Pelvic Pain In PregnancyAPPROACH

WOMEN'S HEALTH, PREGNANCY, AND GU · 19 SECTIONS

⚲

554 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Vaginal Discharge Hyperemesis Gravidarum Concern Hypertensive Disorders Of Pregnancy Symptoms Postpartum Hemorrhage Concern Postpartum Infection Concern Sexual Assault Medical Evaluation Overview Pelvic Pain Vaginal Bleeding, Nonpregnant Vaginal Bleeding In Pregnancy Pelvic Pain In Pregnancy Post Procedure Or Post Abortion Complications Concern

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx78

Pregnancy context

›Pregnancy status and gestational age

›LMP and dating

›Prior ultrasound location and viability

›Assisted reproduction or fertility treatment

›Bleeding and obstetric symptoms

›Vaginal bleeding amount and timing

›Passage of tissue

›Leakage of fluid

›Contractions or tightening pattern

›Decreased fetal movement if viable gestation

›Ectopic risk history

›Prior ectopic pregnancy

›Tubal surgery or tubal ligation

›Pelvic inflammatory disease history

›IUD in situ or recent removal

›Assisted reproduction

Onset

›Onset characteristics

›Sudden

›Gradual

›After exertion

›After intercourse

Provocation/Palliation

›Triggers and relief

›Worse with movement

›Worse with urination

›Worse with defecation

›Worse with intercourse

›Relief with rest

Quality

›Pain quality

›Cramping

›Sharp

›Colicky

›Constant

Region/Radiation

›Location and radiation

›Unilateral adnexal

›Suprapubic midline

›Right lower quadrant

›Left lower quadrant

›Radiation to back or flank

›Radiation to shoulder tip

Severity

›Severity and trajectory

›Current severity

›Peak severity

›Worsening trend

›Functional limitation

Timing

›Timing pattern

›Intermittent

›Persistent

›Episodic waves

›Relation to meals

›Relation to urination

Associated symptoms

›GI symptoms

›Nausea

›Vomiting

›Anorexia

›Diarrhea

›Constipation

›GU symptoms

›Dysuria

›Frequency

›Hematuria

›Flank pain

›Systemic symptoms

›Fever

›Chills

›Syncope

›Dizziness

›Gyn symptoms

›Vaginal discharge

›Dyspareunia

›Cervical pain with intercourse

Prior episodes and baseline

›Similar prior pain episodes

›Prior ovarian cyst

›Prior torsion

›Prior renal colic

›Prior appendicitis evaluation

›Baseline function

›Baseline activity tolerance

›Baseline bowel and bladder pattern

02Alarm Features/alarm43

Hemodynamic and shock triggers

›Hemodynamic instability

›SBP less than 90 mmHg

›HR greater than 120

›Altered mental status

›Cool clammy skin

›Hemorrhage concern

›Syncope or presyncope

›Shoulder tip pain

›Rapidly increasing abdominal distension

Peritoneal and surgical abdomen

›Peritonitis

›Rebound tenderness

›Guarding

›Rigid abdomen

›Torsion concern

›Sudden severe unilateral pain

›Recurrent severe waves of pain

›Persistent vomiting

Infection and sepsis triggers

›Sepsis concern

›Temperature 38.0 C or higher

›Rigors

›Hypotension

›Lactate elevation

›Pyelonephritis concern

›Fever with flank pain

›CVA tenderness

Pregnancy specific emergencies

›Ectopic pregnancy rupture concern

›Positive pregnancy test without confirmed intrauterine pregnancy

›Severe abdominal pain with syncope

›Shoulder tip pain

›Placental abruption concern

›Third trimester pain with vaginal bleeding

›Uterine tenderness

›Hypertonic uterus

›Uterine rupture concern

›Prior uterine surgery with sudden pain

›Abnormal fetal heart rate pattern

Immediate escalation triggers

