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Acute Pelvic Pain (Women)

Pregnancy status first — then torsion, then the rest.

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Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobPregnancy status first — then torsion, then the rest.

  1. Pregnancy test first. Unstable with suspected ruptured ectopic: resuscitate and involve obstetrics for surgery; bedside US must not delay care.
  2. Then torsion: sudden unilateral pain — Doppler is supportive, not exclusive.
  3. Transvaginal US is the workhorse; CT when US is non-diagnostic and pregnancy is excluded.
  4. IVF: an IUP does not exclude heterotopic pregnancy.

Acute pelvic pain in women is triaged by pregnancy status and hemodynamic stability.

The threats are ectopic pregnancy, ovarian torsion, tubo-ovarian abscess, and hemorrhagic cyst rupture — all imaging-and-surgery decisions made early. Transvaginal ultrasound is the workhorse.

Ruptured ectopic pregnancy Critical

Key: hCG first in every patient of childbearing potential; unstable = operating room, not imaging.

Ovarian torsion Critical

Key: Sudden severe unilateral pain ± mass; Doppler US — delay loses the ovary.

Tubo-ovarian abscess Critical

Key: PID with mass or sepsis — admission, IV antibiotics, drainage per response.

Hemorrhagic ruptured ovarian cyst Critical

Key: Sudden pain with free fluid; watch hemodynamics, especially anticoagulated.

Septic abortion / puerperal infection Critical

Key: Fever + bleeding + uterine tenderness in pregnancy or postpartum.

Appendicitis / diverticulitis Emergent

Key: GI mimics — CT when US is non-diagnostic and pregnancy excluded.

UTI / kidney stone Common

Key: Dysuria or flank-to-groin radiation — urinalysis ± CT.

Mittelschmerz / dysmenorrhea / endometriosis Common

Key: Cyclical patterns with a benign exam.

Tick what your patient has — the banner updates as you go.

LMP, contraception (IUD), fertility treatments (↑torsion/ectopic risk)

Pain

sudden vs gradual, unilateral vs central, migration

Vaginal bleeding, discharge, fever, dysuria

Prior ectopic, PID, pelvic surgery, endometriosis

Sexual history and reliability of contraception

Vitals incl. orthostatics; peritoneal signs

Abdomen

rebound, guarding, masses

Pelvic

cervical motion tenderness, adnexal mass/tenderness, discharge

Quantify any bleeding; volume status

Bedside

  • Urine/serum hCG immediately
  • POCUS then transvaginal US — the definitive study

Labs

  • Quantitative β-hCG, CBC, type & screen, CRP; urinalysis
  • Cervical cultures / wet mount for PID

Imaging

  • Transvaginal US for ectopic, torsion, masses
  • CT when US non-diagnostic and pregnancy excluded; MRI in pregnancy if needed
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Benign/cyclical pain, negative hCG, normal imaging when indicated, reliable follow-up with strict return precautions.

Admit

  • PID/TOA on IV antibiotics, medically-managed ectopic per criteria, hemorrhagic cyst under observation, uncontrolled pain.

Emergency surgery / IR

  • Ruptured ectopic, ovarian torsion, ruptured TOA, unstable hemorrhagic cyst.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Acute Pelvic Pain (Women):
    • Positive hCG with pain or bleeding — ectopic until excluded
    • Hypotension, syncope, or peritoneal signs
    • Sudden severe unilateral pain (torsion)
    • Fever with adnexal tenderness (TOA)
    • IUD in situ with pain or pregnancy
    • Bleeding at any stage of pregnancy
  3. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Pregnancy test first, always — unstable + positive hCG goes to the OR, not the scanner.
  • Ovarian torsion is a clinical diagnosis; Doppler is supportive, not exclusive.
  • Free fluid in the pouch of Douglas with a positive hCG is ruptured ectopic until proven otherwise.
  • IVF patients can have heterotopic pregnancy — seeing an IUP is not enough.

Pitfalls

  • Ectopic with no risk factors and a normal exam is common — the hCG decides.
  • Preserved Doppler flow does not exclude torsion (dual blood supply).
  • Heterotopic pregnancy in IVF — an IUP does not exclude an ectopic.
  • PID with an IUD can progress rapidly to TOA.
  • Don’t assume threatened abortion — image first.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Vaginal BleedingAbdominal PainScrotal Pain & Swelling

Selected guidance · source check 2026-09-07. These 2 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — acute pelvic pain
  • ACOG Practice Bulletins (ectopic pregnancy; PID)
  • Tintinalli’s 9th ed. — gynecologic emergencies
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