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Old Aug 9th, 2008, 04:30 AM   1
Carley
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Common second trimester pains


2nd Trimester Pelvic Pain

The second trimester of pregnancy, defined as the period from 13 weeks until 29 weeks, is mostly associated with growth of the fetus and uterus. The causes of second trimester (sometimes called mid-trimester) pain can be very different from first trimester pain. During this time frame, the uterus may be responsible for many pain symptoms.

During the second trimester, it is common to develop pelvic cramping as the uterus continues growing upward. At approximately 20 weeks in your pregnancy, your uterus will be at about the level of your belly button. By 29 weeks, your uterus will be halfway between your belly button and your ribs. This is a large amount of change in only 9 weeks. All of your pelvic and abdominal organs are being pushed upwards and sideways due to the enlarging uterus. Displacement of your intestines can cause many discomforts and lead to other conditions resulting in abdominal and pelvic pain.

So what are the major causes of second trimester pelvic and abdominal pain? The most important causes for mid-trimester pain include:

1. Displacement of the intestines leading to constipation and cramping.
2. Pressure on the ureters causing difficulty getting urine from your kidneys to your bladder.
3. Bladder or Urinary Tract Infection
4. Uterine contractions and premature labor (preterm labor)
5. Round ligament spasm
6. Baby movements
7. Muscular pain
8. Indigestion
9. Gall bladder issues

Intestinal displacement

As mentioned above, your growing uterus pushes your intestines upwards and laterally. Prior to pregnancy, your intestines filled your entire abdominal cavity from your ribs to your pelvic bone. By the time you reach 29 weeks, your intestines will be squashed into a 4 inch area under your ribs. This is a tremendous change and may lead to a multitude of abdominal cramps, constipation problems, bloating and distention. It is important to avoid becoming constipated. You will need to drink much more water during this time frame to keep everything moving through. Sources recommend 6 to 8 glasses of water per day (16 oz glasses). The intestines get very sluggish during pregnancy and without adequate fluid consumption, your intestines will revolt. Stool softeners are safe in pregnancy and can be purchased at your favorite drug store. If you feel that you are becoming constipated, then add 30 ml of Milk of Magnesia to your regimen at bedtime. This laxative is safe in pregnancy and usually works well. Discuss your symptoms with Dr. Damery at your next office visit to help you overcome this problem.

Ureter Compression

As your uterus grows, it tends to rotate and lean to your right. This can result in directly impacting your right ureter. The ureter is the small tube that runs from your kidney, along the side of your abdominal and pelvic wall, and connects into your bladder. If the ureter is compressed midway along it's path, then urine will accumulate above the blockage and in your right kidney. This can lead to pain known as renal or ureteral colic. If you have ever had a kidney stone, then you will have an understanding of how bad this discomfort can be. Sometimes a kidney stone may develop which acts to enhance the pain. These pains have been described as some of the most intense pain that an individual will ever experience. (Similar to labor pains ☺)

The difficulty with ureteral compression is that the symptoms mimic a kidney infection or appendicitis, and these can be life threatening. Therefore, if you develop marked abdominal, pelvic, or flank pain, then you will need to be seen urgently for an evaluation. Contact the office for an evaluation the same day. If it is after-hours, then you will need to be seen in the Emergency Dept if you are less than 20 weeks gestation. If you are over 20 weeks pregnant, then go to Labor & Delivery for a full evaluation.

Bladder or Urinary Tract Infection

Because bladder function is greatly impaired by your enlarging uterus, bladder infections are common in pregnancy. The symptoms can vary from mild cramping to severe. Your urine may look normal, or may become the color of blood and you may or may not have burning with emptying your bladder. Urinary frequency is a common symptom of pregnancy and therefore cannot be used as guidance of whether there is a bladder infection. In pregnancy, bladder infections can become very severe because of impaired bladder emptying. Bacteria may creep upwards into your kidneys, resulting in a kidney infection, called a pyelonephritis. A pyelonephritis in pregnancy is very serious and can lead to death if untreated.

