What is the appropriate initial management for a patient with hypotension and lower abdominal pain after stopping medroxyprogesterone acetate (Depo‑Provera) who has a history of ovarian cyst?

Immediate Management of Hypotension with Lower Abdominal Pain After Depo-Provera Discontinuation

This patient requires urgent evaluation for hemorrhagic shock from a ruptured ovarian cyst, with immediate IV access, rapid isotonic crystalloid resuscitation (500-1000 mL bolus), and emergent bedside ultrasound (FAST exam) to identify intra-abdominal bleeding. 1, 2

Initial Stabilization and Assessment

Establish IV access immediately and begin rapid isotonic crystalloid resuscitation with 0.9% normal saline at 10-20 mL/kg (approximately 500-1000 mL for a typical adult) while simultaneously identifying the underlying cause. 2 The combination of hypotension and lower abdominal pain in a patient with known ovarian cysts raises critical concern for hemorrhagic shock from cyst rupture or torsion. 1

Critical First Steps:

• Measure blood pressure in both arms and obtain orthostatic vital signs to quantify the degree of hypotension 1
• Perform immediate bedside ultrasound (FAST exam) to rapidly identify free intra-abdominal fluid, which would indicate hemorrhage requiring urgent surgical consultation 1
• Draw arterial blood gas and serum lactate immediately as markers of tissue perfusion and shock severity 1
• Obtain complete blood count (though initial hematocrit has low sensitivity for acute hemorrhage), comprehensive metabolic panel, and coagulation studies 1

Fluid Responsiveness Testing

Before administering additional fluids beyond the initial bolus, perform a Passive Leg Raise (PLR) test to determine fluid responsiveness, as only 54% of hypotensive patients respond to fluid bolus and inappropriate fluid administration worsens outcomes. 1, 3 A positive PLR test (improvement in blood pressure with leg elevation) predicts fluid responsiveness with 92% specificity in hypovolemic shock. 1

If PLR Test is Positive:

• Continue isotonic crystalloid resuscitation with repeated 250-500 mL boluses, reassessing hemodynamic response after each bolus 3
• Target mean arterial pressure (MAP) ≥65 mmHg during initial resuscitation 4

If PLR Test is Negative:

• Initiate vasopressor therapy with norepinephrine starting at 8-12 mcg/minute rather than additional fluids 3

Surgical Evaluation

If the patient remains hypotensive despite initial fluid resuscitation AND bedside ultrasound shows free intra-abdominal fluid, proceed directly to emergency surgery without waiting for CT imaging. 1 Hemodynamically unstable patients with evidence of intra-abdominal bleeding require immediate surgical intervention. 1

If the patient stabilizes with fluid resuscitation and is hemodynamically stable, obtain CT imaging of the abdomen and pelvis to definitively characterize the ovarian pathology and rule out other causes of abdominal pain. 1

Continuous Monitoring Requirements

Admit to a monitored setting with continuous vital sign monitoring including:

• Continuous ECG, blood pressure, and oxygen saturation monitoring for at least 24 hours 1
• Hourly urine output measurement (target >0.5 mL/kg/hour) 4
• Serial lactate measurements to assess treatment response 1
• Repeat hemoglobin/hematocrit every 4-6 hours if bleeding is suspected 1

Depo-Provera Relationship

While medroxyprogesterone acetate has been used to treat pelvic pain from venous congestion 5, the discontinuation of Depo-Provera itself does not directly cause hypotension. The temporal relationship suggests the hypotension and abdominal pain are related to the underlying ovarian cyst pathology (rupture, hemorrhage, or torsion) rather than medication withdrawal. 5

Critical Pitfalls to Avoid

• Do not rely on initial hematocrit as an isolated marker for bleeding, as it has low sensitivity for detecting acute hemorrhage requiring surgical intervention 1
• Do not delay surgical consultation in unstable patients to obtain CT imaging if bedside ultrasound shows free fluid 1
• Avoid reflexive fluid administration without PLR testing in non-hypovolemic patients, as this worsens outcomes 1, 3
• Do not administer hypotonic solutions like Ringer's lactate in hemorrhagic shock, as isotonic solutions distribute more evenly in the intravascular space 2