Case 2 A 25-year-old woman presenting as an emergency with low abdominal pain

Case 2 A 25-year-old woman presenting as an

emergency with low abdominal pain

Kenzi Anderson is a 25-year-old woman who presents to the

gynaecology ward as an emergency admission. She

complains of lower abdominal pain which started 2 days

ago and has become progressively worse. Although she

complains of feeling sore across the lower part of her

abdomen, the pain is worse on the left side.

What is the first thought that comes to

mind which would influence your

differential diagnoses?

Is this patient pregnant?

If pregnant, what would be your

differential diagnosis?

• Ectopic pregnancy

• Miscarriage – threatened/incomplete/septic

• Rupture of corpus luteal cyst

• Haemorrhage into corpus luteal cyst

And if she is not pregnant?

• Acute pelvic inflammatory disease (PID)

• Ovarian cysts (haemorrhage or rupture)

• Ovarian cyst torsion

• Endometriosis

• Uterine fibroid degeneration

• Primary dysmenorrhoea

• Mittelschmerz

• Pelvic vein congestion

Do not forget other (nongynaecological) causes of acute

pelvic pain

• Gastrointestinal

• Urological

• Trauma

• Sickle cell crisis

• Mesenteric vascular occlusion

What would you like to elicit from

the history?

Period of amenorrhoea

Be wary that the patient may be pregnant.

History of presenting complaint

• Frequency, duration and intensity of pain, relieving or

aggravating factors.

• Constant, spasmodic, cramping or colicky type pain.

• Site of pain – unilateral pain may suggest pathology

within the adnexae, appendicitis or ureteric colic while

bilateral pain may suggest a uterine origin involving both

tubes, such as endometritis and salpingitis. Suprapubic

pain may indicate cystitis.

Associated symptoms

• Vaginal bleeding, vaginal discharge

• Urinary symptoms – dysuria, frequency

• Gastrointestinal and/or bowel symptoms – anorexia,

vomiting, constipation, diarrhoea

• Fever

Gynaecological history

• Regular/irregular menstrual cycle

• Contraception – particularly intrauterine device (IUD)

because of increased risk of ectopic pregnancy and pelvic

infection

• Previous history of pelvic infections (PID)

• Previous ectopic pregnancy

• Previous history of endometriosis, infertility, fibroids

• Previous pelvic surgery, such as removal of ovarian

cysts, oophorectomy, myomectomy, tubal surgery

(including sterilization)

• Cervical smear history

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.34 Part 2: Cases

PART 2: CASES

Obstetric history

• Parity

• Previous miscarriages

Medical history

• Sickle cell disease (relevant in certain ethnic groups)

• Any other abdominal surgery – may cause adhesion

leading to pain, intestinal obstruction

Review of systems

• Gastrointestinal

• Urinary

What other important aspect of this

young woman’s history are you

particularly interested in?

Sexual history

• Previous sexual transmitted infections

• Recent sexual activity

• Change of sexual partner

• Unprotected sex

Kenzi tells you that the pain is severe, constant and she

occasionally feels nauseous. She cannot remember when her

last menstrual period was, but is adamant that she is not

pregnant as her partner always uses condoms. She does not

have any vaginal bleeding or discharge and has had no

previous gynaecological surgery. She recalls that she has had

a pelvic infection in the past, possibly Chlamydia, for which

she and her partner were treated. She is still with the same

partner.

What would you look for on

physical examination?

General examination

• Body mass index

• Pallor, tachycardia and hypotensive (she could be

septicaemic)

• Fever

Observation is very important. A patient with peritonitis or peritonism may be lying very still and be reluctant

to move.

Abdominal examination

• Tenderness in the iliac fossae, rebound tenderness or

involuntary guarding

• Suprapubic tenderness

• Her abdomen may be distended (intestinal obstruction)

• Any palpable masses

Pelvic examination

Speculum e xamination

The cervix should always be visualized with a Cusco

speculum. A high vaginal swab should be performed as

well as an endocervical swab for Chlamydia. Look especially for profuse yellow malodorous discharge which

may indicate gonococcal or chlamydial infection. If she

is pregnant, the cervical os should be inspected to determine if open or closed, or blood or products of conception observed in the vagina or in the cervical canal.