The major factors associated with a bladder infection are:
bullet Pregnant
bullet Pelvic pain which is commonly midline and crampy.
bullet Sometimes there is bloody urine.
bullet Sometimes there is flank pain

Since an untreated bladder infection can become serious, you should seek treatment as soon as possible. During office hours, please call for an evaluation and treatment. If it is after hours, then you have a couple of options. If your symptoms are very mild in nature, then you can try drinking cranberry juice, which has known benefits in treating bladder infections. Taking 1000 mg of Vitamin C will cause your urine to become acidic which may assist in eradicating the offending bacteria. If your symptoms worsen and it is still after hours, then you will need to be evaluated in the Emergency Dept. where urine cultures can be obtained and appropriate antibiotics can be started. If it appears that you are developing a pyelonephritis, then you may need to be admitted for IV antibiotics.

Uterine contractions and premature labor (preterm labor)

Beginning in the second trimester, you may begin to feel uterine contractions. If you have been pregnant before, then you will have an understanding of what you are feeling. If this is your first pregnancy, then it may be much more difficult to know what is going on, since you will never have had contractions before. Contractions are best described as a tightening of the uterus. You may have to place your hand on your abdomen to confirm that it is getting firm to associate your pain with the contraction. Everyone feels contractions in a different way. Some women feel contractions in their abdomen, but not everyone does. Others feel their contractions in their low back (a prelude to back labor), while others still, feel their contractions in their thighs.

Beginning in this mid-trimester, the uterus begins practice contractions, so that it will be ready when it is time for labor. Usually these contractions are irregular and sporadic. This is commonly called "False Labor" and is difficult to tell apart from real labor, since both are uterine contractions. In False Labor, there is no change in your cervix. True labor results in cervical softening, thinning and dilation, in preparation for delivery of your baby. With these cervical changes occurring, sometimes there is some light vaginal spotting, a loss of your mucus plug, or an increase in your vaginal discharge. Unfortunately, these findings are variable and so you cannot count on them. So how do you tell false labor from true labor? Well, the simple answer is that you can't. At least you can't unless you are able to check your cervix for changes. Dr. Damery can perform a cervical exam for you as well as perform a chemical test (Fetal Fibronectin, abbreviated FFN) which helps to determine if you are having real or false labor. If you begin feeling recurrent uterine contractions, take note how often they are occurring. If you begin having 6 contractions per hour, then you have reached the maximum allowable contractions per hour for a preterm state.

The major symptoms associated with preterm labor are:
bullet Pregnant in the later 2nd trimester or 3rd trimester
bullet Recurring pain that may be centered in 1) your abdomen, 2) your low back, or 3) your thighs.
bullet Sometimes there is increased vaginal discharge
bullet Sometimes there is light vaginal bleeding or spotting.
bullet The pain may be crampy in nature.
bullet The pain may come and go as the uterus contracts and relaxes.

If you are having symptoms suggestive of preterm labor, then you should be evaluated as soon as possible. If Dr. Damery's office is open, please contact us for an emergent office evaluation. If it is after hours, and you are over 20 weeks gestation, then please go to the hospital Labor & Delivery unit for evaluation. Just explain to the nurses that you are having pain and they will know what to do. If you are less than 20 weeks gestation, then it would be much more likely that there is something else going on rather than preterm labor. You should be evaluated in this case too. Please contact the office for an evaluation.

If you are having true labor, then you will not be able to stop it. If left untreated for very long, then you will begin to have cervical changes and this could lead to a preterm birth, something you do not want to happen. If you are having false labor, then sometimes you may be able to slow it down, or stop it, thus letting you know that it is not true labor. Here are some tricks you can try to slow down or stop your contractions. Keep in mind that if these things don't work after an hour, then you should be evaluated in the office or in the hospital.

The uterus is very sensitive to your fluid status. If you become dehydrated, then your uterus may start contracting. Therefore, the first thing you should do is sit down and have a large glass of water. If your contractions stop, then you are safe for the time being, and were probably experiencing false labor. This also tells you that you need to be drinking more water each day.

If the water doesn't help, then the next thing to try is lying down on your left side. This will increase the blood flow to your uterus and may assist in stopping your contractions.

Finally, if the above 2 things don't work, then try taking a nice, warm, soothing bath. Sometimes the warmth and relaxation may assist in stopping your contractions.

