Round ligament pain

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Round ligament pain (RLP) is pain associated with the round ligament of the uterus, usually during pregnancy. RLP is one of the most common discomforts of pregnancy [1] and usually starts at the second trimester of gestation and continues until delivery.[ citation needed ] It usually resolves completely after delivery although cases of postpartum RLP (that is, RLP that persisted for a few days after delivery) have been reported. RLP also occurs in nonpregnant women. [2] [3]

Contents

The round ligament of the uterus goes from the pelvis, passes through the internal abdominal ring, and runs along the inguinal canal to the labia majora. [4] It is the structure that holds the uterus suspended inside the abdominal cavity. [5] There are at least 2 other round ligaments in the human body, the round ligament of the liver (ligamentum teres hepatis) and the round ligament of the head of the femur ( ligamentum teres femoris ).

Symptoms

The most common symptoms of RLP are:

Causes

The pathogenesis of RLP is varied. Although very common during pregnancy, non-gestating women can also experience RLP. The most common causes of RLP are as follows:

Diagnosis

Abdominal pains during pregnancy may be due to various pathologies. RLP is one of the most common and benign of these pains. However, diagnosis of RLP is problematic. Some of the conditions that may present symptoms similar to those of RLP are appendicitis, ectopic pregnancy, kidney stones, urinary tract infection, uterine contractions, inguinal hernia, ovarian cysts, and endometriosis. If abdominal pain is continuous and accompanied by vaginal bleeding, excessive vaginal discharge, fever, chills, or vomiting, then it is most unlikely to be RLP and immediate consultation with a health care provider is warranted. [10]

Physical examination, ultrasonography, and blood and urine tests may be able to pinpoint the actual cause of abdominal pain. In some cases, however, RLP was only diagnosed during exploratory surgery. [2] [7]

Case reports

In many cases, RLP is confused with other conditions that cause abdominal pain. [10] Described below are some problematic diagnoses related to RLP.

RLP and appendicitis

A 22-year-old pregnant woman presenting abdominal pains was initially diagnosed with RLP and was discharged. Subsequent symptoms and further tests revealed acute non-perforated appendicitis that required surgery. Appendectomy was successful but premature labor occurred 7 days after discharge, leading to spontaneous abortion. [6]

RLP and inguinal hernia

Several cases of varicosity, of the round ligament during pregnancy leading to RLP have been reported although they were frequently misdiagnosed as inguinal hernia. [11]

In one case, a woman in the 28th week of gestation developed a lump in the left pubic area. The swelling was prominent when standing but not in the supine position and has a cough impulse. Ultrasonography revealed varicosities on the uterine round ligament. [4]

In another case, a woman at 22 weeks gestation was diagnosed with inguinal hernia and underwent surgery. Explorative surgery did not locate a hernia but revealed varicosities of the round ligament. Resection of the uterine ligament was successfully performed and no perinatal and postpartum complications were reported. [7]

Postpartum RLP

Several cases of postpartum RLP have been reported. In one case, a 27-year-old woman presented with abdominal pain 24 hours after normal vaginal delivery. Another case was that of a 29-year-old woman who presented with RLP 3 days after delivery. In both cases, initial diagnosis was inguinal hernia. In the first case, emergency surgery did not locate any hernia but found the round ligament of the uterus to be edematous and filled with thrombosed varicose veins. [2] The thrombosed part was excised and the patient recovered without sequelae. [2]

Another case report described a 37-year-old woman presenting with inguinal mass 6 days after normal vaginal delivery. CT and MRI revealed thrombosed blood vessels along the inguinal course of the uterine round ligament that extended towards the labia majora. [3]

RLP and endometriosis

Several cases of inguinal endometriosis, that infiltrates the round ligament of the uterus have been reported in fertile, non-pregnant women. In the majority of these cases, diagnosis was problematic. In some cases, definitive diagnosis of round ligament endometriosis was only possible during exploratory surgery. [12] [13]

RLP and myoma

Cases of myoma-like growth occurring on the uterine round ligament have been reported. [14] [15]

RLP and IVF

Gonadotropin stimulation during in vitro fertilization can induce cyst development in certain parts of the female reproductive system. A case report documented the development of a mesothelial cyst on the uterine round ligament of a woman after IVF stimulation. [16]

Treatment

Once RLP has been diagnosed, there are many ways to reduce the pain without jeopardizing the pregnancy.

