Pregnancy · Symptoms
Abdominal Pain in Pregnancy
Why your stomach hurts in pregnancy: common benign causes vs red flags. Round ligament pain, Braxton Hicks, constipation vs pre-eclampsia, abruption, ectopic, appendicitis, preterm labour. Safe painkillers + when to call. NICE NG201.
Last reviewed 2 June 2026
Abdominal pain in pregnancy
Triage with red-flag flowchart + differentials
Red flags (tick all that apply)
Action
Symptomatic workup
Targeted workup by site (RLQ). FBC, U+E, LFT, urine dip + culture. Bedside ultrasound (and formal if needed). Symptomatic pain relief (paracetamol first; opioid only if severe + supervised). Re-assess at 4 hours; if not improving or any red flag develops, escalate to emergency pathway.
Differentials to consider
- Appendicitis (commonest non-obstetric surgical cause in pregnancy — may present higher in upper abdomen as gravid uterus displaces caecum)
- Ovarian torsion (right ovary commoner)
- Ureteric / renal colic
- Round ligament pain (if mid-2nd trimester)
- Ectopic (if early)
Troubleshooting + common pitfalls
- Pitfall: Missing appendicitis because pain is high.
Solution: Gravid uterus displaces the caecum cephalad. Late-pregnancy appendicitis can present in the RUQ. Maintain suspicion despite atypical site; surgical opinion early; MRI is the imaging of choice if ultrasound non-diagnostic (CT acceptable if MRI unavailable). - Pitfall: Delaying surgery from radiation concerns.
Solution: Untreated appendicitis with perforation has far higher fetal mortality than the small radiation exposure of CT. SAGES 2017 + ACOG endorse laparoscopy in any trimester. Don’t delay. - Pitfall: Attributing pain to “round ligament” without ruling out serious causes.
Solution: Round ligament pain is a diagnosis of exclusion. Document the negatives (no peritonism, no fever, no vital-sign derangement, normal exam, soft uterus) before labelling. - Pitfall: Missing placental abruption in concealed presentations.
Solution: Up to 20 % of abruptions are concealed (no visible PV bleed). Severe constant abdominal pain + tonic uterus + non-reassuring CTG + maternal shock out of proportion to visible blood loss — suspect abruption. - Pitfall: Uterine rupture missed in TOLAC.
Solution: Sudden severe pain, FHR deterioration, loss of contractions, recession of presenting part — uterine rupture until proven otherwise in any woman with prior CS. Move to theatre. - Pitfall: Cholecystitis treated as “normal pregnancy reflux”.
Solution: RUQ pain + Murphy’s + fever + WCC elevation = cholecystitis. Pregnancy increases biliary sludge / stones. US is first-line imaging. Laparoscopic cholecystectomy preferred in 2nd trimester if needed. - Pitfall: Pyelonephritis underestimated.
Solution: Pregnant women with pyelonephritis have ~3× the ARDS / sepsis-shock rate of non-pregnant. Admit, IV antibiotics, urine + blood cultures, daily urine culture, repeat US to rule out obstruction. - Pitfall: Ovarian torsion missed.
Solution: Sudden severe unilateral lower-abdominal pain + nausea + sometimes a previously-known ovarian cyst — consider torsion. Doppler may show absent flow but normal Doppler does NOT rule out (intermittent torsion). Surgical exploration is often needed despite ambiguous imaging. - Pitfall: Fibroid degeneration not on differential.
Solution: 2nd-3rd trimester focal pain over a known fibroid, low-grade fever, leucocytosis. Conservative management with paracetamol + opioids if needed; resolves in days. - Pitfall: Sickle crisis dismissed.
Solution: Pregnant women with sickle cell disease have more frequent and severe crises. Treat aggressively with IV fluids + analgesia + oxygen; transfuse per haematology. - Pitfall: HELLP / AFLP not considered in 3rd-trimester RUQ pain.
Solution: RUQ + nausea + headache + visual disturbance + raised LFTs / platelets < 100 = HELLP differential; jaundice + coagulopathy + hypoglycaemia = AFLP. Both are obstetric emergencies needing delivery. - Pitfall: Inadequate analgesia from drug-concern paralysis.
Solution: Paracetamol first (safe). Opioids (morphine, fentanyl) safe in supervised hospital use. NSAIDs avoided > 30 wk (ductus arteriosus). Don’t leave women in pain — uncontrolled pain itself is harmful and worsens diagnostic accuracy. - Pitfall: No reassessment loop.
Solution: Re-examine at 4 hours. Most diagnoses declare themselves — either improve, progress, or red-flag escalation. Static observation without reassessment is the failure mode for missed surgical pathology.
Educational tool only — not medical advice. RCOG GTG 25 (2024); SAGES 2017; ACOG / SMFM. Triage by obstetric + emergency + surgical teams.
What does this mean?
