tubal

pregnancy and ovarian lesion reliance should be placed on the size and consistency of the uterus. If the latter corresponds to the supposed duration of pregnancy (frequently eight weeks or thereby) ectopic gestation can nearly always be ruled out, for ovarian pregnancy is a

rarity, and combined uterine and tubal gestation just as uncommon. When acute symptoms arise from rupture of the tube the diagnosis is

usually easy, for a degree of collapse follows the onset of severe pain. Shoulder pain, due to blood reaching the diaphragm, is common in

such cases and is a valuable sign when present. In less severe cases

(often tubal abortion), especially when not seen for twenty-four hours or more after the onset of symptoms, diagnosis is often difficult.

Appendicitis is frequently diagnosed. Four points bear emphasis here : sudden onset of lower abdominal pain, marked tenderness on


movement of the cervix, the presence in the pelvis of a swelling of

varying consistency (coagulated blood) and vaginal bleeding. Seldom

indeed is vaginal bleeding delayed for more than twenty-four to thirty hours after the onset of acute abdominal pain ; its absence after such

an interval of time should always cast doubt on the diagnosis of tubal

rupture or abortion, though it does not negative it absolutely, as

Dougal 5 showed in his series of cases. Retroflexion of the gravid uterus and small twisted ovarian tumours

may simulate tubal pregnancy, but diagnosis can usually be deter- mined by a careful history of the character of the pain, by the palpation of a rounded discreet swelling in the pelvis and its relation to the

cervix.

Uterine abortion and tubal abortion are still frequently confused, mainly through insufficient care to detail. The old adage is true?

much pain and little bleeding point to ectopic ; little pain and much bleeding point to abortion.

Pain arising from the Ovary

Intraperitoneal haemorrhage from rupture of the corpus luteum of

pregnancy in the ovary causes symptoms almost identical with those of ruptured ectopic pregnancy. In the last eight months I have seen

two such cases, occurring about ninth or tenth week. In one I could

not satisfy myself that the uterus was of the size and consistency expected, and operated on account of pain and symptoms of internal haemorrhage. A normal pregnant uterus was found and intra-

peritoneal haemorrhage had occurred from the corpus luteum. The

patient stated later that the sudden severe pain followed marital inter- course. In the other case I was sure the uterus was pregnant, and as the patient's condition was moderately good I treated her con-

servatively, while keeping close observation. She rapidly improved and the pregnancy progressed normally. The symptoms here were identical with those in the previous case, and I have little doubt the

diagnosis was the correct one. The point may here be raised as to whether the non-inflamed

intact ovary, cystic or haemorrhagic, can cause pain in the iliac fossa. Full discussion of this point is impossible now as it would involve

the whole question of visceral pain. The late Sir James MacKenzie 6

would have answered " yes "

to the question. Morley 7 of Manchester would definitely answer

" no." Morley would be supported, but from

an entirely different angle, by Brown 8 of Dundee, who, arguing on

embryological grounds, would claim that the mobile ovary could

cause pain only up in the renal area. But work over recent years on

the autonomic nervous system supports the clinician who believes

that ovarian pain may be appreciated in the iliac fossa. White and

Smithwick,9 in their classic work on the autonomic nervous system, state that it is highly probable that

" visceral afferent impulses may


also give rise to pain which is referred to the cutaneous areas of the

corresponding cerebro-spinal nerves." If this is proved, then the

ovary must be finally accepted as a possible cause of iliac fossa pain. We shall indeed be back to Mackenzie's theory of viscero-cutaneous reflex.

Angular Pregnancy.?This condition, though often omitted from discussion in obstetrical textbooks, is one of some clinical interest.

The term Angular Pregnancy was first employed in this country

by Munro Kerr 10 in 1908, though American and Continental clinicians had previously advised its adoption for the implantation of the ovum at the tubal angle of the uterus. When Munro Kerr reported his

case to the Edinburgh Obstetrical Society in 1908, exception was taken to the term angular, on the grounds that it was identical with

interstitial tubal pregnancy. But whereas the latter grows in the

wall of the uterus and ruptures about the third or fourth month into the peritoneal cavity, the former grows into the uterine cavity and

may carry on to full-time. From personal experience I am in agree- ment with those who regard angular pregnancy as a definite clinical

entity. Pain on one or other side is almost an invariable feature between

the second and the fourth month, and intermittent vaginal haemorrhage may be an accompaniment. These two features are of course the

common symptoms of tubal pregnancy from which angular pregnancy must be differentiated. The pain may be spasmodic, or sharp and

stabbing, and tends to recur at intervals due, according to Munro

Kerr,11 to haemorrhage at the implantation site and contraction of the circular muscle fibres at the tubal angle. The pain may, on occasion, be so severe as to suggest an abdominal emergency, such as a ruptured tube or appendicitis.

