Acute abdominal pain in pregnancy

Abstract

A 19-year-old gravida 2, para 0 woman at 17 weeks gestation, with one prior elective termination of pregnancy, presented after waking at 4:30 a.m. with sharp, severe right lower quadrant abdominal pain. The patient denied any prior symptoms, including vaginal bleeding or discharge, fever, nausea, vomiting, and painful urination. The patient stated she “felt fine” prior to waking with this pain. At presentation she was laying on her side in a fetaltype position holding her abdomen. The vital signs were as follows: temp 36.6°C, blood pressure 130/72 mm Hg, pulse 108 beats/min, and respirations 18 breaths/min with an oxygen saturation of 99% on room air. Physical examination was remarkable for marked localized tenderness in the right lower quadrant with voluntary guarding. Peritoneal signs otherwise were absent. The pelvic examination was significant for a gravid uterus about 18–20 weeks in size. Marked cervical motion tenderness was present as well as a large firm mass in the right adnexa. No vaginal bleeding or discharge was noted and the cervical os was closed. Fetal heart tones were documented at 150 beats/min. A portable ultrasound done in the Emergency Department demonstrated a large 10 10 cm adnexal cystic mass (Figure 1). Also noted was an intrauterine gestation with cardiac activity and fetal movement consistent with a 17-week gestation. The radiologic ultrasound examination confirmed an 8 10 cm cystic mass with a dermoid component on the right ovary (Figure 2). The arterial flow to that ovary was noted to be diminished, consistent with a torsion. The OB/GYN resident was notified of the findings. Immediate laparoscopic surgery was performed, demonstrating a right ovarian dermoid cyst along with an infarcted, necrotic right ovary, which was removed (Figures 3 and 4). The patient did well following the procedure despite an 8% chance of fetal demise. The patient continues to do well with subsequent follow-up visits to the obstetrician.