Abdominalpainduringpregnancy
MitchellS.Cappell,MD,PhD,FACGa,b,*,
DavidFriedel,MDc
aDivisionofGastroenterology,DepartmentofMedicine,WoodhullMedicalCenter,760BroadwayAvenue,Brooklyn,NY11206,USAbStateUniversityofNewYorkDownstateMedicalSchool,450ClarksonAvenue,Brooklyn,NY11203,USAcDivisionofGastroenterology,DepartmentofMedicine,TempleUniversitySchoolofMedicine,3401NorthBroadStreet,Philadelphia,PA19149,USA
Abdominalpainisacommoncomplaintoffemaleinpatientsand
outpatientsofallages[1],includingwomenduringtheirchildbearingyears,
andthusoftenoccursduringpregnancy.Abdominalpainduringpregnancy
presentsuniqueclinicalchallenges.First,thedifferentialdiagnosisduring
pregnancyisextensive,inthattheabdominalpainmaybecausedby
obstetricorgynecologicdisordersrelatedtopregnancy,aswellasby
intraabdominaldiseasesincidentaltopregnancy.
Second,theclinicalpresentationandnaturalhistoryofmanyabdominal
disordersarealteredduringpregnancy.Third,thediagnosticevaluationis
alteredandconstrainedbypregnancy.Forexample,radiologictestsand
invasiveexaminationsraiseissuesoffetalsafetyduringpregnancy.Fourth,
theinterestsofboththemotherandthefetusmustbeconsideredintherapy
duringpregnancy.Usually,theseinterestsdonotconflict,becausewhatis
goodforthemotherisgenerallygoodforthefetus.Sometimes,however,
maternaltherapymustbemodifiedtosubstitutealternativebutsafertherapy
becauseofconcernsaboutdrugteratogenicity(eg,substitutingahistamine2receptorantagonistformisoprostol,anabortifacientthatiscontraindicated
duringpregnancy)[2,3].Rarely,thematernalandfetalinterestsarediametri-
callyopposed,asintheuseofchemotherapyformaternalcancer,atherapy
thatispotentiallylife-savingtothemotherbutlife-threateningtothefetus[4].
Theseconflictsraisesignificantmedical,legal,andethicalissues.
Gastroenterologists,aswellasobstetricians,gynecologists,internists,
andsurgeons,shouldbefamiliarwiththemedicalandsurgicalconditionsGastroenterolClinNAm32(2003)1–58
*Correspondingauthor.DepartmentofMedicine,WoodhullMedicalCenter,760BroadwayAvenue,Brooklyn,NY11206.
0889-8553/03/$–seefrontmatterÓ2003,ElsevierScience(USA).Allrightsreserved.PII:S0889-8553(02)00064-Xthatcanpresentinpregnancyandhowtheseconditionsaffectandare
affectedbypregnancy.Thisarticlereviewsobstetric,gynecologic,medical,
andsurgicalcausesofabdominalpainduringpregnancy,withafocuson
aspectsofabdominaldiseasesuniquetopregnancy.
Abdominalpainduringpregnancy:generalconsiderations
Neurophysiologyofabdominalpain
Nociceptioninvolvesaffectiveorautonomicreflexesfromabdominal
visceratothecerebralcortexinvolvingthreelevelsofneurons.Thefirst-
orderneuronsareeitherCorA-deltafibers.Cfibersarenarrow,slowly
conducting,andunmyelinatedandproduceadullandnonlocalized
sensationofpain.A-deltafibersarewider,partlymyelinated,andfaster
conductingandproduceasharpandlocalizedsensationofpain.Thefirst-
levelafferentneuronstravelfromabdominalstructurestosynapseinthe
dorsalhornofthespinalcord.Thesecond-orderneuronscrossthemid-
linetothecontralateralsideofthespinalcordtoascendthroughthe
spinothalamicandspinoreticulartractstothethalamicandreticularareas
oftheponsandmedulla[5].Third-orderneuronstraveltothelimbicsystem
andsensorycortexwherepainisperceived[6–8].
Abdominalpaincanbevisceral,arisingfromgastrointestinalorgans;
parietal,arisingfromperitonealirritation;somatic,arisingfromthe
abdominalwall;neurologic,arisingfromdiseasesaffectingabdominal
nerves;extraintestinal,fromreferredpain;orcerebral,fromneuropyschi-
atricdisordersorfactitiousdisease.Visceralpaintendstobedull,poorly
localized,andperceivedinthemidabdomenbecauseafferentnervefibers
fromabdominalvisceratypicallyareCfibersandreceivemultisegmental
andbilateralafferentinnervationfromthespinalcord.Visceralpainmay
beaccompaniedbyautonomicconcomitantsofnausea,diaphoresis,and
pallor.Abdominalvisceraaremostsensitivetomuralstretch.Parietalpain
tendstobemoreacute,intense,andfocalbecauseitisconveyedbya
mixtureofA-deltaandCfibersandtendstohavemorediscreteinnerva-
tionfromthespinalcord[9].Parietalpainisexacerbatedbycoughing,
movement,anddeepinspiration.Somatictissueinskin,subcutaneous
tissue,andmuscleisinnervatedpredominantlybyA-deltanervefibersso
thatsomaticpainisfocalandsharp.
Referredpainisfeltremotelyfromtheaffectedareabecauseofthe
convergenceofvisceralandsomaticafferentneuronstothesamelevelofthe
spinalcordandtheuseofthesamesecond-orderneurons.Forexample,
painfromgastrointestinaldisorders,suchasacutecholecystitis,orpain
fromobstetricdisorders,suchasectopicpregnancy,maybereferredtothe
shoulderorback[10].Conversely,painfromanextraabdominalcondition,
suchasamigraineheadache,maybereferredtotheabdomen.2M.S.Cappell,D.Friedel/GastroenterolClinNAm32(2003)1–58
