**8. Common causes of abdominal pain during pregnancy**

#### **8.1 Miscarriage**

A combination between pain and vaginal bleeding should alert a clinician to a possible threatened, inevitable, incomplete or septic miscarriage. Pain is typically described as a 'cramping ach'. On examination, the fundal height of the uterus corresponds to the period of amenorrhea and signs of peritoneal irritation are absent. The internal cervical os might be opened or closed based on the type of miscarriage. An open os is diagnostic of an inevitable or incomplete miscarriage. Ultrasound examination is helpful to confirm viability, intra-uterine pregnancy and exclude a sub chorionic hematoma [7].

#### **8.2 Ectopic pregnancy**

Pregnancy is rarely located outside the normal endometrial cavity, most commonly in the fallopian tubes. Pain is typically unilateral and colicky. It may be superimposed on dull aching pain and may be associated with dizziness or fainting episodes. On clinical examination, unilateral iliac fossa tenderness, cervical excitation and adnexal tenderness may be elicited, The size (i.e., the measured fundal height) of the uterus is often less than what would be expected for the period of amenorrhea.

Demonestration of an empty uterine cavity on transvaginal ultrasound despite serum beta HCG levels of over 1500 IU/L may help clinician for the diagnosis.

Presence of any symptoms including abdominal pain or evidence of significant hemoperitoneum is a contraindication for medical treatment and surgical treatment is indicated. This includes emergency salpingectomy via laparoscopy or laparotomy.

### **8.3 Ovarian cyst accidents**

Ovarian cyst complicate 1 in 1000 pregnancies and a vast majority are benign (98%). Pain is often described as intermittent and unilateral. Torsion also occurs more frequently on the right than the left, by a ratio of 3:2, owing to the presence of the colon on the left that limits the space available for torsion. Clinical examination may confirm tenderness in either iliac fossa and a large cyst may be palpable during abdominal and/or bimanual examination. However, in modern obstetric practice, the cyst is usually detected on ultrasound.

Most torsions and cyst accidents present as an acute abdomen and would warrant surgical treatment. Twenty percent of adnexal torsions occur during pregnancy. This also includes torsion o morphologically normal ovary. About 50% of cases of adnexal torsion have an associated ovarian mass.

In early pregnancy, symptomatic benign ovarian cysts may be removed by laparoscopic ovarian cystectomy. In view of inaccessibility of the adnexa in late pregnancy, a midline or Para median incision is recommended. Any ovarian cyst that exhibits sonographic features that are suggestive of malignancy should be referred to the oncological team for further imaging and appropriate treatment.
