Approach to acute pelvic pain with a positive pregnancy test
In a female patient of reproductive age, presenting with acute pelvic pain, the first distinction is whether the pain is pregnancy-related or non-pregnancy-related on the basis of a serum pregnancy test.
In the patient with acute pelvic pain associated with pregnancy, the next step is localization of the tissue responsible for the hCG production.
Transvaginal ultrasound should be performed to identify an intrauterine gestation. Ectopic pregnancy is characterized by a noncystic adnexal mass and fluid in the cul-de-sac.
If a gestational sac is not demonstrated on ultrasonography, the following possibilities exist:
Ectopic pregnancy
Very early intrauterine pregnancy not seen on ultrasound
Recent abortion
Management of patients when a gestational sac is not seen with a positive pregnancy test
Diagnostic laparoscopy is the most accurate and rapid method of establishing or excluding the diagnosis of ectopic pregnancy.
Examination of endometrial tissue. For pregnant patients desiring termination, and for those patients in whom it can be demonstrated that the pregnancy is nonviable, suction curettage with immediate histologic examination of the curettings is a diagnostic option. The presence of chorionic villi confirms the diagnosis of intrauterine pregnancy, whereas the absence of such villi indicates ectopic pregnancy.
Management of the ectopic gestation
Two IV catheters of at least 18 gauge should be placed and 1-2 L of normal saline infused.
Laparoscopy or laparotomy with linear salpingostomy or salpingectomy should be accomplished in unstable patients. An HCG level should be checked in one week to assure that it is declining.
Methotrexate. Stable patients can be treated with methotrexate in a single intramuscular dose of 50 mg per meter2. Treatment response should be assessed by serial HCG measurements made until the hormone is undetectable.
Approach to acute pelvic pain in non-pregnant patients with a negative HCG
Acute PID is the leading diagnostic consideration in patients with acute pelvic pain unrelated to pregnancy. The pain is usually bilateral, but may be unilateral in 10%. Cervical motion tenderness, fever, and cervical discharge are common findings.
Acute appendicitis should be considered in all patients presenting with acute pelvic pain and a negative pregnancy test. Appendicitis is characterized by leukocytosis and a history of a few hours of periumbilical pain followed by migration of the pain to the right lower quadrant. Neutrophilia occurs in 75%. A slight fever exceeding 37.3EC, nausea, vomiting, anorexia, and rebound tenderness may be present.
Torsion of the adnexa usually causes unilateral pain, but pain can be bilateral in 25%. Intense, progressive pain combined with a tense, tender adnexal mass is characteristic. There is often a history of repetitive, transitory pain. Pelvic sonography often confirms the diagnosis. Laparoscopic diagnosis and surgical intervention are indicated.
Ruptured or hemorrhagic corpus luteal cyst usually causes bilateral pain, but it can cause unilateral tenderness in 35%. Ultrasound aids in diagnosis.
Endometriosis usually causes chronic or recurrent pain, but it can occasionally cause acute pelvic pain. There usually is a history of dysmenorrhea and deep dyspareunia. Pelvic exam reveals fixed uterine retrodisplacement and tender uterosacral and cul-de-sac nodularity. Laparoscopy confirms the diagnosis
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