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Pelvic Pain During Early Pregnancy

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

Pelvic pain is common during early pregnancy and may accompany serious or minor disorders. Some conditions causing pelvic pain also cause vaginal bleeding. In some of these disorders (eg, ruptured ectopic pregnancy, ruptured hemorrhagic corpus luteum cyst), bleeding may be severe, sometimes leading to hemorrhagic shock.

Causes of upper and generalized abdominal pain are similar to those in nonpregnant patients.

Etiology

Causes of pelvic pain during early pregnancy (see Some Causes of Pelvic Pain During Early Pregnancy) may be

  • Obstetric

  • Gynecologic, nonobstetric

  • Nongynecologic

Sometimes no particular disorder is identified.

The most common obstetric cause is

  • Spontaneous abortion (threatened, inevitable, incomplete, complete, septic, or missed)

The most common serious obstetric cause is

  • Ruptured ectopic pregnancy

Nonobstetric gynecologic causes include adnexal torsion, which is more common during pregnancy because during pregnancy, the corpus luteum causes the ovaries to enlarge, increasing the risk of the ovary twisting around the pedicle.

Common nongynecologic causes include various common GI and GU disorders:

  • Viral gastroenteritis

  • Irritable bowel syndrome

  • Appendicitis

  • Inflammatory bowel disease

  • UTI

  • Nephrolithiasis

Pelvic pain during late pregnancy may result from labor or one of the many nonobstetric causes of pelvic pain.

Some Causes of Pelvic Pain During Early Pregnancy

Cause

Suggestive Findings

Diagnostic Approach

Obstetric disorders

Ectopic pregnancy

Abdominal or pelvic pain, which is often sudden, localized, and constant (not crampy), with or without vaginal bleeding

Closed cervical os

No fetal heart sounds

Possibly hemodynamic instability if ectopic pregnancy has ruptured

Quantitative β-hCG measurement

CBC

Blood type and Rh typing

Pelvic ultrasonography

Spontaneous abortion (threatened, inevitable, incomplete, complete, missed)

Crampy, diffuse abdominal pain, often with vaginal bleeding

Open or closed cervical os depending on the type of abortion (see Some Causes of Vaginal Bleeding During Early Pregnancy)

Evaluation as for ectopic pregnancy

Septic abortion

Usually, apparent history of recent instrumentation of the uterus or induced abortion (often illegal or self-induced)

Fever, chills, constant abdominal or pelvic pain with a purulent vaginal discharge

Open cervical os

Evaluation as for ectopic pregnancy plus cervical cultures

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

Crampy or burning sensation in the lower abdomen, pelvis, lower back, or a combination

Evaluation as for ectopic pregnancy

Diagnosis of exclusion

Nonobstetric gynecologic disorders

Uterine fibroid degeneration

Sudden onset of pelvic pain, often with nausea, vomiting, and fever

Sometimes vaginal bleeding

Evaluation as for ectopic pregnancy

Adnexal (ovarian) torsion

Sudden onset of localized pelvic pain, which may be colicky and often mild if torsion spontaneously resolves

Often, nausea, vomiting

Evaluation as for ectopic pregnancy plus Doppler ultrasonography

Ruptured corpus luteum cyst

Localized abdominal or pelvic pain, sometimes mimicking adnexal torsion

Vaginal bleeding

Usually, sudden onset

Evaluation as for ectopic pregnancy plus Doppler ultrasonography

Pelvic inflammatory disease (uncommon during pregnancy)

Cervical discharge, significant adnexal tenderness

Evaluation as for ectopic pregnancy plus cervical cultures

Nongynecologic disorders

Appendicitis

Usually, continuous pain, tenderness

Possibly atypical location (eg, right upper quadrant) or qualities (milder, crampy, no peritoneal signs) compared with pain in nonpregnant patients

Evaluation as for ectopic pregnancy plus cervical cultures

Pelvic/abdominal ultrasonography

Consideration of CT if ultrasonography is inconclusive

UTI

Suprapubic discomfort, often with bladder symptoms (eg, burning, frequency, urgency)

Urinalysis and culture

Inflammatory bowel disease

Variable pains (crampy or constant) in no consistent location, often with diarrhea and sometimes with mucus or blood

Usually, a known history

Clinical evaluation

Sometimes endoscopy

Bowel obstruction

Colicky pain, vomiting, no bowel movements or flatus

Distended, tympanitic abdomen

Usually, history of abdominal surgery (causing adhesions) or sometimes an incarcerated hernia detected during examination

Evaluation as for ectopic pregnancy plus cervical cultures

Pelvic/abdominal ultrasonography

Consideration of CT if ultrasonography is inconclusive

Gastroenteritis

Usually, vomiting, diarrhea

No peritoneal signs

Clinical evaluation

*β-hCG =β subunit of human chorionic gonadotropin.

Evaluation

Evaluation should exclude potentially serious treatable causes (eg, ruptured or unruptured ectopic pregnancy, septic abortion, appendicitis).

History

History of present illness should include the patient’s gravidity and parity as well as the pain’s onset (sudden or gradual), location (localized or diffuse), and character (crampy or colicky). A history of illicitly attempted termination of pregnancy suggests septic abortion, but absence of this history does not exclude this diagnosis.

Review of systems should seek GU and GI symptoms that suggest a cause. Important GU symptoms include vaginal bleeding (ectopic pregnancy or abortion); syncope or near syncope (ectopic pregnancy); urinary frequency, urgency, or dysuria (UTI); and vaginal discharge and history of unprotected intercourse (pelvic inflammatory disease). Important GI symptoms include diarrhea (gastroenteritis, inflammatory bowel disease, or irritable bowel syndrome), vomiting (due to many disorders, including gastroenteritis and bowel obstruction), and obstipation (bowel obstruction, irritable bowel, or a functional disorder).

