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Pelvic Pain During Early Pregnancy

by Geeta K. Swamy, MD, R. Phillips Heine, MD

Early in pregnancy, many women have pelvic pain. Pelvic pain refers to pain in the lowest part of the torso, in the area below the abdomen and between the hipbones (pelvis). The pain may be sharp or crampy (like menstrual cramps) and may come and go. It may be sudden and excruciating, dull and constant, or some combination. Usually, temporary pelvic pain is not a cause for concern. It can occur normally as the bones and ligaments shift and stretch to accommodate the fetus.

If caused by a disorder, pelvic pain may be accompanied by other symptoms, including vaginal bleeding ( Vaginal Bleeding During Early Pregnancy ). In some disorders, such bleeding can be severe, sometimes leading to dangerously low blood pressure (shock).

Pelvic pain differs from abdominal pain, which occurs higher in the torso, in the area of the stomach and intestine. However, sometimes women have trouble discerning whether pain is mainly in the abdomen or pelvis. Causes of abdominal pain during pregnancy are usually not related to the pregnancy.

Causes

During early pregnancy, pelvic pain may result from disorders that are related to

  • The pregnancy (obstetric disorders)

  • The female reproductive system (gynecologic disorders) but not the pregnancy

  • Other organs, particularly the digestive tract and urinary tract

Sometimes no particular disorder is identified.

The most common obstetric causes during early pregnancy are

  • The normal changes of pregnancy

  • A miscarriage that has occurred or is occurring (spontaneous abortion)

  • A miscarriage that may occur (threatened abortion)

In a miscarriage that has occurred, all of the contents of the uterus (fetus and placenta) may be expelled (complete abortion) or not (incomplete abortion).

The most common serious obstetric cause is

  • Rupture of an abnormally located (ectopic) pregnancy—one that is not in its usual place in the uterus, for example, one that is in a fallopian tube

When an ectopic pregnancy ruptures, blood pressure may drop very low, the heart may race, and blood may not clot normally. Immediate surgery may be required.

Pelvic pain may also occur when an ovary twists around the ligaments and the tissues that support it, cutting off the ovary's blood supply. This disorder, called adnexal torsion, is not related to the pregnancy but is more common during pregnancy. During pregnancy, the ovaries enlarge, making an ovary more likely to twist.

Digestive and urinary tract disorders, which are common causes of pelvic pain in general, are also common causes during pregnancy. These disorders include

  • Gastroenteritis (infection of the digestive tract) due to a virus

  • Irritable bowel syndrome

  • Appendicitis

  • Inflammatory bowel disease

  • Urinary tract infections (UTIs)

  • Kidney stones

Pelvic pain during late pregnancy may result from labor or from a disorder unrelated to the pregnancy.

Risk factors

Various characteristics (risk factors) increase the risk of some obstetric disorders that cause pelvic pain.

For miscarriage, risk factors include

  • Age over 35

  • One or more miscarriages in previous pregnancies

  • Cigarette smoking

  • Use of drugs such as cocaine, consumption of alcohol, or consumption of a lot of caffeine

  • Abnormalities in the uterus, such as fibroids or scars, as may be caused by surgery, dilation and curettage (D and C), radiation therapy, or infections

For ectopic pregnancy, risk factors include

  • A previous ectopic pregnancy (the most important risk factor)

  • Previous abdominal surgery, especially surgery to sterilize the woman (tubal ligation)

  • A previous infection with a sexually transmitted disease or pelvic inflammatory disease

  • Cigarette smoking

  • Use of an intrauterine device (IUD)

  • Age over 35

  • A history of infertility, use of fertility drugs, or use of assisted reproductive techniques

  • Several sex partners

  • An abortion in a previous pregnancy

  • Douching


Evaluation

If a pregnant woman has sudden, very severe pain in the lower abdomen or pelvis, doctors must quickly try to determine whether prompt surgery is required—as is the case when the cause is an ectopic pregnancy or appendicitis.

