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Pelvic Pain During Early Pregnancy

By

Emily E. Bunce

, MD, Wake Forest Baptist Health;


Robert P. Heine

, MD, Wake Forest School of Medicine

Last full review/revision Dec 2020| Content last modified Dec 2020
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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 table Some Causes of Pelvic Pain) may be

  • Obstetric

  • Gynecologic, nonobstetric

  • Nongynecologic

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 (threatened, inevitable, incomplete, complete, septic, or missed)

The most common serious obstetric cause is

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 gastrointestinal and genitourinary disorders:

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

Table
icon

Some Causes of Pelvic Pain During Early Pregnancy

Cause

Suggestive Findings

Diagnostic Approach

Obstetric disorders

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 beta-hCG measurement

Complete blood count

Blood type and Rh typing

Pelvic ultrasonography

Laparoscopy or, if the patient is hemodynamically unstable, laparotomy

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 table Some Causes of Vaginal Bleeding)

Evaluation as for ectopic pregnancy

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 evaluation for STDs and vaginitis

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

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

Localized abdominal or pelvic pain, sometimes mimicking adnexal torsion

Vaginal bleeding

Usually, sudden onset

Evaluation as for ectopic pregnancy

Pelvic inflammatory disease (uncommon during pregnancy)

Purulent cervicovaginal discharge, significant cervical motion tenderness

Often fever and/or abnormal bleeding

Evaluation as for ectopic pregnancy

Evaluation for STDs and vaginitis

Possibly testing for gonorrhea, chlamydial infection, bacterial vaginosis, trichomoniasis, yeast infections, HIV infection, and syphilis

Nongynecologic disorders

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 evaluation for STDs and vaginitis

Pelvic/abdominal ultrasonography, followed by MRI if ultrasonography is inconclusive

Consideration of CT if MRI is not readily available

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

Urinalysis and culture

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

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

Abdominal imaging with flat and upright x-rays, ultrasonography, and possibly CT (if x-ray and ultrasonography results are equivocal)

Usually, vomiting, diarrhea

No peritoneal signs

Clinical evaluation

Beta-hCG = beta subunit of human chorionic gonadotropin; STDs = sexually transmitted diseases.

Evaluation

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

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

Important gastrointestinal symptoms include

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 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

  • 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

Interpretation of findings

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

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.

Testing

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

Treatment of pelvic pain during early pregnancy 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 abortion 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 are treated conservatively with oral analgesics.

Treatment of adnexal torsion is surgical:

  • If the ovary is viable: Manual detorsion

  • If the ovary is infarcted and nonviable: Oophorectomy or salpingectomy

Key Points

  • 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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