Early in pregnancy, many women have pelvic pain. Pelvic pain refers to pain in the lowest part of the abdomen (pelvis). Pain in the middle or upper part of the abdomen, in the area of the stomach and intestine, is called abdominal pain. However, sometimes women have trouble discerning whether pain is mainly in the abdomen or pelvis. Causes of abdominal pain during pregnancy may or may not be related to the pregnancy.
Pelvic pain in pregnancy may be related to normal changes of pregnancy or may be a sign of a problem. It can occur normally as the bones and ligaments shift and stretch to accommodate the fetus. Normal pain may be sharp or crampy (like menstrual cramps) and may come and go. Usually, pelvic pain that is not severe or persistent is not a cause for concern.
Pain that is caused by a pregnancy complication may be accompanied by other symptoms, including vaginal bleeding. Women should contact their doctor if they have any bleeding during pregnancy. In some disorders, such bleeding can be severe, sometimes leading to dangerously low blood pressure (shock). Pain that is severe, persistent, or in the middle or upper abdomen may be caused by a pregnancy complication or another disorder and is also a reason to contact a doctor.
Causes of Pelvic Pain in Early Pregnancy
During pregnancy, pelvic pain may result from disorders that are related to
The pregnancy
The female reproductive system but not the pregnancy
Other organs, particularly the digestive tract and urinary tract
Sometimes no particular cause is identified.
The most common pregnancy-related causes of pelvic pain during early pregnancy are
Normal changes of pregnancy
A miscarriage (spontaneous abortion)
An ectopic pregnancy(a pregnancy that is implanted outside the uterus, for example, in a fallopian tube)— the most serious cause of pelvic pain during early pregnancy
An ectopic pregnancy is life threatening. A pregnancy implanted outside the uterus will not develop normally. As the pregnancy grows in a fallopian tube or other body part (such as the ovary, cervix, or abdomen), it may cause that part to burst. This leads to severe pain and heavy bleeding, which can result in severe harm or even death to the pregnant woman. When an ectopic pregnancy is diagnosed, the treatment is to end the pregnancy with medications or remove it with surgery.
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.
Common causes of pelvic pain in general, which are also common causes during pregnancy, are digestive and urinary tract disorders, including the following:
Urinary tract infections (UTIs)
Gastroenteritis (infection of the digestive tract)
Urinary tract infections occur more frequently during pregnancy, and there is an increased risk of the infection spreading from the bladder to a kidney and becoming a more serious infection.
Risk factors
Various characteristics (risk factors) increase the risk of some pregnancy-related disorders that cause pelvic pain.
For miscarriage, risk factors include the following:
Age over 35
One or more miscarriages in previous pregnancies
Use of illicit drugs, such as cocainecocaine, or possibly other substances, such as alcohol
Abnormalities in the uterus, such as fibroids, scarring, or an abnormal uterine shape
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)
Fallopian tube abnormalities (for example, a swollen fallopian tube, called a hydrosalpinx)
Current use of an intrauterine device (IUD)
Use of assisted reproductive techniques (in vitro fertilization) to conceive current pregnancy
Additional risk factors for ectopic pregnancy include history of sexually transmitted infection or pelvic inflammatory disease, current use of estrogen/progestin oral contraceptives, cigarette smoking, infertility, and prior miscarriage or intentional termination of pregnancy (induced abortion).
Evaluation of Pelvic Pain in Early Pregnancy
If a pregnant woman has pelvic or abdominal pain, a doctor will evaluate whether this is caused by normal changes of pregnancy or if there is a problem. If there is 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:
Fever and chills, particularly if accompanied by pain with urination, upper back (flank) pain, or a vaginal discharge that contains pus
Pain that is severe and is made worse with movement
Fainting, light-headedness, or a rapid heart rate—symptoms that suggest very low blood pressure
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 the woman's 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, 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 also 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* | Diagnostic Approach† |
|---|---|---|
Normal changes of pregnancy, including stretching and growth of the uterus and surrounding connective tissues | A crampy sensation or pressure in the lower abdomen, pelvis, and/or lower back Sometimes, sudden sharp pain with movement (round ligament pain) | Regular prenatal check-up with maternal vital signs, examination of the abdomen, sometimes pelvic examination, and measurement of fetal heart rate Sometimes ultrasonography of the pelvis |
Crampy pain in the pelvis Usually vaginal bleeding, sometimes with passage of tissue from the pregnancy | Fetal heart rate measurement A pregnancy blood test Ultrasonography of the pelvis | |
An ectopic pregnancy (an abnormally located pregnancy—not in its usual place in the uterus) | Abdominal or pelvic pain that
If the ectopic pregnancy has ruptured, possibly fainting, light-headedness, or a rapid heart rate | A pregnancy blood test 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) |
Ovarian hyperstimulation syndrome | Use of fertility medications for current pregnancy Dull abdominal pain or pressure If moderate or severe, weight gain, abdominal distension and ascites, acute kidney disease, pleural effusion, or disseminated intravascular coagulation | Ultrasonography Blood tests |
Often burning during urination, an urge to urinate often (frequency), and a need to urinate immediately (urgency) Sometimes, discomfort felt in the area above the pubic bone Sometimes, blood in urine Sometimes, fever and chills | Urine tests (urinalysis) and culture | |
* Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present. | ||
† In pregnant women with concerning symptoms, the doctor assesses maternal vital signs, does a physical examination, and evaluates the status of the fetus with a fetal heart rate monitor or ultrasound. | ||
Testing
A pregnancy test using a urine sample is usually 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. If a pregnancy is very early, it is sometimes not possible to confirm if the pregnancy is in the uterus.
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 rapid heart rate) suggest that an ectopic pregnancy may have ruptured, blood tests are done to determine whether the woman's blood can clot normally.
The doctor does other tests 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 of Pelvic Pain in Early Pregnancy
Specific disorders are treated, as in the following examples:
Ectopic pregnancy: A medication to stop growth of the ectopic pregnancy or surgery to remove it
Miscarriage: Pain relievers, a medication to help the pregnancy pass, or a dilation and curettage (D & C) procedure to remove pregnancy tissue
Septic abortion (infection of the contents of the uterus before, during, or after a miscarriage): Antibiotics given intravenously and D & C to remove the contents of the uterus as soon as possible
Adnexal torsion (a twisted ovary or fallopian tube): 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.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
To help avoid or lessen some types of pain during pregnancy, women may be advised to
Have a fitness routine with exercises that are safe during pregnancy
Avoid heavy lifting or pushing
Maintain good posture
Sleep with a pillow between their knees
Rest when needed
Wear clothing with elastic that supports the back or abdomen
See a physical therapist with expertise in pregnancy
Possibly try acupuncture
Key Points
Pelvic pain during early pregnancy usually results from changes that occur normally during pregnancy.
Sometimes it results from disorders related to the pregnancy, or related 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.
