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Disorders causing pelvic pain related to early pregnancy include spontaneous abortion, septic abortion, ruptured or unruptured ectopic pregnancy, and a ruptured corpus luteum cyst (an ovarian cyst at the site of ovum release). Nonobstetric disorders that should be considered include appendicitis, pyelonephritis, nephrolithiasis, musculoskeletal pain, irritable bowel syndrome, growth or degeneration of fibroids, and, rarely, pelvic inflammatory disease. Ectopic pregnancy can lead to hemorrhagic shock; septic abortion can lead to septic shock. Either should be treated with IV fluid resuscitation and other measures before and during evaluation.
Evaluation
Certain historical and examination findings may suggest causes of pregnancy-related pelvic pain (see Table 2: Approach to the Pregnant Woman and Prenatal Care: Findings in Some Disorders Causing Pelvic Pain Related to Early Pregnancy ). Nonobstetric disorders are evaluated as in nonpregnant women (see Approach to the Gynecologic Patient: Pelvic Pain).
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Table 2
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Findings in Some Disorders
Causing Pelvic Pain Related to Early Pregnancy
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Finding
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Ectopic Pregnancy
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Spontaneous Abortion
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Septic Abortion
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Corpus Luteal Cyst
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Hemorrhagic shock out of proportion to external bleeding
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Y*
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N
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N
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N†
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Septic shock
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N
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N
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Y
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N
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Peritonitis
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Y*
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N
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Y
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Y*
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Open cervical os or tissue passed through vagina
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N
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Y
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Y
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N
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Purulent vaginal discharge
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N
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N
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Y
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N
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Vaginal bleeding
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Y
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Y
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Y
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N
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Colicky pain
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N (usually)
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Y
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Y (early)
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N
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Adnexal mass
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Y
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N
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N
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Y
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History of illicitly attempted abortion
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N
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N
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Y
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N
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Y = finding is common or characteristic; N = finding is not characteristic.
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*Ruptured.
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†Unless ruptured and bleeding.
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History and examination:
Risk factors for ectopic pregnancy include previous ectopic pregnancy, history of a sexually transmitted disease or pelvic inflammatory disease, current use of an intrauterine device, prior pelvic (particularly tubal) surgery, and smoking. A history of illicitly attempted termination of pregnancy or termination by an inexperienced practitioner suggests septic abortion, but absence of such a history does not exclude this diagnosis. Severe pain, particularly if worsened by movement, suggests peritonitis.
General and pelvic examinations are done. If the internal cervical os is open or if tissue has passed, spontaneous abortion is likely.
Testing:
Pregnancy is confirmed (see Normal Pregnancy, Labor, and Delivery: Diagnosis). If an obstetric cause is suspected, CBC, PT, PTT, fibrinogen level, and usually blood typing and screening or cross-matching are indicated. If the internal cervical os is open or if tissue has passed, further testing may be unnecessary unless septic abortion is suspected; then, blood cultures are obtained. If the os is closed and there is no evidence of tissue passage, ectopic pregnancy must be excluded; testing begins with quantitative measurement of the β subunit of human chorionic gonadotropin (β-hCG) and pelvic ultrasonography (see Abnormalities of Pregnancy: Ectopic Pregnancy). If hemorrhagic shock persists despite initial fluid resuscitation, ruptured ectopic pregnancy is presumed.
Treatment
Treatment is directed at the underlying disorder. Presumed ruptured ectopic pregnancy requires immediate laparoscopy or laparotomy.
Last full review/revision November 2005
Content last modified November 2005
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