Some Causes of Pelvic Pain During Early Pregnancy
Cause | Suggestive Findings | Diagnostic Approach* |
|---|---|---|
Obstetric Conditions | ||
Normal changes of pregnancy, including those due to stretching and growth of the uterus and surrounding connective tissues | Crampy sensation or pressure in the lower abdomen, pelvis, lower back, or a combination Sometimes, with movement, sudden sharp pain (round ligament pain) | Routine prenatal evaluation with maternal vital signs, abdominal examination, sometimes pelvic examination, and fetal heart rate auscultation (depending on gestational age) Sometimes, pelvic ultrasound Evaluation for ectopic pregnancy or other conditions, if suspected |
Abdominal or pelvic pain, which is often sudden, localized, and constant (not crampy), usually with vaginal bleeding Closed cervical os No fetal heart sounds Possibly hemodynamic instability if ectopic pregnancy has ruptured Sometimes, a palpable adnexal mass | Quantitative beta-hCG measurement, repeated every 2 days if diagnosis is uncertain (pregnancy of unknown location) Complete blood count Pelvic ultrasound Sometimes, endometrial sampling Laparoscopy or, if the patient is hemodynamically unstable, laparotomy | |
Spontaneous abortion (threatened, inevitable, incomplete, complete, missed) | Crampy, diffuse, lower abdominal pain, often with vaginal bleeding Open or closed cervical os depending on the type of abortion (see table Some Causes of Vaginal Bleeding) | Quantitative serum beta-hCG measurement, repeated every 2 days if diagnosis is uncertain Complete blood count Pelvic ultrasound |
Usually, history of recent induced or spontaneous abortion (risk is higher if induced abortion is performed without appropriately trained clinicians and equipment or if self-induced) Fever, chills, constant abdominal or pelvic pain Vaginal bleeding and/or purulent vaginal discharge Uterine tenderness Open cervical os | Evaluation as for spontaneous abortion plus evaluation for STIs and vaginitis | |
Gynecologic Conditions | ||
Uterine fibroid degeneration | Sudden onset of pelvic pain, dull or sharp, usually severe, often with nausea, vomiting, and fever Sometimes, vaginal bleeding Uterine tenderness | Pelvic ultrasound MRI (used only if diagnosis is uncertain) |
Sudden onset of localized pelvic pain, which may be severe and intermittent (if torsion spontaneously resolves) Often, nausea, vomiting | Pelvic ultrasound with Doppler | |
Ruptured corpus luteum cyst | Localized abdominal or pelvic pain Sometimes, vaginal bleeding Usually, sudden onset | Pelvic ultrasound Complete blood count |
Pelvic inflammatory disease (uncommon during pregnancy) | Purulent cervicovaginal discharge Significant cervical motion, uterine, and/or adnexal tenderness Often, fever and/or abnormal vaginal bleeding | Evaluation for STIs and vaginitis Complete blood count |
Benign or malignant ovarian tumor | Dull abdominal pain or pressure Sometimes, weight loss Sometimes, abdominal distension and ascites Sometimes, ovarian cancer risk factors | Pelvic ultrasound Tumor markers (eg CA-125, human epididymis protein 4 (HE4), alphafetoprotein (AFP), lactate dehydrogenase (LDH), carcinoembryonic antigen (CEA), and b-hCG); importantly, tumor markers can be elevated during normal pregnancy (1) Sometimes, diagnostic laparoscopy |
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 | Pelvic ultrasound Complete blood count Comprehensive metabolic panel |
Nongynecologic Conditions | ||
Usually, continuous diffuse or localized abdominal pain, tenderness Possibly atypical location (eg, right upper quadrant) or qualities (milder, crampy, no peritoneal signs) compared with pain in nonpregnant patients; appendix may be in a different position due to enlarged uterus Sometimes, peritoneal signs Sometimes, nausea, vomiting, or loss of appetite | Pelvic/abdominal ultrasound, followed by MRI if ultrasound is inconclusive; consideration of CT if MRI is not readily available Complete blood count or C-reactive protein | |
Suprapubic discomfort, often with bladder symptoms (eg, burning, frequency, urgency) Sometimes, fever, chills, and/or flank pain (risk of pyelonephritis is increased in pregnancy) | Urinalysis and culture Consider complete blood count and blood culture if concern for systemic infection | |
Variable pains (crampy or constant) in no consistent location, often with diarrhea and sometimes with mucus or blood Sometimes, fever Usually, a known history of IBD | Sometimes, fecal calprotectin Sometimes, endoscopy if needed to confirm diagnosis and/or determine management (2) | |
Acute nausea and vomiting, usually in patients who have had abdominal surgery, have an intraabdominal malignancy, or sometimes an incarcerated hernia detected during examination Colicky pain, vomiting, no bowel movements or flatus Distended, tympanitic abdomen May be caused by or occur in patients with appendicitis | Evaluation as for ectopic pregnancy and ovarian torsion Abdominal imaging with flat and upright radiographs, ultrasound, and possibly CT (if radiograph and ultrasound results are equivocal) | |
Usually, vomiting, diarrhea No peritoneal signs | Sometimes, stool tests (if bacterial or parasitic infection is suspected) | |
Pancreatitis | Abdominal pain (typically epigastric or left upper quadrant) and vomiting, pain is often severe and may radiate to the back | Serum lipase Comprehensive metabolic panel Abdominal ultrasound, consideration of magnetic resonance cholangiopancreatography if ultrasound is nondiagnostic |
Beta-hCG = beta subunit of human chorionic gonadotropin; STIs = sexually transmitted infections. | ||
* Evaluation of concerning symptoms in all pregnant patients should include assessment of maternal vital signs, physical examination, and evaluation of fetal status with fetal heart rate monitoring or ultrasound. | ||