PAIN IN EARLY PREGNANCY
A
22-year-old woman attends
the emergency department complaining of abdominal pain. She is 7 weeks 4 days pregnant by certain menstrual dates. She had
a normal vaginal delivery at term 18 months ago.
Her periods are
usually regular every
27 days, with
bleed- ing for 3–5 days. She has no previous gynaecological history. Her medical
history involves mild asthma and two episodes of cystitis.
The
pain started suddenly two nights ago
and is localized to the right
iliac fossa with
some radiation down the
right thigh. It is constant though worse on movement, so she has tended to lie still.
She has not taken any analgesia as she is uncertain whether
this is safe for
the baby. She is always constipated and this is worse since
she became pregnant. She has urinary frequency but no dysuria
or haematuria. She
has a slightly reduced appetite but does not feel feverish or sweaty.
Her
temperature is 36.4°C,
heart rate 90/min
and blood pressure
96/58 mmHg. There
are no signs of anaemia and
she feels warm
and well perfused. She is slim
and the abdomen is not distended. There
is focal tenderness on palpation of the right
iliac fossa, with
slight rebound tenderness but no guarding. Rovsing’s sign is not present.
Speculum examination is unremarkable. The uterus is bulky and retroverted with no cervical
excitation. The right adnexa is tender with a suggestion of ‘fullness’.
·
What is the likely
diagnosis and what are the differential diagnoses for the pain?
·
How
would you further
investigate and manage this woman?
The ultrasound shows a single
viable intrauterine pregnancy and haemorrhage into a corpus luteal cyst.
Urinary tract infection or calculi are excluded
by the urinalysis result. Constipation is more likely to cause left-sided pain and the sudden onset
of pain would
perhaps be unusual. Appendicitis should
be considered but
the lack of systemic features, the normal tempera- ture, white count and C-reactive protein
are suggestive of this not being the diagnosis.
The
corpus luteum is the cystic
area that develops on the ovary
at the ovulation site. It may be solid, cystic
or haemorrhagic and may vary in size.
On colour Doppler
ultrasound it has a typical ‘ring
of fire’ appearance, distinguishing it from
other types of ovarian cyst. In this case the
‘spider web’ or reticulated pattern
of echoes within
the cyst suggests that it is haemorrhagic.
Management is supportive with analgesia (paracetamol in the first
instance followed by codeine derivatives if necessary) and reassurance. There
is no evidence that bleeding into the corpus luteum
adversely affects the
pregnancy outcome. As the cyst
is so large, it may be
sensible to repeat
an ultrasound scan
in 2–4 weeks
to confirm resolution.
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