My first case was a parous woman with a history of two normal pregnancies. In the third pregnancy, after two or three attacks of

right-sided pain low in the iliac fossa, in one of which attacks vomiting occurred, she had a further attack of severe pain about the tenth week. A tentative diagnosis of appendicitis had been offered because of

pain, vomiting and tenderness. When I saw the patient, examination revealed a tender soft swelling at the right cornu making the softened uterus lopsided. As there was no temperature and no vaginal bleeding I kept the patient under observation. Bleeding began the next day and continued slightly for a further three days, during which time the right-sided pain was intermittent but not severe. On the fifth

day the patient aborted, but much of the placental tissue was retained. When this was removed under anaesthesia, one's finger passed up into a channel at the right cornu to which the adherent portion of the placenta was attached. I have had the opportunity to observe three other patients from the early weeks of gestation. One aborted at the

tenth week, while two carried on almost to term. In one, a tubal

pregnancy could not be excluded with absolute certainty until observa-


tion in a nursing home had been maintained for some time ; in the

other, a double uterus was at first wrongly suspected. In both these

cases there were present intermittent attacks of pain of a sharp character, scanty irregular vaginal bleeding and a uterus irregular in shape owing to a soft swelling at the cornu, which was tender on

palpation. The histories of these two cases are as follows.

CASE No. i.?Para i. First pregnancy normal, seven years

previously. Seen at seventh week with diagnosis by doctor of ? ectopic gestation. Slight bleeding present and uterus enlarged with slight irregular contour. Intermittent bleeding continued for three to four weeks with pain low down on the right side. Uterus at tenth week

was definitely irregular with a tender swelling at the right cornu.

The diagnosis lay between interstitial tubal pregnancy and angular pregnancy. The patient was kept in bed for nine weeks ; occasional

spotting from time to time with occasional mild pain, and one attack of marked pain which made patient actually sick and feel a little faint.

By the fourteenth week, as all bleeding had ceased, patient was allowed

up. However, two further attacks of pain, one accompanied by slight haemorrhage, occurred ten days later and patient was therefore rested again. No further adverse symptoms occurred, and the patient carried on to two weeks before term and spontaneously delivered herself of a normal healthy infant. The lopsidedness of the uterus was palpable till the sixth month, after which time it became less and less noticeable as patient approached term. There was no difficulty in the third

stage of labour?a feature of interest, as difficulty may be experienced as Munro Kerr first pointed out.

Case No. 2.?Primigravida. I saw this patient at the fourth

month. From the tenth week she had had slight irregular bleeding or brownish discharge, with never more than two days clear of discharge. On two occasions the loss had been fairly free from two to three hours and was followed by the escape of almost black blood. Vague right-sided abdominal pain had been present from time to time, but no severe pain. In spite of rest in bed for six to seven weeks slight discharge was present, and this did not finally cease till the pregnancy had nearly reached the fifth month. After that time there was neither loss nor pain, and the patient carried on to deliver herself spontaneously of a healthy child, two weeks before full-time. When I first saw this patient marked irregularity of the uterus was evident, the right cornu extending higher than on the other side. Angular pregnancy was diagnosed and the patient was treated conservatively. In

this case the lobulated right side persisted up to the time of labour, though it was much less noticeable from the thirty-second week of

pregnancy onwards. Again no trouble was experienced in the third

stage of labour.

Angular pregnancy in the earlier stages may not be easy to dis-

tinguish from ordinary tubal pregnancy and impossible to distinguish clinically from interstitial tubal pregnancy?a rare condition. How-


ever, only last month I operated for a ruptured tubal pregnancy at the eleventh week and found a ruptured interstitial gestation. The

history was one of irregular haemorrhage and colicky pain, but the

patient had not been seen till after the rupture occurred.

The Middle Trimester of Pregnancy

Hydatidiform Mole.?Pain is a frequent symptom of this con-

dition, especially when the uterus has become an abdominal organ and is enlarging rapidly. The pain may be colicky in type, as when the uterus contracts as if to expel the mole, and irregular bleeding is the rule in such cases. But in rapidly growing moles the pain may be described as a sensation of acute stretching and tenseness, and it

is then almost invariably associated with marked tenderness of the uterus. Bleeding may be scanty or entirely absent, as in a case treated

recently in which the uterus reached a level well above the umbilicus. Records show that the uterus may, in fact, reach the size of a full-

time pregnancy in the absence of vaginal bleeding. It is the case

without haemorrhage that may present diagnostic difficulty, but X-rays and the Ascheim Zondek test can be called on to differentiate the

condition from hydramnios, twins, etc. Severe vomiting may be

present and this, combined with marked pain and flatulent distension,

may raise the suspicion of a visceral lesion. I have known intestinal

obstruction considered under such circumstances. The localisation

of pain and tenderness to the uterus itself is an important factor in the diagnosis, together with absence of any fcetal heart beat.

