A 42-year-old woman comes to the emergency department for severe lower abdominal pain. The pain started several hours ago and has progressively worsened. She has associated nausea and vomiting but no fever, diarrhea, or abnormal vaginal discharge. The patient was diagnosed with adenomyosis last month due to increasingly heavy menses and dysmenorrhea and is currently taking tranexamic acid as needed. Her menses started yesterday, but she reports that the pain is more severe than usual and radiates to the left lower quadrant. Temperature is 37.8 C (100 F), blood pressure is 110/74 mm Hg, and pulse is 110/min. The abdomen is soft with normoactive bowel sounds, and there is voluntary guarding in the left lower quadrant. On pelvic examination, the uterus is globular and boggy, and there is dark red blood with small clots in the vagina. The left adnexa is tender on bimanual examination, and there are no palpable adnexal masses. Urine pregnancy testing is negative. Hemoglobin is 11 g/dL. Which of the following is the best next step in management of this patient?

Question

A 42-year-old woman comes to the emergency department for severe lower abdominal pain.  The pain started several hours ago and has progressively worsened.  She has associated nausea and vomiting but no fever, diarrhea, or abnormal vaginal discharge.  The patient was diagnosed with adenomyosis last month due to increasingly heavy menses and dysmenorrhea and is currently taking tranexamic acid as needed.  Her menses started yesterday, but she reports that the pain is more severe than usual and radiates to the left lower quadrant.  Temperature is 37.8 C (100 F), blood pressure is 110/74 mm Hg, and pulse is 110/min.  The abdomen is soft with normoactive bowel sounds, and there is voluntary guarding in the left lower quadrant.  On pelvic examination, the uterus is globular and boggy, and there is dark red blood with small clots in the vagina.  The left adnexa is tender on bimanual examination, and there are no palpable adnexal masses.  Urine pregnancy testing is negative.  Hemoglobin is 11 g/dL.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d983_4bfb_bc81_7f1b71f736f0_MD0003_00 This patient has adenomyosis, a common cause of pelvic pain in women age >40 that typically presents with heavy menstrual bleeding and a tender, globular uterus (as seen in this patient). However, adenomyosis typically causes chronic, dull, midline pelvic pain; therefore, this patient's sudden change in pain severity and acute onset of symptoms are concerning for another acute gynecologic condition. adenomyosis This patient's sudden-onset unilateral pelvic pain accompanied by nausea/vomiting is most likely due to ovarian torsion, which represents partial or complete rotation of the ovary around the infundibulopelvic (IP) ligament. The IP ligament contains the ovarian vessels; rotation acutely interrupts ovarian blood flow, causing acute-onset pain. As ovarian ischemia progresses, patients may develop radiating pain, ovarian edema (eg, adnexal tenderness or fullness, with or without a palpable mass), and peritonitis (eg, rebound/guarding, fever). Ovarian torsion is a gynecologic emergency that is clinically diagnosed in patients with classic symptoms. Although a Doppler ultrasound revealing decreased or absent ovarian blood flow can support the diagnosis, normal findings do not exclude torsion. Because of the risk of tissue necrosis and loss of ovarian function (eg, infertility, menopause), ovarian torsion requires urgent diagnostic laparoscopy to manually untwist the adnexa and restore blood flow. (Choices A and F) Tranexamic acid (an antifibrinolytic agent) and oral contraceptives can be used to decrease heavy menstrual bleeding due to adenomyosis. This patient's new pain symptoms are inconsistent with adenomyosis and require additional evaluation. In addition, discontinuation of tranexamic acid may increase this patient's menstrual bleeding. (Choice B) Conservative management (eg, observation with serial abdominal examinations) is appropriate for patients with self-limiting, nonurgent causes of pelvic pain (eg, ruptured simple ovarian cyst). This patient has severe pain and guarding consistent with an acute abdomen and requires immediate surgery. (Choices D and E) Endometrial ablation (ie, cauterization of the uterine lining) and uterine artery embolization can be used to treat heavy vaginal bleeding. This patient's bleeding is normal (dark red blood with small clots), and her hemoglobin is appropriate; therefore, these procedures are not indicated at this time. Educational objective: Ovarian torsion, or rotation of the ovary around the infundibulopelvic ligament, classically presents with nausea/vomiting; new-onset, severe unilateral pelvic pain; and adnexal tenderness. Ovarian torsion is a gynecologic emergency and requires diagnostic laparoscopy. References: Adnexal torsion. (http://www.ncbi.nlm.nih.gov/pubmed/29941434) Accuracy of pelvic ultrasound in diagnosing adnexal torsion. (http://www.ncbi.nlm.nih.gov/pubmed/31354994)

A 42-Year-Old Woman Comes to the Emergency Department for Severe