›Resuscitation bay criteria

›Persistent hypotension after fluids

›Ongoing heavy bleeding

›Concern for ruptured ectopic pregnancy

›Immediate specialty activation

›OB and anesthesia for unstable pregnant patient

›Surgery for peritonitis or suspected appendicitis with instability

03Medications/meds30

Current and recent medications

›Prescription medications

›Anticoagulants

›Antiplatelets

›Antihypertensives

›Antiepileptics

›OTC medications

›NSAIDs

›Acetaminophen

›Decongestants

›Supplements and herbals

›Prenatal vitamins

›Iron

›Herbal supplements

›Recent medication changes

›New antibiotics

›New hormones or fertility meds

Medication related risks

›Teratogenic exposure concern

›Retinoids

›ACE inhibitors

›Valproate

›Pain management constraints in pregnancy

›Avoid NSAIDs in third trimester

›Opioid risks and constipation

Contraindications to likely therapies

›Medication allergies

›Beta lactams

›Macrolides

›Opioids

›QT prolonging combinations

›Antiemetics plus other QT agents

›Electrolyte abnormalities

04Diet/diet13

Intake and hydration

›Recent oral intake

›Poor intake from nausea

›Vomiting frequency

›Ability to tolerate fluids

›Hydration indicators

›Decreased urine output

›Orthostasis

Exposures

›Caffeine and energy drinks

›Recent increase

›Palpitations association

›Foodborne illness exposures

›Undercooked food

›Sick contacts with GI illness

05Review of Systems/ros27

Constitutional and cardiopulmonary

›Constitutional

›Fever

›Chills

›Weight loss

›Cardiopulmonary

›Chest pain

›Dyspnea

›Palpitations

GI and GU

›Gastrointestinal

›Nausea

›Vomiting

›Diarrhea

›Constipation

›Genitourinary

›Dysuria

›Frequency

›Hematuria

›Flank pain

Neuro and pregnancy symptoms

›Neurologic

›Syncope

›Headache

›Focal deficits

›Pregnancy related

›Vaginal bleeding

›Leakage of fluid

›Contractions

›Decreased fetal movement if viable gestation

06Collateral History and Family History/chafh16

Collateral and reliability

›Collateral source

›Partner or family

›EMS

›Prior records

›Reliability

›Language barrier

›Altered mental status

Family history

›Thrombosis and clotting disorders

›VTE in first degree relative

›Known inherited thrombophilia

›Gynecologic conditions

›Endometriosis

›Ovarian cyst disease

›Genetic and obstetric history

›Recurrent pregnancy loss

›Congenital anomalies

07Risk Factors/rf23

Pregnancy and gynecologic risks

›Ectopic pregnancy risks

›Prior ectopic

›Tubal surgery

›PID history

›Assisted reproduction

›Ovarian torsion risks

›Ovarian mass or cyst

›Early pregnancy corpus luteum cyst

›Ovarian hyperstimulation

Infection risks

›UTI and pyelonephritis risks

›Prior recurrent UTI

›Diabetes mellitus (E11.9)

›Recent instrumentation

›STI risks

›New partner

›Prior chlamydia or gonorrhea

Thrombosis and vascular risks

›VTE risk in pregnancy

›Prior VTE (I82.90)

›Thrombophilia

›Prolonged immobility

›Vascular emergencies

›Known aneurysm

›Connective tissue disease

08Differential Diagnosis/ddx54

Life threatening

›Ectopic pregnancy (O00.90)

›Risk increased with prior ectopic or tubal disease

›Rupture concern with syncope or peritonitis

›Ovarian torsion (N83.5)

›Sudden severe unilateral pain

›Vomiting common

›Appendicitis (K35.80)

›RLQ pain may shift with gestational age

›Leukocytosis less specific in pregnancy

›Sepsis from pyelonephritis (O23.0)

›Fever with flank pain

›Risk of preterm labor

›Placental abruption (O45.90)

