Round Ligament Pain

Round ligament pain is a benign, sharp or stretching pain in the lower abdomen or groin caused by stretching and spasm of the round ligaments as the uterus enlarges.

• The round ligaments run from the uterine fundus through the inguinal canal to the labia majora.
• It is commonest between 14 and 28 weeks of gestation, when uterine growth is rapid.
• It affects about a quarter to a third of pregnant women, more often in multiparous women and in twin pregnancy.
• It is a diagnosis of exclusion and does not harm the pregnancy.

The pain is brief and triggered by movement.

• Sharp, jabbing or pulling pain in one or both lower quadrants radiating to the groin, lasting seconds to minutes.
• Triggered by sudden position changes, rolling over, standing up, coughing, sneezing or walking.
• Right side is more commonly affected because of normal uterine dextrorotation.
• Relieved by rest and change of position.
• No fever, vaginal bleeding, regular contractions, dysuria or abdominal guarding.
• Differential diagnosis: appendicitis, urinary tract infection, ovarian torsion, degenerating fibroid, placental abruption, preterm labour, inguinal hernia, symphysis pubis dysfunction and muscle strain.
• Complications: none directly. Delayed diagnosis of a serious condition mistaken for ligament pain is the main concern.

Diagnosis is clinical after exclusion of more serious causes.

• History of characteristic movement-triggered pain and examination showing a soft, non-tender abdomen apart from mild groin tenderness.
• Urinalysis to exclude infection.
• Fetal heart rate and observations are normal.
• Ultrasound if pain is persistent, severe, associated with bleeding, or atypical, to exclude fibroid degeneration, ovarian pathology or appendicitis.

Treatment is reassurance and comfort measures.

• Supportive: explain the cause and that it is harmless. Change position slowly, avoid sudden twisting movements, flex the hips toward the pain before coughing or sneezing, warm baths or a warm compress, rest on the painful side, and a maternity support belt.
• Pharmacological: paracetamol 500 mg to 1 g every 6 hours as needed (maximum 4 g in 24 hours). Avoid non-steroidal anti-inflammatory drugs in pregnancy.
• Procedures: none.
• Special groups: pain with fever, bleeding, regular contractions, or persistent unilateral pain needs full assessment.
• Red flags: constant severe pain, fever, vaginal bleeding, leaking fluid, regular contractions, reduced fetal movements, vomiting, haematuria and abdominal guarding.
• Follow-up: routine antenatal care. Review if pain changes in character or persists beyond a few days.