Acute hydramnios, most commonly associated with uniovular

twins, is often accompanied by constant uterine pain similar to the last condition. Toxaemia is not unusual. One point worth noting in

regard to diagnosis is the difficulty in eliciting a fluid thrill in acute cases when twins are present. The absence of fluid thrill may be

misleading. Pyelitis.?Acute pyelitis complicates pregnancy most frequently

towards the end of the second trimester or shortly after it. It declares

itself in one of two ways?either as the renal type or as the abdominal type. In the renal type the symptoms point unmistakably to the

kidney, with pain and tenderness in the loin, the pain often shooting down towards the groin. Rigors or high temperature accompany or precede the onset of pain. The diagnosis is seldom in doubt. In the

abdominal type, however, diagnosis can be extremely difficult, and

appendicitis, cholecystitis or obstruction may have to be excluded.

Acute pain may be, at the onset, generalised over the abdomen, and accompanied by vomiting and intestinal distension. No complaint whatever of pain in the back or loin may be made by the patient, and the examiner's attention may thus be concentrated on the abdomen

to determine which of the viscera is at fault. Again the temperature is usually high early in the illness and rigors may, or may not, occur.


The whole side of the abdomen is tender on palpation, and muscular

rigidity in some degree generally present ; as a result appendicitis is

simulated. The tongue is furred, the bowels constipated, and flatulent distension almost the rule ; these, when associated with repeated vomiting, may suggest intestinal obstruction. The presence of the

large uterus naturally makes examination more difficult. The patient is restless and may look extremely ill. Urinary symptoms are not an

early feature. But even in these cases, tenderness in the renal area

can generally be demonstrated if sought for ; and this, combined

with marked pyrexia, should make the examiner alert to the possibility of pyelitis. The finding of a few coliform bacilli in the urine may mean nothing ; and while the microscopic evidence of pus in a single drop of urine is significant, the absence of pus does not negative the

diagnosis of pyelitis. Murphy, the American surgeon of many forceful

sayings, once remarked that if you strike the kidney region with the clenched fist, the patient, if she has pyelitis, will arise and smite you. But not all Murphy's aphorisms were meant to be taken too seriously !

Ureteral Spasm.?This is undoubtedly a cause of intermittent

pain in the lower abdomen, and sometimes pain of severe degree. Its recognition is not of recent date, for clinicians such as Montgomery

4

wrote of it a hundred years ago. The point of special interest here is that recurrent ureteral pain may occur without either pyrexia or infection in the urine. Haematuria may be present, as Middleton

12

and others have shown, but it is the exception rather than the rule.

Vomiting may accompany the attacks of pain. Morison 13 recently spoke on ureteritis as a cause of pain ; but whether stricture be present or not, ureteral spasm may be a cause of disconcerting lower abdominal

pain to the pregnant woman. In some cases the kidney is tender, but it is by no means always so. The patient, and sometimes her

physician, fears a chronic appendix. If doubt persists urethral

catheterisation will settle the question. Appendicitis.?I have already referred several times to this con-

dition. Individual obstetricians see this illness but rarely, and to

some extent the reason may be that the surgeon and not the obstetrician is called on to deal with such cases. Munro Kerr 11 states that he has seen only a few cases in all his clinical experience. In private practice I can only recall one pregnant woman under my care who developed acute appendicitis, and I have seldom seen it in hospital Work. In the old Simpson Memorial Maternity Hospital there are records of only seven cases in the sixteen years from 1923 to 1938, and four of these seven patients died. Only two cases are recorded in the new Simpson Hospital reports. Records published in the last

twenty years from centres in America and on the Continent are at

great variance in regard to the incidence of the disease?quoted from article by Baer 15?the figure varying from 2 per cent, in the Mayo Clinic to -oi per cent, in the Baudelocque clinic ; but we must remember

that the frequency of appendicectomy in the first twenty-five years of


life reduces the possibility of the condition complicating pregnancy. It would appear that appendicitis occurs most frequently in the middle period of pregnancy, though Jerlov,14 in analysing 360 cases, found the greatest number occurring in the second month. The displacement of the caecum by the growing uterus, and the tendency in pregnancy to constipation and bowel distension appear to make more likely an acute flare-up of a previously diseased appendix, for it is an important clinical fact that a history of previous attacks is very commonly obtained. Typical acute cases are almost as readily diagnosed as

in the non-pregnant woman, for pain, vomiting and temperature occur in their usual order of precedence. But the atypical case presents great difficulties, for the character and situation of the pain may not at once suggest the appendix as the cause of the symptoms. It is

safer to remember the appendix than to forget it when considering the cause of pain, for rupture and gangrene are admittedly commoner in cases that reach the operating table than in the non-pregnant woman. The work of Baer et a/.15 shows how the appendix alters in position as the uterus enlarges, and consequently the site of pain may vary according to the time of pregnancy. At the fifth month the appendix reaches the level of the umbilicus, and later it lies at an even higher level. This point is of importance ; but it must be realised that the

caecum and appendix will not follow their usual positional change if

previous disease has affected their mobility to any marked degree. In discussing the difficulty in attributing with certainty to the appendix pain in the abdomen, Maes 16 writes :