›Third trimester pain with bleeding

›Uterine tenderness or hypertonus

›Uterine rupture (O71.1)

›Prior cesarean or uterine surgery

›Fetal distress

›Hemorrhagic ovarian cyst (N83.20)

›Sudden pain with peritoneal signs possible

›Anticoagulation increases risk

Common

›Threatened miscarriage (O20.0)

›Cramping with vaginal bleeding

›Closed cervix on exam

›Round ligament pain (O26.89)

›Positional sharp groin pain

›No systemic illness

›UTI cystitis (O23.1)

›Dysuria and frequency

›Suprapubic discomfort

›Constipation and gas pain (K59.00)

›Reduced bowel movements

›Relief after stool or flatus

›Gastroenteritis (A09)

›Diarrhea and vomiting

›Sick contacts

Less common and mimics

›Nephrolithiasis (N20.0)

›Colicky flank to groin pain

›Hematuria may be absent

›Degenerating fibroid

›Localized uterine tenderness

›Fever can occur without infection

›Endometriosis flare

›Chronic pelvic pain history

›Dyspareunia history

›Cholecystitis (K81.0)

›RUQ pain with nausea

›Fever

›Pneumonia with referred pain (J18.9)

›Pleuritic symptoms

›Hypoxia

›Pulmonary embolism (I26.99)

›Dyspnea or pleuritic chest pain

›Syncope

09Past Medical History/pmh21

Obstetric and surgical history

›Prior pregnancies and outcomes

›Prior ectopic pregnancy

›Prior miscarriage

›Prior preterm birth

›Prior uterine surgery

›Cesarean delivery

›Myomectomy

›Dilation and curettage

Medical conditions

›Chronic diseases

›Hypertension (I10)

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›Hematologic conditions

›Sickle cell disease (D57.1)

