Severe Abdominal Pain in a Woman of Childbearing Age = ….

It’s been over a year since J. started working, but he still remembers this experience from a student posting.

There was a 36-year-old lady who had come in with a 3-day history of abdominal pain, starting from the umbilical region, subsequently radiation to the right hypochondrium/flank region, bilateral shoulders and was exacerbated by lying down and relieved by sitting up.

Physical examination demonstrated tenderness over the areas of pain (including the shoulders) but no guarding or rebound tenderness, a low grade temperature of 37.6 degrees, BP 100/60mmHg, pulse 90 beats/min, SpO2 100% on room air. Initial investigations: Hb 11.6, TW 22.1, Plt 200, PT/PTT renal panel (U/E/Cr) liver function tests and serum amylase levels all normal.

She was admitted to General Surgery, who initiated basic cultures, fluids, antibiotics and ordered a CT abdomen/pelvis to look for any possible perforated appendix/viscus as she (as the registrar pointed out, “she doesn’t look too well…”). This lady was in sufficient pain that she needed IV morphine 2mg in order to lie down flat for the CT scan. Right before the scan, however, the registrar noted that her bladder was full and she had not been catheterised. He considered that her last reported menses was 1 month prior and lasted only 2 days (instead of her usual 5). He then flipped through the A&E notes and noted that the urine pregnancy test had been ordered but had not been performed (since the pt had not passed urine). The GS medical officer catheterised the patient in the CT scan room and ran the urine combur 9 and urine pregnancy test.

Positive.

CT scan withheld, O&G registrar informed, and the patient was wheeled to the labour ward immediately where a repeat pregnancy test was confirmed, and a transvaginal ultrasound demonstrated free fluid in the peritoneal cavity and a right adnexal mass – confirming the diagnosis of ectopic pregnancy. Care was handed over by the GS side to O&G who proceeded to prepare the patient for an operation. One life saved, thanks to an astute GS registrar.

That was the only case ectopic pregnancy J.’s seen… The UPT must always be checked for any woman of childbearing age. That’s what J. thinks when he sees a patient in the A&E referred to GS for abdominal pain.

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