PAIN IN PREGNANCY
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.
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 heart- beat is heard with hand-held fetal Doppler.
· 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?
The diagnosis is of fibroid degeneration. The uterine size larger than dates and the local- ized 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 hyperoe- strogenic 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 con- firmed 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 sim- ple 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 preg- nancy 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 inflamma- tory 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 during the puerperium, so consideration of surgery should be deferred for at least 3 months after delivery.