Abdominal pain in pregnancy is one of the most common reasons for emergency obstetric attendance and one of the most diagnostically treacherous. Pregnancy physiology alters anatomy (cephalad displacement of the appendix, ureteric dilation, gallbladder stasis), masks classical signs (peritonism less prominent), and elevates the risk of catastrophic causes (ectopic, abruption, uterine rupture, HELLP, AFLP). The single most useful triage tool is the red-flag review: haemodynamic instability, peritonism, sustained tachycardia, PV bleeding more than spotting, fever ≥ 38, reduced fetal movements, shoulder-tip pain, sudden tearing pain, sustained pain > 4 hours unrelieved — any one means same-day emergency assessment. The two most-missed obstetric causes are concealed abruption (up to 20 % have no visible bleed; constant pain + tonic uterus + non-reassuring CTG + maternal shock out of proportion) and uterine rupture in TOLAC (sudden severe pain + FHR deterioration + loss of contractions + recession of presenting part). The single most-missed non-obstetric surgical cause is appendicitis presenting atypically high because the gravid uterus pushes the caecum cephalad — late-pregnancy appendicitis can present in the RUQ. Practical operating principles: (1) don’t delay surgery for radiation concerns — SAGES 2017 + ACOG support laparoscopy in any trimester; untreated perforation is worse for the fetus than any imaging or anaesthesia; (2) don’t under-analgese — paracetamol then opioids if needed; pain itself worsens diagnostic accuracy; (3) reassess at 4 hours — most diagnoses declare themselves.
Why does my stomach hurt?
Most causes are benign. Common:
- Round ligament pain — sharp twinges as ligaments stretch.
- Stretching of uterus + abdominal muscles.
- Braxton Hicks (practice contractions).
- Constipation.
- Heartburn / reflux.
- Wind / bloating.
- SPD (pubic pain).
Serious causes: pre-eclampsia, abruption, ectopic, UTI, appendicitis, preterm labour.
Red flags — call today
- Severe pain not relieved by paracetamol.
- Constant (not coming + going).
- With vaginal bleeding.
- With fever >38°C.
- Dizziness / fainting / fast HR.
- Upper right pain (under right rib).
- Regular contractions before 37 weeks.
- Sudden onset.
- Reduced fetal movements.
- Visual changes / severe headache / swelling.
Round ligament pain (commonest)
- Brief (seconds-minutes).
- Sharp / stabbing.
- One side typically (often right).
- Triggered by sudden movement.
- 12-24 weeks commonest.
Settles with slow position changes, lying on opposite side, warm compress, gentle stretching.
Painkillers in pregnancy
- Paracetamol: safe; first choice.
- NSAIDs (ibuprofen): avoid, especially after 28-30 wk.
- Opioids: short-term only with doctor.
- Aspirin: never (except low-dose for PE prevention).
Braxton Hicks vs labour
- Braxton Hicks: irregular, painless/mild, stops with rest, <60 sec, localised.
- Real labour: regular + progressive, stronger, closer, doesn’t stop, back-to-front, 30-90 sec.
5-1-1 rule at term = hospital.
Different scenarios
Scenario 1: Sharp groin twinge standing up, 18 wk
Round ligament. Slow movements. Warm compress.
Scenario 2: Persistent RUQ + new headache, 32 wk
Hospital. PE / HELLP workup.
Scenario 3: Sudden severe + bleeding, 30 wk
999. Possible abruption.
Scenario 4: Lower cramping + burning urination + fever
UTI. Same-day GP. Antibiotics.
Scenario 5: 9 wk, one-sided pelvic + spotting
EPAU same day. Rule out ectopic.
Care guidance
- Most causes benign; red flags need same-day review.
- Paracetamol safe; avoid NSAIDs.
- RUQ = think liver / PE / HELLP.
- Sudden severe = emergency.
- UTI signs need prompt antibiotics.
- Preterm contractions = same-day maternity.
- Itchy palms + soles = check ICP.
Sources
- NICE NG201. Antenatal care.
- RCOG. Multiple Green-top guidelines.
- NHS. Pregnancy advice.
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Frequently asked questions
Why does my stomach hurt during pregnancy?
MANY causes — most NORMAL. COMMON benign: round ligament pain (sharp twinges 12-20 wk); uterus / muscle stretching; Braxton Hicks; constipation (progesterone slows gut); heartburn; wind / bloating; SPD (pubic pain). SERIOUS (same-day): pre-eclampsia (RUQ pain); placental abruption; ectopic; UTI; appendicitis; preterm labour. ASSESS pattern + severity + accompanying signs. NEVER 'tough out' severe / persistent pain.
Sharp pain in my groin — round ligament?
PROBABLY YES if: brief (seconds-minutes); sharp / stabbing; one side (often right); triggered by sudden movement (changing position, coughing); 12-24 weeks commonest. Ligaments stretch as uterus grows. NOT dangerous. Settles with: slow position changes; lying on opposite side; warm compress; gentle stretching. CALL midwife if persistent, severe, with bleeding, or other red flags.
