Acute Pelvic Pain

Acute Pelvic Pain - The Painful Puzzle

Acute onset pain, lower abdomen/pelvis. Duration < 3 months. Crucial first step: Urine Pregnancy Test (UPT)! Prioritize life-threatening: Ectopic, Ovarian Torsion, Appendicitis.

• Assessment:
  • Vitals (ABCDE approach).
  • History: LMP, sexual activity, red flags (fever, syncope, bleeding).
  • Exam: Abdominal (peritonism?), Pelvic (Cervical Motion Tenderness - CMT? Adnexal mass?).
• Key Investigations: UPT, CBC, Transvaginal Ultrasound (TVS).

⭐ Ruptured ectopic pregnancy is a common cause of 1st-trimester maternal mortality.

Gynae Culprits (Non-Pregnant) - Womb Woes

• Pelvic Inflammatory Disease (PID):
  • Criteria: Cervical motion tenderness (CMT) OR uterine/adnexal tenderness. 📌 PID CAN (CMT, Adnexal/Uterine tenderness, No other cause).
  • Supportive: Fever >38.3°C; ↑ESR/CRP.
  • Fitz-Hugh-Curtis: Perihepatitis (RUQ pain, "violin-string" adhesions).
• Ovarian Torsion:
  • Sudden, severe unilateral pain, N/V; adnexal mass.
  • USG: Enlarged ovary, stromal edema, ↓/absent Doppler flow (key!), whirlpool sign.

  ⭐ Ovarian torsion: surgical emergency. "Time is ovary" for function preservation.

• Ruptured Ovarian Cyst:
  • Sudden pain, often post-coitus/exercise.
  • Hemorrhagic: Severe pain, risk of hemoperitoneum. USG: Complex cyst, free fluid.
  • Simple: Milder pain. USG: Simple cyst, free fluid.
• Tubo-ovarian Abscess (TOA):
  • PID complication. Fever, pain, tender adnexal mass.
  • USG: Complex multiloculated adnexal mass, thick walls. oka

Gynae Culprits (Pregnant) - Baby Blues & Beyond

• Ectopic Pregnancy: Life-threatening!

  • Triad: Amenorrhea, abdominal pain, vaginal bleeding. Shoulder tip pain (Kehr's sign).
  • Risks: Prior ectopic, tubal surgery, PID, ART, IUD.
  • Dx: Serum hCG >1500-2000 IU/L (TVUS) or >6000 IU/L (TAS) with empty uterus. USG: Adnexal mass (e.g., tubal ring sign), free fluid.
  • Rx: Methotrexate (if stable, hCG <5000 IU/L, mass <3.5-4cm, no fetal cardiac activity); Surgery (if unstable or MTX contraindicated).

  ⭐ Ruptured ectopic pregnancy is a leading cause of maternal mortality in the 1st trimester.

• Miscarriage Types (Spontaneous Abortion):

  • Threatened: Cervix closed, bleeding +/- pain, viable fetus on USG.
  • Inevitable: Cervix open, bleeding, pain, products of conception (POC) may be passing.
  • Incomplete: Cervix open, some POC retained, ongoing bleeding.
  • Complete: Cervix (usually) closed, all POC expelled, uterus empty.
  • Septic: Any above type + signs of infection (fever, purulent discharge, uterine tenderness).

• Ovarian Cyst Accidents:

  • Torsion: Sudden, severe, unilateral pain, nausea/vomiting. USG: enlarged ovary, stromal edema, whirlpool sign.
  • Hemorrhage/Rupture: Acute onset pain, may have peritoneal signs. Often corpus luteum cyst in early pregnancy.

Non-Gynae Masqueraders - Gut & Grumbles

⭐ Appendicitis in pregnancy: pain often atypical (e.g., RUQ/periumbilical) due to uterine displacement. Most common non-gynae surgical emergency.

Cracking the Case - Detective Workup

Rapid, systematic evaluation is vital. Prioritize life-threatening conditions.

⭐ In suspected ectopic pregnancy (positive UPT), TVS is key. Absence of intrauterine sac with β-hCG >1500-2000 mIU/mL (discriminatory zone) is highly suggestive.

High‑Yield Points - ⚡ Biggest Takeaways

• Ectopic pregnancy: rule out first in reproductive-age women with amenorrhea & acute pelvic pain.
• PID: presents with bilateral lower abdominal pain, cervical motion tenderness (CMT), adnexal tenderness.
• Ovarian torsion: sudden, severe unilateral pain; ultrasound with Doppler is diagnostic.
• Ruptured ovarian cyst: sudden, sharp unilateral pain; risk of hemoperitoneum.
• Appendicitis: common mimic; pain migrates to RLQ, often with fever/anorexia.
• UTI/Pyelonephritis: features dysuria, frequency, urgency, suprapubic or flank pain.