A 32-year-old woman comes to the emergency department due to left lower quadrant abdominal pain. The pain started suddenly this morning along with nausea, but she has had no vomiting or diarrhea. The patient has a history of heavy menstrual bleeding due to uterine fibroids, which was previously controlled with combined oral contraceptives. She recently stopped the pills to try for pregnancy, and her last menstrual period was 2 weeks ago. BMI is 30 kg/m². Temperature is 37.2 C (99 F), blood pressure is 122/84 mm Hg, and pulse is 82/min. The abdomen is soft and diffusely tender to deep palpation in the left lower quadrant, but there is no rebound or guarding. The uterus is enlarged, irregular in contour, and nontender. Urine pregnancy testing is negative. Ultrasound reveals multiple subserosal and intramural uterine fibroids, a homogenous endometrial stripe, moderate free fluid in the pelvis, and a left ovary with a 4-cm cyst with thin walls. Which of the following is the best next step in the immediate management of this patient?

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11ec25c8_d98b_3b4a_bc81_0d85e7183735_MD0003_00 In reproductive-aged women, sudden abdominal pain can have a variety of etiologies (eg, gastrointestinal, gynecologic) due to the proximity of anatomic structures. Initial evaluation aims to differentiate between emergent (ie, acute abdomen) and nonemergent conditions, and to identify the anatomy involved (eg, appendix, adnexa). Pregnancy testing is required, and imaging (eg, ultrasonography) may be performed. This patient with a thin-walled ovarian cyst and pelvic free fluid likely has a ruptured ovarian cyst. Ovarian cysts are common in reproductive-aged women due to physiologic cyst formation from ovulation. This patient's risk for ovarian cysts likely increased due to discontinuation of her combined oral contraceptives that typically suppress cyst formation. Physiologic ovarian cysts are usually small (eg, <3 cm) and asymptomatic, but they can become larger and rupture with vigorous activity (eg, intercourse). Patients typically have acute-onset, unilateral pain due to cyst rupture and spilling of fluid into the peritoneal cavity. Diagnosis is confirmed by ultrasound, which typically reveals a simple, thin-walled cyst with free fluid in the pelvis. Hemodynamically stable patients with no signs of infection (eg, fever) are managed with observation and reassurance. In contrast, hemodynamically unstable patients may have continued bleeding from the ruptured cyst and require surgery (Choice D). (Choice A) Broad-spectrum antibiotics are used to treat tuboovarian abscesses (TOA). Patients are typically acutely ill (eg, fever, tachycardia) and have complex, multilocular adnexal masses (rather than a simple, thin-walled cyst) on ultrasound. (Choice B) CT scan of the abdomen and pelvis is indicated in patients with an acute abdomen (eg, rebound/guarding) or concern for malignancy (eg, complex-appearing ovarian mass), which are not present in this patient. (Choice C) Diagnostic peritoneal lavage assesses for hemoperitoneum caused by abdominal trauma; it has been largely replaced by CT imaging and the focused assessment for the evaluation of trauma (FAST) examination unless the patient is hemodynamically unstable. (Choice E) Laparotomy with myomectomy treats symptomatic uterine fibroids (eg, bulk symptoms, heavy vaginal bleeding, anemia). Although this patient has multiple fibroids, they are not the likely cause of her presentation because they typically do not cause acute pain or pelvic free fluid; therefore, myomectomy is not indicated at this time. fibroids Educational objective: Ovarian cyst rupture, a common cause of acute, unilateral lower abdominal pain in reproductive-aged women, typically appears on ultrasound as a thin-walled ovarian cyst with pelvic free fluid. Hemodynamically stable patients are managed with observation and reassurance. References: Successful conservative management of ruptured ovarian cysts with hemoperitoneum in healthy women. (http://www.ncbi.nlm.nih.gov/pubmed/24608424)

A 32-Year-Old Woman Comes to the Emergency Department Due to Left