Past medical history should seek disorders known to cause pelvic pain (eg, inflammatory bowel disease, irritable bowel syndrome, nephrolithiasis, ectopic pregnancy, spontaneous abortion). Risk factors for these disorders should be identified.

Risk factors for ectopic pregnancy include

  • History of sexually transmitted disease or pelvic inflammatory disease

  • Cigarette smoking

  • Use of intrauterine device

  • Age> 35

  • Previous abdominal surgery (especially tubal surgery)

  • Use of fertility drugs or assisted reproductive techniques

  • Previous ectopic pregnancy (the most important)

  • Multiple sex partners

  • Douching

Risk factors for spontaneous abortion include

  • Age > 35

  • History of spontaneous abortion

  • Cigarette smoking

  • Drugs (eg, cocaine, alcohol, high doses of caffeine)

  • Uterine abnormalities (eg, leiomyoma, adhesions)

Risk factors for bowel obstruction include

  • Previous abdominal surgery

  • Hernia

Physical examination

Physical examination begins with a review of vital signs, particularly for fever and signs of hypovolemia (hypotension, tachycardia).

Evaluation focuses on abdominal and pelvic examinations. The abdomen is palpated for tenderness, peritoneal signs (rebound, rigidity, guarding), and uterine size and is percussed for tympany. Fetal heart sounds are checked using a Doppler probe.

Pelvic examination includes inspection of the cervix for discharge, dilation, and bleeding. Discharge, if present, should be sampled and sent for culture. Any blood or clots in the vaginal vault are gently removed. Bimanual examination should check for cervical motion tenderness, adnexal masses or tenderness, and uterine size.

Red flags

The following findings are of particular concern:

  • Hemodynamic instability (hypotension, tachycardia, or both)

  • Syncope or near syncope

  • Peritoneal signs (rebound, rigidity, guarding)

  • Fever, chills, and purulent vaginal discharge

  • Vaginal bleeding

Interpretation of findings

Certain findings suggest causes of pelvic pain but are not always diagnostic (see Some Causes of Pelvic Pain During Early Pregnancy).

For all women who present with pelvic pain during early pregnancy, the most serious cause—ectopic pregnancy—must be excluded, regardless of any other findings. Nonobstetric causes of pelvic pain (eg, acute appendicitis) must always be considered and investigated as in nonpregnant women.

As in any patient, findings of peritoneal irritation (eg, focal tenderness, guarding, rebound, rigidity) are a concern. Common causes include appendicitis, ruptured ectopic pregnancy, and, less often, ruptured ovarian cyst. However, absence of peritoneal irritation does not rule out such disorders, and index of suspicion must be high.

Vaginal bleeding accompanying the pain suggests spontaneous abortion or ectopic pregnancy. An open cervical os or tissue passed through the cervix strongly suggests an inevitable, incomplete, or complete abortion. The presence of fever, chills, and a purulent vaginal discharge suggests a septic abortion (particularly in patients with a history of instrumentation of the uterus or illicitly attempted termination of pregnancy). Pelvic inflammatory disease is rare during pregnancy but may occur.

Testing

If an obstetric cause of pelvic pain is suspected, quantitative measurement of β-hCG, CBC, blood type, and Rh typing should be done. If the patient is hemodynamically unstable (with hypotension, persistent tachycardia, or both), blood should be cross-matched, and fibrinogen level, fibrin split products, and PT/ PTT are determined.

Pelvic ultrasonography is done to confirm an intrauterine pregnancy. However, ultrasonography can and should be deferred in the hemodynamically unstable patient with a positive pregnancy test, given the very high likelihood of either ectopic pregnancy or spontaneous abortion with hemorrhage. Both transabdominal and transvaginal ultrasonography should be used as necessary. If the uterus is empty and tissue has not been passed, ectopic pregnancy is suspected. If Doppler ultrasonography shows that blood flow to the adnexa is absent or decreased, adnexal (ovarian) torsion is suspected. However, this finding is not always present because spontaneous detorsion can occur.

Treatment

Treatment is directed at the cause. If ectopic pregnancy is confirmed and is not ruptured, methotrexate can often be considered, or surgical salpingotomy or salpingectomy may be done. If the ectopic pregnancy is ruptured or leaking, treatment is immediate laparoscopy or laparotomy.

Treatment of spontaneous abortions depends on the type of abortion and the patient’s hemodynamic stability. Threatened abortions are treated conservatively with oral analgesics. Inevitable, incomplete, or missed abortions are treated medically with misoprostol or surgically with uterine evacuation via D & C. Septic abortions are treated with uterine evacuation plus IV antibiotics.

Women who have Rh-negative blood should be given Rh 0 (D) immune globulin if they have vaginal bleeding or an ectopic pregnancy.

Ruptured corpus luteum cysts and degeneration of a uterine fibroid are treated conservatively with oral analgesics.

Treatment of adnexal torsion is surgical: manual detorsion if the ovary is viable; oophorectomy or salpingectomy if the ovary is infarcted and nonviable.

Key Points

  • Clinicians should always be alert for ectopic pregnancy.

  • Nonobstetric causes should be considered; acute abdomen may develop during pregnancy.

  • If no clear nonobstetric cause is identified, ultrasonography is usually necessary.

  • A septic abortion is suspected when there is a history of recent uterine instrumentation or induced abortion.

  • If vaginal bleeding occurred, Rh status is determined, and all women with Rh-negative blood are given Rh 0 (D) immune globulin.

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