Pelvic Pain During Early Pregnancy

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8/03/2022

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Pelvic Pain During Early Pregnancy

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.

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If caused by a disorder, pelvic pain may be accompanied by other symptoms, including vaginal bleeding. 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 of pelvic pain 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 of pelvic pain is

Rupture of an abnormally located pregnancy ( ectopic pregnancy)—one that is not in its usual place in the uterus, for example, 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 the following:

Gastroenteritis (infection of the digestive tract)
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 the following:

Age over 35
One or more miscarriages in previous pregnancies
Cigarette smoking
Use of drugs such as cocaine, alcohol, or consumption of a lot of caffeine
Abnormalities in the uterus, such as fibroids, scarring, or an abnormal uterine shape
Poorly controlled medical problems such as diabetes, thyroid disease, or lupus

For ectopic pregnancy, risk factors include the following:

A previous ectopic pregnancy (the most important risk factor)
Previous abdominal surgery, especially surgery for permanent sterilization (tubal ligation)
A previous infection with a sexually transmitted infection 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 (in vitro fertilization)
Several sex partners
Vaginal 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 a ruptured 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 and chills, 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 Some Causes and Features of Pelvic Pain During Early Pregnancy).

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 the following:

Other symptoms, such as vaginal bleeding, a vaginal discharge, a need to urinate often or urgently, vomiting, diarrhea, and constipation

Previous pregnancy-related events (obstetric history), including past pregnancies, miscarriages, and intentional terminations of pregnancy (induced abortions) for medical or other reasons

Risk factors for miscarriage and ectopic pregnancy

The physical examination focuses on the pelvic examination (examination of the external and internal reproductive organs and sometimes the rectum). Doctors gently press on the abdomen to see whether pressing causes any pain.

Testing

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), 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, fallopian tubes, and ovaries to further evaluate the cause of the pain. Rarely, a larger incision (a procedure called laparotomy) is required.

Treatment

Specific disorders are treated, as in the following examples:

Ectopic pregnancy: A drug to stop growth of the ectopic pregnancy or surgery to remove it

Miscarriage: Pain relievers, a drug to help the pregnancy pass, or dilation and curettage (D & C) to remove it

Septic abortion: Antibiotics given intravenously and D & C to remove the contents of the uterus as soon as possible

A twisted ovary or fallopian tube ( adnexal torsion): Surgery to untwist (if possible) or to remove the ovary or tube

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

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Change the activity causing pain

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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