Intended for healthcare professionals

Practice Rational Testing

Imaging of acute abdominal pain in the third trimester of pregnancy

BMJ 2018; 361 doi: (Published 21 June 2018) Cite this as: BMJ 2018;361:k2511
  1. J Shur, specialty registrar, clinical radiology1,
  2. C Bottomley, consultant obstetrician and gynaecologist2,
  3. K Walton, general practitioner3,
  4. JH Patel, consultant radiologist4
  1. 1St. Mark’s Hospital, Middlesex, UK
  2. 2Chelsea and Westminster Hospital, London, UK
  3. 3Brook Green Medical Centre, London, UK
  4. 4Imaging Department, St. George’s University Hospital, London, UK
  1. Correspondence to JH Patel jaymin.patel{at}

What you need to know

  • Ultrasound is generally first line and magnetic resonance imaging (MRI) second line for investigating acute abdominal pain in the third trimester of pregnancy.

  • We suggest early discussion of the case with a member of the maternity multidisciplinary team, an experienced radiologist, and other relevant clinical teams.

  • Avoid computed tomography unless the diagnosis cannot be made with other investigations and the benefit to mother and baby is deemed to outweigh the ionising radiation risk to the fetus.

A 25 year old woman at 29 weeks’ gestation in her first pregnancy presents to her local hospital with a 12 hour history of constant abdominal pain and vomiting. She has no relevant medical or surgical history, and the pregnancy has been uncomplicated. She reports normal fetal movements and no vaginal fluid or blood loss. On examination, she has a tachycardia of 100 beats/min, blood pressure 108/70 mmHg and a temperature of 37.9°C. Abdominal examination finds generalised abdominal tenderness without peritonism. On vaginal speculum examination, the cervix appears long and closed. Urinalysis is negative for blood, protein, leucocytes, and nitrites but shows ketonuria. Cardiotocography is performed, which confirms a normal fetal heart rate pattern with no evidence of uterine activity. Initial full blood count, electrolytes, renal, and liver function are normal, except for an elevated white cell count of 15.0×109/L and C reactive protein of 11.5 mg/L.

Abdominal pain at all stages of pregnancy is a common presentation in both primary and secondary care. More serious causes of abdominal pain, such as appendicitis, can be associated with serious morbidity and mortality to both fetus and mother. Diagnosis and investigation of abdominal pain during pregnancy present specific challenges, particularly in the third trimester, where the large gravid uterus makes clinical and imaging assessment of abdominal pain more complex.

In this article, we present …

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