When should I worry about abdominal pain?
RED FLAGS — call midwife / GP / hospital TODAY: severe pain not relieved by paracetamol; constant (not coming + going); with vaginal bleeding; with fever (>38°C); dizziness, fainting, fast heart rate; UPPER RIGHT pain (under right rib — liver — pre-eclampsia / HELLP); regular contractions before 37 weeks; sudden onset; reduced fetal movements; visual changes; severe headache; sudden swelling face / hands / feet.
Could it be pre-eclampsia or HELLP?
RIGHT UPPER ABDOMINAL pain in pregnancy = think LIVER. Pre-eclampsia / HELLP if combined with: severe headache; visual changes; high BP; sudden swelling; nausea / vomiting; feeling 'just not right'. LIFE-THREATENING — same-day hospital assessment. See /calculators/preeclampsia-diagnosis.
Could it be placental abruption?
PLACENTAL ABRUPTION — placenta separates from uterus. SYMPTOMS: sudden severe abdominal pain; bleeding (sometimes hidden); uterus tense / hard; shock signs; reduced fetal movements. EMERGENCY — 999 / A&E. Risk factors: PE, smoking, cocaine, abdominal trauma.
What about ectopic pregnancy?
EARLY pregnancy (<12 wk usually). One-sided pelvic pain; vaginal bleeding (light, brown); shoulder tip pain (referred from internal bleeding); dizziness / fainting (rupture). MEDICAL EMERGENCY if rupture. Positive pregnancy test + pelvic pain + bleeding = same-day EPAU referral.
Could it be a UTI?
Lower abdominal / suprapubic pain; burning urination; frequent urination; cloudy / smelly urine; fever / chills (pyelonephritis — kidney). NEEDS antibiotics promptly — untreated can cause preterm labour, sepsis. Safe pregnancy antibiotics: nitrofurantoin, cefalexin, amoxicillin.
Could it be appendicitis?
Incidence similar to non-pregnant (~1 in 500-2000). DIAGNOSIS harder — uterus pushes appendix upward; classical signs less reliable. Persistent right-sided pain + nausea + fever + loss of appetite = urgent surgical assessment. Appendectomy safe in pregnancy if needed.
What's preterm labour pain?
Regular contractions before 37 weeks. Signs: contractions every 5-10 min for over an hour; lower back pain that comes + goes; pelvic pressure; menstrual-like cramps; discharge change; 'show' (mucus plug). Same-day maternity unit. Possible tocolysis, steroids, antibiotics if appropriate.
Braxton Hicks vs real contractions?
BRAXTON HICKS: irregular; painless/mild; stops with rest/water; <60 sec; localised. REAL labour: regular + progressive; getting stronger; getting closer; doesn't stop with rest; back to front; 30-90 sec. AT TERM (37+ wk): 5-1-1 rule (5 min apart, 1 min long, 1 hour) = hospital.
Constipation pain or something worse?
CONSTIPATION: dull lower abdominal ache; relieved by bowel movement; bloating. Management: water (2L/day); high-fibre; gentle exercise; lactulose / movicol if severe. MORE: severe pain, vomiting, no bowel movement several days = could be obstruction (rare); fever + tender abdomen = colitis / appendicitis.
What about gallstones?
MORE COMMON in pregnancy (progesterone slows bile). Severe right upper abdominal pain after fatty meals; nausea / vomiting; sometimes jaundice; fever if infected. Ultrasound diagnoses. Conservative (low-fat, painkillers) usual; surgery sometimes needed; postpartum definitive treatment often.
Can I take painkillers?
PARACETAMOL safe — first choice. NSAIDs (ibuprofen, diclofenac, naproxen) AVOID — especially after 28-30 weeks. Opioids (codeine, tramadol) — short-term only with doctor. NEVER aspirin except low-dose prescribed for PE prevention. Position change + warm compress + hydration + rest also help.
What if pain wakes me at night?
Persistent severe night pain warrants review. Consider: PE symptoms (RUQ pain); severe reflux; musculoskeletal; preterm labour. Call midwife / out-of-hours / NHS 111 if severe, persistent, with other symptoms. DON'T just tough it out.
What about ICP / itchy palms differential?
Itchy palms + soles in late pregnancy (without rash) = check for ICP (obstetric cholestasis). Same-day bile acid blood test. /calculators/icp-cholestasis.
How does this relate to other calculators on BumpBites?
Companion: /calculators/preeclampsia-diagnosis; /calculators/hellp-classifier; /calculators/methotrexate-ectopic; /calculators/contraction-timer; /calculators/cervical-length; /calculators/icp-cholestasis; /calculators/pregnancy-symptom-check; /calculators/maternal-sepsis.