Abdominal Pain In Pregnancy

Abdominal pain or periods like cramps are one of the very common symptoms of pregnancy. Most of the time it is normal and nothing to worry about but sometimes there may be some serious underlying reason for the pain. 

Normal Pregnancy Pains

- Once you get pregnant your uterus starts to grow and this may cause mild to moderate pain in your lower abdomen and lower back. The pain feels like a pressure or like some stretching or pulling. Some woman may describe it as similar to usual periods like cramps. 

Later in pregnancy when baby grows and puts on weight , you may feel uncomfortable and abdominal organs do get pushed away giving a sense of pressure and pain. 

How to Get Relief   

If abdominal pain is mild and not a sign of labor or any other serious underlying condition it usually gets relieved by:

- Changing your posture

- Lying down and getting some rest.

- Drinking plenty of fluids. 

- Taking a warm bath.

- Eating some light snacks.

- Gentle stretching of back and leg muscles. 

Serious Causes 

Management Of Asthma In Pregnancy

Introduction
Asthma is the most common respiratory disorder affecting 3% of women of childbearing age. Pregnancy has a variable effect on asthma but for the vast majority of women there is no impact whatsoever.

The most common reason due to which asthma symptoms appear is that patients reduce their treatment because of a belief that the medication may be harmful. All commonly used medications
to control asthma are safe in pregnancy. All patients must be reassured that any flairs of their asthma must not be ignored and that treatment with medication such as steroids is safe both for themselves and for their fetus.

With regard to the effect of asthma on fetal outcome, there is no evidence that there is any significant impact on fetal growth or outcome.

Any patient whose asthma seems to be deteriorating, particularly in the third trimester, should be seen by an obstetric physician for review. It is obviously desirable that control of their asthma should be at its optimum prior to the onset of labor.

Management Of Asthma In Pregnancy
The best way to manage asthma is to avoid having an attack in the first place. 

Patient should be counselled to avoid exposure to her asthma triggers. This would help in improving the symptoms and decreasing the need of medications. 

The treatment and medicines are almost the same for pregnant woman as well as non pregnant asthma patients.

Management of Acute Asthma

• Pregnant women with asthma should be considered to be high-risk patients, and their management requires a close monitoring by the physician as well as an obstetrician.
• Evaluation in the emergency department and treatment of the pregnant asthmatic patient is almost the same as in the nonpregnant state, with some modifications.

Gynecological Examination - A Brief Discussion

General Principles
The majority of women have varying degrees of anxiety about vaginal examination.
Examination is usually more informative in a relaxed patient and a number of simple measures can be used to make the patient feel at ease.

Women should be given an appropriate area to change in privacy. A sheet should be provided to allow the woman to cover herself. A chaperone should be present for any intimate examination. This should apply for both male and female practitioners. The chaperone provides two purposes, firstly as a source of support and distraction for the patient but also to provide evidence that no improper behavior has taken place.
Formal consent should be given for any intimate examination by a student including under anesthesia.

An explanation of the purpose of the examination should be given to the woman and permission sought to perform the examination. Simple terms should be used to explain the likely sensations experienced. The examination should be thorough but gentle. The patient should feel confident that you will stop the examination if she wishes.

Abdominal Examination:
This must never be omitted, whatever be the patient’s complaint.

• Many gynecological tumors form large swellings, which could be palpated on abdominal examination. 
• Also an abdominal examination may reveal an undisclosed pregnancy
• Always examine the upper abdomen. 
• Be certain that the bladder is empty.
• Ask the patient to tell you if you are hurting her.

All the classical techniques of inspection, palpation, percussion and auscultation are advised, but the most important is gentle palpation with the flat of the hand to detect solid or semi-solid tumors.
The examiner must bear in mind the various intra-abdominal structures which may give rise to swellings.

Sickle-cell Disease in Pregnancy

Sickle-cell disease (SCD) is caused by a group of hemoglobin disorders (single gene recessive) which predispose to ‘sickling’ of red cells in low oxygen conditions causing vaso-occlusion in small vessels, and cells prone to increased haemolytic breakdown.
Sickle cell disease is most prevalent in those of African descent but it is also prevalent in the Caribbean, Middle East, Mediterranean, parts of India, South and Central America.

