Acute Pelvic Pain — MCQs
A 19-year-old woman presents to the emergency department reporting that she fainted at work earlier in the day. She has mild vaginal bleeding and her abdomen is diffusely tender and distended. She also complains of shoulder and abdominal pain. Her vital signs show temperature 97.6°F (36.4°C), pulse 120/min, and blood pressure 96/50 mmHg. To confirm the diagnosis suggested by the available clinical data, the best initial diagnostic procedure is
A woman attends an antenatal clinic with a complaint of mild pain in the lower abdomen on the left side, her periods are regular, and a urine pregnancy test was positive at home. A transvaginal ultrasound was performed, revealing an empty uterine cavity and no adnexal mass. Her serum beta human chorionic gonadotropin (hCG) level is 700 IU/L. What is the next step?
A 14-year-old female presented with acute retention of urine. She complains of cyclical pain in the abdomen. On examination, a tense blue swelling is seen on local examination. On PR examination - suprapubic bulge present. Her condition is most likely due to?
Endosalpingitis is best diagnosed by?
A G2 P1 female with 6 weeks amenorrhea presents with bleeding PV, hypotension, and altered sensorium. She has pain in the abdomen and on per vaginal examination cervical movement tenderness is present. On USG, there is free fluid present in the right paracolic gutter. What is the most probable diagnosis?
All are signs / features of ectopic pregnancy on USG except –
Regarding medical treatment of ectopic pregnancy, all are true except:
Violin string adhesion is seen in ?
A patient has dyspareunia, and dysmenorrhea with adnexal tenderness. What is the first step of investigation?
18-year-old girl presents with 6 months of amenorrhea with h/o low-grade fever, weight loss, pain abdomen, generalized weaknesses. On PR examination, palpable left-sided pelvic mass felt... Diagnosis is
Acute Pelvic Pain Indian Medical PG Practice Questions and MCQs
Question 1: A 19-year-old woman presents to the emergency department reporting that she fainted at work earlier in the day. She has mild vaginal bleeding and her abdomen is diffusely tender and distended. She also complains of shoulder and abdominal pain. Her vital signs show temperature 97.6°F (36.4°C), pulse 120/min, and blood pressure 96/50 mmHg. To confirm the diagnosis suggested by the available clinical data, the best initial diagnostic procedure is
- A. Serum beta-hCG levels
- B. Transvaginal ultrasound (Correct Answer)
- C. FAST (Focused Assessment with Sonography in Trauma)
- D. Diagnostic laparoscopy
Explanation: ***Transvaginal ultrasound*** - This patient presents with **ruptured ectopic pregnancy**: hemodynamic instability (syncope, tachycardia, hypotension), vaginal bleeding, abdominal pain with peritoneal signs, and **Kehr's sign** (shoulder pain from diaphragmatic irritation by blood). - In a **hemodynamically unstable patient** with suspected ruptured ectopic pregnancy, **transvaginal ultrasound** is the best initial diagnostic procedure because it: - Rapidly confirms or rules out **intrauterine pregnancy** - Detects **free fluid (blood) in the pelvis** indicating rupture - Visualizes **adnexal masses** suggestive of ectopic pregnancy - Can be performed quickly at bedside - Directly guides the decision for **emergency surgery** - While beta-hCG should be sent concurrently, ultrasound findings take precedence in guiding immediate management in unstable patients. *Serum beta-hCG levels* - Beta-hCG is essential for confirming pregnancy and is the **initial test in stable patients** with suspected ectopic pregnancy. - However, in this **hemodynamically unstable patient**, waiting for beta-hCG results delays definitive diagnosis and treatment. - Beta-hCG should be sent but **does not replace imaging** when rupture is suspected - a positive hCG only confirms pregnancy, not its location or rupture status. - Management decisions in unstable patients are based on **imaging findings**, not hCG levels alone. *Diagnostic laparoscopy* - This is both a **diagnostic and therapeutic procedure** for ectopic pregnancy. - While it may be needed for definitive treatment, it is **invasive** and requires operating room setup. - **Ultrasound should be performed first** to confirm the diagnosis and guide surgical planning, unless the patient is in extremis requiring immediate laparotomy. *FAST (Focused Assessment with Sonography in Trauma)* - FAST can detect **free intraperitoneal fluid** and may be useful in identifying hemoperitoneum. - However, **transvaginal ultrasound is superior** in this obstetric emergency because it provides more specific information about pregnancy location, adnexal pathology, and pelvic free fluid. - FAST does not adequately visualize pelvic structures or confirm/exclude intrauterine pregnancy.