Try each of the above suggestions for about 20 minutes each, to see if your contractions decrease or stop. If you have tried all of the above and your contractions have continued for an hour, then you will need to be evaluated to see if you are having true labor. If it is during office hours, then please call the office. If it is after office hours, then go to the hospital Labor & Delivery unit and tell the nurses that you are having contractions. They will check you in for evaluation of preterm labor.

Round ligament spasm

Round ligament spasm is another cause of 2nd and 3rd trimester pain. So just what is the round ligament? The round ligaments are 2 cord-like bands that connect to the top of the uterus and run down to the low pelvic sidewall.

As you can see in the picture, these supporting ligaments are short bands measuring about 3 to 4 inches long when you are not pregnant. Just imagine how much these stretch as the uterus grows upwards. By the time your reach your due date, these ligament can measure over 16 inches long!

As you walk, your uterus sways left, then right. The ligaments help provide support for this back and forth swaying action. Being tugged-on with one step, then relaxing with the next. Sometimes these ligaments will go into spasm, very similar to a charly horse (muscle spasm) that you can get in your calf. These can be quite painful and may last several minutes each. If you've never had one before, you'll likely wonder what in the world is this terrible side and groin pain.

The major symptoms associated with round ligament spasm are:
bullet Pregnant in the late 2nd trimester or 3rd trimester.
bullet Sharp, stabbing pain that is usually on one side or the other, but is usually not on both sides at the same time.
bullet The pain often travels down your side and heads right into your groin area.
bullet The pain may be crampy in nature.
bullet Other than the pain, you will feel normal otherwise.
bullet The pain usually resolves within 15 minutes.

So what can you do if this happens to you? First, you must make sure that you are truly having round ligament spasm and not something else. Round ligament spasm is usually short-lived, lasting only 10 or 15 minutes or so. If your pain lasts longer, then you may be experiencing something else and you should be evaluated. If the pain is light and mostly an aching sensation, then you should contact Dr. Damery's office and schedule an appointment for an evaluation. If the pain is more severe, and doesn't seem to be going away, then you should be evaluated soon. If it is during normal business hours, then please schedule an appointment for an emergent evaluation. If it is after hours, then you will need to go to hospital for an evaluation. If you are over 20 weeks gestation, then you should go to Labor and Delivery. If you are less than 20 weeks gestation, then you should go to the emergency room.

Let's say that you believe that your symptoms are round ligament spasm. Is there anything you can do to stop the pain. Fortunately, yes! There are several things that you can try. First, if you think of round ligament spasm as a type of charly horse, then the same treatment for charly horses should work for round ligament spasm. And it turns out that it does. Charly horses (muscle spasms) frequently occur if you become deficient in calcium. Calcium is the mineral which is critical for muscle contractions. Lower your blood calcium level and your muscles will begin to twitch. Lower it more and your muscles will spasm.

Try taking some calcium supplementation. During the second and third trimesters, your growing fetus is busily making it's bones. Therefore, the baby will aggressively use up your calcium. The end result is that you end up with muscle and ligament spasms unless you provide additional calcium intake. If your round ligament spasms occur during the day, then take a calcium supplement in the morning. If your spasms occur at night then take a calcium supplement in the evening. If you need to, you can take calcium supplements in the morning and evening. In almost every instance, calcium supplements make a tremendous improvement.

What about milk? If you are a heavy milk drinker, doesn't this provide enough calcium? Dr. Damery has been working with pregnant women for over 20 years and he has come to the conclusion that milk just doesn't work well enough. He as seen many, many women over the years who drink a lot of milk and who develop muscle spasms. When a calcium supplement (a pill) is added, the cramps almost always go away. Why you ask? Well, he asks the same question. The answer is unknown.

Finally, there is one additional thing you can try if you're getting round ligament spasm. Try laying down and taking the tension off of the ligament that is in spasm. In other word, lay down on the side that hurts. Often this will help to stop the spasm.

Baby movements

Sometimes the baby itself is the cause of your pain. While in utero, your fetus will stretch, kick, roll, yawn, hiccup, twitch, suck it's thumb and kick some more. Sometimes your fetus will push on one of your internal organs and cause pain. Frequently babies will push their heads tightly up against your bladder and you'll feel the pain. Other times your fetus may press on your sciatic nerve as it crosses your pelvis - the result will be pain that shoots down you leg. The more active your baby, the better, but this means that you will take the brunt of it's activity.

