Abdominal Pain in Females of Childbearing Years
Management of the potentially pregnant female with abdominal pain can be broken down into simple steps.
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Objectives
- Describe the anatomy of the female abdominal and pelvic cavities.
- Describe the components of an effective physical exam of the abdomen and pelvis in the female patient.
- List causes of abdominal pain and relate them to specific body systems.
- Discuss the prehospital management of the patient with abdominal pain.
Squad 54 has been dispatched to Curtis Hall for a complaint of abdominal pain. As the crew arrives on scene, they are directed to a 19-year-old female lying in bed, clutching her abdomen and complaining of pain. As Michael, the EMT crew chief, begins his assessment, he notes that she is able to talk, indicating that both her airway and breathing are adequate. Her skin is pink and her extremities are warm and dry, indicating that for the moment she has adequate circulation. Michael asks her what is wrong, and she says she is having pain in her lower stomach. Before continuing this scenario, let’s consider abdominal pain in the childbearing-age female.
Epidemiology
Abdominal pain is an extremely common complaint in the emergency setting, accounting for up to 10% of all emergency department visits.1 Although abdominal pain frequently occurs, it can be a frustrating chief complaint, as it is a rather non-specific problem that may not even directly represent the disease process actually affecting the patient. Because of their more complex anatomy, females of reproductive age require special consideration when they present with abdominal discomfort. A survey of women of reproductive age reported that 39% of this group experience non-menstrual pelvic pain yearly, which may manifest as abdominal pain.2 Every year in the United States, 5.8% of every 1,000 women presenting to an ED receive a diagnosis of pelvic inflammatory disease, and 1.1% of 1,000 women are diagnosed with an ectopic pregnancy.3 These are both serious conditions carrying significant morbidity. Ectopic pregnancies also have a significant mortality.
Anatomy
The abdominal cavity is the largest internal cavity in the body (Table 1). Its complexity lies not only within its many structures, but also with its interaction of the nerves that innervate them. There are three distinct pathways in the abdomen that transmit pain: visceral, somatic and referred. Nociceptors sense and transmit pain sensation, which is described as either visceral or somatic. Visceral is pain sensed from the actual internal organs and their autonomic innervation that may be the earliest manifestation of pain. This pain is often a response to stretching or inflammation and is responsible for referred pain due to many organ nerve plexi and pathways crossing. Somatic pain receptors lie within both the skin and internal tissues and are able to pick up sensations related to temperature, swelling and vibration. Somatic pain is usually more focalized and may present as sharp pain, where visceral pain, sometimes called peritoneal pain, is more generalized, dull and achy. Referred pain, on the other hand, occurs away from the injured organ and is a result of the brain’s inability to determine where the pain in a particular area is coming from. While the absolute reason for referred pain is uncertain and debated, it is thought to be a function of how the nerves develop in the fetal period along with crossed connections as they synapse.