Question 2: A woman attends an antenatal clinic with a complaint of mild pain in the lower abdomen on the left side, her periods are regular, and a urine pregnancy test was positive at home. A transvaginal ultrasound was performed, revealing an empty uterine cavity and no adnexal mass. Her serum beta human chorionic gonadotropin (hCG) level is 700 IU/L. What is the next step?
- A. Give single dose of methotrexate
- B. Perform laparoscopy
- C. Perform serum beta HCG after 48 hr (Correct Answer)
- D. Perform serum beta HCG after 7 days
Explanation: ***Perform serum beta HCG after 48 hr*** - An **empty uterine cavity** with a **hCG level of 700 IU/L** and no adnexal mass is inconclusive for a definitive diagnosis of ectopic pregnancy or intrauterine pregnancy. - Repeating the **hCG level after 48 hours** is crucial to assess its doubling time, which helps differentiate between a normal intrauterine pregnancy, failed pregnancy, or ectopic pregnancy. *Give single dose of methotrexate* - Administering methotrexate requires a **definitive diagnosis of ectopic pregnancy**, which is not yet established given the inconclusive ultrasound and hCG level. - Giving methotrexate prior to a definitive diagnosis would be **premature and potentially harmful** if the pregnancy were intrauterine or a failed pregnancy. *Perform laparoscopy* - **Laparoscopy is an invasive procedure** typically reserved for cases where ectopic pregnancy is strongly suspected or rupture is a concern, or when medical management fails. - At this stage, with an **unclear diagnosis and stable patient**, less invasive diagnostic steps are warranted first. *Perform serum Beta HCG after 7 days* - Waiting 7 days to re-check hCG levels would be **too long** in a potentially developing abnormal pregnancy or ectopic pregnancy. - A **48-hour interval** provides more timely information to guide management and detect rapid changes in hCG, which is critical for early diagnosis and intervention.
Question 3: A 14-year-old female presented with acute retention of urine. She complains of cyclical pain in the abdomen. On examination, a tense blue swelling is seen on local examination. On PR examination - suprapubic bulge present. Her condition is most likely due to?
- A. Imperforate hymen (Correct Answer)
- B. Transverse vaginal septum
- C. Cervical agenesis
- D. Longitudinal vaginal septum
Explanation: ***Imperforate hymen*** - This condition is characterized by a **complete obstruction** of the vaginal opening, leading to the accumulation of menstrual blood (hematocolpos) behind the hymen. - The classic presentation includes **cyclical abdominal pain** (due to trapped menstrual bleeding), **amenorrhea**, and a visible **tense, blue bulging mass** at the introitus, which can cause urinary retention due to pressure on the urethra. *Transverse vaginal septum* - A **transverse vaginal septum** is a congenital anomaly where a band of tissue completely or partially blocks the vaginal canal, typically higher up than the hymen. - While it can also cause **hematocolpos** and cyclical pain, the physical examination would reveal the obstruction deeper within the vagina rather than a bulging blue mass at the introitus. *Cervical agenesis* - **Cervical agenesis** refers to the congenital absence of the cervix. This condition would lead to obstruction of menstrual flow, causing hematometra (blood in the uterus) and hematocolpos. - However, unlike imperforate hymen, it would not present with a **tense blue swelling at the introitus**, as the obstruction is higher up at the level of the cervix. *Longitudinal vaginal septum* - A **longitudinal vaginal septum** divides the vagina into two separate canals, often associated with a uterine anomaly like uterus didelphys. - This condition does **not typically cause obstruction** of menstrual flow or urinary retention, as menstrual blood can still exit through one of the vaginal canals.