Related Research Articles

<span class="mw-page-title-main">Ectopic pregnancy</span> Female reproductive system health issue

Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.

<span class="mw-page-title-main">Hernia</span> Abnormal exit of tissues or organs from the cavity they usually reside in

A hernia is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal development of the intestinal tract, referring to the retraction of the intestine from the extra-embryonal navel coelom into the abdomen in the healthy embryo at about 7½ weeks.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

<span class="mw-page-title-main">Adenomyosis</span> Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

<span class="mw-page-title-main">Gynecologic ultrasonography</span> Application of medical ultrasonography to the female pelvic organs

Gynecologic ultrasonography or gynecologic sonography refers to the application of medical ultrasonography to the female pelvic organs as well as the bladder, the adnexa, and the recto-uterine pouch. The procedure may lead to other medically relevant findings in the pelvis.This technique is useful to detect myomas or mullerian malformations.

<span class="mw-page-title-main">Uterine fibroid</span> Medical condition with benign tumors of uterus

Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumors of the uterus, part of the female reproductive system. Some women with fibroids have no symptoms while others may have painful or heavy periods. If large enough, they may push on the bladder, causing a frequent need to urinate. They may also cause pain during penetrative sex or lower back pain. A woman can have one uterine fibroid or many. It is uncommon but possible that fibroids may make it difficult to become pregnant.

<span class="mw-page-title-main">Uterine rupture</span> Medical condition

Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth. Symptoms, while classically including increased pain, vaginal bleeding, or a change in contractions, are not always present. Disability or death of the mother or baby may result.

<span class="mw-page-title-main">Uterine myomectomy</span> Surgical removal of uterine fibroid

Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle.

Adenomyoma is a tumor (-oma) including components derived from glands (adeno-) and muscle (-my-). It is a type of complex and mixed tumor, and several variants have been described in the medical literature. Uterine adenomyoma, the localized form of uterine adenomyosis, is a tumor composed of endometrial gland tissue and smooth muscle in the myometrium. Adenomyomas containing endometrial glands are also found outside of the uterus, most commonly on the uterine adnexa but can also develop at distant sites outside of the pelvis. Gallbladder adenomyoma, the localized form of adenomyomatosis, is a polypoid tumor in the gallbladder composed of hyperplastic mucosal epithelium and muscularis propria.

<span class="mw-page-title-main">Round ligament of uterus</span> Ligament connecting the uterus to the labia majora

The round ligament of the uterus is a ligament that connects the uterus to the labia majora. It originates at the junction of the uterus and uterine tube. It passes through the inguinal canal to insert at the labium majus.

<span class="mw-page-title-main">Uterine prolapse</span> Medical condition

Uterine prolapse is a form of pelvic organ prolapse in which the uterus and a portion of the upper vagina protrude into the vaginal canal and, in severe cases, through the opening of the vagina. It is most often caused by injury or damage to structures that hold the uterus in place within the pelvic cavity. Symptoms may include vaginal fullness, pain with sexual intercourse, difficulty urinating, and urinary incontinence. Risk factors include older age, pregnancy, vaginal childbirth, obesity, chronic constipation, and chronic cough. Prevalence, based on physical exam alone, is estimated to be approximately 14%.

