What are the potential causes of sharp pains and a small protrusion in a 14-week pregnant patient with a known fibroid, and what signs should she monitor for further medical attention?

Sharp Pains and Lower Abdominal Protrusion in 14-Week Pregnancy with Known Fibroid

The sharp, positional pain (6-7/10) near the fibroid location combined with gastrointestinal upset is most likely red degeneration of the fibroid, a common and typically self-limited complication in pregnancy, while the small egg-like protrusion when lying flat is likely diastasis recti or normal uterine prominence at 14 weeks—neither requires urgent intervention unless accompanied by severe unrelenting pain, fever, peritoneal signs, or vaginal bleeding. 1, 2, 3

Potential Causes of the Sharp Pain

Red Degeneration (Most Likely)

• Fibroids commonly undergo red degeneration during pregnancy, particularly in the second trimester, causing acute sharp pain localized to the fibroid site. 2, 4
• The pain is characteristically sharp, positional (worse with movement), and can reach 6-7/10 intensity, matching this patient's presentation exactly. 2, 4
• Red degeneration occurs when the fibroid outgrows its blood supply, leading to hemorrhagic infarction and inflammation within the fibroid capsule. 2, 4
• This is a self-limited process that typically resolves over 4-7 days with conservative management (rest, hydration, NSAIDs if not contraindicated). 2, 3

Round Ligament Pain (Less Likely Given Severity)

• Round ligament pain is common at 14 weeks but typically presents as brief, sharp pains with position changes, usually rated 3-5/10 rather than 6-7/10. 1
• The localization specifically to the fibroid area makes this less likely as the primary cause. 1

Gastrointestinal Factors

• The correlation between stomach upset and worsened pain suggests gastrointestinal distension may be exacerbating pressure on the fibroid or surrounding structures. 2
• Pregnancy-related constipation and bloating commonly worsen pelvic pressure symptoms from fibroids. 2, 3

The Lower Abdominal Protrusion

Normal Uterine Prominence (Most Likely)

• At 14 weeks gestation, the uterus is approximately grapefruit-sized and beginning to emerge from the pelvis, which can create a visible lower abdominal prominence when lying supine, particularly in lean patients or those with anterior uterine position. 1
• The "egg-like" appearance when flat is consistent with normal uterine fundal prominence at this gestational age. 1

Diastasis Recti

• Separation of the rectus abdominis muscles can occur even in early pregnancy, creating a midline protrusion that becomes more apparent with certain positions. 1
• This is benign and does not require intervention during pregnancy. 1

Pedunculated Subserosal Fibroid (Less Likely)

• If the known fibroid is pedunculated and subserosal, it could theoretically create a palpable mass, though this would typically have been noted on the recent ultrasound one week ago. 1

Signs That Are Normal and Expected

Expected Findings at 14 Weeks with Fibroids

• Mild to moderate positional discomfort with movement is expected as the uterus enlarges and fibroids stretch. 2, 3
• Intermittent sharp pains lasting seconds to minutes that resolve spontaneously are typical of round ligament stretching. 1
• Visible lower abdominal prominence when supine is normal uterine growth at this gestational age. 1
• Mild gastrointestinal upset (nausea, bloating, constipation) remains common through early second trimester. 2

Fibroid-Specific Expected Changes

• Fibroids typically enlarge during pregnancy due to hormonal stimulation, which can cause increased pressure sensations. 2, 3
• Pain from red degeneration, while uncomfortable, is self-limited and does not harm the pregnancy when managed conservatively. 2, 4

Warning Signs Requiring Medical Attention

Seek Urgent Evaluation (Emergency Department) If:

• Severe, unrelenting pain (8-10/10) that does not improve with rest or position changes, suggesting possible fibroid rupture (extremely rare but life-threatening). 4
• Fever >100.4°F (38°C), which could indicate infection or septic degeneration of the fibroid. 2, 4
• Vaginal bleeding (more than light spotting), which could indicate placental complications or threatened miscarriage. 1
• Signs of peritoneal irritation: rigid abdomen, rebound tenderness, inability to walk due to pain—suggesting possible fibroid rupture with hemoperitoneum. 4
• Sudden onset of severe pain with lightheadedness, tachycardia, or hypotension—concerning for hemorrhage. 4

Seek Precautionary Evaluation (Contact OB Provider Within 24 Hours) If:

• Pain persists beyond 5-7 days without improvement, as prolonged symptoms may warrant imaging reassessment. 1, 2
• The protrusion enlarges rapidly, becomes tender, or changes in character—requiring ultrasound evaluation to rule out complications. 1
• Decreased fetal movement perception (though this is early for consistent movement, any previously felt movement that stops should be evaluated). 1
• Persistent vomiting leading to dehydration or inability to keep down fluids. 1
• New urinary symptoms: inability to void, severe frequency, or dysuria—suggesting possible urinary obstruction from fibroid mass effect. 2, 3

Recommended Management Approach

Conservative Management for Likely Red Degeneration

• Rest and avoid sudden position changes that trigger pain. 2
• Adequate hydration to support circulation and reduce constipation. 2
• Acetaminophen for pain control (avoid NSAIDs after 20 weeks, but can be used cautiously in second trimester if needed). 2
• Warm compresses to the painful area may provide symptomatic relief. 2

Monitoring Strategy

• Document pain patterns: frequency, duration, triggers, and severity over the next 3-5 days. 2
• Monitor for fever daily. 4
• Observe the protrusion for any changes in size, tenderness, or appearance. 1
• Continue routine prenatal care with ultrasound surveillance as recommended by her OB provider for fibroid monitoring. 1, 2

Important Caveats

• While fibroid rupture with hemoperitoneum is exceedingly rare (fewer than 30 reported cases), it is life-threatening and requires immediate surgical intervention—any signs of peritoneal irritation or hemodynamic instability warrant emergency evaluation. 4
• Rapid fibroid growth in pregnancy is usually benign hormonal response, but in rare cases (particularly postmenopausal women, not applicable here) could indicate leiomyosarcoma—this patient's recent ultrasound provides reassurance. 2, 5
• The medicated IVF cycle history does not change fibroid management during pregnancy but may warrant closer monitoring given the investment in achieving pregnancy. 1