›Thrombophilia

Prior procedures and devices

›Gynecologic procedures

›Tubal surgery

›IUD history

›Recent procedures

›Pelvic instrumentation

›Recent abdominal surgery

10Physical Exam/exam32

Vitals and general

›Vital signs pattern

›Fever

›Tachycardia

›Hypotension

›Tachypnea

›General appearance

›Toxic or ill appearing

›Pallor

›Diaphoresis

Abdominal and pelvic

›Abdominal exam

›Focal tenderness location

›Guarding

›Rebound

›Distension

›CVA tenderness

›Pelvic exam when indicated

›Speculum bleeding source

›Cervical os open or closed

›Cervical motion tenderness

›Adnexal tenderness or mass

Pregnancy assessment

›Uterine findings

›Fundal height approximation

›Uterine tenderness

›Fetal assessment if viable gestation

›Fetal heart rate

›Contraction pattern

Pitfalls and subtle findings

›Pregnancy physiologic changes

›Baseline mild tachycardia

›Leukocytosis in pregnancy

›Pain localization shifts with gestational age

›Appendix displacement

›Reduced peritoneal signs late pregnancy

11Lab Studies/labs27

Pregnancy and bleeding labs

›Pregnancy confirmation if status uncertain

›Urine pregnancy test

›Serum beta hCG

›Type and screen

›Transfusion planning if bleeding

›Rh status documentation

›CBC

›Hemoglobin trend

›Leukocytosis context

Infection and urinary labs

›Urinalysis

›Nitrites and leukocyte esterase

›Hematuria

›Urine culture

›Pyelonephritis concern

›Recurrent UTI history

›Blood cultures

›Fever and suspected sepsis

›Before antibiotics when feasible

Metabolic and other labs

›CMP

›Creatinine for imaging and dosing

›AST and ALT if RUQ pain

›Lactate

›Sepsis risk stratification

›Shock monitoring

›Lipase

›Epigastric pain with vomiting

›Pancreatitis mimic

12Imaging/img32

Scoring Systems

›Appendicitis risk tools in pregnancy

›Alvarado score limitations in pregnancy

›Use as adjunct only with imaging pathway

›Ectopic pregnancy risk stratification

›Pregnancy of unknown location framework

›Follow up and repeat testing pathway

MRI

›MRI abdomen pelvis without gadolinium

›Suspected appendicitis with nondiagnostic ultrasound

›Suspected adnexal pathology with unclear ultrasound

›MRI considerations in pregnancy

›Avoid gadolinium unless benefits outweigh risks

›Claustrophobia and positioning

›CT abdomen pelvis

›Use when MRI unavailable and urgent diagnosis needed

›High concern appendicitis or alternate surgical diagnosis

›CT pregnancy considerations

›Radiation risk discussion and documentation

›Minimize dose with protocol optimization

›Contrast use based on maternal benefit and renal function

Ultrasound

›Transvaginal ultrasound

›Intrauterine pregnancy confirmation

›Adnexal mass evaluation

›Free fluid assessment

›Transabdominal ultrasound

›Dating and viability

›Later pregnancy placenta location

›Ovarian torsion ultrasound with Doppler

›Enlarged ovary and peripheral follicles

›Doppler limitations with intermittent torsion

›Renal ultrasound

›Hydronephrosis

›Distinguish physiologic from obstructive when possible

13Special Tests/spec15

Bedside and pelvic testing

›Pelvic wet mount testing

›Trichomonas

›Bacterial vaginosis

›NAAT for STIs

›Chlamydia

›Gonorrhea

›Cervical evaluation

›Products of conception visible

›Cervical dilation

Fetal and uterine monitoring

›Fetal monitoring when viable gestation

›Continuous fetal heart rate tracing

›Contraction monitoring

›Tocolysis decision support

›Local protocol dependent thresholds

›Contraindications in infection or abruption concern

14ECG/ecg7

Indications and high risk patterns

›ECG indications in pelvic pain presentations

›Syncope or presyncope

›Significant tachycardia with unclear source

›High risk ECG findings

›Ischemic changes

›Tachyarrhythmia

›QT prolongation with antiemetic use

15Assessment/ax22

Problem representation and risk

›Pelvic pain in pregnancy working frame

›Gestational age category

›Hemodynamic stability

›Presence of vaginal bleeding

›Presence of fever

›Pregnancy location status

›Confirmed intrauterine pregnancy

›Pregnancy of unknown location

›Confirmed ectopic pregnancy

Severity and complications

›Severity stratification

›Stable with mild pain

›Stable with severe pain

›Unstable or shock

›Complications to rule out

›Ruptured ectopic pregnancy

›Torsion with threatened ovarian viability

›Appendiceal perforation

›Sepsis from pyelonephritis

Diagnostic uncertainty

›Alternative diagnoses

›Non obstetric surgical abdomen

›Urinary obstruction

›Gastrointestinal infection

16Plan/plan51

First 5 minutes critical pathway

›Immediate stabilization

›Cardiac monitor and pulse oximetry

›Two large bore IV lines if unstable or heavy bleeding

›Crystalloid bolus if hypotensive

›Massive transfusion protocol if exsanguinating hemorrhage local protocol dependent

›Immediate tests

›Point of care glucose if altered mental status

›Bedside ultrasound for free fluid if unstable

Analgesia and symptom control

›Analgesia

›Acetaminophen PO or IV

›PO 1000 mg once

›Maximum 3000 mg per day typical

›Opioid for severe pain

›Morphine IV 2 mg

›Repeat every 5 to 10 minutes to effect

›Avoid NSAIDs in third trimester

›Ductus arteriosus constriction risk

›Oligohydramnios risk

›Antiemetic

›Doxylamine pyridoxine if mild

›Local protocol dependent dosing

›Sedation caution

›Ondansetron if refractory

›QT risk

›Use lowest effective dose

Diagnostic sequencing

›Labs based on risk

›CBC and type and screen with bleeding or instability

›Urinalysis and culture with urinary symptoms or fever

›Imaging sequence

›Transvaginal ultrasound early pregnancy

›MRI without gadolinium for suspected appendicitis after nondiagnostic ultrasound

