Reproductive System
Core concepts
Pregnancy status changes every abdominal pain algorithm: any reproductive-age woman with abdominal or pelvic pain gets a pregnancy test. A positive test with pain or bleeding means ectopic until localized. A transvaginal ultrasound showing an intrauterine pregnancy essentially excludes ectopic in a low-risk patient; an empty uterus with a discriminatory human chorionic gonadotropin level above the expected threshold is suspicious. Stable, unruptured ectopic pregnancy may be treated with methotrexate; hemodynamic instability means surgery.
Pelvic inflammatory disease is a clinical diagnosis with lower abdominal pain, cervical motion tenderness, and adnexal tenderness; outpatient treatment combines ceftriaxone with doxycycline and metronidazole.
Testicular torsion is a surgical emergency with sudden severe unilateral pain, a high-riding testis, and an absent cremasteric reflex; do not delay exploration for a Doppler study.
Obstetric emergencies: painless vaginal bleeding after 20 weeks suggests placenta previa and digital examination is contraindicated; painful bleeding with a tense uterus suggests abruption; new hypertension after 20 weeks with proteinuria or end-organ dysfunction is preeclampsia, managed with magnesium for seizure prophylaxis and delivery as the definitive treatment.
Traps
- Anchoring on a urinary tract infection in a woman with pelvic pain and never testing for pregnancy.
- Sending a torsed testis for ultrasound before calling the surgeon.
- Performing a digital cervical exam in third-trimester painless bleeding.
- Prescribing estrogen-containing contraception to a smoker over 35 or a patient with migraine with aura.
Rule of thumb
An empty uterus on transvaginal ultrasound with a positive pregnancy test and a quantitative beta-hCG above the discriminatory zone is an ectopic pregnancy until another explanation is proven.