PAIN DURING PREGNANCY

DEFINITION

An unpleasant sensory and emotional experience associated with actual or potential tissue
damage.

- Farlex medical dictionary

OR

It is a varying degree of unpleasant sensation, It may be acute with rapid onset and ends in days
or chronic that recurs or persists for more than six months.

- Muhammad El Hennawy

CAUSES OF PAIN DURING PREGNANCY

ECTOPIC PREGNANCY

 The most common obstetric cause of an acute abdominal pain in the first trimester is
ectopic pregnancy.

 History, pelivc examination, serum ß-hCG, culdocentesis, vaginal sonography, and

laparoscopy can all be valuable in establishing the diagnosis.

 Treatment is surgical, with laparoscopy or laparotomy. Linear salpingotomy, linear

salpingostomy, or salpingectomy can be performed

ROUND LIGAMENT PAIN

 With advancing gestational age as the uterine size increases.

 The round ligaments, found on the right and left sides of the uterus, attach to the pubic
bone and help support the placement of the uterus in the abdominal cavity.
 These ligaments endure continual stretching and are a common source of pain in the latter
part of pregnancy.
 Pain, either a sharp spasm or dull ache continuous, and may be described as a stretching
or pulling sensation, is felt on one, or sometimes both, sides of the lower abdomen , often
described as "round ligament pain"; however the exact origin of this pain many vary from
patient to patient.
  This pain may be relieved by heat or acetaminophen,
 It is a benign and usually self-limiting occurrence that commonly causes discomfort in
the second trimester

UTERINE TORTION

 The uterus rotates axially 30 °- 40° to the right in 80% of normal pregnancies.
 Rarely, it rotates > 90° causing acute uterine torsion in mid or late pregnancy with
abdominal pain, shock, a tense uterus, and urinary retention (catheterization may reveal a
displaced urethra in twisted vagina).
 Fibroids, adnexal masses, or congenital asymmetrical uterine anomalies are present in
90%.
 Diagnosis is usually at laparotomy.
 Delivery is by caesarean section

PRESSURE SYMPTOMS

 Upper abdominal pressure -- pain due to flaring of the ribs particularly in breech
presentation - The ribcage expands enormously during pregnancy to help make room for
the expanding uterus and to maintain adequate lung capacity. Many pregnant women
experience rib discomfort from this expansion, as well as the occasional little foot or knee
of fetus that might habitually press against the ribs.
 Mid abdominal pressure -- distension of the abdominal wall ( Twins , polyhydramnios )
 Lower abdominal pressure -- engagement of the head
PLACENTAL ABRUPTION

 Placental abruption is premature separation of the placenta from the uterus, resulting in
bleeding from the site of placental attachment (concealed , revealed . Combined )
 Abruption The triad of abdominal pain, uterine rigidity, and vaginal bleeding suggests
this.
 It occurs in between 1 in 80 and 1 in 200 pregnancies.
 Fetal monitoring may indicate fetal tachycardia and Fetal loss is high (up to 60%).
 A tender uterus is highly suggestive and may be identified on tocography
  Ultrasound may be diagnostic (but not necessarily so).
 Minor abruptions with no maternal or fetal compromise may be managed conservatively,
while others are true obstetric emergencies
 A live viable fetus merits rapid delivery as demise can be sudden.
 Prepare for DIC, which complicates 33% -50% of severe cases.
 Beware PPH, which is also common
SEVERE PREECLAMPSIA

 Right upper quadrant pain may be a manifestation of severe pregnancy-induced

hypertension or preeclampsia, and is related to a combination of hepatic edema and
ischemia - subcapsular hepatic hematoma even hepatic rupture
 Women with severe pre-eclampsia must be delivered rapidly

INTERSTITIAL CYSTITIS

 Interstitial cystitis is another painful condition of the bladder, which causes a burning
pain over the bladder area.
 Urine analysis may reveal mast cells in this condition but their significance is debated.
 Some studies have reported greater numbers of these cells in the detrusor muscle of
patients with interstitial cystitis than in normal detrusor muscle
ACUTE PYELONEPHRITIS