Warning signs

In pregnant women with pelvic pain, the following symptoms are cause for concern:

  • Fainting, light-headedness, or a racing heart—symptoms that suggest very low blood pressure

  • Fever, particularly if accompanied by a vaginal discharge that contains pus

  • Vaginal bleeding

  • Pain that is severe and is made worse with movement


When to see a doctor

Women with warning signs should see a doctor immediately. Women without warning signs should try to see a doctor within a day or so if they have pain or burning during urination or pain that interferes with daily activities. Women with only mild discomfort and no other symptoms should call the doctor. The doctor can help them decide whether and how quickly they need to be seen.


What the doctor does

To determine whether emergency surgery is needed, doctors first check blood pressure and temperature and ask about key symptoms, such as vaginal bleeding. Doctors then ask about other symptoms and the medical history. They also do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done (see Table).

Doctors ask about the pain:

  • Whether it begins suddenly or gradually

  • Whether it occurs in a specific spot or is more widespread

  • Whether moving or changing positions worsens the pain

  • Whether it is crampy and whether it is constant or comes and goes

Doctors also ask about other symptoms, such as vaginal bleeding, a vaginal discharge, a need to urinate often or urgently, vomiting, diarrhea, and constipation. They ask particularly about previous pregnancy-related events (obstetric history), including past pregnancies, miscarriages, and intentional terminations of pregnancy (induced abortions) for medical or other reasons, as well as risk factors for miscarriage and ectopic pregnancy.

The physical examination focuses on the pelvic examination. Doctors gently press on the abdomen to see whether pressing causes any pain.

Some Causes and Features of Pelvic Pain During Early Pregnancy

Cause

Common Features *

Tests

Pregnancy-related (obstetric) disorders

An ectopic pregnancy (an abnormally located pregnancy—not in its usual place in the uterus)

Abdominal or pelvic pain that

  • Is often sudden and constant (not crampy)

  • Begins in a specific spot

  • May or may not be accompanied by vaginal bleeding

If the ectopic pregnancy has ruptured, possibly fainting, light-headedness, or a racing heart

A blood test to measure a hormone produced by the placenta (human chorionic gonadotropin, or hCG)

Ultrasonography of the pelvis

Sometimes laparoscopy (insertion of a viewing tube through an incision in the abdomen) or laparotomy (surgery involving an incision into the abdomen)

A miscarriage that

  • Has occurred or is occurring (spontaneous abortion)

  • May occur (threatened abortion)

Crampy pain in the pelvis and often throughout the abdomen

Often vaginal bleeding, sometimes with passage of tissue from the fetus

Tests as for ectopic pregnancy

Septic abortion (infection of the contents of the uterus before, during, or after a miscarriage)

Usually in women who have had an abortion (often done by untrained practitioners or by the women themselves)

Fever and chills, constant abdominal or pelvic pain, and a vaginal discharge that contains pus

Cultures of a sample taken from the cervix (the lower part of the uterus)

Normal changes of pregnancy, including stretching and growth of the uterus during early pregnancy

A crampy or burning sensation in the lower abdomen, pelvis, and/or lower back

Ultrasonography of the pelvis

Gynecologic disorders unrelated to the pregnancy

Degeneration of a fibroid in the uterus

Pelvic pain that

  • Begins suddenly

  • Is often accompanied by nausea, vomiting, and fever

Sometimes vaginal bleeding

Ultrasonography of the pelvis

Adnexal torsion (twisting) of an ovary

Pelvic pain that

  • Begins suddenly

  • May be colicky and is often mild if the ovary untwists on its own

Often nausea or vomiting

Doppler ultrasonography (to evaluate blood flow to and from the ovary)

Sometimes laparoscopy or laparotomy

Rupture of a corpus luteum cyst (which develops in the structure that releases the egg after the egg is released)

Abdominal or pelvic pain that

  • Occurs in a specific spot

  • Sometimes resembles pain due to a twisted ovary

  • Usually begins suddenly

Vaginal bleeding

Ultrasonography of the pelvis

Sometimes laparoscopy or laparotomy

Pelvic inflammatory disease (which is uncommon during pregnancy)

Pelvic pain that

  • Is continuous

  • Usually develops gradually

  • Usually occurs on both sides

A vaginal discharge that contains pus

Sometimes fever or chills

More common among women who have sexual intercourse with new partners and do not use condoms or diaphragms

