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Author: Christina Schramm, MSIV Medical Student
St. George’s University School of Medicine
AAEM/RSA Social Media Committee
A 31-year-old gravida 0, para 0 female patient presented to the emergency department with lower abdominal pain that started during sexual intercourse three days prior. She presented with abdominal distension, diffuse, constant, and cramping bilateral lower abdominal pain, referred pain to her shoulders, exertional dyspnea, orthostatic hypotension, and near-syncopal episodes. The patient reported constipation that turned to loose stools on day three. The patient denied fevers, vomiting, vaginal discharge or foul odor, vaginal bleeding, and dysuria. The patient had a past medical history of anemia and stated that her hemoglobin was within normal limits during her last routine blood draw. The patient had Mirena intrauterine device (IUD) inserted three years prior, and her last menstrual period was unknown. The patient had been in a mutually monogamous relationship with a male partner and stated no concern for sexually transmitted infection (STI). Differential diagnosis included IUD displacement, ectopic pregnancy, pelvic inflammatory disease, ovarian cyst rupture, ovarian torsion, and appendicitis.
In triage, the patient was afebrile with a blood pressure of 138/82 mmHg and a heart rate of 116 beats per minute (bpm). After six hours, her blood pressure dropped to 83/53 mmHg with a heart rate of 111 bpm. She was administered four liters of intravenous fluids, raising her blood pressure to 96/70 mmHg. Her complete blood count revealed a drop in her hemoglobin from 9 g/dL to 7.6 g/dL over the past six hours, increasing concern for acute hemorrhage versus vagal nerve irritation.
Physical exam revealed tenderness to palpation bilaterally in the lower abdomen without guarding, positive rebound tenderness, and mild distension. The genitourinary exam was unremarkable with no cervical motion tenderness or evidence of trauma, and her IUD was in place. The quantitative urine beta-human chorionic gonadotropin pregnancy test was negative.
A computed tomography (CT) of the abdomen and pelvis with contrast revealed a moderate volume of hemoperitoneum in the abdomen and pelvis with a moderate amount of hyperdense ascites greatest about the liver and spleen tracking into the paracolic gutter. Both CT and pelvic ultrasound demonstrated a cystic lesion in the right adnexa measuring up to 4.1 centimeters with a moderate amount of pelvic free fluid. Gynecology and general surgery were consulted. The patient was then taken to the operating room and underwent a laparoscopic right ovarian cystectomy (Figure 1) and a one-liter evacuation of hemoperitoneum. (Figure 2)
|Figure 1: Laparoscopic view of the right ovarian cyst before the specimen was extracted.|
|Figure 2: Free blood in the peritoneum during laparoscopic surgery. (a) 1 liter of blood was evacuated from the peritoneum.|
Ovarian cysts are common, typically asymptomatic, and usually do not require treatment. Ruptured hemorrhagic corpus luteum is one of the most common gynecologic causes of hemoperitoneum. Hemorrhagic cysts can rupture due to physical trauma, sexual intercourse, or during the luteal phase of the menstrual cycle. The mechanism for postcoital hemoperitoneum is not well understood. It is hypothesized that the rupture is due to acceleration-deceleration forces or due to a change in intraluminal pressure during intercourse. Both pelvic ultrasound and CT scans are useful in the emergency department (ED) for diagnosing hemorrhagic cysts. Ultrasound is more specific in detecting ovarian cysts. However, CT is the recommended imaging modality for detecting hemorrhagic ovarian cysts or hemoperitoneum and can differentiate between other causes of intra-abdominal pathology.
Triage is designed to classify the acuity of emergent patients within minutes of arrival to the ED. While over-triage can overwhelm resources, under-triage may delay care of emergent patients. This patient waited three days after her ovarian cyst ruptured before walking into the ED. During triage, she was never asked about pain or history; the only information provided by triage was “female abdominal pain.” The Emergency Severity Index (ESI) is an algorithm that groups patients from one (most urgent) to five (least urgent) and is the standard of triage in the United States. This patient waited three hours before she was seen by a provider due to incorrect triage. She was triaged as an ESI-4 but may have been more appropriately triaged as an ESI-2 based on her pain and tachycardia.
Patients with a ruptured ovarian hemorrhagic cyst may present with a wide range of clinical signs and may be mistriaged based on pain tolerance and initially stable appearing vital signs. Maintain vigilance that our patients may be inadequately triaged in the emergency department. Don’t wait for hours to see your patient because they were triaged at an ESI-5. That ESI-5 who had pain with sex could very well be hemodynamically unstable with a hemoperitoneum.
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