"

Morning sickness and general malaise in the early months are fruitful sources of error. Right- sided pain is not infrequent between the fourth and seventh months. Constipation and flatulence are general accompaniments of pregnancy, and abdominal distension is noted often before the size of the uterus could possibly account for it. Localised tenderness may be difficult to elicit because of the size of the uterus ; and while, theoretically, the location of the pain at an increasingly higher level as pregnancy advances seems an excellent point of distinction, actually it does little more than introduce the possible diagnosis of upper abdominal disease." With this statement clinicians will surely agree.

In *933 Marbury 17 drew attention to the fact that even in acute cases rigidity of the abdominal wall may be little in evidence owing to the thinning of the musculature consequent on pregnancy. In

order to palpate the appendix area more readily, it has been suggested that examination be made with the patient in the left lateral position, so that the uterus may move away towards the left side as far as possible. If after consideration of every point in detail, pyelitis and intra-uterine conditions can be definitely ruled out, and if the clinical picture is

such that the appendix cannot be excluded with certainty, then

exploratory operation should be considered, for appendicitis is a

particularly serious disease in pregnancy for both mother and child. I recall clearly a patient, at the eighth month of pregnancy, whose

pain, mid-abdominal tenderness, ill appearance and toxaemia led to


the diagnosis of concealed accidental haemorrhage. It was only several hours later that the clinical picture led to a revision of the diagnosis. On opening the abdomen I found the appendix abscess completely shut off behind the uterus. Access was almost impossible owing to the size of the uterus and, in fear and trembling, I carried out Caesarean

section, stitched up the uterus, and drained the abscess. Both mother

and child survived, though the post-operative convalescence was,

indeed, stormy. In this case it was the retro-uterine position of the

appendix that led to the original false diagnosis. Fibroid tumours of the uterus give rise to pain under two condi-

tions, degeneration and torsion of a subperitoneal tumour. Degenera- tion causes pain of a constant aching type ; it is seldom really acute. The tumour itself is tender, and pyrexia occasionally occurs, but it is

never of a high degree. Indeed, I would stress the fact that a high temperature is sufficient to make the clinician seek for some other

explanation of the symptoms. Fibroids on the posterior uterine wall cannot be palpated and, accordingly, pain due to degenerative change may be difficult to evaluate. Fibroids seldom cause symptoms of

degeneration until after the mid-term of pregnancy, yet in the early months a tender swelling close to the uterus has been so diagnosed when the true condition was a tubal pregnancy or pelvic haamatocele. Torsion of a fibroid, rare in occurrence, causes severe acute pain and leads to the clinical picture of an acute abdomen.

Ovarian Tumours.?Unlike fibroids, torsion of the pedicle of an ovarian cyst is common in pregnancy, and most common in the middle

months. The diagnosis, unless in stout patients, is not difficult as

the tumour can be felt apart from the uterus. Ovarian neoplasms complicating pregnancy are sometimes malignant and cause pain and

vomiting of less intensity than that due to torsion. Ovarian tumours

without torsion usually give rise to no pain whatever in pregnancy. Adhesions.?These may cause intermittent pain of a dragging

nature in the region of an old scar, but my belief is that they do so relatively seldom. Pain of the sharp, fleeting type may be felt in the scar itself, but this is not the result of adhesions, though patients seem happy to think that it is. The frequency of symptomless adhesions to old scars is known to everyone who performs Cassarean section ;

findings at these operations lead me to be most critical of attributing abdominal pain in pregnancy to adhesions. Only by excluding all

other possible causes can the diagnosis be made?and even then with little conviction.

Intestinal Pain.?Reference has already been made to the

tendency to constipation and distension of the bowel during pregnancy. Attacks of colicky pain, occasionally quite severe, may cause con-

siderable alarm on the part of the patient, and may perhaps simulate contractions of the uterus. The absence of vomiting, localised tenderness and other constitutional signs enable more serious lesions to be

discounted. On occasion the intestinal distension may make the

abdomen uniformly enlarged, and care must be taken not to mistake


such enlargement as being due entirely to the undue size of the uterus itself.