Question 4: Endosalpingitis is best diagnosed by?
- A. laparoscopy (Correct Answer)
- B. X-Ray abdomen
- C. Hysterosalpingography
- D. Hystero-laparoscopy
Explanation: ***Laparoscopy*** - **Laparoscopy** is the **gold standard** for diagnosing endosalpingitis as it allows direct visualization of the fallopian tubes, pelvic organs, and peritoneal cavity. - It enables identification of **inflammation, adhesions, tubal edema, and purulent exudate** characteristic of endosalpingitis. - It also permits **tissue sampling** for histopathological confirmation and culture of infectious agents. - Laparoscopy has high sensitivity and specificity for diagnosing pelvic inflammatory disease (PID) and its complications. *X-Ray abdomen* - An **X-ray abdomen** provides limited information regarding soft tissue structures like the fallopian tubes. - It is primarily used for visualizing bones or detecting gross abnormalities like bowel obstruction or free air. - It **cannot directly diagnose endosalpingitis** or provide detailed images of adnexal structures. *Hysterosalpingography* - **Hysterosalpingography (HSG)** is an imaging technique used to assess the patency and contour of the fallopian tubes and uterine cavity by injecting contrast dye. - While it can detect **tubal occlusion or hydrosalpinx**, it cannot visualize external tubal inflammation, adhesions, or the peritoneal surface. - HSG is more useful for evaluating **tubal patency in infertility workup** rather than diagnosing acute inflammation. *Hystero-laparoscopy* - This term refers to **combined hysteroscopy and laparoscopy** performed together. - While the laparoscopic component can diagnose endosalpingitis, **hysteroscopy** (visualization of the uterine cavity) adds no additional value for diagnosing tubal inflammation. - For endosalpingitis specifically, **laparoscopy alone** is sufficient and is the most direct diagnostic approach.
Question 5: A G2 P1 female with 6 weeks amenorrhea presents with bleeding PV, hypotension, and altered sensorium. She has pain in the abdomen and on per vaginal examination cervical movement tenderness is present. On USG, there is free fluid present in the right paracolic gutter. What is the most probable diagnosis?
- A. Abruptio placenta
- B. Placenta previa
- C. Missed abortion
- D. Ruptured ectopic (Correct Answer)
Explanation: ***Ruptured ectopic*** - The combination of **amenorrhea**, **vaginal bleeding**, **abdominal pain**, and signs of **hypovolemic shock** (hypotension, altered sensorium) is highly suggestive of a ruptured ectopic pregnancy. - The presence of **cervical motion tenderness** and **free fluid in the paracolic gutter** on ultrasound strongly indicates intra-abdominal hemorrhage. *Abruptio placenta* - This condition typically occurs in the **second or third trimester** of pregnancy, not at 6 weeks gestation. - While it causes vaginal bleeding and abdominal pain, the presentation of **profound shock** in early pregnancy with free fluid suggests an ectopic rupture rather than placental abruption. *Placenta previa* - **Painless vaginal bleeding** in the second or third trimester is characteristic of placenta previa. - It would not explain the severe abdominal pain, cervical motion tenderness, or signs of hypovolemic shock in a 6-week pregnancy. *Missed abortion* - A missed abortion involves the **death of the embryo/fetus** with retention of products of conception, often with minimal or no symptoms. - It would not typically present with **hypotension**, **altered sensorium**, **severe abdominal pain**, or **free fluid in the abdomen**.
