Where do pregnant patients usually feel round ligament pain?

Round Ligament Pain in Pregnancy: Location and Characteristics

Round ligament pain in pregnancy is typically felt in the lower abdomen, specifically in the right or left lower quadrant, extending into the groin area. 1

Anatomical Basis and Presentation

Round ligament pain occurs due to stretching, spasm, or tension on the round ligaments that support the uterus. These ligaments extend from the sides of the uterus, through the inguinal canal, and insert into the labia majora. Key characteristics include:

• Most commonly felt in the right lower quadrant (similar location to appendicitis pain)
• Can be unilateral or bilateral
• May radiate to the groin area
• Often described as sharp, stabbing pain that can be triggered by:
  • Sudden movements
  • Standing up quickly
  • Coughing
  • Sneezing
  • Laughing

Differential Diagnosis

It's important to distinguish round ligament pain from other conditions that can cause similar symptoms:

1. Round Ligament Varicocele (RLV): Presents as a groin swelling (unilateral or bilateral) that may be painful or painless, commonly mistaken for inguinal hernia 2, 3, 4. Almost exclusively occurs during pregnancy 4.

2. Appendicitis: The most common non-obstetric surgical emergency in pregnancy, also presenting with right lower quadrant pain 1. Unlike round ligament pain, appendicitis typically presents with:

   • Persistent pain rather than intermittent
   • Associated symptoms like fever, nausea, vomiting
   • Pain that doesn't resolve with position changes

3. Inguinal Hernia: Can present similarly to round ligament varicocele with groin swelling 2, 4.

Diagnostic Approach

When a pregnant patient presents with lower quadrant pain:

• Ultrasound is the first-line imaging modality for evaluating acute abdominal pain in pregnancy 1
• For suspected round ligament varicocele, Doppler ultrasound is diagnostic in >90% of cases and can prevent unnecessary surgical intervention 3, 4
• If ultrasound is inconclusive and concerns for appendicitis exist, MRI without contrast is recommended 1

Management

• Round ligament pain: Conservative management including:

  • Rest
  • Position changes
  • Warm compresses
  • Acetaminophen if approved by obstetrician

• Round ligament varicocele: Conservative management is successful in >90% of cases, with spontaneous resolution postpartum 3, 4

Clinical Pitfalls to Avoid

1. Misattribution: Avoid attributing all right lower quadrant pain to normal pregnancy without thorough evaluation 1

2. Misdiagnosis: Round ligament varicocele is often misdiagnosed as inguinal hernia, which may lead to unnecessary surgery during pregnancy 4

3. Delayed diagnosis: If appendicitis is suspected, prompt imaging and surgical intervention within 24 hours is recommended to minimize maternal and fetal complications 1

By understanding the typical location and characteristics of round ligament pain, clinicians can better differentiate it from more serious conditions requiring intervention, while providing appropriate reassurance and management for this common pregnancy symptom.