Disease complications include 

• painful crises, 
• stroke,
• pulmonary hypertension,
• renal dysfunction, 
• leg ulcers, 
• retinal disease, 
• avascular necrosis (eg of hip).

Pregnancy complications include

• maternal painful crises,
• prematurity 
• fetal growth restriction. 
• increased chances of maternal infection, 
• thromboembolic events and 
• pre-eclampsia.

Preconception Care 

• Women with SCD should be under annual clinic review to monitor disease. Arrange hematology specialist for a preconception review. 

A Brief Discussion on Different Types of Abortion/Miscarriage.

Spontaneous Miscarriage is associated with

• vaginal bleeding an abdominal discomfort. 
• Severe pain, 
• heavy bleeding, 
• passage of clots or tissue, and 
• hypotension may also be present. 

Threatened Abortion: Mild cramping an vaginal bleeding that are not accompanied by passage of tissue or cervical dilation constitutes a threatened abortion.

Inevitable Abortion: Uterine cramping with progressive cervical dilation indicates an inevitable abortion.

Incomplete Abortion: An incomplete abortion is diagnosed when some products of conception (POC) have passed, while other retained intrauterine tissue leads to ongoing symptoms.

Septic Abortion: Fever, leukocytosis, pelvic tenderness, and malodorous cervical discharge suggest a septic abortion.

Completed Abortion: is characterized by the passage of confirmed POC, followed by resolution of bleeding and closure of the cervical os. Large blood clots or intrauterine decidual casts may be mistaken for POC and their presence cannot be use to rule out ectopic pregnancy.

Management: 

• Immediately obtain large-bore intravenous access an institute aggressive fluid resuscitation for any patient with severe pain, heavy bleeding, or hypovolemia. Also request cross-matched blood an urgent gynecologic consultation. 

Invasive Prenatal Diagnosis

Introduction
Once a woman has been given a high risk of aneuploidy based on a Down screening, a structural anomaly detected on scan or because of her previous history an obstetrician would normally counsel the women on the options of invasive karyotyping.
This counselling should be based on the risk of aneuploidy, the voluntary nature of the test, the option of no testing, the technique of the proposed test, the procedure-related loss rate and other common complications associated with the test, the timing of the result and the possible management options depending on the result of the test. This decision to balance the potential risk of the loss of an unaffected fetus against that of having an affected child is a very difficult and traumatic one and it is
important that the parents are not rushed into a premature decision.

1. Amniocentesis
Amniocentesis should be performed after 15 weeks when the uterus is an abdominal organ and the proportion of fluid needed to be removed (15–10 ml) is relatively small compared to the overall liquor volume at this gestation (150–250 ml).

Procedure: The procedure is performed under aseptic conditions under continuous ultrasound guidance. Best practice is for the operator to introduce a gauge 22–20 needle percutaneously while he or she is continuously scanning using the free hand. The needle is preferably introduced into a cord free pool of liquor avoiding the placenta. Once in place the inner stylet of the needle is withdrawn and an initial 2 ml of amniotic fluid is withdrawn by an assistant and discarded to avoid maternal contamination. Then a further 15–20 ml is removed using a 10–20 ml syringe.
A few operators use a needle guide attached to the transducer, but this has the disadvantage of being less flexible if the needle needs to be realigned.

There is clearly a learning curve with any invasive procedure. Studies have demonstrated the significance of operator experience in terms of both failed attempts and miscarriage. Amniocentesis is therefore not a routine procedure and it is recommended by the Royal College of Obstetricians
and Gynaecologists (RGOG) that it is only performed by adequately trained individuals with at least 50–100 supervised procedures and 50 procedures per annum to maintain their skills. In general only two needle insertions should be attempted and if these fail then the woman should be referred to a tertiary level fetal medicine unit for repeat attempts.
The miscarriage rate for amniocentesis is generally quoted as 1:100 (1%) .