The Last Trimester of Pregnancy

Haematoma of the Rectus Abdominis Muscle. This com-

plication, probably not so rare as is generally supposed, occurs most commonly after the sixth month of pregnancy and during labour, and it has frequently given rise to errors in diagnosis. In Torpin's

18

recent article referring to twenty-eight cases from various authors, the correct diagnosis appears to have been made in the first instance in

only eight cases ; that is, in less than a third of the number. Ovarian

and fibroid tumours, placental separation, rupture of the uterus,

hydronephrosis?all these have been erroneously diagnosed at one

time or another. The most important precipitating causes are cough, sudden exertion, and the strain of labour ; and one or other of these

^etiological factors has been noted by all who have recorded individual cases from time to time. Sudden severe pain and the development of a tender abdominal swelling?these form the main clinical features, which result from rupture of the epigastric vessels and laceration of the muscle fibres. A degree of shock may accompany the worst cases ;

and when the haematoma is in the lower part of the rectus muscle it

may burst through the parietal peritoneum with consequent internal haemorrhage which may prove rapidly fatal. Parous women are much

more likely to suffer from the condition than primigravidae. I have seen the condition three or four times. On the first occasion

I operated at the thirtieth week of pregnancy, under the diagnosis of a twisted ovarian cyst, and I confess that the possibility of a rectus haematoma was absent from my mind. There was a large tender swelling in the middle of the abdomen, extending to the left side, the uterus lying to the right. The true nature of the condition was at once apparent on incising the abdominal wall, and the abdominal cavity was therefore not entered. The patient carried on to full-time without further incident, apart from the continuance of her chronic cough, which was the precipitating factor in the case. In her succeeding pregnancy I saw this same patient again with exactly the same condition in the right rectus muscle, though the swelling was smaller on this occasion. In another case a patient, seven weeks from term, developed acute pain and tenderness just below the rib margin on the

right side. An indefinite small swelling was felt on careful examination ; it was so tender, and accompanied by such pain and vomiting, that the gall-bladder was suspected as the cause of the symptoms. A surgical colleague supported this diagnosis ; but the later coagula- tion of the blood led to a small swelling being recognised as a haematoma lying in direct relation to the upper part of the rectus muscle. It gradually subsided without operation.

It may be recalled that there is evidence to show that diseases

such as typhoid fever and influenza may cause degeneration of the rectus muscle. Indeed

" Zenker's necrosis of muscle

" is the term


sometimes applied to the condition, as Zenker in 1876 was one of the first to describe it. Influenza with severe coughing is so common

that this point is worth noting. Torpin makes the useful suggestion that a soft tissue X-ray photo-

graph might show the outline of a large rectus haematoma anterior to the uterus. This might be a helpful diagnostic procedure ; but it is

clear that, if the condition is kept in mind, the diagnosis should seldom be difficult.

Costal Margin Pain.?Late in pregnancy primigravidae may

complain of sharp pain at the attachment of the rectus muscle to the costal margin, and usually the area is tender on pressure. I have

noted this several times and attributed it to stretching of the muscular attachments. Browne 2 states that there is no evidence that stretching of the anterior or lateral abdominal walls causes pain in pregnancy ;

but I think that pain, in the localised area just referred to, may have the explanation suggested. In two cases I applied Elastoplast bandages with great benefit to the patient. De Lee19 refers to

this pain, and Montgomery 4 wrote of it long ago, stating that he had known of the pain being mistaken for that due to inflammation

of the liver.

Separation of Placenta

(?) Placental separation of minor degree gives rise to a small

retroplacental haematoma, which causes sharp pain in the uterus of short duration. If the placenta is anterior a tender area on the uterine wall can be made out ; but if the placenta is posterior no tenderness can be elicited. The foetus is unaffected in these minor cases.

Evidence of pregnancy toxaemia may or may not be present. (?) Accidental Haemorrhage.?The external variety, associated

with uterine pain and vaginal haemorrhage, gives rise to no difficulty in diagnosis, and the patient's general condition is good or bad according to the amount of obvious haemorrhage. We need not discuss it further.