›CT only if urgent diagnosis needed and MRI unavailable

Condition specific treatments

›Rh immune globulin when indicated

›Rh negative with bleeding or pregnancy loss concern

›Dose by gestational age local protocol dependent

›Pyelonephritis treatment

›IV antibiotics

›Ceftriaxone IV 1 g daily

›Adjust per culture and local resistance

›Admission for IV therapy and monitoring

›STI and cervicitis treatment

›Pregnancy compatible regimens

›Partner treatment and public health reporting local protocol dependent

Consultation and reassessment loop

›Consult triggers

›OB for suspected ectopic pregnancy or pregnancy loss

›Surgery for suspected appendicitis or peritonitis

›Urology for obstructing stone with infection

›Reassessment loop

›Pain score and abdominal exam every 30 to 60 minutes in ED

›Repeat vitals every 15 minutes if unstable

›Repeat hemoglobin if ongoing bleeding or clinical deterioration

17Disposition/dispo23

ICU and inpatient criteria

›ICU criteria

›Ongoing vasopressor requirement

›Massive transfusion

›Severe sepsis with organ dysfunction

›Inpatient admission

›Suspected ectopic pregnancy requiring intervention

›Ovarian torsion

›Appendicitis

›Pyelonephritis

›Uncontrolled pain or vomiting

Observation pathway

›Observation appropriate

›Stable pregnancy of unknown location with reliable follow up

›Nondiagnostic imaging with improving symptoms

›Mild dehydration responsive to fluids

Discharge criteria and follow up

›Discharge criteria

›Hemodynamic stability

›Pain controlled with oral medications

›No peritonitis

›Clear follow up plan and reliability

›Follow up timing

›OB follow up within 24 to 48 hours for pregnancy of unknown location

›Repeat beta hCG timing per local protocol

›Return for repeat ultrasound per risk

18Discharge Instructions/di22

Copy discharge instructions

›You were evaluated for pelvic pain during pregnancy

›Your tests today did not show an emergency cause that requires admission right now

›Some pregnancy related problems can develop over time and need repeat testing

›Medicines

›Use acetaminophen as directed on the label

›Avoid NSAIDs unless your pregnancy care team tells you it is safe

›If you were given an opioid, do not drive and avoid alcohol

›Activity

›Rest as needed

›Avoid heavy lifting until you are feeling better

›Follow up

›Follow up with your obstetric clinician within 1 to 2 days

›If you were told you have pregnancy of unknown location, you need repeat blood work and possibly repeat ultrasound

›Return to the emergency department now for

›Fainting or severe dizziness

›Worsening abdominal pain

›New shoulder pain

›Heavy vaginal bleeding

›Fever

›Trouble breathing

›Persistent vomiting or inability to keep fluids down

›Decreased fetal movement if you are far enough along to feel movement

19References/r18

Guidelines and key sources

›ACOG, Ectopic Pregnancy Practice Bulletin, 2018

›Diagnostic framework for ectopic pregnancy

›Management options and follow up

›ACOG, Early Pregnancy Loss Practice Bulletin, 2018

›Threatened and early pregnancy loss pathways

›Rh immune globulin considerations

›ACOG, Urinary Tract Infections in Pregnant Individuals, Clinical Consensus, 2023

›Pyelonephritis admission and IV antibiotics

›Culture guided therapy

›ACR, Appropriateness Criteria, Acute Pelvic Pain in the Pregnant Patient, most recent version

›Ultrasound first imaging strategy

›MRI preferred after nondiagnostic ultrasound for appendicitis concern

›ACEP, Clinical Policy and emergency ultrasound guidance for early pregnancy evaluation, 2017 to 2020 era updates

