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CASE STUDY 15.1: ABDOMINAL PAIN DURING PREGNANCY

DIRECTIONS

Read and analyze this case study individually. When the others in your group have finished reading it, answer the case study questions. Consider the steps in clinical decision-making as you answer the questions. The other groups in the room are working on the same or a similar case study. When all groups have finished, we will discuss the case studies and the answers each group has developed.

CASE STUDY

ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests)

1. What will you include in your initial assessment of Mrs. A., and why?

2. What particular aspects of Mrs. A.'s physical examination will help you make a diagnosis or identify her problems/needs, and why?

3. What screening procedures/laboratory tests will you include (if available) in your assessment of Mrs. A., and why?

DIAGNOSIS (Identification of Problems/Needs)

Mrs. A. tells you that the pain started 12 hours ago and is mainly in the lower abdominal area. Rebound tenderness is present. Her temperature is 37.8º C and her pulse is 90 beats/minute. Her blood pressure is 120/80 mm Hg, the same as it was at her antenatal visit 2 weeks ago. She has not had an appendectomy.

4. Based on these findings, what is Mrs. A.'s diagnosis, and why?

CARE PROVISION (Planning and Intervention)

5. Based on your diagnosis, what is your plan of care for Mrs. A., and why?

EVALUATION

Mrs. A.'s husband took her to the district hospital, arriving there 1 hour after she had been seen at the clinic. However, an inpatient bed is not available for Mrs. A. until 6 hours later. At the time of admission, her temperature is 38º C, her abdominal pain has increased, and she now has nausea and vomiting. No bowel sounds are heard.

6. Based on these findings, what is your continuing plan of care for Mrs. A., and why?

CASE STUDY 15.1: ABDOMINAL PAIN DURING PREGNANCY

ANSWER KEY

Mrs. A. is 18 years old and 20 weeks pregnant. You have been providing antenatal care for her since she first visited the clinic 2 weeks ago, at 18 weeks gestation. At that visit she was well and had no abnormal findings. She has come to the clinic today complaining of lower abdominal pain. She says that she has not had a fever, vaginal bleeding, dysuria or increased urinary frequency.

ASSESSMENT (History, Physical Examination, Screening Procedure/Laboratory Tests)

1. What will you include in your initial assessment of Mrs. A., and why?

• Mrs. A. should be greeted respectfully and with kindness.

• She should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner.

• A rapid assessment should be done to determine Mrs. A.'s degree of illness; her temperature, pulse, respiration rate and blood pressure should be checked, she should be asked about the duration and nature of the pain. In addition, Mrs. A. should be asked whether she has had an appendectomy.

2. What particular aspects of Mrs. A.'s physical examination will help you make a diagnosis or identify her problems/needs, and why?

• An abdominal examination should be done to check the location of the pain and whether there is tenderness and/or a palpable mass (a palpable, tender discrete mass may be a presenting sign of ovarian cyst) or rebound tenderness (typically present in cases of appendicitis).

• Fetal heart sounds should be checked.

3. What screening procedures/laboratory tests will you include (if available) in your assessment of Mrs. A., and why?

• Her blood should be tested for white cell count. Her urine should be tested to rule out a urinary tract infection.

DIAGNOSIS (Identification of Problems/Needs)

You have completed your assessment of Mrs. A. and your main findings include the following:

Mrs. A. tells you that the pain started 12 hours ago and is mainly in the lower abdominal area. Rebound tenderness is present. Her temperature is 37.8º C and her pulse is 90 beats/minute. Her blood pressure is 120/80 mm Hg, the same as it was at her antenatal visit 2 weeks ago. She has not had an appendectomy.

4. Based on these findings, what is Mrs. A.'s diagnosis, and why?

• Mrs. A.'s symptoms and signs (e.g., lower abdominal pain, rebound tenderness, low-grade fever) are consistent with appendicitis.

CARE PROVISION (Planning and Intervention)

5. Based on your diagnosis, what is your plan of care for Mrs. A., and why?

• Arrangements should be made for Mrs. A. to be admitted to the district hospital for immediate surgical exploration.

• An IV of normal saline or Ringer's lactate should be started.

• A combination of ampicillin 2 g IV every 6 hours, gentamicin 5 mg/kg body weight IV every 24 hours and metronidazole 500 mg IV every 8 hours should be started.

• The steps taken to manage the complication should be explained to Mrs. A. and she should be encouraged to express her concerns, listened to carefully, and provided emotional support and reassurance.

EVALUATION

Mrs. A.'s husband took her to the district hospital, arriving there 1 hour after she had been seen at the clinic. However, an inpatient bed is not available for Mrs. A. until 6 hours later. At the time of admission, her temperature is 38º C, her abdominal pain has increased, and she now has nausea and vomiting. No bowel sounds are heard.

6. Based on these findings, what should be the continuing plan of care for Mrs. A., and why?

• General peritonitis from rupture of the appendix has likely developed.

• If severe pain is present, pethidine can be given IM or IV or morphine IM.

• The nature of the surgical procedure and the risks involved should be explained to Mrs. A. and her husband, their questions answered, and continuing emotional support and reassurance provided.

• IV antibiotics should be continued postoperatively until Mrs. A. has been fever-free for 48 hours.

• Nasogastric suction should be provided. IV fluids should be continued.

• Mrs. A.'s temperature, pulse and blood pressure should be monitored. She should also be monitored for signs of preterm labor, as the presence of peritonitis increases the likelihood of this happening.

• When Mrs. A. is well enough to be discharged from hospital, she should be referred back to the antenatal clinic with a written report of the care received, her condition on discharge, and her followup needs.

REFERENCES

Managing Complications in Pregnancy and Childbirth: pages S-115 to S-118