What is the next step in managing a 39-year-old female with vaginal bleeding, diffuse abdominal pain, and diarrhea, who has a history of ectopic pregnancy and a cyst rupture, with a recent transvaginal ultrasound showing no significant sonographic abnormality and an unseen right ovary?

From the Guidelines

The next step in managing this patient should be to perform a transvaginal ultrasound and obtain quantitative beta-hCG levels immediately, as this is essential to rule out another ectopic pregnancy, which is more likely in patients with a previous history, as suggested by 1 and 1. Given the patient's presentation with vaginal bleeding, diffuse abdominal pain, diarrhea, history of ectopic pregnancy, and an ultrasound that doesn't visualize the right ovary, it is crucial to prioritize the diagnosis of potential life-threatening conditions such as ectopic pregnancy or ovarian torsion.

• The patient's history of ectopic pregnancy increases her risk for another ectopic pregnancy, making it essential to rule out this condition promptly.
• The inability to visualize the right ovary on ultrasound is concerning and warrants further investigation to rule out conditions such as ovarian torsion or hemorrhage.
• Additional workup should include a complete blood count, comprehensive metabolic panel, and blood type with Rh factor, as these tests can provide valuable information about the patient's overall health and potential risks.
• If beta-hCG is positive and the transvaginal ultrasound doesn't show an intrauterine pregnancy, the patient should be closely monitored and possibly undergo laparoscopy if an ectopic pregnancy is suspected, as recommended by 1.
• Maintaining a high index of suspicion for gynecological emergencies is crucial in this patient, given her history and current symptoms.
• The patient should be kept NPO (nothing by mouth) in case urgent surgical intervention becomes necessary, and IV access should be established with fluid resuscitation if there are signs of significant blood loss or hemodynamic instability, as this can help stabilize the patient and prepare her for potential surgery.
• It is also important to consider the potential risks and benefits of each diagnostic test and treatment option, as well as the patient's individual preferences and values, when making decisions about her care, as emphasized by 1.

From the Research

Next Steps in Management

The patient's symptoms of vaginal bleeding, diffuse abdominal pain, and diarrhea, along with a history of ectopic pregnancy and cyst rupture, and a recent transvaginal ultrasound showing no significant sonographic abnormality and an unseen right ovary, suggest the possibility of ovarian torsion.

• The patient's clinical presentation is consistent with ovarian torsion, which is a surgical emergency characterized by a partial or complete rotation of the ovarian vascular pedicle, causing obstruction to venous outflow followed by arterial inflow 2.
• Given the limitations of ultrasonography in visualizing the right ovary, further imaging with CT or MRI may be necessary to confirm the diagnosis, as these modalities can provide more detailed information about the ovarian anatomy and potential torsion 2, 3.
• A comprehensive patient history is essential in guiding the diagnostic workup and management plan, and should include information about the patient's symptoms, medical history, and previous surgeries or interventions 4.
• The patient's history of ectopic pregnancy and cyst rupture increases the risk of ovarian torsion, and prompt surgical intervention may be necessary to prevent permanent damage to the ovary 2, 3.

Diagnostic Considerations

• Ultrasonography is the first-line imaging modality for evaluating ovarian torsion, but it may not always provide a clear diagnosis, especially if the ovary is not visualized 2, 3.
• CT and MRI can be useful problem-solving tools in patients with equivocal or non-diagnostic ultrasonography studies, and can provide more detailed information about the ovarian anatomy and potential torsion 2, 3.
• The measurement of endometrial thickness by pelvic ultrasound may be relevant for screening for endometrial cancer, especially in postmenopausal women with abnormal uterine bleeding 5.

Treatment Options

• Ultrasound-guided interventional therapy may be a viable treatment option for patients with benign ovarian cysts, and has been shown to improve treatment effectiveness, shorten hospital stay, and reduce intraoperative blood loss compared to conventional surgical treatment 6.
• However, the patient's symptoms and clinical presentation suggest that ovarian torsion may be a more likely diagnosis, and prompt surgical intervention may be necessary to prevent permanent damage to the ovary 2, 3.