Concealed Accidental Haemorrhage. Sudden severe pain associated with a tender uterus, followed by marked deterioration of the patient's condition ending in shock?these form the typical clinical picture. Vaginal bleeding is scanty or completely absent. The tender uterus is hard, very hard, and toxic symptoms are nearly always present. In such typical cases the diagnosis is usually at once evident. But atypical cases do occur. De Lee,19 whose obstetric experience over many years has been equalled by few, wrote in the last edition ?f his textbook : "In the concealed haemorrhages, which are the

severe cases, the pain is often more marked, but it may be slight or absent." And again :

"

Exceptionally the uterus is flabby and dilated. One would expect the board-like uterus in the concealed cases and the relaxed uterus where the blood finds ready exit, but this is not

constant." I have personally seen only one case of concealed accidental

haemorrhage in which the uterus was not hard. Severe uterine pain and uterine hardness are classical features, but rarely one or both

vol. li. no. 5 Q


may be absent. Marked tenderness over the uterus is, however,

practically always present, and fcetal death commonly follows the

placental separation. The pulse, too, may be misleading. It is usually rapid and soft

early in the illness, but it may be full and bounding, even when severe

pain and other clinical features suggest the diagnosis of concealed

haemorrhage. If shock rapidly follows the placental separation the

pulse quickly accelerates and weakens ; but the pulse may be slow until further haemorrhage or later shock brings the inevitable change. The slow pulse and acute abdominal pain may suggest conditions such as appendicitis or perforation of a viscus. In 1923 Fordyce and

Johnstone 20 described a case of concealed haemorrhage of considerable interest. The patient was parous, and her stoutness made accurate examination of the abdomen difficult. The family doctor, on account of the severe pain, diagnosed rupture of a viscus ; a short time later,

though the patient was pale and had an agonised look, the diagnosis of impending eclampsia was considered by Dr Fordyce and for three reasons. Firstly, the urine was solid with albumen ; secondly, the severe pain was then more in the epigastric area ; and thirdly, the

pulse was slow. Two hours later vaginal haemorrhage began and the pulse accelerated ; concealed haemorrhage was then confidently diagnosed and the case treated accordingly.

The pain of concealed haemorrhage has been variously described as a dull tense ache, pain as if to burst, something giving way, pain of a tearing character ; but one thing is clear, when the pain has

begun it is constant and not intermittent, whether it is felt mainly in the abdomen, as is the rule, or in the back, as occasionally is the case. If palpation can be carried out with little difficulty, the tenderness is found localised to the uterus and the abdominal muscles may show a

degree of rigidity. Sudden, severe abdominal pain occurring late in pregnancy should always bring to mind the possibility of concealed accidental haemorrhage, but it is obvious that various factors may make difficult the correct assessment of such pain at the first examination. When shock is minimal, or has passed off, labour rapidly ensues ;

but in a recent case the onset of labour was delayed for six days, even though the placental separation was so great that the foetus had at once died. Throughout these six days the pain was moderate in

degree, constantly present, and mainly in the back. The long period of delay made one at times doubt the diagnosis, especially as the

general condition of the patient caused little anxiety. Rupture of the Uterus.?During pregnancy this is rare unless

there has been a previous operation such as a classical Caesarean

section. If the rupture is sufficient to allow the foetus to escape into

the abdomen, the foetus is easily felt, and the now smaller contracted uterus may be palpated separate from the child. Sudden acute pain is the first sign of disturbance, and collapse usually follows quickly from intraperitoneal bleeding. But occasionally the tear in the old

scar is small in extent and the foetus remains in utero ; consequently


no alteration in the normal contour of the uterus occurs. Collapse will of course occur if much internal bleeding occurs. These cases

are not easy to diagnose?the acute pain, the collapse, and the some- what tender uterus together make a picture closely simulating that of concealed accidental haemorrhage, a similarity made still closer

should pregnancy toxaemia be an accompanying complication. As

the diagnosis between the two conditions may mean the difference between urgent abdominal operation and conservative treatment,

every effort must be made to assess accurately every feature. The first

case of rupture of the uterus that I was called upon to deal with in

private practice was one of rupture of an old Caesarean scar at the

thirty-fifth week of pregnancy, which was complicated by toxaemic symptoms. In spite of the history being known, my own diagnosis of concealed accidental haemorrhage was confirmed by a colleague. The diagnosis was changed to rupture of the uterine scar some hours later when the uterine contour altered as the foetus began to escape. I think it may be fairly stated that operation should be undertaken at once if any doubt is present in the examiner's mind.

Rupture of Vein on the Uterine Wall.?Instances of this

condition are uncommon, but reference is made to it by different

writers. My own experience is limited to two cases, one primigravid and one parous. The rupture of the vein occurred in each case about four weeks from term and led to marked abdominal pain, which

became generalised over the abdomen. Intestinal distension followed

and this was associated with vomiting in one of the two cases. Uterine

tenderness was absent and the foetal heart audible ; but the pulse steadily rose while the temperature remained subnormal. In the first

case operation was performed for "

possible obstruction," as vomiting was so severe and shock not a marked feature. In the second case

no diagnosis was made prior to operation except " internal haemor-

rhage." In each case blood was found issuing from a vein on the posterior uterine wall about two-thirds of the way down. I know of no way of making a definite diagnosis?the symptoms point only to the probability of internal haemorrhage if the loss is free.

