Understanding Pelvic Pain in the First Trimester

Are you experiencing pelvic pain early in pregnancy? I’ve got you covered! Let me start by giving a very important disclaimer – I am a pelvic floor physical therapist, not a midwife or OBGYN. I am not your girl when it comes to questions concerning an acute miscarriage, but rather musculoskeletal pain. What is that? Typically pain that changes with movement, so please consider this blog through a musculoskeletal lens. 

Common causes of pelvic pain in early pregnancy

Among many other symptoms (hello fatigue, nausea and vomiting), pelvic pain can be a sneaky first trimester symptom that a lot of women aren’t expecting to happen so soon. Body changes might not be occurring yet, so the pelvic and low back pain can catch women off guard. But why does this happen? 

Relaxin is a hormone that is very important during pregnancy. It helps with implantation, growth of the placenta, cervical softening and loosening of the ligaments to help make birth a little easier. 

Relaxin peaks toward the end of the first trimester around week 12. Relaxin does exactly what it sounds like it should do – relaxes – the ligaments surrounding the pelvis, which can lead to instability at some of the joints that rely on those ligaments for support. 

Normal vs. abnormal pelvic pain during the first trimester

Here’s the thing – maternal instinct is very real. I personally always air on the side of caution and value peace of mind. That peace of mind typically comes from making sure any symptom I (or a loved one) am experiencing is normal and not considered a red flag that needs medical attention.

All of that to say, if you are losing your peace over any symptom during pregnancy, ask your provider if it is normal (not common, but normal), or if it is something you should be concerned about or seeking medical attention for. 

As far as I am concerned, even musculoskeletal pain is not “normal” during pregnancy, but common. There is a huge difference between normal and common. Pain during pregnancy is not something you have to deal with for months, and there is actually a lot that can be done to help. 

If you are experiencing pain as early as the first trimester, the odds of it going away on its own are low.   

Hormonal changes and their impact on pelvic pain

As stated above, relaxin plays a major role in pelvic girdle pain towards the end of the first trimester. Relaxin peaks around weeks 12-14 and causes the ligaments that surround the pelvis to loosen if you will. 

The primary joints we see an increase in pain at around this time are the sacroiliac joint (SIJ). These joints are in the back of your pelvis and are where the ilium and sacrum connect. They are supported by several ligaments including: 

• Interosseous sacroiliac ligament

• Posterior sacroiliac ligament

• Sacrotuberous ligament

• Sacrospinous ligament

• Ilio-lumbar ligament

These ligaments have receptors on them that relaxin can bind to and allow them to loosen (this is a good thing for birth purposes), but can lead to pain if the joints are too lax and don’t have support coming from other structures around them (hello muscles). 

Pelvic girdle pain vs. round ligament pain

Pelvic girdle pain and round ligament pain are two of the most common types of pain women experience during pregnancy. Pelvic girdle pain is generally felt more in the back of the pelvis and will radiate up into the back. It is generally achy in nature, rather than sharp. This pain generally comes from the sacroiliac joint referred to above. Most patients are typically surprised to find that what they thought was low back pain was actually pelvic girdle pain. 

Round ligament pain is typically felt more in the front and is more sharp in nature. Patients will usually feel this more when the uterus starts growing as the round ligament is a support structure for the uterus and can become stretched. Ligaments don’t like to be stretched, so it becomes painful. Patients will say they experience round ligament pain with things like rolling over in bed, standing on one leg to put their clothes or shoes on, or going from sitting to standing. 

The good news is both of these are very easily treated with pelvic PT. You’ll want to find someone who is well trained in obstetric PT and well versed in treating pregnancy pain so they are able to tease out exactly what the pain generator is. 

Managing Pelvic Pain in Early Pregnancy

How to relieve mild pelvic pain at home

For mild pain, ironically I recommend daily movement. The only times I felt or experienced pain early in my first pregnancy were the days that I did not participate in some kind of movement. That includes light strength training or walking. Moderate intensity exercise during pregnancy is totally safe (unless you’ve been given restrictions), however if you are trying to participate in exercise for pain relief something light is going to be best. 

For pain that does not get better (or gets worse) with movement, I recommend seeing a pelvic PT. If movement is what is exacerbating your pain, the pain source is likely musculoskeletal in nature and a pelvic PT is going to be able to tease out what exactly is causing your pain and prescribe more specific exercises to alleviate it. 

Safe exercises to reduce pelvic pain in the first trimester

Unless told otherwise by your provider, exercise is totally safe to participate in during the first trimester. The biggest barrier to exercise during the first trimester is usually fatigue, so if that is the case I would recommend something light like a walk or bodyweight workouts. Bonus if you add exercise bands to the body weight workouts – they help with pelvic pain by recruiting more glute engagement. 

