The previous cycle may have been irregular, or there may have been extra bleeding. Amenorrhoea does not always occur.
Should always be considered when the pregnancy test is positive but there is no ultrasonographic evidence of pregnancy inside the uterus.
Ultrasonography
If the serum human chorionic gonadotrophin concentration is ≥ 1000 IU/l, the pregnancy should be detectable in the uterus. The pregnancy may sometimes be located in an old caesarean section scar.
If the uterine cavity is empty or only a small fluid cavity (pseudogestational sac) is visible, an ectopic pregnancy should be suspected. In such a case, a tubal or ovarian pregnancy is usually detected.
A typical view resembles a millstone; the homogenous placental tissue forms a thick ring around an anechoic central cavity. A minute foetus or a pulsating heart may sometimes be detected within the central cavity.
The detection of an abdominal pregnancy with ultrasound examination may be very difficult, or even impossible, in early pregnancy.
An ectopic pregnancy may also be located in the cervical canal or in the uterine cornua.
Ovulation
An acute, often unilateral pain in the middle of the cycle that usually subsides in 24 hours.
The history may include twisting of the body, e.g. bowling, belly dancing or washing the floor on the knees.
In ultrasound the cyst may appear irregular and free fluid may be detected in the peritoneal cavity.
Rupture of the corpus luteum
The symptoms are similar to extrauterine pregnancy yet the pregnancy test is negative.
There is blood in the peritoneal cavity.
Treatment is operative if the pain is severe.
Rupture of an endometriosis cyst
The symptom is an acute and very severe irritation of the peritoneum.
Treatment is usually an acute operation.
Rupture of a dermoid cyst
Rare
Very painful because the sebum causes strong irritation in the peritoneal cavity.
Torsion of the ovary or the tube
The cause is usually a cyst.
Gynaecological investigation reveals a tender, possibly moveable mass.
In ultrasound the ovary may appear oedematous and hyperechoic. Rotated Fallopian tubes may form fluid cavities. In multiple torsion, colour Doppler usually fails to detect vascularity in the ovarian tissue.
All medicines used for the induction of ovulation (letrozole rarely) may cause OHSS, in which the reaction of the ovaries to the hormonal medication is excessive.
The syndrome typically begins 3-10 days after the induction.
The symptoms include abdominal pain, oedema, nausea, and in a severe case dyspnoea.
Ovarian ultrasonography Gynaecological Ultrasound Examination and basic blood count with platelet count are the primary tests, and CRP is used for differential diagnosis.
In strong suspicion of OHSS, gynaecological investigation should be avoided.
Refer readily to hospital or to the doctor in charge of the fertility treatment.
Torsion and necrosis of a pedunculated uterine myoma
The symptom is cyclic pain resembling childbirth.
The myoma may grow into the vagina through the cervix.
CRP is usually elevated.
Ultrasound: in case of necrosis the shape and structure of the myoma may change and it may shrink.
May cause acute pelvic pain when they rupture or bleed, although this is rare.
The patient has a tender mass in the lower abdomen and often ascites.
Ultrasonography
As an ovarian tumour grows it may bleed either inside the tumour itself or to the surrounding tissues. The tumour may become twisted. Malignant tumours are often associated with ascites which may cause sudden and significant swelling of the abdomen.
Labour
Sudden severe acute pelvic pain may originate from a labour without the pregnant woman or her parents knowing of the pregnancy. Sometimes the pregnant female (usually a schoolgirl) knows but her mother does not.
Perforation of the vagina
The most common aetiologies are intercourse, or trauma caused by a foreign body.
The cause is tightness of the cervix that is often due to treatment of the cancer of the cervix (e.g. loop electrosurgical, cryo- or laser-conization).
Symptoms
Begins gradually.
The condition becomes acute when a bloody and purulent discharge appears, and pain and fever begins.