Torsion of the Gravid Uterus.?This extremely rare condition

presents the picture of " an acute abdomen." The only full description

in the English language is that by Leyland Robinson,21 whose article, written in a truly masterful manner, well repays careful study. Con-

tinental writers infer that diagnosis is almost impossible, but Leyland Robinson presents a clear, reasoned statement as to how an accurate

diagnosis can be made of such a rare complication of pregnancy. I shall quote just one paragraph.

" The appearance of acute symptoms

Jn a pregnancy that is known to be associated with either a bicornuate

uterus or fibroids, especially when the symptoms resemble perforation of the bowel, extra-uterine gestation or concealed accidental haemor-

rhage, should always arouse the suspicion of torsion. Information

must be sought as to the posture of the patient immediately preceding the onset of symptoms, for in most cases the one is directly related to


the other. Some reliance should be placed on the general condition of the patient, for in all cases of severe torsion of the gravid uterus there is initial and profound shock. The absence of the latter will be

a strong contra-indication to the diagnosis." Epigastric Pain.?The onset of sudden epigastric pain late in

pregnancy should raise in the mind of the physician the possibility of underlying severe toxaemia. That the pain is due to some degenerative or vascular change in the liver is commonly accepted ; but the

actual determining cause of the pain is still unknown. On occasion

the pain is intensely severe and may develop in a woman in whom, up to that time, signs of toxaemia had not been marked ; indeed, there

may have been no obvious signs of toxaemia at an examination made a few days previously. In such cases a diagnosis of perforation of

gastric or duodenal ulcer may be seriously considered ; and it is

known that operation on such a diagnosis has on more than one

occasion been performed. Some rigidity of the upper abdomen may accompany the pain, though it is never as marked as that due to

perforation of an ulcer. But when the uterus completely fills the tight abdomen of a primigravid woman it is not easy to determine whether

marked rigidity is present or not. From my own experience I should

say that the acute epigastric pain of toxaemia is commoner in those

women who exhibit little or no oedema, but the blood pressure is always elevated. I cannot recall any case of severe pain without some degree of hypertension being present ; but I have known those in whom

both oedema and albuminuria were practically absent when the pain developed. Typical cases present no difficulty ; but if a gastric ulcer should perforate in a patient showing toxaemic symptoms, the diagnosis may be extremely difficult until a period of observation clarifies the clinical picture. But disaster may follow just such a period of delay if perforation has actually occurred, and one such case came to my personal notice last year. Vomiting is frequently absent in cases of toxaemic epigastric pain, but it may follow after a short interval and so increase the difficulty in diagnosis. But the pain remains in the original situation, whereas with the perforated ulcer it may extend lower down in the abdomen. In doubtful cases enquiry should, if

possible, be made as to any symptoms prior to pregnancy suggestive of ulceration in the upper digestive tract, for it is a fact that perforation is a rare occurrence in pregnant women without such previous history- Perhaps the infrequency of hyperchlorhydria in the latter part of

pregnancy has a bearing on this point ; on the other hand, hypo- chlorhydria is by no means uncommon.

The gall-bladder, too, must be considered as one of the causes of

upper abdominal pain in the later weeks of pregnancy. In parous women symptoms of gall-bladder disturbance are not uncommon, for

pregnancy seems liable to affect adversely a previously diseased organ- If pyrexia is absent the diagnosis may not be clear, but scapular pain and jaundice, if present, will be helpful features when palpation is rendered difficult by the presence of the large uterus. In toxic


epigastric pain scapular pain is absent, jaundice uncommon, and

pyrexia unusual. From the preceding discussion it is clear that in the differential

diagnosis of abdominal pain of doubtful origin there are, in particular, four acute surgical conditions that must be kept in mind. These are

appendicitis, obstruction, gall-bladder disease and gastric ulcer.

Difficulty in diagnosis increases with the progressive advancement of pregnancy.

Pain associated with Foetal Movements.?Pain due to the

presence of the foetal head in the fundus of the uterus and to move-

ment of the limbs is met with commonly. Some women suffer con-

siderably from movements of a limb against the same part of the uterine wall, the localised area affected being markedly tender in

many cases. At first sight it might seem not unreasonable that women should suffer in this way, but the explanation is not, I think, altogether clear. The upper part of the uterus is more often the site of a painful area than the lower part, as far as movements of the limbs are con-

cerned. But why should pain ever be caused by foetal movements ? Is the pain appreciated by the parietal- peritoneum overlying the area, or is it felt in the uterine wall itself ? The uterus, we believe, is supplied entirely by nerves of the autonomic system and, on general principles, pain should not therefore be appreciated by the uterine wall when the stimulus is of the type which should only produce the sensation of

