The Journal of Emergency Medicine, Vol. 25, No. 1, p. 89 92, 2003 Copyright 2003 Elsevier Inc.

. Printed in the USA. All rights reserved 0736-4679/03 $see front matter

doi:10.1016/S0736-4679(03)00126-4

Visual Diagnosis in Emergency Medicine

ACUTE ABDOMINAL PAIN IN PREGNANCY

David Effron,
MD

and James Aiello,

MD

Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio; The Cleveland Clinic Foundation, Cleveland, Ohio Reprint Address: David Effron, MD, Emergency Medicine, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, Ohio 44109-1998

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 ne 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 36.6C, 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 signicant for a gravid uterus about 18 20 weeks in size. Marked cervical motion tenderness was present as well as a large rm 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 conrmed an 8 10 cm cystic mass with a dermoid component on the right ovary (Figure 2). The arterial ow to that ovary was noted to be diminished, consistent with a torsion. The OB/GYN resident was notied of the ndings. 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.

Visual Diagnosis in Emergency Medicine is coordinated by Stephen R. Hayden, MD, of the University of California San Diego Medical Center, San Diego, California

RECEIVED: 11 June 2002; ACCEPTED: 10 September 2002

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Figure 1. Ultrasound view of a large right ovarian cyst (arrow).

Figure 2. Transabdominal ultrasound (oblique view) of the right ovarian mass (arrow).

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Figure 3. (A) An infarcted right ovary (arrow). (D) Torsion of the right adnexa next to the gravid uterus.

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Figure 4. (A) Torsion of the right fallopian tube (arrow). (B) A large right ovarian mass next to the gravid uterus approximately 17 weeks.