CHAPTER 30 Abdominal Pain During Pregnancy

Mild abdominal pain is relatively frequent during pregnancy and in most cases it poses no danger to the mother or fetus. However, when faced by a pregnant woman with abdominal pain, we should first exclude the possibility of ectopic pregnancy or threatened miscarriage: these will be discussed at the end of this chapter and in Chapter 31.

Pathology

Blood deficiency

During pregnancy, some of the mother’s Blood is diverted to nourishing the fetus and therefore any pre-existing deficiency of Blood will be aggravated. In particular, when Blood is deficient, the Uterus Vessel becomes Empty and obstructed and abdominal pain may result. This pain results from a deficiency and it will therefore be mild.

Stagnation of Qi

During pregnancy some of the mother’s Blood is diverted to nourishing the fetus and therefore any pre-existing deficiency of Blood will be aggravated. Since the Liver stores Blood, a deficiency of Blood may often induce a secondary stagnation of Liver-Qi, causing abdominal pain. This condition is often caused by emotional stress such as anger, resentment, frustration, guilt or worry.

Empty-Cold

If the pregnant woman suffers from a pre-existing condition of Kidney-Yang deficiency, the pregnancy will tax the Kidneys and may aggravate such deficiency, giving rise to Empty-Cold. Cold obstructs the circulation of Qi and therefore causes pain.

Blood stasis

A predisposition to Blood stasis may be aggravated during pregnancy as the Lower Burner is ‘obstructed’ by the growing fetus. Blood stasis frequently causes severe abdominal pain.

We should ascertain the character of the pain clearly in order to differentiate clearly between deficiency, excess, Cold and Heat. If an abdominal pain is improved by pressure, this indicates deficiency; if it is worsened, Fullness. If it is eased by warm liquids this indicates Cold; if worsened, Heat. Abdominal pain with a feeling of distension indicates stagnation of Qi; stabbing, severe pain is due to stasis of Blood.

Identification of patterns and treatment

The treatment principle for abdominal pain during pregnancy is essentially to move Qi and invigorate Blood, adjusted according to the respective predominance of deficiency or excess. In any case, during pregnancy one must avoid using too many pungent, warm, drying herbs or herbs that strongly invigorate Blood.

If the deficiency of Blood and/or Kidneys predominates, then one must also adopt the treatment principle of ‘calming the fetus’ by choosing herbs that calm the fetus and also strengthen the Kidneys and nourish Blood such as Du Zhong Cortex Eucommiae, Xu Duan Radix Dipsaci and Sang Ji Sheng Herba Taxilli.

The patterns discussed are:

• deficiency of Blood

• stagnation of Qi

• Blood stasis.

Deficiency of Blood

Clinical manifestations

Mild abdominal pain that comes and goes and that improves with pressure, dull, pale complexion, dizziness, blurred vision, history of scanty periods, insomnia. Tongue: Pale and Thin. Pulse: Choppy or Fine.

Treatment principle

Nourish Blood, calm the fetus, stop pain.

Herbal treatment

Women’s Treasure remedy

– PRECIOUS SEA

This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. It has been modified with the addition of Kidney tonics. The tongue presentation appropriate to this remedy is a Pale and Thin body.

Stagnation of Qi

Clinical manifestations

Abdominal pain with a feeling of distension, hypochondriac pain and distension, irritability, belching, poor appetite. Tongue: slightly Red sides or normal. Pulse: Wiry.

Treatment principle

Pacify the Liver, move Qi, eliminate stagnation, calm the fetus.

Herbal treatment

Empty-Cold

Clinical manifestations

Dull abdominal pain that improves with the application of heat and by drinking warm liquids, feeling of cold, dull, bright complexion, cold limbs. Tongue: Pale and wet. Pulse: Deep and Weak.

Treatment principle

Warm the Yang, expel cold, calm the fetus, stop pain.

Herbal treatment

Prescription

– JIAO AI TANG

– Colla Corii Asini-Artemisia Decoction

Blood stasis

Clinical manifestations

Severe abdominal pain, uterine bleeding, mental restlessness. Tongue: Purple if the Blood stasis is severe. Pulse: Choppy, Wiry or Firm.

Treatment principle

Invigorate Blood, regulate the Penetrating Vessel, calm the fetus.

Prognosis and prevention

The prognosis depends largely on the Western differentiation. If abdominal pain in pregnancy is not due to an ectopic pregnancy or threatened miscarriage, it responds well to treatment with acupuncture and/or Chinese herbs. The pattern from deficiency of Blood is the easiest to treat while those from Empty-Cold and stagnation of Qi are the most difficult because the pregnant state of the patient imposes several restrictions on the choice of acupuncture points or herbs. For example, the pattern of Empty-Cold would require the application of moxa to points in the lower abdomen which cannot be done during pregnancy. Similarly, the pattern of Qi stagnation would require the needling of points in the lower abdomen.

