Case 52: Pain in pregnancy

 

Case 52: Pain in pregnancy

CASE 52: PAIN IN PREGNANCY

History

A 33-year-old Asian woman complains of worsening abdominal pain for 4 days. She is 16

weeks pregnant in her third pregnancy. She has a 10-year-old son, by normal delivery, and

had a miscarriage 8 years ago. Her pregnancy has been uneventful until now with an unremarkable first-trimester scan.

The pain is in the left lower abdomen and is constant and sharp. She has taken paracetamol

with little effect and she is unable to sleep due to the pain.

She has had no vaginal bleeding and reports urinary frequency since the beginning of the

pregnancy. She is mildly constipated and has no nausea and vomiting. There is no history of

trauma. She has not felt the baby moving yet.

Examination

The woman is apyrexial and pulse rate is 125/min, with blood pressure 110/68 mmHg. The

uterus is palpable just above the umbilicus. There is significant tenderness over the left uterine fundal region, where it also feels firm. The abdomen is otherwise soft and non-tender.

There is voluntary guarding but no rebound tenderness. Bowel sounds are normal. Speculum

examination shows a normal, closed cervix and no blood. The fetal heartbeat is heard with

hand-held fetal Doppler.

INVESTIGATIONS

Normal range for

pregnancy

Haemoglobin 10.6 g/dL 11–14 g/dL

Mean cell volume 79 fL 74.4–95.6 fL

White cell count 7.2×109/L 6–16×109/L

Platelets 378×109/L 150–400×109/L

C-reactive protein 5 mg/L <10 mg/L

Questions

• What is the likely diagnosis and how should it be confirmed?

• How would you manage this woman?

• What effect will this condition have on the pregnancy?100 Cases in Obstetrics and Gynaecology

138

ANSWER 52

The diagnosis is of fibroid degeneration. The uterine size larger than dates and the localized

uterine tenderness are the important features in making this diagnosis. Fibroids affect 20–30

per cent of the female population, commonly developing between 30 and 50 years. They are

particularly common in African-Caribbean women.

Fibroids are oestrogen sensitive and therefore grow in pregnancy in response to the hyperoestrogenic state. When they outgrow their blood supply they undergo ‘red degeneration’, with necrosis within the fibroid causing the intense localized pain. The diagnosis of

fibroids is confirmed by ultrasound visualization of an encapsulated mass in the uterus.

The degeneration is confirmed by the ultrasound appearance of cystic spaces within the

fibroid mass.

Degeneration pain usually starts gradually, and some women manage at home with simple

paracetamol and rest until the pain subsides. However it is common for the pain to be severe

enough for admission to hospital for opiate analgesia. Opiates are safe in pregnancy provided

use is not prolonged. Intravenous fluids may be required if the woman is not drinking, or is

vomiting due to the pain.

Most women remain well systemically, although a full blood count and C-reactive protein

should be taken to check haemoglobin and to assess the white blood count and inflammatory

markers. In this case the woman has a mild microcytic anaemia of pregnancy and should be

given ferrous sulphate.

The pregnancy itself is not usually compromised by degenerating fibroids except in the rare

cases where sepsis develops, in which case miscarriage may occur.

Fibroids are managed expectantly in pregnancy but may cause malpresentation at term, or

obstructed labour if there is a pelvic fibroid. In either of these circumstances, caesarean section should be performed. Most fibroids shrink spontaneously during the puerperium, so

consideration of surgery should be deferred for at least 3 months after delivery.

KEY POINTS

• Fibroids are common and may cause pain as they outgrow their blood supply and

undergo ‘red degeneration’.

• The pain is self-limiting and treatment is pain management.