 Acute pyelonephritis must always be considered in the differential diagnosis of

abdominal or flank pain in pregnancy, and must also be considered in any patient with
obstructive urinary calculi.
 Classic symptoms include back or flank pain in association with fever, chills, nausea,
vomiting, and malaise. Patients may also complain of uterine contractions. On
examination the patient is often febrile, looks ill, and will have costovertebral angle
tenderness on the affected side. Clinical presentation may range from mild, nonspecific
discomfort to urosepsis.
 Initial evaluation of the patient with suspected acute pyelonephritis should include a
microscopic analysis of the unspun urine. Pyuria is almost always present and a Gram
stain will often reveal bacteria, indicating >105 colony forming units per milliliter.
  Early identification of either gram-negative or gram-positive bacteria in this manner can
also help guide initial antibiotic selection.79,80 Leukocytosis will generally be present,
often with an increase in immature forms, or bands, and urine and blood cultures should
also be obtained prior to initiation of antibiotics. A serum BUN and creatinine should
also be obtained for assessment of baseline renal function in any patient with suspected
pyelonephritis. While urine cultures of >105 colony forming units per milliliter are
generally seen with pyelonephritis, 20 percent of patients will have urine cultures with
lower colony counts.79,80
 Pregnant women with pyelonephritis generally warrant inpatient therapy. Many will
require intravenous hydration, and may be too ill to tolerate oral antibiotics, and those
who have reached the stage of fetal viability will require close observation for the first 24
to 48 hours for preterm labor.
 Initial antibiotic therapy may be guided by the Gram stain before the urine culture results
are available. Second- or third-generation cephalosporins are generally effective against
gram-negative bacteria,
 Although local resistance patterns should always be considered. Demonstration of gram-
positive bacteria on Gram stain is concerning for enterococci and so empiric therapy with
ampicillin and gentamicin should be instituted.
PUBIC SYMPHYSIS PAIN OR PELVIC PAIN

 Pubic symphysis separation is a recognized complication of pregnancy with incidence

estimates ranging from one in 300 to one in 30,000.
 Characteristic symptoms of symphyseal separation include suprapubic pain and
tenderness with radiation to the back of legs, difficulty ambulating and, occasionally,
bladder dysfunction.
 There is a minor pregnancy-induced physiological increase in laxity of the symphyseal
soft tissue. There is no evidence that the degree of symphyseal distention determines the
severity of pelvic pain in pregnancy or after childbirth
 A diagnosis can often be made on the basis of clinical history, presenting symptoms but
sometimes ultrasound documentation of symphyseal separation are frequently used to
confirm the diagnosis.
  Ultrasound measurement of the symphyseal width shows around 4 mm in non-pregnant
women. Asymptomatic pregnant women have an average width of 6.3 mm. The majority
of pregnant women with 9.5 mm or more have symphyseal pain
 It is associated with two or more children, large babies and an abnormal loosening of the
joints typical of pregnancy.
 Treatment of this condition conservatively with bedrest, pelvic binders, ambulation
devices and mild analgesics.
SACROILIAC STRAIN OF PREGNANCY

 The sacroiliac joint is where the back of the pelvis connects with the sacral vertebrae of
the lower spine.
 Most body types display a small dimple on each side of the low back at the sacroiliac
joint. Generally, this joint moves very little, however; instability from increased ligament
laxity at this joint can occur during the last half of pregnancy and, more commonly, the
postpartum period.
 Sacroiliac instability is painful and may cause functional weakness in one or both legs,
and low back muscle spasms. Bending, lifting and carrying, sitting with the legs crossed
or to one side, prolonged standing/slouching, or walking up a steep hill may aggravate the
condition.
BACK PAIN

Pregnancy back pain typically happens where the pelvis meets your spine, at the
sacroiliac joint.

There are many possible reasons why it happens. Here are some of the more likely causes:

 Weight gain . During a healthy pregnancy, women typically gain between 25 and 35
pounds. The spine has to support that weight. That can cause lower back pain. The weight
of the growing baby and uterus also puts pressure on the blood vessels and nerves in the
pelvis and back.
 Posture changes. Pregnancy shifts your center of gravity. As a result, you may gradually
-- even without noticing -- begin to adjust your posture and the way you move. This may
result in back pain or strain.
  Hormone changes. During pregnancy, your body makes a hormone called relaxine that
allows ligaments in the pelvic area to relax and the joints to become looser in preparation
for the birth process. The same hormone can cause ligaments that support the spine to
loosen, leading to instability and pain.
 Muscle separation. As the uterus expands, two parallel sheets of muscles (the rectal
abdominal muscles), which run from the rib cage to the pubic bone, may separate along the
center seam. This separation may worsen back pain.
 Stress . Emotional stress can cause muscle tension in the back, which may be felt as back
pain or back spasms. You may find that you experience an increase in back pain during
stressful periods of your pregnancy.

