Postcoital pelvic pain can turn into a specialist turf battle – but point-of-care ultrasound can help marshal resources and guide disposition

Screen Shot 2014-06-01 at 5.54.47 PMA 25-year-old female presents to the ED with her boyfriend after she developed sudden onset pelvic pain during sexual intercourse at around 10 pm. The pain gradually worsened and spread to her ribs and she felt bloated and had the urge to defecate, so she got up from bed and went to the bathroom. Unfortunately she fainted on the way there, though she landed on carpet without injury. Her boyfriend had fallen asleep and woke when he heard her fall. He helped her to the bathroom but despite the strong urge to defecate she was unable to have a bowel movement. She then fainted a second time in his arms, so he brought her to the ED.

She denies any significant pain or injury from the initial faint and fall, but continues to have pelvic pain, bloating, discomfort just below her ribs, tenesmus and light-headedness. She denies any fever, vomiting, diarrhea, vaginal discharge or bleeding or other symptoms. She states she is otherwise healthy, felt fine earlier today, and has never had problems with constipation or fainting in the past. She states she had a completely normal period about two weeks ago.

On physical exam she appears to be in mild distress with normal vital signs except for a pulse of 118 at triage, which is now down to 81. Her BP is 102/53, temperature 98.8 and respiratory rate is 19. Her abdomen does not appear enlarged but she states it is usually flatter than it is now and her boyfriend agrees. She has diffuse tenderness with diffuse guarding and possibly some mild rebound tenderness. The rest of the physical exam is essentially normal.

Worried about the possibility of a ruptured ectopic, despite the history of a normal period two weeks ago, you perform a bedside ultrasound of the abdomen and transabdominal ultrasound of the pelvis and obtain the following views (Images 1, 2 & 3). What do the images show? What should you do next?

What do the images show? What should you do next? Continued on next page



# Did Sex Send Her to the ER?DR A K M AHMED 2014-06-30 05:55
Image 1: Fluid at the Morrisons pouch.
2 & 3: Pseudogestation al sac:
Stromgly Suggestive of Ruptured Ectopic.

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