Bimanual e xamination

Assess the size of uterus and direction (anteverted or

retroverted). An enlarged uterine size may suggest pregnancy or fibroids. Also, palpate for adnexal masses. There

may be cervical excitation or tenderness, and the uterine

size and adnexae may be difficult to assess because of

pain. The uterus may lack mobility if there is a past

history of PID or endometriosis from adhesions.

To summarize your findings so far, Kenzi is a 25-year-old

para 0+0 with an acute episode of pelvic pain, especially in

the left lower abdomen. She has a history of pelvic

infection, possibly Chlamydia, in the past and is unsure of

her last menstrual period. Her abdomen was tender on

examination with guarding especially on the left side, and

on speculum examination, there was a small amount of

white vaginal discharge noted. It was quite difficult to assess

the uterus and adnexae on bimanual examination, as they

were tender.

What do you do next?

A urine pregnancy test is mandatory. This should be

performed on admission to the gynaecology ward for

most emergency admissions. The result of the test will

influence your differential diagnosis as well as the investigations you may choose to do.

What other investigations would

you recommend?

• Full blood count. A raised white cell count (leucocytosis) and neutrophils may suggest an inflammatory

process, such as PID, ovarian torsion or appendicitis,

although a normal white cell count does not exclude PID.

A raised platelet count may indicate sepsis.

• Clotting. May be deranged in septicaemia, or following

internal haemorrhage.

• Urea and electrolytes. May be deranged in septicaemia.Case 2 35

PART 2: CASES

• Group/save or group/cross - match. Particularly in suspected ectopic pregnancy.

• C - reative protein (CRP). Can indicate inflammation.

This is a delayed marker and may indicate acute or

chronic inflammation.

• Sickledex/blood film. To test for sickle cell disease.

• Urinalysis. Mid - stream specimen of urine (MSSU) for

culture and sensitivity. Urine can also be tested for Chlamydia using amplification techniques .

• Endocervical and vaginal swabs.

The urine pregnancy test is negative and initial results of

blood investigations for Kenzi indicate a raised white blood

cell count of 17 × 109/L. In light of her pelvic pain, white

vaginal discharge, leucocytosis and past history of pelvic

infection you are inclined to think that she has PID and

therefore commence her on antibiotics and analgesics

(Box 2.1).

About 6 hours later, you are called by one of the nurses

to review Kenzi. She is doubled over and complaining of

worsening pain despite analgesics. She has also had two

episodes of vomiting. Her pulse is 112 beats/minute.

What would you do now?

Check all observations – pulse, blood pressure, temperature and urine output. Instigate intravenous rehydration

because of the vomiting.

Re-evaluate all your differential diagnoses

• Acute PID: still possible and worsening or persistent

symptoms may be related to abscess formation

• Mittelschmerz and/or primary dysmenorrhoea: unlikely

with this degree of severity and not resolving with

analgesics

• Endometriosis: no previous history

• Ovarian cyst accident: torsion/rupture/haemorrhage

have still to be excluded and could give this clinical picture

• Gastrointestinal causes: still to be excluded, although

appendicitis less likely as pain is left - sided

• Urinary tract infection: unlikely if urinalysis negative

What further investigations

are warranted?

Imaging

• Pelvic ultrasound

• Abdominal X - ray – indicated if a gastrointestinal cause

is considered, such as intestinal obstruction

An ultrasound scan performed shows a 7-cm left-sided

ovarian cyst. The patient is very tender during the scan.

How does this now affect

your diagnosis?

In light of persistent pain, clinically unwell patient, leucocytosis and ultrasound findings, you think it is likely

that she may have an ovarian cyst accident.

How would you manage this?

• Inform senior staff and anaesthetists

• Patient to be booked in emergency theatre for a diagnostic laparoscopy

• Keep fasted

Box 2.1 Acute pelvic inflammatory disease

Pelvic inflammatory disease (PID) is usually the result of

ascending infection from the endocervix causing:

endometritis, salpingitis, parametritis, oophoritis,

tubo-ovarian abscess and pelvic peritonitis

It can be caused by:

• Chlamydia trachomatis

• Neisseria gonorrhoeae

• Mycoplasma genitalium

• Anaerobes and other organisms

Clinical features

• Lower abdominal pain/tenderness

• Abnormal vaginal/cervical discharge

• Deep dyspareunia

• Fever

• Cervical excitation and adnexal tenderness

Treatment options

• Oral doxycycline and metronidazole

• Oral ofloxacin

• IM ceftriaxone or cefoxitin

• IV cefoxitin or clindamycin

Points to note

• When PID is suspected, screen for Chlamydia and

gonorrhoea

• Sexual partners should be contacted and offered

screening and treatment

• Long-term sequelae – ectopic pregnancy, infertililty,

chronic pelvic pain36 Part 2: Cases

PART 2: CASES

Box 2.2 Ovarian cyst accidents

• Rupture

• Torsion

• Haemorrhage into cyst

Points to note

• Ovarian cysts can be physiological, benign or malignant

• Cysts presenting acutely are usually benign or physiological

• If complex or solid features of cyst on ultrasound, consider

a serum CA125 test

Complications

• Rupture can lead to heavy blood loss

• Prolonged torsion leads to necrosis and loss of ovary, and

may progress to sepsis

• Rarely, torsion can cause a coagulopathy

Treatment

• Depends on size and nature of cyst

• Some may be managed on an outpatient basis, with

follow-up ultrasound scans if suspected to be physiological

and small size (cysts <6cm rarely undergo torsion)

• Analgesia

• Some may require further imaging – computed tomography

(CT) scan or magnetic resonance imaging (MRI)

• Ultrasound-guided cyst aspiration may be appropriate for

some

• Laparoscopy

• Laparotomy

• Rehydration – intravenous fluids

• Adequate analgesia – she is likely to require opioids,

such as morphine

The patient subsequently underwent a diagnostic

laparoscopy at which a torsion of the left-sided ovarian cyst

was discovered (Box 2.2). A laparoscopic ovarian cystectomy

was performed. Prior to the operation, Ms Anderson was

consented for this procedure as well as for an oophorectomy

if this was thought to be necessary, for instance in the case

of a necrotic ovary, or unable to identify normal ovarian

tissue within the torted mass.

What other issues would you discuss

when you consent a patient for a

laparoscopic procedure?

You must inform women of the risk of inadvertent

trauma to major blood vessels, bowel and bladder as well

as the possible need for laparotomy.

CASE REVIEW

This young woman presented with an episode of acute

pelvic pain. As ectopic pregnancy is an important differential diagnosis, it is crucial that a pregnancy test be performed early on, particularly if there is a history of a missed

period.

Following the history and examination findings, the

initial impression in this case was an acute pelvic infection

which can present with severe abdominal pain as well as

findings in keeping with an acute abdomen. However, with

worsening of the patient ’ s condition, an ultrasound scan

was performed which showed a large ovarian cyst. Therefore, it can be recommended that imaging be performed

as part of the first line investigations for a woman with

acute abdominal pain.

Ovarian cyst accidents such as rupture or haemorrhage

into a cyst can be managed with analgesia and intravenous

fluids if dehydrated, while a suspected torsion should have

surgical exploration. In this patient, ongoing abdominal

pain, raised white blood cell count (leucocytosis), tachycardia and the discovery of an ovarian cystic mass on ultrasound scan all pointed to the diagnosis of torsion. Rapid

intervention is required as prolonged torsion will compromise the blood supply to the ovary and an oophorectomy

will then be required.

The benefits of laparoscopic surgery include quick

recovery, less blood loss and a reduced thrombotic risk

when compared with open surgery. However, there are

risks of bowel and major vascular injury during any laparoscopic procedure and this may lead to a laparotomy. The

patient must be advised of this and, in addition, an open

procedure may be necessary in the event that the laparoscopic procedure cannot be performed, as in the presence

of multiple adhesions from previous surgery or difficult

access because of severe endometriosis.Case 2 37

PART 2: CASES

KEY POINTS

• Ectopic pregnancy is an important differential diagnosis in

a young woman with acute pelvic pain

• Pelvic infection can present as an acute abdomen

• A full gynaecological history, including a sexual history, is

essential in assessing acute pelvic pain

• An ultrasound scan should be performed as a first line

investigation in the management of pelvic pain

• Chlamydia is a common cause of acute PID, and recurrent

infections may affect fertility and increase the risk of

ectopic pregnancy

• Acute pelvic pain can be caused by non-gynaecological

causes, such as appendicitis or nephrolithiasis