Cultures of a sample taken from the cervix

Sometimes ultrasonography of the pelvis

Other disorders

Appendicitis

Usually continuous pain and tenderness in the lower right part of the abdomen

Possibly pain in a different location (for example, higher in the abdomen) or a different kind of pain (milder and crampy) from that in people who are not pregnant

Ultrasonography of the pelvis and abdomen

Possibly CT if ultrasonography is inconclusive

Urinary tract infections

Discomfort felt in the area over the pubic bone

Often burning during urination, an urge to urinate often (frequency), and a need to urinate immediately (urgency)

Sometimes blood in urine

Urine tests (urinalysis) and culture

Inflammatory bowel disease including

  • Crohn's disease

  • Ulcerative colitis

Pain that

  • May be crampy or constant

  • Can occur in various locations

Often diarrhea that sometimes contains mucus or blood

Usually in women known to have the disease

Sometimes endoscopy of the upper digestive tract, lower digestive tract (sigmoidoscopy or colonoscopy), or both

A blockage in the intestine (intestinal obstruction)

Cramping pain that comes and goes

Vomiting

No bowel movements or gas (flatulence)

A swollen abdomen

Usually in women who have had abdominal surgery

Ultrasonography of the pelvis and abdomen

Possibly CT if ultrasonography is inconclusive

Gastroenteritis

Usually vomiting and diarrhea

A doctor's examination

* Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present.

A urine pregnancy test is typically done if women have had only a home pregnancy test. Because an ectopic pregnancy can be very dangerous, tests are done to look for ectopic pregnancy in most pregnant women with pelvic pain, unless symptoms clearly point to another disorder (such as gastroenteritis).

CT= computed tomography.


Testing

Doctors use a handheld Doppler ultrasound device, placed on the woman's abdomen, to check for a heartbeat in the fetus.

A pregnancy test using a urine sample is almost always done. If the pregnancy test is positive, ultrasonography of the pelvis is done to confirm that the pregnancy is normally located―in the uterus―rather than somewhere else (an ectopic pregnancy). For this test, a handheld ultrasound device is placed on the abdomen, inside the vagina, or both.

Blood tests are usually done. If a woman has vaginal bleeding, testing usually includes a complete blood cell count and blood type plus Rh status (positive or negative—see Rh Incompatibility), in case the woman needs a transfusion. Knowing Rh status also helps doctors prevent problems in subsequent pregnancies. If doctors suspect an ectopic pregnancy, testing also includes a blood test to measure a hormone produced by the placenta early during pregnancy (human chorionic gonadotropin, or hCG). If symptoms (such as very low blood pressure or a racing heart) suggest that an ectopic pregnancy may have ruptured, blood tests are done to determine whether the woman's blood can clot normally.

Other tests are done depending on which disorders are suspected. Doppler ultrasonography, which shows the direction and speed of blood flow, helps doctors identify a twisted ovary, which can cut off the ovary’s blood supply. Other tests can include cultures of blood, urine, or a discharge from the vagina and urine tests (urinalysis) to check for infections.

If pain is persistently troublesome and the cause remains unknown, doctors make a small incision just below the navel and insert a viewing tube (laparoscope) to directly view the uterus and thus identify the cause of the pain. Rarely, a larger incision (a procedure called laparotomy) is required.


Treatment

Specific disorders are treated. If pain relievers are needed, acetaminophen is the safest one for pregnant women, but if it is ineffective, an opioid may be necessary.

Pain due to normal changes during pregnancy

Women may be advised to

  • Limit how much they move, but move often.

  • Avoid heavy lifting or pushing.

  • Maintain good posture.

  • Sleep with a pillow between their knees.

  • Rest as much as possible with their back well-supported.

  • Apply heat to painful areas.

  • Do Kegel exercises (squeezing and releasing the muscles around the vagina, urethra, and rectum).

  • Use a maternity support belt.

  • Possibly try acupuncture.


Key Points

  • Pelvic pain during early pregnancy usually results from changes that occur normally during pregnancy.

  • Sometimes it results from disorders, which may be related to the pregnancy, to female reproductive organs but not the pregnancy, or to other organs.

  • Doctors’ first priority is to identify disorders that require emergency surgery, such as an ectopic pregnancy or appendicitis.

  • Ultrasonography is usually done.

  • General measures (such as resting and applying heat) can help relieve pain due to the normal changes during pregnancy.

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