Specific exercises that are light and generally help with pelvic pain during the first trimester include: 

• Banded side steps 

• Banded squats 

• Banded squat to row 

• Reverse lunges in a pain free range of motion 

• Lateral lunges in a pain free range of motion 

• Deadlifts (with good core coordination) in a pain free range of motion 

Using heat and cold therapy for pelvic pain relief

Heat and cold therapy is generally not recommended during pregnancy, especially over the abdomen or pelvic region. 

The unfortunate thing about pregnancy is the symptoms are so much more pronounced, yet most treatments are contraindicated during pregnancy.

Best sleeping positions to alleviate pelvic pain

Sleeping on your left side is recommended during pregnancy, especially as the abdominal cavity grows to allow for maximum venous return via the inferior vena cava. Laying on your back as your abdomen grows can limit the amount of venous blood returned to the heart due to the uterus putting pressure on the inferior vena cava (inferior vena cava syndrome). 

As far as sleeping positions for pain, I recommend laying on the left side with pillows stacked between the knees AND the ankles. Most people get the knee part, but forget about the ankles. Only having pillows between your knees allows your ankles to touch, and puts traction on the joints in the back of the pelvis. 

Additionally, I recommend avoiding extreme end range positions for sleeping. Because the ligaments are already more lax, you really want to avoid putting them in more compromised positions. 

When to Seek Medical Help

Signs that pelvic pain may indicate a serious issue

As I mentioned at the beginning of this blog, I am a pelvic floor physical therapist that specializes and treats musculoskeletal pain. I do not treat patients in emergency situations, but do know how to screen for this type of situation and when and where to refer appropriately. 

Signs that your pain requires medical attention and is not musculoskeletal in nature: 

• Pain that is constant and doesn’t change with movement 

• Pain accompanied by vaginal bleeding/discharge 

• Alteration in vitals (blood pressure/heart rate) 

When to consult your doctor about pelvic pain in early pregnancy

I am a fan of peace of mind, so if you have any questions or concerns regarding the signs mentioned above it is always best to talk to your provider rather than seeking medical information from the internet. 

I do like to ask a clarifying question when talking to my own providers: is what I am experiencing normal or common and if it is common who can you refer me to that can help with ___ symptom. 

Long-Term Pelvic Pain Management During Pregnancy

How to prevent pelvic pain from worsening as pregnancy progresses

The best way to prevent pelvic pain from worsening is to treat the pain as specifically and early as possible. Pain is a sign of tissue dysfunction, and should be treated prior to birth as it can inhibit a smooth labor process if tissues aren’t aligned and symmetrical. 

Outside of treatment, I am a big advocate for continued movement throughout pregnancy that feels good and that you enjoy. It should not increase or exacerbate your pain. 

If the pelvic floor is the source of pelvic pain, managing constipation is always a good idea for decreasing the pain. A full rectum sits on top of the pelvic floor like a weight, and typically, eliminating constipation (pun intended) will decrease the pain. 

Physical therapy for pelvic pain during pregnancy

When is it okay to start physical therapy during pregnancy and what will it look like? Physical therapy can be started at any point during pregnancy. In fact, we have patients that see us for fertility treatment, and then continue their care throughout pregnancy after a positive pregnancy test. Physical therapy is a very conservative (and effective) treatment approach to managing pain during pregnancy. 

Your treatment will typically include a very thorough examination at your first visit. During your first trimester, it will not include a pelvic floor muscle examination, but after the first trimester it might pending consent and the specific symptoms you are seeking physical therapy for. It will most likely include a thorough musculoskeletal evaluation, explanation of findings, an exercise prescription to get you started in person and at home, and a follow up plan. At follow up visits, your treatment should consist of continued manual therapy to manage the pain followed by an exercise prescription progression. 

We also help patients prepare for birth in these sessions — here is our comprehensive guide to preparing for a vaginal birth.

Prenatal yoga and stretches for pelvic pain relief

I am a huge fan of pelvic floor yoga and stretches during the third trimester to prepare for birth, but not as big of a fan during the first trimester as stability is typically needed more than mobility due to hormonal laxity. During the third trimester I recommend yoga poses and stretches like: 

• Child's pose 

• Happy baby

• Deep squat 

• Puppy pose 

• Cat cow 

• Adductor stretches 

Managing pelvic pain throughout all trimesters

Common types of pain I treat varies throughout each trimester. During the first trimester we often see pelvic girdle pain as described in this blog. 

During the second trimester, patients experience more abdominal growth and can start to experience more low back pain or round ligament pain. This will carry over into the third trimester as well. 

Other types of pain we treat during pregnancy include:

• Tailbone pain 

• Pelvic pain 

• Pain with sex 

• Pain following sex 

• Abdominal pain 

• Round ligament pain 

• Mid Back pain 

• Hip pain 

If any of these are symptoms you are experiencing – good news! We are currently taking new patients with prolapse in Rockwall, Canton, and Sulphur Springs. If you are interested in scheduling an appointment, please request an appointment here and someone from our team will reach out to you to get you scheduled.