Fainted at work with lower abdominal pain, a 27-year-old: an emergency case to work up

Why lower abdominal pain with collapse in a young woman matters

Any woman of reproductive age with abdominal pain and a faint needs a pregnancy test straight away, whatever she says about her periods or contraception. Pain felt at the tip of the shoulder can mean blood or fluid irritating the diaphragm. Resuscitate while you find the source.

What to ask in the history

• The pain: when it started, where, which side, what it is like
• The faint: what happened, how quickly she came round
• Last menstrual period, cycle, contraception (including a coil), sexual history
• Vaginal bleeding or discharge
• A previous ectopic pregnancy, pelvic infection, tubal surgery or fertility treatment
• Urinary and bowel symptoms, fever
• The shoulder pain: when it started, worse lying flat

Red flags

• Fainting, a fast pulse, low blood pressure, pallor
• Shoulder-tip pain
• Guarding, rigidity or a swollen abdomen
• Heavy vaginal bleeding
• A positive pregnancy test with pain

What to examine

• Airway, breathing, circulation: pulse, blood pressure, capillary refill
• Abdomen: tenderness, guarding, rebound, swelling
• Pelvic examination by the right clinician with a chaperone: cervical motion tenderness, adnexal tenderness or mass, bleeding
• Temperature

First investigations

• Urine or blood pregnancy test at once
• Full blood count, blood group and crossmatch, clotting
• Bedside ultrasound for free fluid in the abdomen
• Transvaginal ultrasound
• Quantitative serum hCG
• Urine dipstick and culture, CRP

Differential diagnosis of lower abdominal pain with collapse in a young woman

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• Not doing a pregnancy test because she says she cannot be pregnant.
• Being reassured by a normal first haemoglobin: it can be normal early in acute bleeding.
• Sending an unstable patient away for imaging instead of calling the gynaecology team and theatre early.