Lower abdominal pain is a frequent symptom during pregnancy and can have numerous causes, ranging from physiological adaptation to an acute emergency. The spectrum of possible differential diagnoses depends on the time of occurrence during pregnancy. The primary challenge is to distinguish serious or even life-threatening diagnoses, such as an ectopic pregnancy or premature placental abruption from those that do not directly threaten the mother and/or the fetus. Ultrasonography and magnetic resonance imaging can be used without hesitation as imaging diagnostics throughout the course of pregnancy. This article provides an overview of the possible differential diagnoses in early and late pregnancy and presents a target-oriented diagnostic pathway.