›POCUS role in intrauterine pregnancy confirmation

›Limitations in ruling out ectopic pregnancy

›Project instructions

›Evidence based clinical reference generator rules

›Formatting and structure constraints

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Pelvic Pain In PregnancyAPPROACH

WOMEN'S HEALTH, PREGNANCY, AND GU · 19 SECTIONS

⚲

554 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx78

Pregnancy context

›Pregnancy status and gestational age

›LMP and dating

›Prior ultrasound location and viability

›Assisted reproduction or fertility treatment

›Bleeding and obstetric symptoms

›Vaginal bleeding amount and timing

›Passage of tissue

›Leakage of fluid

›Contractions or tightening pattern

›Decreased fetal movement if viable gestation

›Ectopic risk history

›Prior ectopic pregnancy

›Tubal surgery or tubal ligation

›Pelvic inflammatory disease history

›IUD in situ or recent removal

›Assisted reproduction

Onset

›Onset characteristics

›Sudden

›Gradual

›After exertion

›After intercourse

Provocation/Palliation

›Triggers and relief

›Worse with movement

›Worse with urination

›Worse with defecation

›Worse with intercourse

›Relief with rest

Quality

›Pain quality

›Cramping

›Sharp

›Colicky

›Constant

Region/Radiation

›Location and radiation

›Unilateral adnexal

›Suprapubic midline

›Right lower quadrant

›Left lower quadrant

›Radiation to back or flank

›Radiation to shoulder tip

Severity

›Severity and trajectory

›Current severity

›Peak severity

›Worsening trend

›Functional limitation

Timing

›Timing pattern

›Intermittent

›Persistent

›Episodic waves

›Relation to meals

›Relation to urination

Associated symptoms

›GI symptoms

›Nausea

›Vomiting

›Anorexia

›Diarrhea

›Constipation

›GU symptoms

›Dysuria

›Frequency

›Hematuria

›Flank pain

›Systemic symptoms

›Fever

›Chills

›Syncope

›Dizziness

›Gyn symptoms

›Vaginal discharge

›Dyspareunia

›Cervical pain with intercourse

Prior episodes and baseline

›Similar prior pain episodes

›Prior ovarian cyst

›Prior torsion

›Prior renal colic

›Prior appendicitis evaluation

›Baseline function

›Baseline activity tolerance

›Baseline bowel and bladder pattern

02Alarm Features/alarm43

Hemodynamic and shock triggers

›Hemodynamic instability

›SBP less than 90 mmHg

›HR greater than 120

›Altered mental status

›Cool clammy skin

›Hemorrhage concern

›Syncope or presyncope

›Shoulder tip pain

›Rapidly increasing abdominal distension

Peritoneal and surgical abdomen

›Peritonitis

›Rebound tenderness

›Guarding

›Rigid abdomen

›Torsion concern

›Sudden severe unilateral pain

›Recurrent severe waves of pain

›Persistent vomiting

Infection and sepsis triggers

›Sepsis concern

›Temperature 38.0 C or higher

›Rigors

›Hypotension

›Lactate elevation

›Pyelonephritis concern

›Fever with flank pain

›CVA tenderness

Pregnancy specific emergencies

›Ectopic pregnancy rupture concern

›Positive pregnancy test without confirmed intrauterine pregnancy

›Severe abdominal pain with syncope

›Shoulder tip pain

›Placental abruption concern

›Third trimester pain with vaginal bleeding

›Uterine tenderness

›Hypertonic uterus

›Uterine rupture concern

›Prior uterine surgery with sudden pain

›Abnormal fetal heart rate pattern

Immediate escalation triggers

›Resuscitation bay criteria

›Persistent hypotension after fluids

›Ongoing heavy bleeding

›Concern for ruptured ectopic pregnancy

›Immediate specialty activation

›OB and anesthesia for unstable pregnant patient

