Pelvic pain Female Pelvic Pain Pelvic pain is discomfort in the lower abdomen and is a common complaint. It is considered separately from vaginal pain and from vulvar or perineal pain, which occurs in the external genitals... read more 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.
Sometimes no particular disorder is identified.
The most common obstetric causes of pelvic pain during early pregnancy are
The normal changes of pregnancy
Spontaneous abortion Spontaneous Abortion Spontaneous abortion is pregnancy loss before 20 weeks gestation. Threatened abortion is vaginal bleeding without cervical dilation before 20 weeks in a confirmed viable intrauterine pregnancy... read more (threatened, inevitable, incomplete, complete, septic, or missed)
The most common serious obstetric cause is
Nonobstetric gynecologic causes include adnexal torsion Adnexal Torsion Adnexal torsion is twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia. Adnexal torsion is uncommon, occurring most often during reproductive... read more , 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 gastrointestinal and genitourinary disorders:
Pelvic pain during late pregnancy may result from labor or one of the many nonobstetric causes of pelvic pain.
Evaluation of patients with of pelvic pain during early pregnancy should exclude potentially serious treatable causes (eg, ruptured or unruptured ectopic pregnancy, septic abortion, appendicitis).
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), effect of movement on the pain, 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 genitourinary and gastrointestinal symptoms that suggest a cause.
Important genitourinary symptoms include
Vaginal bleeding: Ectopic pregnancy Ectopic Pregnancy Ectopic pregnancy is the implantation of a pregnancy in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal... read more or abortion Spontaneous Abortion Spontaneous abortion is pregnancy loss before 20 weeks gestation. Threatened abortion is vaginal bleeding without cervical dilation before 20 weeks in a confirmed viable intrauterine pregnancy... read more
Syncope or near syncope: Ectopic pregnancy
Urinary frequency, urgency, or dysuria: Urinary tract infection Introduction to Urinary Tract Infections (UTIs) Urinary tract infections (UTIs) can be divided into upper tract infections, which involve the kidneys ( pyelonephritis), and lower tract infections, which involve the bladder ( cystitis), urethra... read more
Vaginal discharge and history of unprotected intercourse: Pelvic inflammatory disease Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be sexually transmitted... read more
Important gastrointestinal symptoms include
Diarrhea: Gastroenteritis Overview of Gastroenteritis Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most cases are infectious, although gastroenteritis may occur after ingestion of drugs and chemical... read more , inflammatory bowel disease Overview of Inflammatory Bowel Disease Inflammatory bowel disease (IBD), which includes Crohn disease and ulcerative colitis, is a relapsing and remitting condition characterized by chronic inflammation at various sites in the gastrointestinal... read more , or irritable bowel syndrome Irritable Bowel Syndrome (IBS) Irritable bowel syndrome is characterized by recurrent abdominal discomfort or pain with at least two of the following characteristics: relation to defecation, association with a change in frequency... read more
Vomiting: Due to many disorders, including gastroenteritis and bowel obstruction Intestinal Obstruction Intestinal obstruction is significant mechanical impairment or complete arrest of the passage of contents through the intestine due to pathology that causes blockage of the bowel. Symptoms include... read more
Obstipation: Bowel obstruction Intestinal Obstruction Intestinal obstruction is significant mechanical impairment or complete arrest of the passage of contents through the intestine due to pathology that causes blockage of the bowel. Symptoms include... read more , 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
Previous ectopic pregnancy (the most important)
History of sexually transmitted infection or pelvic inflammatory disease
Use of intrauterine device
Age > 35
Previous abdominal surgery (especially tubal surgery)
Use of fertility drugs or assisted reproductive techniques
Multiple sex partners
Risk factors for spontaneous abortion include
Age > 35
History of spontaneous abortion
Drugs (eg, cocaine, alcohol, high doses of caffeine)
Uterine abnormalities (eg, leiomyoma, adhesions)
Risk factors for bowel obstruction include
Previous abdominal surgery
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.
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
Interpretation of findings
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.
Findings that suggest a cause include
Vaginal bleeding accompanying the pain: Spontaneous abortion or ectopic pregnancy
An open cervical os or tissue passed through the cervix: Generally, an inevitable, incomplete, or complete abortion
Presence of fever, chills, and a purulent vaginal discharge: 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.
If an obstetric cause of pelvic pain is suspected, quantitative measurement of beta-hCG, complete blood count, 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 prothrombin time/partial thromboplastin time (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.
Laparoscopy can be used to diagnose pain that remains significant and undiagnosed after the usual tests.
Treatment of pelvic pain during early pregnancy is directed at the cause.
If ectopic pregnancy Treatment Ectopic pregnancy is the implantation of a pregnancy in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal... read more 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 abortion Treatment Spontaneous abortion is pregnancy loss before 20 weeks gestation. Threatened abortion is vaginal bleeding without cervical dilation before 20 weeks in a confirmed viable intrauterine pregnancy... read more 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 dilation and curettage (D & C). Septic abortions are treated with uterine evacuation plus IV antibiotics.
Women who have Rh-negative blood should be given Rho(D) immune globulin if they have vaginal bleeding or an ectopic pregnancy.
Ruptured corpus luteum cysts and degeneration of a uterine fibroid Treatment Uterine fibroids are benign uterine tumors of smooth muscle origin. Fibroids frequently cause abnormal uterine bleeding, pelvic pain and pressure, urinary and intestinal symptoms, and pregnancy... read more are treated conservatively with oral analgesics.
Treatment of adnexal torsion Treatment Adnexal torsion is twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia. Adnexal torsion is uncommon, occurring most often during reproductive... read more is surgical:
If the ovary is viable: Manual detorsion
If the ovary is infarcted and nonviable: Oophorectomy or salpingectomy
Pelvic pain in early pregnancy should always raise concern for ectopic pregnancy.
Consider nonobstetric etiologies as a cause of acute abdomen during pregnancy.
If no clear nonobstetric cause is identified, ultrasonography is usually necessary.
Suspect a septic abortion when there is a history of recent uterine instrumentation or induced abortion.
Determine blood type and Rh status for all women during early pregnancy; if heavy vaginal bleeding or ectopic pregnancy occurs, all women with Rh-negative blood should be given Rho(D) immune globulin.
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