Muscular pain

There are many musculo-skeletal changes in pregnancy and many will cause you some type of discomfort. Muscle spasms were discussed above under round ligament spasm. Please refer to that section for details regarding muscle spasms.

There are 2 major muscle groups that are frequently associated with pain in pregnancy:
bullet The rectus muscles, or more commonly, the Abs
bullet The back muscles

Let's start with the rectus abdominis muscles. These are the muscles which are touted as being one's 6-pack. Every fitness magazine you pick up has pictures of some mighty fitness guru showing her slim and trim sculptured mid-drift. The rectus abdominis muscles attach on the lower end of your ribs and then run like a strap downward to your pelvic bone.

As your uterus grows, it will push against your rectus muscles. The larger your uterus gets, the greater is the pushing. So where does it hurt?

The muscles themselves, do not hurt, but the top and bottom connection sites can become very tender. These attachment areas are called the muscle insertion sites. Thus, you may get tender along the bottom edge of your ribs, or you may get tender along the top of you pubic bone. Usually it is one or the other, but typically you will not become tender at both the top and bottom.

The unpleasant thing about this pain is that it can last for a long time. Sometimes it will remain until you deliver.

Is there anything you can do to help with the rectus muscle tenderness? Unfortunately, this one doesn't have an easy cure. Decreasing your activity may help some. Remaining more recumbent helps, but this may wreak havoc on the rest of your life's activities. Delivery may be your only cure, but this may be weeks away.

The other muscular areas that frequently becomes tender in pregnancy are the muscles that run along-side your spine. These muscles become tender because all pregnant women arch their backs. This arching is a natural response to the growing uterus and arching helps you to keep your center of gravity over your feet. The result is a continual backache. This too may be long lasting.

Finally, if you have ever had a back injury, then prepare for the worst, because pregnancy can really make an old back injury flare up. Fortunately, there are some things you can do for both of these back issues. A good back massage is without a doubt, the best remedy you can get. A hand massage will help relax those tense muscles and reduce muscle spasms. If you can have someone perform a daily massage (twice daily is better yet), your back will love you for it. If you can't get that much attention, then you might consider a medical device called a Theracane. This is a large plastic candy-cane shaped contraption that allows you to perform self-massages on your back, shoulder blades, and neck. It works well to reach those difficult spots. Theracanes are sold in medical supply stores as well as on the Internet.

We recommend that you avoid the power-driven massage units that vibrate. The effect on your fetus is unknown. We also recommend that you do not go to a chiropractor for "manipulations". These are expensive and often these practitioners have little to no training in pregnancy. Heating pads on your low back and abdomen should also be avoided. These units can greatly increase your core body temperature and could potentially cause harm to your fetus.

There are some medications that can be safely used for these pains. Tylenol should be your first option. If this is not adequate, then please talk to Dr. Damery at your next office visit and he will prescribe stronger medications that are safe.

If you would prefer a non-medicine approach, there is a great device available, which is similar to the old TENS units that were first developed for chronic back pain. This device is about the size of the small individual-serving cereal boxes. This unit attaches to your belt, just like a cell phone. Electrical wires are attached to the "box" and then these are attached to your skin on your back with special application pads. The unit is programmable and will perform a number of functions. Most importantly, it will scramble the nerve impulses from the nerves which send pain signals to your brain and your pain will stop. Secondly, it will administer massages that stimulate special muscle groups. It can be programmed to provide several massages per day if you wish. This device is covered by most private insurance companies and will require a prescription, that Dr. Damery can write. Discuss this with him at your next office visit if you are interested.

Indigestion

Pregnancy is hard on your digestive tract. As we mentioned earlier, your intestines get pushed upward by your growing uterus. This can lead to very cramped quarters for all of your abdominal and pelvic organs. One of those organs that is markedly affected is your stomach. Not only is the stomach compressed from below, but it is also impacted by your pregnancy hormones. Progesterone, the dominant hormone in pregnancy, acts on the valve between your stomach and your esophagus, making it stay open for long periods of time. The longer it remains open, then the greater is the chance that stomach acids will bubble up into your esophagus. The end result is an irritation or burning of your esophagus by your stomach acids. This burning is commonly called heart burn or indigestion.

