Of Abdominal Pain In A Pregnant Patient
Farshad M. Ahadian, MD
To illustrate the use of auriculotherapy for management of abdominal
pain during pregnancy.
A 23-year-old primigravid woman at 28 weeks'
gestation with a 2-week history of right flank and right abdominal pain.
History of Present Illness
The patient's pain was described as having 2
components: a constant dull pain and a colicky pain that worsened with
urination. The patient was unable to lie on her right side, and her
pain was much worse with movement. A heating pad provided limited relief.
At the time the pain management service was consulted, she had used
emergency medical services on 2 occasions followed by admission to the
hospital. She had been on bed rest for 2 weeks solely due to severe
pain. She had been taking Percocet (oxycodone hydrochloride, 5 mg, with
acetaminophen, 325 mg; DuPont Pharmaceuticals), 2 tablets orally every
4-6 hours around the clock, which did not control the pain. She complained
of poor sleep because even slight movements would awaken her with pain.
Her past medical history was significant for
endometriosis, digestive complaints since age 15 years, and infertility
as a young adult. Her surgical history included laparoscopic cholecystectomy
and 5 exploratory laparoscopies for infertility workup and adhesiolysis.
The patient's family history was remarkable
for her mother having chronic headaches and back pain.
The patient's review of systems was remarkable
for a long history of headaches and tension in the neck and shoulder
region. Insomnia was a frequent, long-standing problem and she occasionally
suffered palpitations. She had previously been evaluated for temporomandibular
joint problems and reported grinding her teeth, particularly at night.
Physical examination showed a well-developed,
slender, pregnant female lying on her left side in the fetal position.
She was afebrile. She had a thin build but was not lacking in musculature.
Her face appeared triangular in shape with a distant flat expression.
Her hands were cold and slightly moist with brittle fingernails. She
wore eyeglasses for myopia. Abdominal examination revealed multiple
well-healed laparoscopy scars. Active trigger points were located over
the inferior aspect of the right abdominal obliques with palpable bands
of muscle contraction. Abdominal wall tenderness to palpation was prominent
along the lateral abdominal wall overlying the trajectory of the Shao
Yang (GB) meridian as it traverses the lower thorax (Figures 1-3). Some
tenderness also was present over the quadratus lumborum and the right
paraspinous musculature. The radial pulses were thin, particularly by
deep palpation. Her tongue was dry and narrow in appearance with a raw
tip. The rest of her abdominal, back, lower extremity, and neurological
examination findings were unremarkable.
Laboratory evaluation showed a single isolated
episode of microhematuria, which never recurred on multiple follow-up
studies. Serum chemistry and hematology results were unremarkable. Findings
on multiple abdominal ultrasounds as well as abdominal magnetic resonance
imaging scan were consistent with mild hydronephrosis on the right side.
This patient's pain was considered to be primarily due to intraperitoneal
adhesions involving the ureter and the enlarging uterus associated with
abdominal wall myofascial pain. Such somatic pain may be a manifestation
of visceral processes via a viscerosomatic reflex.
The patient was hooked up to a continuous external fetal heart tone
monitor as well as a tocodynamometer. Using the technique described
previously,,1,2 trigger point injections were made in the previously
described active points. A total of 20 mL of 0.5% lidocaine was injected
intramuscularly in 3-5 mL increments using a 25-gauge 1.5-inch hypodermic
The patient noted an approximate 30% reduction in pain immediately after
the procedure. She was able to stretch her legs out and better tolerate
the supine position. However, her pain returned to baseline within 4
hours. Follow-up over the next 48 hours showed no significant improvement
in pain level or use of analgesics. The patient remained on bed rest.
Thirty minutes after the trigger point injections, she developed uterine
contractions. These contractions were 4-7 minutes apart with an irregular
pattern. Uterine contractions lasted approximately 1.5 hours before
they spontaneously resolved. There were no adverse fetal heart rate
Both the patient and the obstetrical team were concerned about prolonged
use of opioids throughout the rest of the pregnancy. At this point,
the decision was made to proceed with a trial of auricular acupuncture
The patient was treated once daily for 3 sequential
days (alternating left and right ears). Treatment consisted of 4 needles
placed in the external ear (Hwa-To disposable s/steel with spiral-wound
handle, 0.25 x 13 mm). Points included the Chinese points Shen Men,
Sympathetic Tone, Ureter 2, and a point on the Sympathetic chain (at
the junction of the antihelix and the lateral projection of the concha
ridge) [Figure 4]. All points were detected using
Pointer Plus. The needles were left in place for 8 h/d.
For the duration of each treatment, the patient consumed no analgesics
and for the first time in 2 weeks, she denied having any pain whether
at rest, with ambulation, or with urination. She spent most of her time
ambulating in the hospital.
However, on the evening of the first treatment, the patient reported
a gradual recurrence of symptoms. Approximately 1 hour following the
removal of acupuncture needles, her pain returned to baseline. She had
a difficult time sleeping that night due to pain and agitation.
On day 2 of treatment, the patient reported analgesia lasting 4 hours
after removal of the needles. After treatment on day 3, pain relief
lasted through the night. The patient was discharged home on day 4 after
initiation of auriculotherapy.
For the first 5 days after discharge, the patient
was treated once daily. The frequency of treatments was then gradually
decreased to approximately once a week until delivery at 38 weeks. All
outpatient treatments consisted of placement of 2-4 needles in the described
points (Figure 4), and electrically stimulating
them at low frequency (2.5-7 Hz) for 10-20 minutes (Electro Acupuncture
stimulation device, model: IC-1107, Ito Co. Ltd). The needles were left
in place for 1-2 hours. All points were selected using the Pointer Plus.