<span class="mw-page-title-main">Postpartum bleeding</span> Loss of blood following childbirth

Postpartum bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or 1,000 ml of blood following childbirth. Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist. Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breathing rate. As more blood is lost, the patient may feel cold, blood pressure may drop, and they may become restless or unconscious. In severe cases circulatory collapse, disseminated intravascular coagulation and death can occur. The condition can occur up to twelve weeks following delivery in the secondary form. The most common cause is poor contraction of the uterus following childbirth. Not all of the placenta being delivered, a tear of the uterus, or poor blood clotting are other possible causes. It occurs more commonly in those who already have a low amount of red blood, are Asian, have a larger fetus or more than one fetus, are obese or are older than 40 years of age. It also occurs more commonly following caesarean sections, those in whom medications are used to start labor, those requiring the use of a vacuum or forceps, and those who have an episiotomy.

<span class="mw-page-title-main">Uterine inversion</span> Medical condition

Uterine inversion is when the uterus turns inside out, usually following childbirth. Symptoms include postpartum bleeding, abdominal pain, a mass in the vagina, and low blood pressure. Rarely inversion may occur not in association with pregnancy.

<span class="mw-page-title-main">Artery of round ligament of uterus</span>

The artery of the round ligament of the uterus, also known as Sampson's artery, is a branch of the inferior epigastric artery. It runs under, and supplies, the round ligament of the uterus. It constitutes an anastomosis of the uterine artery and ovarian artery. It was originally named after John A. Sampson (1873–1946), an American gynecologist who studied endometriosis.

Ovarian diseases refer to diseases or disorders of the ovary.

Ovarian pregnancy refers to an ectopic pregnancy that is located in the ovary. Typically the egg cell is not released or picked up at ovulation, but fertilized within the ovary where the pregnancy implants. Such a pregnancy usually does not proceed past the first four weeks of pregnancy. An untreated ovarian pregnancy causes potentially fatal intra-abdominal bleeding and thus may become a medical emergency.

Septic pelvic thrombophlebitis (SPT), also known as suppurative pelvic thrombophlebitis, is a rare postpartum complication which consists of a persistent postpartum fever that is not responsive to broad-spectrum antibiotics, in which pelvic infection leads to infection of the vein wall and intimal damage leading to thrombogenesis in the ovarian veins. The thrombus is then invaded by microorganisms. Ascending infections cause 99% of postpartum SPT.

<span class="mw-page-title-main">Uterine incarceration</span> Medical condition

Uterine incarceration is an obstetrical complication whereby a growing retroverted uterus becomes wedged into the pelvis after the first trimester of pregnancy.

Signs and symptoms of pregnancy are common, benign conditions that result from the changes to the body that occur during pregnancy. Signs and symptoms of pregnancy typically change as pregnancy progresses, although several symptoms may be present throughout. Depending on severity, common symptoms in pregnancy can develop into complications. Pregnancy symptoms may be categorized based on trimester as well as region of the body affected.