Having the knowledge that the valve (called the lower esophageal sphincter) stays open in pregnancy, allows us to provide you with some suggestions for treatment and prevention.

The most important thing you can do to prevent the heart burn is to avoid lying down for 2 hours after you eat. Lying down too soon allows your stomach contents to flow into your esophagus, which will worsen your pain.

Avoid eating too large of meals. Many smaller meals are better than 3 larger ones.

Don't eat dinner too late at night. Give your body plenty of time to start digestion before you lie down for bed.

Antacids such as Maalox or Tums are safe to take.

You should sleep on more than one pillow so that your upper body is inclined. This will help to keep your stomach contents from flowing upward into your esophagus.

Gall bladder issues

Oddly enough, we see a fair share of gall bladder problems in the second and third trimester of pregnancy. Pregnancy causes changes in bile composition and also affects the rate of secretion of bile from the gall bladder through the biliary ducts. Due to these disturbances in the release of bile, and it's changed composition, the bile within the gall bladder tends to thicken. Initially it forms a sludge, that with time will further thicken and form gall stones. The medical term for gall stones is cholelithiasis. Therefore, pregnancy is considered one of those times in life that promotes the formation of gall stones. Left untreated, the gall bladder sludge and gall stones can cause the gall bladder and pancreas to become inflamed.

The major symptoms associated with gall stones and gall bladder sludge are:
bullet Pregnant in the 2nd trimester or 3rd trimester
bullet Recurring pain that may be centered in: 1) your right upper abdomen, 2) your right upper back.
bullet Pain symptoms that worsen a couple of hours after eating.
bullet Pain symptoms that worsen with fatty or oily meals.
bullet Symptoms of severe indigestion that are difficult to treat.
bullet A yellowish coloration to your skin and eyes.

So what can we do if you are having these symptoms? If gall bladder problems are suspected, then you will need to have blood testing done to see if your liver and pancreas are being affected and to see if your blood bilirubin levels are increasing. Additionally, you will need to have an ultrasound of your liver, gall bladder, and pancreas to see if a stone or sludge can be visualized. These are usually readily apparent on an ultrasound evaluation.

Treatment will depend upon the severity of your symptoms. You will need to try and eliminate as many fats from your diet as possible to try and stop the gall bladder spasms and decrease the production of bile. You may need to be hospitalized and all oral foods stopped while you are given IV fluids to let the gall bladder calm down. If we're lucky, this should help stop the gall bladder spasms and help with your pain. We can also give you IV pain control medications to help make you comfortable. If these measures don't work and your pain continues, or if you have repeated attacks, then we will have you evaluated by a general surgeon. It may be necessary for you to undergo surgery during your pregnancy for removal of your gall bladder. Fortunately, most women who undergo gall bladder surgery during their mid-trimester do very well. It turns out that the most common, nonobstetric surgery performed in pregnant women is removal of their appendix. The second most common surgery performed in pregnant women is removal of their gall bladders.

Taken from here: http://www.damery.net/pain_2nd_trimester.htm

For third trimester common pains go here: http://www.damery.net/pain_3rd_trimester.htm



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Old Aug 9th, 2008, 07:03 AM   2
PeanutBean
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What a compendium! Thanks Carley!



 
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Old Feb 27th, 2013, 16:50 PM   3
jdcurly
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Very helpful!



 
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Old Mar 18th, 2013, 07:34 AM   4
kimmym
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THIS is exactly what i've been looking for



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Old Sep 4th, 2013, 10:35 AM   5
archangel24
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Very helpful! Thank you for taking the time to post!



 
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Old Sep 4th, 2013, 15:27 PM   6
Dubibump
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Great thanks for that!



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Old Sep 4th, 2013, 15:33 PM   7
happigail
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Awesome thablame. Glamour all the way!



 
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Old Sep 4th, 2013, 15:55 PM   8
sept2010
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Great info thanks defo got the tender muscles near the spine...



 
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