pain when transmitted by the nerves of the somatic system. That the

pain from repeated foetal movement at one area may be appreciated by the uterus itself is shown by the fact that, if the patient is turned on her side so that the uterus moves away from its previous position, palpation of the uterine area will still reveal tenderness. It would

therefore appear that the uterus does, in certain circumstances, appreciate pain from stimuli that are not usually so interpreted by the autonomic system. Further, it is not an uncommon experience, particularly in parous women, to find the uterus generally tender in the latter part of pregnancy ; and some of the women who suffer

from such a tender uterus have false labour on more than one occasion. When the uterus does go into labour, inertia is not infrequently present. That the uterus appreciates pain when the muscle contracts is what

one would expect on account of its nerve supply, but our present knowledge of the uterine nervous mechanism does not reveal why pain and tenderness should result from a traumatic stimulus to a

localised area. I have noticed, when carrying out Cassarean section under local anaesthesia, that the patient may register sensation when the uterine wall is incised and when every care is taken not to exert

pressure as the incision is made. Again, clamping of the tube (avoiding the broad ligament tissues) may also be felt quite definitely by the

Patient, and the tube is, after all, only the upper part of the Mullerian duct from which the uterus is developed. The peritoneum covering the uterus is derived from the same mesothelial tissue as the peritoneum ^hich covers the posterior abdominal wall, which is, of course, supplied

vol. li. no. 5 Q 2


by somatic nerve elements. It is not clear at what stage in development the differentiation occurs between the somatic nerve supply to the posterior parietal peritoneum and the autonomic supply to the

peritoneum which develops over the growing Mullerian ducts. White

and Smithwick have drawn attention to the fact that more is yet to

be discovered on the nervous mechanism of the uterus.

Pain of Orthopaedic Origin

Postural Pain.?During pregnancy aching pain in the lower

abdomen on one or other side may result from postural defect in the

spine. The individual may complain mainly of backache, but some stress iliac fossa aching as the main disturbance. If strain is present at the junction of the dorsal and lumbar curves of the spine as the result of altered carriage consequent upon the increasing size of the

uterus, pain may be referred through the ilio-hypogastric and ilio-

inguinal nerves, for these arise in the last dorsal and first lumbar

segments and have a cutaneous distribution in the iliac fossa.

Symphysis Pubis Pain.?Towards the end of pregnancy, laxity may occur at the symphysis of a degree sufficient to cause sharp pain on movement such as walking or rising from a chair. But the individual

may state that the pain is felt in the lower abdomen. She may not

appreciate the fact that the pain arises from the anterior part of the

bony pelvis until the manipulations of the examiner demonstrate the site of origin. The pain from this cause is sharp in character and midline in position. I have found it in both primigravid and parous women.

REFERENCES

1 Hamilton, A. (1796), Outlines of the Theory and Practice of Midwifery, London. 2 BROWNE, F. J. (1942), Ante-Natal and Post-Natal Care. 3 Adair, F. L., and Stieglitz, E. J. (1934), Obstetric Medicine. 1 Montgomery, W. F. (1856), An Exposition of the Signs and Syjnptoms of

Pregnancy, 2nd ed. 5 DOUGAL, D. (1927), Brit. Med. Journ., 2, 1074. 6 Mackenzie, J. (1893), Brain, 16, 321. 7 Morley, J. (1931), Abdominal Pain. 8 Brown, F. R. (1942), Brit. Med. Jour?i., 1, 543. 9 White and Smithwick (1942), The Autonomic Nervous System.

10 Munro Kerr, J. M. (1907-08), Trans. Edin. Obstet. Soc., 33, 185. 11 Munro Kerr, J. M. (1937), Operative Obstetrics. 12 MlDDLETON, D. S. (1929), Trans. Edin. Obstet. Soc., 49, 193. 13 MORISON, D. M. (1943). Edin. Med. Journ., 50, 661. 14 JERLOV, E. (1925-26), Acta Obst. Gyn. Scandi?iav., 4, Suppl., H. 1-2, 1. 15 Baer, J. L., Reis, R. A., and Urens, R. A. (1932), Journ. Amer. Med. Assoc.,

98, 1359- 16 Maes, U., et al. (1934), Amer. Journ. Obst. and Gyn., 27, 214. 17 Marbury, W. B. (1933). Amer. Journ. Surgery, 19, 437. 18 TORPIN, R., and HOLMES, L. P. (1943), Amer. Journ. Obst. and Gyn., 46, 268. is De Lee, J. (1938), Principles and Practice of Obstetrics. 20 Fordyce, W., and Johnstone, R. W. (1923), Trans. Edin. Obst. Soc., 43, 29. 21 Robinson, A. L., and Duvall, H. M. (1931), Journ. Obst. Gyn. Brit. Emp?>

38,55.

Abdominal Pain in Pregnancy - Semantic Scholar

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