References

  1. ↑ "What is Round Ligament Pain?". Babies Online. Archived from the original on 2016-05-03. Retrieved 2010-02-10.
  2. 1 2 3 4 5 al-Qudah MS (October 1993). "Postpartum pain due to thrombosed varicose veins of the round ligament of the uterus". Postgraduate Medical Journal. 69 (816): 820–1. doi:10.1136/pgmj.69.816.820. PMC   2399978 . PMID   8290419.
  3. 1 2 Tokue H, Aoki J, Tsushima Y, Endo K (2008). "Characteristic of computed tomography and magnetic resonance imaging finding of thrombosed varices of the round ligament of the uterus: a case report". Journal of Computer Assisted Tomography. 32 (4): 559–61. doi:10.1097/RCT.0b013e318133a9f1. PMID   18664843.
  4. 1 2 Murphy IG, Heffernan EJ, Gibney RG (July 2007). "Groin mass in pregnancy". The British Journal of Radiology. 80 (955): 588–9. doi:10.1259/bjr/63118673. PMID   17704320.
  5. 1 2 3 4 Aguilera PA. (Pregnancy, Round Ligament Pain http://www.webmd.com/baby/pregnancy-round-ligament-pain) WebMD. Retrieved 2010-01-25
  6. 1 2 Pastore PA, Loomis DM, Sauret J (2006). "Appendicitis in pregnancy". Journal of the American Board of Family Medicine. 19 (6): 621–6. doi: 10.3122/jabfm.19.6.621 . PMID   17090795.
  7. 1 2 3 4 IJpma FF, Ijpma FF, Boddeus KM, de Haan HH, van Geldere D (February 2009). "Bilateral round ligament varicosities mimicking inguinal hernia during pregnancy". Hernia. 13 (1): 85–8. doi:10.1007/s10029-008-0395-8. PMID   18594758. S2CID   23295781.
  8. ↑ Apostolidis S, Michalopoulos A, Papavramidis TS, Papadopoulos VN, Paramythiotis D, Harlaftis N (February 2009). "Inguinal endometriosis: three cases and literature review". Southern Medical Journal. 102 (2): 206–7. doi:10.1097/SMJ.0b013e318186d36e. PMID   19139703. S2CID   25470776.
  9. ↑ Tokue H, Tsushima Y, Endo K (January 2009). "Magnetic resonance imaging findings of extrapelvic endometriosis of the round ligament". Japanese Journal of Radiology. 27 (1): 45–7. doi:10.1007/s11604-008-0293-0. PMID   19373532. S2CID   11224001.
  10. 1 2 Chi C, Taylor A, Munjuluri N, Abdul-Kadir R (November 2005). "A diagnostic dilemma: round ligament varicosities in pregnancy". Acta Obstetricia et Gynecologica Scandinavica. 84 (11): 1126–7. doi: 10.1111/j.0001-6349.2005.00120c.x . PMID   16232186. S2CID   19596030.
  11. ↑ Castro Copete MA, Carnero Ruiz M, Jiménez Yáñez R, Humanes López L (December 2009). "Varices en el ligamento redondo" [Varices in the round ligament]. Radiología (in Spanish). 52 (1): 81–4. doi:10.1016/j.rx.2009.11.003. PMID   20035959.
  12. ↑ Licheri S, Pisano G, Erdas E, et al. (October 2005). "Endometriosis of the round ligament: description of a clinical case and review of the literature". Hernia. 9 (3): 294–7. doi:10.1007/s10029-004-0314-6. PMID   15703860. S2CID   22043793.
  13. ↑ Terada S, Miyata Y, Nakazawa H, et al. (2006). "Immunohistochemical analysis of an ectopic endometriosis in the uterine round ligament". Diagnostic Pathology. 1: 27. doi: 10.1186/1746-1596-1-27 . PMC   1570479 . PMID   16961927.
  14. ↑ Tabrizi NM, Dabirashrafi B, Salehi P, Shams S, Dabirashrafi H (2006). "Nodular adenomyosis of the uterus causing severe groin pain". JSLS. 10 (1): 74–5. PMC   3015687 . PMID   16709363.
  15. ↑ Ghafari V, Moghadami-Tabrizi N, Bahadon M, Dabirashrafi H, Zandinejad K, Isadi N (August 1996). "Myoma of the Round Ligament Causing Severe Groin and Thigh Pain". The Journal of the American Association of Gynecologic Laparoscopists. 3 (4, Supplement): S15. doi:10.1016/S1074-3804(96)80179-4. PMID   9074123.
  16. ↑ Ryley DA, Moorman DW, Hecht JL, Alper MM (October 2004). "A mesothelial cyst of the round ligament presenting as an inguinal hernia after gonadotropin stimulation for in vitro fertilization". Fertility and Sterility. 82 (4): 944–6. doi: 10.1016/j.fertnstert.2004.03.042 . PMID   15482776.
  17. ↑ Andrews CM, O'Neill LM (1994). "Use of pelvic tilt exercise for ligament pain relief". Journal of Nurse-Midwifery. 39 (6): 370–4. doi:10.1016/0091-2182(94)90156-2. PMID   7830145.
  18. ↑ Dolan, Mary. "Relieving Back Pain During Pregnancy: Pelvic Tilt, Leg Lift". Northern Inyo Hospital. Archived from the original on 2016-08-12. Retrieved 2010-02-10.
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