Treatments for Back Pain in Pregnancy

 Exercise . Regular exercise strengthens muscles and boosts flexibility. That can ease the
stress on your spine. Safe exercises for most pregnant women include walking, swimming,
and stationary cycling. Your doctor or physical therapist can recommend exercises to
strengthen your back and abdomen.
 Heat and Cold . Applying heat and cold to your back may help. If your health care provider
agrees, start by putting cold compresses (such as a bag of ice or frozen vegetables wrapped in
a towel) on the painful area for up to 20 minutes several times a day. After two or three days,
switch to heat -- put a heating pad or hot water bottle on the painful area. Be careful not to
apply heat to your abdomen during pregnancy.
 Improve your posture. Slouching strains your spine. So using proper posture when working,
sitting, or sleeping is a good move. For example, sleeping on your side with a pillow between
the knees will take stress off your back. When sitting at a desk, place a rolled-up towel behind
your back for support; rest your feet on a stack of books or stool and sit up straight, with your
shoulders back. Wearing a support belt may also help.
 Counseling. If back pain is related to stress, talking to a trusted friend or counselor may be
helpful.

LUMBAR DISC HERNIATION

 The prevalence of symptomatic lumbar disc herniation during pregnancy may be on the
increase because of the increasing age of patients who are becoming pregnant.
 pregnancy at any stage is no contraindication to magnetic resonance imaging scan, epidural
and/or general anesthesia,
 surgical disc excision as disc surgery during gestation is a safe method of management in
severe neurologic deficits
BREAST PAIN

 Breast pain during pregnancy is nothing unusual or uncommon. In fact, it is one of the very
earliest possible signs of pregnancy. Pain in the breast is prominent in the first trimester of
pregnancy. Your breasts feel sore, swollen, tender, and sensitive. It begins from the fourth to
sixth week of the pregnancy. Most expectant women note that the breast pain disappears or
reduces in the second and third trimester of pregnancy.

CHEST PAIN

 Chest pain during your pregnancy can be caused by many things, and it’s important to keep
in mind that a pregnant mother is going to experience pains that are unavoidable, inevitable
and down right painful throughout the pregnancy term. Chest pain, although scary at times,
can be normal, due to things such as foods, or it can be the sign that something else is very
wrong. If you’re experiencing chest pains during your pregnancy, you should not wait to
contact your doctor. This way, your doctor can determine the cause behind the pain, and
ways to treat the pain.

Causes of Chest Pain

 Heartburn- This could be caused by indigestion, gas or eating/drinking certain foods and
beverages. If you suffered from heartburn before your pregnancy, it’s important you
discuss this with your doctor.
 Indigestion- Indigestion is caused when gas is trapped in your chest. This can cause
severe pain for extended periods of time, so it’s important you avoid certain foods that
give you indigestion (especially if they gave you gas before you were pregnant).
 Pressure from Baby- As the baby grows, your body is transforming. During this
transformation, chest pain could be triggered from the pressure on your ribs or
diaphragm.
 Stress- Besides causing muscle tension and other pain, stress can cause chest pain too.
Find what it is that is stressing you out, and cut it out of your routine if possible.
 Breasts- As your pregnancy progresses, the size of your breasts will become larger. This
can be the cause of your shortness of breath or chest pain.
 Asthma- If you have asthma before you get pregnant, your pregnancy will more than
likely trigger your symptoms making it difficult to breathe after normal activities. Talk
with your doctor to make sure your asthma medication is appropriate for you to be taking
while you’re pregnant.
  Widening of Rib Cage- As your pregnancy progresses, so does your rib cage. This can
cause lots of tension within your chest. As your baby gets bigger and begins putting
pressure on your muscles, ribs and diaphragm, shortness of breath tends to follow.

Treating Chest Pain

 If your chest pain is severe, persistent or accompanied by shortness of breath, dizziness

and weakness, you should call your doctor immediately. Other treatment includes
making sure you are taking in the correct amounts of vitamins and nutrients such as iron,
calcium and magnesium. Also, taking on a yoga class or other stress relief technique can
reduce the amount of pain your body, especially your chest, receives.

LEG CRAMPS

 Pain or a“ jumpy” sensation in your legs.

 Leg cramps (otherwise known as charley horses) are actually quite common during
pregnancy. Leg cramps tend to be even more common (and painful!) in the third
trimester, because your legs have all that extra weight to carry around late in pregnancy.
 To prevent cramps caused by dehydration, be sure you're drinking between 8 and 12
glasses of water a day. If water's not quite your thing, you can include milk, juice (avoid
juice packed with sugar), sparkling water and decaf tea and coffee in the mix too.
 The other problem may be your diet. Drops in potassium, calcium or magnesium can all
lead to muscle spasms. Now that you're pregnant, you should have 4,700 mg of
potassium, 1,000 to 1,300 mg of calcium and 350 to 360 mg of magnesium per day.
 Warm baths just before bed to help relax the muscles are a good way to help counter the
pain. Also, your partner can give you a massage of the feet and legs just before bed to
help get the legs relaxed and reduce the pain.
 Avoid standing or sitting while your legs are crossed. When seated, try and keep rotating
your ankles and wriggling your toes to keep the blood circulating. This relieves the
pressure on the legs and allows blood flow and so reduces the chances of pain.
 Take a walk every day, unless your midwife or doctor has advised you not to exercise.
 Avoid getting too tired. Lie down on your left side to improve circulation to and from
your legs.