Question 6: All are signs / features of ectopic pregnancy on USG except –
- A. Hyperechoic rim
- B. Echogenic mass with multicystic spaces within endometrial cavity (Correct Answer)
- C. Adnexal mass
- D. Pseudo sac
Explanation: **Echogenic mass with multicystic spaces within endometrial cavity** - This description is characteristic of a **hydatidiform mole**, a form of gestational trophoblastic disease, not an ectopic pregnancy. - A **hydatidiform mole** typically presents with an enlarged uterus and an echogenic, multicystic mass (often described as a "snowstorm" appearance) within the **endometrial cavity**. *Hyperechoic rim* - A **hyperechoic rim (or decidual reaction)** around an adnexal mass can be a sign of an ectopic pregnancy, representing the decidualized tissue surrounding the gestational sac. - This is part of the "ring of fire" sign on Doppler ultrasound, indicating increased vascularity around the ectopic gestational sac. *Adenexal mass* - The presence of an **adnexal mass** separate from the ovary, especially if it contains a gestational sac or yolk sac, is a primary ultrasonographic feature of an **ectopic pregnancy**. - This mass represents the ectopic implantation site, most commonly in the **fallopian tube**. *Pseudo sac* - A **pseudo sac (or pseudo gestational sac)** is a collection of intrauterine fluid that can mimic a gestational sac but lacks an embryo or yolk sac. - It is a common finding in **ectopic pregnancies** and results from decidual reactions within the uterus in response to elevated hCG levels from the ectopic pregnancy.
Question 7: Regarding medical treatment of ectopic pregnancy, all are true except:
- A. Best prognostic indicator for success is initial HCG levels
- B. Perform baseline CBC, LFT, KFT
- C. Initial beta HCG is an indicator for the number of doses required (Correct Answer)
- D. Failure rates increase if cardiac activity is present
Explanation: ***Initial beta HCG is an indicator for the number of doses required*** - The initial **beta-HCG level** is a strong predictor of methotrexate treatment success, but it does **not delineate the number of doses** required. - The decision for single-dose vs. multi-dose methotrexate regimen is typically based on factors like initial HCG levels, size of ectopic mass, and physician preference, not predetermined by HCG for dose count. *Best prognostic indicator for success is initial HCG levels* - An initial **HCG level below 5000 mIU/mL** is the most significant positive prognostic indicator for successful medical management of ectopic pregnancy with methotrexate. - Higher HCG levels are associated with a **reduced success rate** and may necessitate surgical intervention. *Perform baseline CBC, LFT, KFT* - **Baseline complete blood count (CBC)**, **liver function tests (LFTs)**, and **kidney function tests (KFTs)** are essential before methotrexate treatment to assess for contraindications. - Methotrexate is **hepatotoxic** and **nephrotoxic**, and can cause myelosuppression, making these blood tests crucial for patient safety. *Failure rates increase if cardiac activity is present* - The presence of **fetal cardiac activity** within the ectopic pregnancy is a key predictor of failure with medical management and often a contraindication to methotrexate, favoring surgical intervention. - An embryo with cardiac activity indicates a **larger, more viable pregnancy**, which is less likely to respond to methotrexate and carries a higher risk of rupture.
Question 8: Violin string adhesion is seen in ?
- A. Ruptured ectopic pregnancy
- B. Endometriosis
- C. PCOS
- D. Fitz-Hugh-Curtis syndrome (Correct Answer)
Explanation: ***Fitz-Hugh-Curtis syndrome*** - **Fitz-Hugh-Curtis syndrome** is a perihepatitis characterized by inflammation of the liver capsule and adjacent peritoneal surfaces. - The classic "violin string" adhesions are **fibrinous adhesions** that form between the liver capsule and the anterior abdominal wall or diaphragm. *Ruptured ectopic pregnancy* - A ruptured ectopic pregnancy typically presents with acute abdominal pain and **hypovolemic shock** due to hemoperitoneum. - While it can cause pelvic adhesions, "violin string" adhesions are not a characteristic finding; the primary concern is **intra-abdominal hemorrhage**. *Endometriosis* - **Endometriosis** involves the presence of endometrial-like tissue outside the uterus, causing pain, inflammation, and adhesions, especially in the pelvis. - While it does lead to adhesions, these are usually **dense and diffuse pelvic adhesions**, not the specific "violin string" pattern associated with the liver capsule. *PCOS* - **Polycystic ovary syndrome (PCOS)** is an endocrine disorder characterized by hormonal imbalances, anovulation, and polycystic ovaries. - It primarily affects **ovarian function** and metabolism and does not directly cause adhesions in the abdominal cavity.
