Case 84: Pain in pregnancy

 

Case 84: Pain in pregnancy

CASE 84: PAIN IN PREGNANCY

History

A 28-year-old nulliparous woman is admitted to the labour ward at 31 weeks and 6 days’

gestation, with abdominal pain.

In this pregnancy she has had chronic low back pain for which she has been under the

physiotherapist. She has also been treated for confirmed urinary tract infections on two

occasions. She underwent two large-loop excisions of the transformation zone (LLETZ) procedures some years ago. Since then her smears have been normal, the most recent being 10

months ago.

Yesterday she noticed an increase in her discharge with some dark vaginal bleeding and

abdominal discomfort. She thought the symptoms may have been related to something she

had eaten but she now feels intermittent abdominal pain every few minutes, with no pain in

between episodes. Fetal movements are normal.

There is no history of leaking of liquor. She has urinary frequency, though this has not worsened recently. She is always constipated.

Examination

The woman is apyrexial with blood pressure 109/60 mmHg and heart rate 96/min.

Symphysiofundal height is 30 cm and moderate contractions are palpated lasting approximately 35 s. The fetus is breech on palpation and the presenting part feels engaged.

No liquor is visible on speculum examination. On vaginal examination the cervix is effaced

and 3 cm dilated, with the breech felt –2 cm above the ischial spines and membranes intact.

INVESTIGATIONS

Cardiotocograph (CTG):

Baseline rate 145/min, variability normal (15/min)

Accelerations present

No decelerations observed

Uterine activity recorded 3 in 10

Questions

• What is the diagnosis?

• What factors predispose to this?

• How would you manage this woman?100 Cases in Obstetrics and Gynaecology

238

ANSWER 84

The woman is in premature labour – she has regular painful contractions (as confirmed by

the history, palpation and uterine activity demonstrated on CTG) and the cervix is effaced

and dilated.

In this history the possible risk factors are the LLETZ procedures and urinary tract

infections, raising the possibility that she could be in premature labour due to a further

untreated urinary tract infection. However many women in premature labour have no

obvious risk factors.

! Risk factors for premature labour

• Maternal:

• history of premature delivery

• young maternal age

• illegal drug use and smoking

• chorioamnionitis

• pre-eclampsia

• polyhydramnios

• sepsis

• previous cervical surgery/

cervical incompetence

• Fetal:

• intrauterine growth retardation

• congenital abnormality

• multiple pregnancy

Management

• Prevention of respiratory distress syndrome (RDS):

• Antenatal corticosteroids (usually betamethasone intramuscular) prior to delivery reduce the incidence of RDS in premature infants, and ideally two doses

should be administered 12 h apart prior to delivery.

• Tocolysis (with atosiban, a beta-agonist or nifedipine) should be started immediately to try and delay labour in order for the steroids to be maximally effective

(24 h), and then discontinued. The other indication for tocolysis is to settle contractions long enough for in utero transfer of the mother to a unit with facilities

to care for a 31-week baby. In other situations tocolysis does not seem to improve

fetal outcome, even though it may prolong time to delivery.

• Mode of delivery: although there is evidence that full-term singleton breech babies

should be delivered by caesarean section (rather than vaginally), there is no clear

evidence that this applies to preterm infants, and as premature delivery is generally

reasonably quick, vaginal delivery should be considered. The contraindications to

this would be signs of fetal compromise on CTG, or maternal objection.

• Postnatal care: the paediatric team should be informed of any woman in actual or

threatened preterm labour, in order that appropriate arrangements are made for

care of the infant after delivery.

KEY POINTS

• Premature delivery is the major cause of perinatal mortality.

• If a woman goes into premature labour one must consider prevention of respiratory distress syndrome and mode of delivery