A 26-year-old female with no PMH presented to our ED with severe left-sided lower abdominal pain. The pain began about 30 minutes after sexual intercourse. The pain was initially very severe and then began to lessen as time went on. She denied vaginal discharge, vaginal bleeding, dysuria, flank pain, fever, vomiting, and diarrhea. She had no history of sexually transmitted infections.


Initial VS: BP 97/72, HR 63, T 36.8 °C (98.2 °F), RR 16, SpO2 99% on RA


Physical exam revealed tenderness in the left lower quadrant with voluntary guarding. Speculum exam was performed, and there was no vaginal bleeding or abnormal discharge present. Cervical motion tenderness and left adnexal tenderness were noted.


Ectopic pregnancy, ovarian torsion, ruptured cyst, and PID were all in the differential.


UA was normal. UPT was negative.


Bedside transvaginal ultrasound was performed. Here is the initial view of the uterus.

This uterus is retroverted. See how the uterus comes in from the left side of the screen and then points downward. An anteverted uterus will come in from the right side of the screen and go straight across the screen. Also notice that there is a small amount of free fluid on the right upper side of the screen near the cervix.


After visualizing the uterus, the right adnexa (unaffected side) was examined. Here is her right ovary.

You can see that the ovary appears normal in size. There are no large cysts present.


This ovary was also assessed for venous and arterial flow with pulsed-wave Doppler. See below.PWD arterial right


PWD venous right

There are normal arterial and venous waveforms present.


Her left ovary was then visualized. The sonographer noted that there was marked tenderness when the transducer touched the patients left ovary.

Her ovary looks normal in size. This finding made torsion less likely because small or normal sized ovaries are much less likely to twist on themselves. The sonographer did note that it appeared like there was clotted blood surrounding the ovary.


Doppler flow was then assessed. Here is the color Doppler flow:

You can see that flow is present, but this does not rule out torsion. Arterial flow may still be present in torsion so the sonographer wanted to assess for both venous and arterial flow.


PWD left arterial


PWD venous left

You can see that both arterial and venous waveforms were present. This also made torsion less likely the cause of the pain. Given that there was free fluid seen on a few different views with marked tenderness over the left ovary, the team felt that ruptured cyst was likely. The team performed a FAST exam. Here are the views that were obtained from the pelvis:




You can see that in all the views there is free fluid with clot surrounding the uterus as well.


Here is a RUQ view:

There is a small amount of fluid seen at the tip of the kidney. These findings were diagnostic of hemoperitoneum thought to be secondary to a ruptured cyst.


CBC revealed hemoglobin of 8.0. Her baseline hemoglobin was 9.8.


A repeat RUQ view was obtained toward the end of her ED course. See below:

You can see that the fluid has now increased.


Gynecology was consulted, and she was admitted to their service for serial hemoglobin checks and abdominal exams. Her hemoglobin fell to 7.2 and then stabilized. Her vital signs remained normal the entire time she was in the hospital. She did well and was discharged on hospital day 2.


Bottom Line: 

1. Torsion is less likely in an ovary that is normal in size (<5 cm).

2. The two most common gynecologic causes of hemoperitoneum are ectopic pregnancy and ruptured cyst.



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