A lady presented with diarrhea and abdominal pain

1. HKCEM College Tutorial A lady presented with diarrhea and abdominal pain AUTHOR DR. PAULIN NG REVISED BY DR. WONG HO TUNG OCT, 2013

2. Triage • Female 20 • ambulatory • BP 120/80 mmHg, P 80/min • Temp 36.8 deg C • c/o: lower abd pain and loose stool twice x1/7 Triage Category IV

3. History • Dull lower abd pain • Loose stool for 2 times • Nausea, no vomiting • No urinary symptoms • PH: well, NKDA Any other things You want to ask The patient? LMP 6 weeks ago, regular period No PV bleed or vaginal discharge

4. Physical findings • General: stable vitals, not pale • Abd.: mild lower abd tenderness, no peritoneal irritation or loin tenderness, normal bowel sound • Systems reviews: normal Anything else? • PV: no cervical excitation or definite adnexal mass/tenderness

5. What are the DDx? • Surgical causes • OBGyn causes • Medical causes Any investigations at this point?

6. Investigations • Urine • WBC (-), nitrate (-) • Preg test (+) • Pelvic USG in ED • TVS • Small GS was noted How useful is USG in female with Lower abd pain?

7. Use of US in lower abd pain • confirm IU preg • rule in ectopic • ovarian cyst (torsion) • tubo_ovarian abscess • appendix + abscess • Urolithiasis • AAA (elderly)

8. Disposition • Patient was discharged with the provisional diagnosis of GE and early pregnancy • She was advised to return if symptoms worsen.

9. Patient returns the next day • Triage note • c/o: syncope and increasing abd pain • vitals: BP 80/40 mmHg, P 120/min • No PV bleed • Category 2 case Diffuse tenderness + guarding of abd++ What has happened?

10. Resuscitation What to do next?

11. Initial resuscitation • High flow O2 • 2 wide bore IV lines with Fluid resuscitation • X-match 4 unit, transfuse if necessary • close monitoring of maternal vitals (and urine output)

12. Investigations • Blood work • Hb, Hct, Plt count, clotting profile • Blood group and X-match What other Ix? Ultrasound

13. Free Fluid Adnexal mass

14. Rupture Ectopic pregnancy in Shock What is the provisional diagnosis?

15. Disposition • Immediate resuscitation • Inform GYN on call • Admission

16. Pitfalls • Ectopic pregnancy cannot be ruled out by: • absence of amenorrhoea • negative urine pregnancy test • denial of sexual activity • passing of tissue mass • contraception e.g. IUD • Beware of Pseudosac in pelvic US exam. A female pt with abd pain has EP until proven otherwise!

17. Pseudosac Sac is thin. No double ring of decidua.

18. Ectopic Pregnancy • defined as any gestation occurring outside the uterine cavity • 95% are tubal pregnancies, others involve ovary, cervix, or abdominal cavity

19. Importance of Ectpoic Pregnancy • the incidence has doubled in past decade • causes 12% of maternal death in US • symptoms range from minimal to frank shock • high index of suspicion is required

20. Clinical Presentations • should always be considered in the differential diagnosis of acute pelvic pain • classical triad may not be present : • Abdominal pain +/- referred pain at shoulder tip, • PV bleeding • Amenorrhoea

21. Who are High Risk ? • previous ectopic pregnancy • current IUCD use • prior tubal surgeries • history of PID • prior infertility and the use of ovarian induction therapy

22. USG findings of Ectopic Pregnancy • absence of Intrauterine sac • adnexal mass ± fetus • free fluid in cul-de-sac

23. USG finding of definite Intrauterine Pregnancy • gestational sac with sonolucent center surrounded by thick, concentric, echogenic ring in the endometrium and containing a fetal pole, yolk sac or both

24. Thank You