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INDEX

    Acute Pelvic Pain

    Pregnancy

    Last Updated Feb 10, 2024
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    By Julian Marsden, Jonathan Bulger

    First 5 Minutes

    • Rule out pregnancy.
    • Ovarian torsion is a surgical emergency, though it is frequently missed in the ED.

    Context

    • Consider the following conditions:
      • Gynecological
        • Ectopic pregnancy
        • Ovarian torsion
        • Ovarian cyst
        • Pelvic Inflammatory Disease and Tubo-ovarian abscess
        • Endometriosis
        • Fibroids
      • Gastrointestinal
        • Appendicitis
        • Diverticulitis
      • Urological
        • Nephrolithiasis
        • UTI (complicated/pyelonephritis)

    Diagnostic Process

    • Presentation of common and/or life-threatening gynecological conditions (not exhaustive).
      * = potentially life-threatening or surgical emergency.

    • Assessment
      • Thorough gynecological history (LMP, pregnancy history, sexual history, STIs, vaginal bleeding/discharge, etc.).
      • Assess for abnormal vitals, perform general abdominal exam, assess for peritonitis.
      • Pelvic examination indicated, though is controversial according to some sources.
        • Pelvic exam often deferred until ultrasound is acquired if positive Beta-HCG.
        • Speculum exam unlikely to change management unless swabs needed for STI testing.
        • Bimanual can assess for cervical motion tenderness.
      • POCUS
        • Can assess for peritoneal free fluid, intrauterine pregnancy, adnexal mass.
    • Investigations
      • Labs
        • Beta-HCG (quantitative)
        • CBC, electrolytes, LFTS, creatinine, +/- group and screen
        • +/- blood RH factor if pregnant and PV bleeding
        • +/- blood culture
        • Urinalysis
        • STI swabs
      • Imaging
        • Ultrasound
          • Both transabdominal and transvaginal indicated in most cases.
          • Indicated to assess for pregnancy location if positive Beta-HCG.
        • CT
          • Valuable to assess for non-gynecological causes.
          • CT abdomen/pelvis for patients with negative Beta-HCG, and clinical signs/symptoms suggestive of gastrointestinal or urological etiologies such as appendicitis, diverticulitis, nephrolithiasis.

    Recommended Treatment

    • Symptom management
      • Analgesia
        • Acetaminophen
        • NSAIDs
        • Rarely opioids (e.g., hydromorphone 1 – 2 mg PO Q 4-6 hours OR hydromorphone 0.2 – 0.5 mg IV Q 2-4 hours)
      • Antiemetics
        • Dimenhydrinate PO/IV 25 – 50 mg Q 4-6 hours
        • Ondansetron 4 – 8 mg PO/IM/IV Q 4-8 hours
      • Antibiotics
        • PID
          • Mild-moderate (outpatient)
            • Doxycycline 100 mg PO Q 24 hours x 14 days AND
            • Ceftriaxone 250 mg IM x1
            • +/- metronidazole 500 mg PO BID x 14 days
          • Moderate-severe (inpatient)
            • Doxycycline 100 mg PO/IV BID
            • Cefoxitin 2g IV Q 6 hours

    Criteria For Hospital Admission

    • Diagnosis of a condition requiring surgical management.
    • Hemodynamic/vital instability.

    Criteria For Transfer To Another Facility

    • Transport to facility with surgical capabilities and/or gynecology service may be indicated in unstable patients and/or patients with surgical emergencies.

    Criteria For Close Observation And/or Consult

    • Abnormal vital signs.
    • Evidence of peritonitis on exam.
    • Gynecology consult indicated:
      • Ectopic pregnancy
      • Ovarian torsion
      • PID
      • Tubo-ovarian abscess
      • Ovarian cyst (may be appropriate for outpatient management if hemorrhage is minor and no evidence of torsion)
      • Malpositioned IUD
    • General surgery or urology consult may be indicated for gastrointestinal or urological conditions.

    Criteria For Safe Discharge Home

    • Patient vitally stable.
    • Symptoms manageable with analgesia.
    • No evidence of life-threatening or fertility-threatening condition on labs or imaging.
    • Outpatient follow-up may be indicated with gynecology (e.g., for dysmenorrhea, endometriosis, ovarian cyst, fibroids).

    Quality Of Evidence?

    Justification

    Multiple studies exist regarding pelvic pain, though there is some existing controversy as to the utility of pelvic exams. More resources appear to focus on chronic pelvic pain as opposed to acute pelvic pain.

    Moderate

    Related Information

    OTHER RELEVANT INFORMATION

    Reference List

    1. Brunham RC, Gottlieb SL, Paavonen J. Pelvic Inflammatory Disease. Campion EW, editor. N Engl J Med. 2015 May 21;372(21):2039–48.


    2. Dewey K, Wittrock C. Acute Pelvic Pain. Emergency Medicine Clinics of North America. 2019 May;37(2):207–18.


    3. Pages-Bouic E, Millet I, Curros-Doyon F, Faget C, Fontaine M, Taourel P. Acute pelvic pain in females in septic and aseptic contexts. Diagnostic and Interventional Imaging. 2015 Oct;96(10):985–95.


    4. Penner RM, Fishman MB. Evaluation of the adult with abdominal pain – UpToDate [Internet]. [cited 2024 Feb 17]. Available from:

      https://www.uptodate.com/contents/evaluation-of-the-adult-with-abdominal-pain?search=acute%20pelvic%20pain&topicRef=5473&source=see_link#H23


    5. Stratton P. Acute pelvic pain in nonpregnant adult females: Evaluation – UpToDate [Internet]. [cited 2023 Dec 9]. Available from:

      https://www.uptodate.com/contents/acute-pelvic-pain-in-nonpregnant-adult-females-evaluation?search=acute%20pelvic%20pain&source=search_result&selectedTitle=1~59&usage_type=default&display_rank=1


    Relevant Resources

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    Ectopic Pregnancy Scan

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