A 29-year-old woman is brought to the emergency department after a syncopal episode while getting out of bed. Yesterday, the patient developed right-sided abdominal pain, which has spread across the lower abdomen over the past few hours. She also noticed a blood stain on her underwear after the syncopal episode. Her last menstrual period was 8 weeks ago. The patient uses condoms intermittently for contraception. Temperature is 37 C (98.6 F), blood pressure is 90/60 mm Hg, and pulse is 125/min. The patient has diffuse lower abdominal pain with rebound tenderness and voluntary guarding. Pelvic examination shows cervical motion tenderness and right-sided adnexal tenderness; no masses are palpated. Which of the following is the most likely diagnosis for this patient?

Question

A 29-year-old woman is brought to the emergency department after a syncopal episode while getting out of bed.  Yesterday, the patient developed right-sided abdominal pain, which has spread across the lower abdomen over the past few hours.  She also noticed a blood stain on her underwear after the syncopal episode.  Her last menstrual period was 8 weeks ago.  The patient uses condoms intermittently for contraception.  Temperature is 37 C (98.6 F), blood pressure is 90/60 mm Hg, and pulse is 125/min.  The patient has diffuse lower abdominal pain with rebound tenderness and voluntary guarding.  Pelvic examination shows cervical motion tenderness and right-sided adnexal tenderness; no masses are palpated.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

11ec160b_3b1c_3bf5_9249_73ace3ed1981_MD0001_00 This patient with diffuse abdominal pain, rebound tenderness with guarding, and hemodynamic instability (eg, hypotension, tachycardia, syncope) likely has intraabdominal bleeding (ie, hemoperitoneum). In the setting of a missed menstrual cycle (ie, last menstrual period 8 weeks ago), right adnexal tenderness, and vaginal bleeding, the most likely cause is a ruptured ectopic pregnancy. Ectopic pregnancies occur due to implantation in an extrauterine location, most commonly the fallopian tube. Unlike the uterus, which has a thick wall of distensible smooth muscle, the fallopian tube cannot expand as the ectopic pregnancy enlarges. This strain on the tubal wall, in addition to surrounding tissue ischemia (from the redirection of blood flow toward the pregnancy), causes unilateral abdominal pain and tubal rupture. Rupture at this highly vascular site typically results in brisk intraabdominal bleeding. Because blood is highly irritating to the peritoneum, patients with hemoperitoneum usually develop diffuse abdominal pain with rebound and guarding; low-grade fever (due to inflammation) is also common. Patients with blood accumulation in the posterior cul-de-sac can also have cervical motion tenderness and a strong urge to defecate. Patients with hemodynamic instability (eg, orthostatic hypotension, syncopal episode) require urgent surgical management. (Choice A) Acute appendicitis can present with right lower abdominal pain that progresses to diffuse pain in cases of appendiceal rupture (ie, peritonitis from spilled intestinal contents). However, this diagnosis is less likely in this patient who also has a missed menstrual cycle and vaginal bleeding. (Choice B) Ovarian torsion can cause unilateral abdominal pain and adnexal tenderness; patients with prolonged torsion may develop rebound and guarding due to ovarian necrosis. However, the pain is typically sudden onset (ie, acute occlusion of ovarian blood flow) and vaginal bleeding is uncommon. An adnexal mass (not present in this patient) may be palpable. (Choices C and E) Pelvic inflammatory disease (PID) typically presents with abdominal pain and cervical motion tenderness due to infection and inflammation of the upper genital tract. Tuboovarian abscess (TOA) is a severe form of PID that has localized to the adnexa. Unlike this patient, those with PID or TOA are typically febrile with malodorous cervical discharge. Educational objective: Ectopic pregnancy may present with unilateral lower abdominal pain, adnexal tenderness, and vaginal bleeding. Patients with a ruptured ectopic pregnancy have severe intraabdominal bleeding, which causes diffuse abdominal pain with rebound/guarding and hemodynamic instability. __________ References: Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. (http://www.ncbi.nlm.nih.gov/pubmed/28620520) Diagnosis and management of ectopic pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/25077500)

A 29-Year-Old Woman Is Brought to the Emergency Department After