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M Character and in Intensity. Colicky, Cramp-Like, Cutting, Tearing

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M Character and in Intensity. Colicky, Cramp-Like, Cutting, Tearing 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 2 " Ante-Natal Care, F. J. Browne states : Fully 80 per cent, of women suffer from abdominal pain of greater or lesser degree during preg- nancy, 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 text- " book 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 con- dition. 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. Second Trimester. Third Trimester. Iliac fossa pain. Hydatidiform mole. Haematoma of rectus abdominis. Round ligament pain. Acute hydramnios. Costal margin pain. Previous obstetric Pyelitis. Concealed accidental haemor- trauma. rhage. Ectopic gestation. Ureteral spasm. Rupture of uterus. Retroflexion of gravid Appendicitis. Rupture of vein on uterine wall. uterus. Ovarian hsemorrhage. Fibroid tumour. Torsion of gravid uterus. Angular pregnancy. Ovarian tumour. Epigastric pain. Adhesions. Gall bladder pain. Intestinal 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- be heard from the of tions may lips sufferers at various stages of preg- ? nancy. Further, some pains are persistent, others intermittent It is note than an not enough to 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. 3 Adair and Stieglitz 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. 2 Browne states that the round ligament, by stretching, may definitely cause pain, and may do so up to the fifth month. Many other writers 4 support this view, and Montgomery 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 gener- ally 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- 232 E. CHALMERS FAHMY 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.
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