DEEP VEIN THROMBOSIS

  Thrombosis is a blood clot in a blood vessel (a vein or an artery). Venous thrombosis
occurs in a vein. Veins are the blood vessels that take blood towards the heart and lungs;
arteries take the blood away.
 A deep vein thrombosis (DVT) is a blood clot that forms in a deep vein of the leg, calf or
pelvis.
 If your doctor suspects you have a venous thrombosis, you will be advised to start on
treatment with an injection of a drug called heparin (an anticoagulant) to ‘thin the blood'.
There are different types of heparin. The most commonly used in pregnancy is ‘low-
molecular-weight heparin' (LMWH).
 There are some steps you can take to reduce your risk of developing a blood clot in a
vein:

 If you smoke, stop smoking.

 Eat healthily, particularly if you are overweight.
 Take regular exercise, such as walking or swimming, to improve
circulation in your legs.
 Wear compression stockings if you are travelling on a long-haul flight or
if you need to stay in hospital. Compression stockings are tight stockings
which squeeze your feet, lower legs and thighs, helping blood to circulate
more quickly.

BRAXTON HICKS CONTRACTIONS

Braxton Hicks contractions can begin anytime after week 20 of pregnancy. (You'll
probably feel them earlier and more intensely if you've been pregnant before.) Braxton Hicks
contractions begin as a painless tightening of the uterine muscles, usually lasting about 15 to 30
seconds, but sometimes as long as two minutes, and causing your abdomen to become very hard
and strangely contorted (almost pointy). Once you get closer to your estimated due date, these
contractions become more frequent and more intense.

Braxton Hicks Contractions — What You Can Do About Them

 Try changing your position during a painful contraction — if you're sitting, stand up (and
vice versa).
 Use these contractions as a chance to practice your breathing and visualization techniques. (If
your partner's around, make him practice, too.)
 If your contractions are quite frequent (more than four in an hour) and/or you're in a lot of
pain or see any kind of vaginal discharge, call your practitioner.

ALTERNATIVE TREATMENTS

 Acupuncture: Has shown to benefit the overall health of the mother

  Chiropractic: Numerous studies show patient satisfaction is very high with overall
reduction in pain
 Massage: Performed carefully, overall relaxation is shown to be beneficial
 Physical Therapy: Similar results to above results
 Vitamins/Herbs: Depends on what is being taken.
 Exercise

RESEARCH FINDINGS

Study design: A longitudinal, prospective, observational, cohort study.

Objectives: To describe the natural history of back pain occurring during pregnancy and
immediately after delivery.

Summary of background data: Back pain during pregnancy is a frequent clinical problem
even during the early stages of pregnancy. The cause is unclear.

Methods: A cohort of 200 consecutive women attending an antenatal clinic were followed
throughout pregnancy with repeated measurements of back pain and possible determinants
by questionnaires and physical examinations.

Results: Seventy-six percent reported back pain at some time during pregnancy. Sixty-one
percent reported onset during the present pregnancy. In this group, the prevalence rate
increased to 48% until the 24th week and then remained stable and declined to 9.4% after
delivery. The reported pain intensity increased by pain duration. The pain score correlated
closely to self-rated disability and days of sickness benefit.

Conclusions: Back pain during pregnancy is a common complaint. The 30% with the highest
pain score reported great difficulties with normal activities. The back pain started early in
pregnancy and increased over time. Young women had more pain than older women. Back
pain starting during pregnancy may be a special entity and may have another origin than back
pain not related to pregnancy.

BIBLIOGRAPHY

Websites:
  http://www.sciencedirect.com
 http://onlinelibrary.wiley.com
 http://pregnancy.about.com
 http://en.wikipedia.org
 http://www.americanpregnancy.org
 http://nanda-nursinginterventions.
 http://currentnursing.com

INDEX

S.NO CONTENT PAGE

 NO

1. OBJECTIVES

2. INTRODUCTION

3. DEFINITION

4. INCIDENCE

5. AETIOLOGY

6. MANAGMENT