Western view

When seeing a pregnant woman with abdominal pain, we must first of all establish whether there is uterine bleeding or not because this sign may indicate either a threatened miscarriage or an ectopic pregnancy. A ‘simple’ abdominal pain during pregnancy is not uncommon and Western medicine has no explanation for it. For example, a textbook on obstetrics says of abdominal pain during pregnancy: “Very few women manage to experience an entire pregnancy without an episode of abdominal pain. Most of these episodes are transitory … The cause for most episodes is never determined.”³

Uterine contractions cause most cases of abdominal pain during pregnancy. If they occur before the twentieth week, painful uterine contractions usually indicate abortion (threatened, inevitable or complete). After the twentieth week, uterine contractions that become progressively more painful usually indicate imminent labour.

If the abdominal pain is severe and is accompanied by uterine bleeding, the woman should be referred to a gynecologist to carry out tests and an examination to exclude the possibility of an ectopic pregnancy or an imminent (or indeed in process) miscarriage. Another possible cause of severe abdominal pain during pregnancy is torsion of a pedunculated ovarian cyst.

Ectopic pregnancy

The term ‘ectopic pregnancy’ refers to pregnancy occurring anywhere outside the uterus. The most common location of an ectopic pregnancy is one of the fallopian tubes, but it may also occur in the abdominal cavity, in an ovary or in the cervix. In the UK, 1 in 200 pregnancies is ectopic. A history of pelvic inflammatory disease is a predisposing factor to ectopic pregnancy. Ectopic pregnancy can present in an acute or subacute way. In the acute presentation, the woman is in a state of shock with hypotension, tachycardia and signs of peritoneal inflammation (very similar to those of acute appendicitis with peritonitis): the abdomen is very distended and acutely tender; there is rebound tenderness, i.e. when pressed down on palpation and then released, acute tenderness manifests upon release. The abdominal pain is very severe and usually precedes the uterine bleeding.

In the subacute presentation, the woman experiences recurrent attacks of vaginal bleeding and abdominal pain. Thus, ectopic pregnancy should always be suspected in a pregnant woman presenting with severe abdominal pain and vaginal bleeding. The only possible treatment for ectopic pregnancy is termination by salpingectomy, salpingotomy or tubal compression. If pregnancy occurs in the abdominal cavity it is a life-threatening condition for the mother because any attempt to remove the placenta (located in the abdominal cavity rather than the uterus) results in massive haemorrhage.

Spontaneous abortion

Spontaneous abortion (or miscarriage) occurs in about 10% of pregnancies under 24 weeks. Threatened abortion presents mainly with vaginal bleeding and abdominal pain is either absent or mild. About 50% of women with such symptoms will continue the pregnancy without aborting. The only treatment for threatened abortion in Western medicine is bed rest; sometimes smooth-muscle relaxants are administered. In Chinese medicine, one can prescribe various formulae or prepared remedies to try to prevent abortion, and these will be discussed in Chapter 31 on threatened miscarriage.

If the pregnancy does not settle, the woman may proceed to abort and one can distinguish an incomplete from a complete abortion. In both cases, the vaginal bleeding becomes profuse with the passage of large clots and the abdominal pain becomes intense. If some of the products of conception are retained, the abortion is incomplete and requires dilatation and curettage.

Again, the role of Chinese medicine in such cases will be discussed in Chapters 43 and 44. If the abortion is complete, the abdominal pain ceases and the vaginal bleeding subsides. Spontaneous completion is more likely in cases of over 16 weeks’ gestation. Abortion, either spontaneous or induced, may give rise to infection: in this case, the vaginal bleeding becomes purulent and the woman has a high temperature.

Abdominal pain and vaginal bleeding also occur in cases when the fetus dies in utero but is not immediately expelled.

Ovarian tumour torsion

Ovarian tumour torsion occurs especially with dermoid cysts and fibromata when the pedicle is long enough to become twisted. When torsion has occurred, twisting of the pedicle occludes the circulation of blood, obstructing first the veins and then the arteries and leading to ischaemia and necrosis of the tumoral tissue. The main symptoms and signs are a severe abdominal pain, vomiting and vaginal bleeding. On palpation, a firm, tender swelling is felt.

Appendix: ectopic pregnancy

Although ectopic pregnancy obviously requires treatment with Western medicine, this can be integrated with treatment with Chinese medicine. As usual in Chinese medicine, a differentiation of patterns is made to decide the treatment. As a general consideration, ectopic pregnancy constitutes a Full condition characterized by Blood stasis and it requires invigorating Blood and eliminating stasis. However, beyond this generalization three patterns can be distinguished and these will be discussed briefly below with their treatment.

Blood stasis

Clinical manifestations

Severe, stabbing abdominal pain, Purple tongue and Wiry pulse.

Treatment principle

Invigorate Blood, eliminate stasis, dissolve masses, terminate pregnancy.

Collapse of Yang

Clinical manifestations

Abdominal pain, bright white complexion, hypertension, sweating, cold hands and feet, nausea, vomiting, Deep-Fine-Scattered pulse.

Treatment principle

Rescue the Yang, nourish Yin, invigorate Blood, eliminate stasis.

Herbal treatment

Prescription

– SHEN FU TANG plus SHENG MAI SAN plus GONG WAI YUN No. 1 FORMULA

– Ginseng-Aconitum Decoction plus Generating the Pulse Powder plus Ectopic Pregnancy Formula No. 1.