ABDOMINAL PAIN CASE 1
‘A young patient with acute abdominal pain’
Lucy is a 32 year old pregnant female. She presents to the Emergency Department (ED) with acute severe abdominal pain after a syncopal episode.
She reports radiation of the abdominal pain to the shoulder. On arrival she is seen by you in the ambulance bay. Her last menstrual period was 8 weeks ago and she has not thus far had an ultrasound for this pregnancy.
She reports ongoing severe right lower quadrant pain and the vital signs are BP 82/50; HR 110; resp rate 20; 02 Sats 99%. She is P2 G3 and the current pregnancy was ‘naturally’ conceived (i.e. no IVF). You are concerned that on a brief abdominal examination she has guarding in the lower abdomen.
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Which of the following is the MOST important immediately life-threatening diagnosis?
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Choices:
- Acute Appendicitis
- Pyelonephritis
- Ectopic Pregnancy
- Ischaemic Colitis
Commit to your answer and Scroll Down…
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CORRECT ANSWER = 3
The Take Home Message:
In females of childbearing age ectopic pregnancy should always be the first consideration and a diagnosis of exclusion regardless of the menstrual and conception history reported.
A Further Explanation:
The presentation described in this case would be highly concerning for a ruptured ectopic pregnancy. Suggestive features include the amenorrhoea, peritonism and shoulder tip pain. These signs are ‘classic’ features of a ruptured ectopic pregnancy. History of “Risk factors’’ should be sought. They include pelvic inflammatory disease (PID), assisted fertilisation, previous ectopic pregnancy, Mirena coil device, and the use of the progesterone only ‘mini-pill’.
In this case management would include appropriate IV access (2x 18g cannula), blood gas (lactate), group and screen and an early senior ED review. The specialist O&G team should be notified immediately using an “I.S.B.A.R.” handover. If available the patient should be taken to Resuscitation bed and attached to full monitoring and kept nil by mouth while and urgent ultrasound is expedited.
The urinary pregnancy test is a good (>96% sensitive) test to rule in pregnancy. You can use the blood sample on a urine test for an immediate (albeit non-validated) result. Blood serum HCG should also be used to exclude pregnancy with a high degree of certainty. While appendicitis is also an important consideration (if missed this can carry a ⅓ risk of fetal demise) it is less time dependent that a ruptured ectopic pregnancy.
Links and References:
- Pregnancy Tests – https://www.aliem.com/2012/04/trick-of-trade-urine-pregnancy-test
- ISBAR – https://emergencypedia.com/2015/01/30/presenting-a-patient-case-like-a-pro
- Problems in Early Pregnancy – PODCAST and BLOG: http://www.stemlynsblog.org/problems-early-pregnancy-induction
EmergencyPedia 
Ectopic
Correct