From the time of discharge from the hospital
until delivery (Figure 5), the patient used an
average of 3 Percocet tablets per week (30 tablets in 10 weeks). She
reported improved sleep. Her pain resolved immediately following delivery.
No untoward effects were noted throughout the course of the auricular
acupuncture treatment with the exception of tenderness of the external
ear due to frequent treatments. The patient routinely reported a transient
"floaty feeling" approximately 20 minutes after each treatment.
This feeling would last several minutes and resolve spontaneously.
Abdominal pain during pregnancy has numerous origins including the visceral
organs, visceral or parietal peritoneum, as well as musculoskeletal
pain and neuropathies. Definitive allopathic treatment relies on laparoscopy
or laparotomy, injections of local anesthetics or steroids, or long-term
use of analgesics. In the pregnant patient, these interventions carry
undesirable fetal and maternal risks, including drug tolerance and subsequent
withdrawals for both the mother and the neonate, teratogenicity, premature
labor and delivery, or abortion. Indeed, these concerns frequently lead
to undertreatment or avoidance of treatment of such painful conditions.
However, undertreatment in itself may lead to increased morbidity and
has significant socioeconomic implications, such as frequent emergency
department visits, multiple or prolonged hospital admissions, and time
lost from work for both the expectant woman and her partner.
Lower abdominal pain during the antenatal period is a frequent cause
of hospital admissions. Although most cases are caused by well-defined
pathology, some present a diagnostic challenge.3-5 More importantly,
because of the inherent maternal and fetal risks of conventional medical
and surgical interventions, these cases also may present a therapeutic
dilemma.6-9 In such cases, alternative medical disciplines may offer
safe and effective therapies. These may be used in combination with,
or in lieu of, conventional medicine.
and Physiologic Basis
of Auricular Acupuncture
Examples of treatments using points on the ear
are found throughout the literature of many ancient cultures, including
Chinese and Persian medical writings as well as Egyptian tomb paintings.
The Hippocratic writings discuss cauterization and bleeding of the ear.
European medical publications in the 17th and 18th centuries reported
the use of ear cautery to treat dental neuralgia and sciatica.2
The scientific exploration and systematic charting
of the auricular correspondences were undertaken by Paul Nogier, a French
neurophysiologist, starting in the early 1950s. Nogier's teachings and
publications were disseminated from France to Germany, and from Germany
to China by way of Japan. In the United States, the precision of the
somatotopic mapping was verified in a blinded experiment, showing 92%
concordance between established medical diagnoses and auricular diagnoses.
Neuroanatomy of the External Ear
The external ear develops from embryonic gill
plates. It is structured of tissue from each of the 3 embryonic layers:
ectoderm, mesoderm, and endoderm. It has a dense and complex nervous
innervation including the greater auricular nerve (C1, C2, C3), auriculotemporal
branch of the trigeminal nerve (CN V), which has sympathetic fibers,
the auricular branch of the vagus nerve (CN X), which has parasympathetic
fibers, as well as the facial (CN VII) and the glossopharyngeal nerve
Physiologic Basis of Auricular Acupuncture
Auricular acupuncture is based on a reflex somatotopic
system organized on the surface of the external ear, one of many such
microsystems on the body. The speculative neuroanatomical model of this
microsystem consists of projections from visceral or somatic organs
and their somatotopic projections onto a modulating center in the brain.
Afferent signals from each organ after arriving at this central modulating
center trigger a change in the corresponding somatotopic focus on the
surface of the ear. This change may be detected as a decreased sensory
threshold or decreased electrical resistance at the somatotopic focus.
Alternatively, stimulation of the somatotopic focus may either modulate
afferent signals from the corresponding organ (Gate Control Theory),
or through its effect on the central modulating center, trigger a change
in the cerebral cortex or the end organ itself. The brainstem reticular
formation with its inhibitory and excitatory influences on ascending
and descending sensory, motor, and autonomic impulses, appears to be
the most likely central modulating center. With or without a defined
scientific mechanism of action, the auricular microsystem is useful
as a diagnostic and therapeutic modality.2,10-12
The benefits of auricular acupuncture in this patient included the following:
reduction in the use of opiates
of complete bed rest, with its own associated risks
of a prolonged hospitalization
use of emergency services
use of diagnostic studies
return of the patient's husband to full-time employment
The lack of
prolonged response on days 1 and 2 of inpatient auriculotherapy is interesting
and deserves further exploration. One possibility is that the rapid
recurrence of pain and agitation may have represented mild opiate withdrawal,
which resolved after 3 auriculotherapy treatments.
This case demonstrates the use of auricular acupuncture as an effective,
low-risk therapeutic option. Auriculotherapy is a sophisticated discipline
of acupuncture that can be studied to a refined level of precision.
However, adequate skills necessary for safe and effective treatment
of more limited problems may be learned quickly, and are well within
the reach of the allopathic physician. The techniques may be used as
a sole treatment or may be combined easily with concurrent therapies.
Auriculotherapy is well suited for painful conditions of a finite duration.
As a word of caution, it should be stressed that the use of auriculotherapy
or body acupuncture in the obstetric population should be undertaken
only with in-depth knowledge of the function of each point used. Use
of inappropriate points may result in uterine contractions and premature
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Dr Farshad M. Ahadian is Assistant Professor of Anesthesiology at University
of California, San Diego, and involved in patient care, research, and
fellow and resident training. Dr Ahadian is Diplomate of American Board
of Anesthesiology, American Board of Pain Management, American Board
of Pain Medicine, and American Board of Medical Acupuncture.
Farshad M. Ahadian,
UCSD Pain Management Medical Group
9500 Gilman Dr #0924
La Jolla, CA 92093-0924