Question 9: A patient has dyspareunia, and dysmenorrhea with adnexal tenderness. What is the first step of investigation?
- A. Colposcopy
- B. Diagnostic laparoscopy
- C. Transvaginal USG (Correct Answer)
- D. Transabdominal pelvic ultrasound
Explanation: ***Transvaginal USG*** - This is the **first-line investigation** for evaluating pelvic pain, dyspareunia, dysmenorrhea, and adnexal tenderness due to its ability to provide **high-resolution images** of the uterus, ovaries, and surrounding structures to identify potential pathology like **endometriomas** or other adnexal masses. - It allows for detailed assessment of **ovarian cysts**, fibroids, and other pelvic abnormalities, which can explain the patient's symptoms. *Colposcopy* - This procedure is primarily used to closely examine the **cervix, vagina, and vulva** for abnormal cells, often following an abnormal Pap test. - It is not the initial step for investigating generalized pelvic pain, dyspareunia, or adnexal tenderness. *Diagnostic laparoscopy* - While a **diagnostic laparoscopy** can provide a definitive diagnosis for conditions like **endometriosis**, it is an **invasive surgical procedure** and typically reserved for cases where non-invasive imaging, such as transvaginal ultrasound, has not yielded a clear diagnosis or when conservative management has failed. - It is not considered the first-step investigation due to its **invasive nature** and associated risks. *Transabdominal pelvic ultrasound* - A **transabdominal pelvic ultrasound** provides a broader view of the pelvic organs but often has **lower resolution** and is less accurate for detailed assessment of the uterus, ovaries, and adnexa compared to transvaginal ultrasound, especially in obese patients. - It is often used if a transvaginal ultrasound is not feasible or for assessing larger pelvic masses, but the **transvaginal approach** is superior for detailed evaluation of the female reproductive organs.
Question 10: 18-year-old girl presents with 6 months of amenorrhea with h/o low-grade fever, weight loss, pain abdomen, generalized weaknesses. On PR examination, palpable left-sided pelvic mass felt... Diagnosis is
- A. Fibroid with degeneration
- B. Ectopic pregnancy
- C. Granulosa cell tumour
- D. TB pelvis with tubo-ovarian mass (Correct Answer)
Explanation: ***TB pelvis with tubo-ovarian mass*** - The presentation of **amenorrhea**, **low-grade fever**, **weight loss**, and **abdominal pain** over 6 months in an 18-year-old girl is highly suggestive of **pelvic tuberculosis** - **Tubo-ovarian masses** are a common manifestation of pelvic TB, where the infection spreads to the fallopian tubes and ovaries, leading to **chronic inflammation and mass formation** - The **pelvic mass on PR examination** combined with constitutional symptoms confirms genital tuberculosis as the diagnosis - Genital TB commonly presents with **primary or secondary amenorrhea** due to endometrial involvement *Fibroid with degeneration* - While fibroids can cause pelvic masses and abdominal pain, **degeneration** typically presents with **acute, severe pain** rather than chronic low-grade fever and weight loss - **Amenorrhea is not a typical symptom** of fibroids; they usually cause menorrhagia or irregular bleeding - **Constitutional symptoms** like prolonged fever and significant weight loss are not characteristic of degenerating fibroids *Ectopic pregnancy* - Ectopic pregnancy presents with **acute onset** of severe abdominal pain, vaginal bleeding, and potential hypovolemic shock with a positive pregnancy test - The patient's **chronic symptoms over 6 months** (low-grade fever and progressive weight loss) are completely inconsistent with ectopic pregnancy - Ectopic pregnancy would have manifested much earlier with acute complications *Granulosa cell tumour* - Granulosa cell tumours are **estrogen-producing ovarian tumours** that typically cause **irregular uterine bleeding or precocious puberty**, not amenorrhea - While they can form a pelvic mass, **constitutional symptoms** like chronic low-grade fever and significant weight loss are not typical features - These tumours usually present with hormonal effects rather than infectious/inflammatory symptoms
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free