›Surgery for peritonitis or suspected appendicitis with instability

03Medications/meds30

Current and recent medications

›Prescription medications

›Anticoagulants

›Antiplatelets

›Antihypertensives

›Antiepileptics

›OTC medications

›NSAIDs

›Acetaminophen

›Decongestants

›Supplements and herbals

›Prenatal vitamins

›Iron

›Herbal supplements

›Recent medication changes

›New antibiotics

›New hormones or fertility meds

Medication related risks

›Teratogenic exposure concern

›Retinoids

›ACE inhibitors

›Valproate

›Pain management constraints in pregnancy

›Avoid NSAIDs in third trimester

›Opioid risks and constipation

Contraindications to likely therapies

›Medication allergies

›Beta lactams

›Macrolides

›Opioids

›QT prolonging combinations

›Antiemetics plus other QT agents

›Electrolyte abnormalities

04Diet/diet13

Intake and hydration

›Recent oral intake

›Poor intake from nausea

›Vomiting frequency

›Ability to tolerate fluids

›Hydration indicators

›Decreased urine output

›Orthostasis

Exposures

›Caffeine and energy drinks

›Recent increase

›Palpitations association

›Foodborne illness exposures

›Undercooked food

›Sick contacts with GI illness

05Review of Systems/ros27

Constitutional and cardiopulmonary

›Constitutional

›Fever

›Chills

›Weight loss

›Cardiopulmonary

›Chest pain

›Dyspnea

›Palpitations

GI and GU

›Gastrointestinal

›Nausea

›Vomiting

›Diarrhea

›Constipation

›Genitourinary

›Dysuria

›Frequency

›Hematuria

›Flank pain

Neuro and pregnancy symptoms

›Neurologic

›Syncope

›Headache

›Focal deficits

›Pregnancy related

›Vaginal bleeding

›Leakage of fluid

›Contractions

›Decreased fetal movement if viable gestation

06Collateral History and Family History/chafh16

Collateral and reliability

›Collateral source

›Partner or family

›EMS

›Prior records

›Reliability

›Language barrier

›Altered mental status

Family history

›Thrombosis and clotting disorders

›VTE in first degree relative

›Known inherited thrombophilia

›Gynecologic conditions

›Endometriosis

›Ovarian cyst disease

›Genetic and obstetric history

›Recurrent pregnancy loss

›Congenital anomalies

07Risk Factors/rf23

Pregnancy and gynecologic risks

›Ectopic pregnancy risks

›Prior ectopic

›Tubal surgery

›PID history

›Assisted reproduction

›Ovarian torsion risks

›Ovarian mass or cyst

›Early pregnancy corpus luteum cyst

›Ovarian hyperstimulation

Infection risks

›UTI and pyelonephritis risks

›Prior recurrent UTI

›Diabetes mellitus (E11.9)

›Recent instrumentation

›STI risks

›New partner

›Prior chlamydia or gonorrhea

Thrombosis and vascular risks

›VTE risk in pregnancy

›Prior VTE (I82.90)

›Thrombophilia

›Prolonged immobility

›Vascular emergencies

›Known aneurysm

›Connective tissue disease

08Differential Diagnosis/ddx54

Life threatening

›Ectopic pregnancy (O00.90)

›Risk increased with prior ectopic or tubal disease

›Rupture concern with syncope or peritonitis

›Ovarian torsion (N83.5)

›Sudden severe unilateral pain

›Vomiting common

›Appendicitis (K35.80)

›RLQ pain may shift with gestational age

›Leukocytosis less specific in pregnancy

›Sepsis from pyelonephritis (O23.0)

›Fever with flank pain

›Risk of preterm labor

›Placental abruption (O45.90)

›Third trimester pain with bleeding

›Uterine tenderness or hypertonus

›Uterine rupture (O71.1)

›Prior cesarean or uterine surgery

›Fetal distress

›Hemorrhagic ovarian cyst (N83.20)

›Sudden pain with peritoneal signs possible

›Anticoagulation increases risk

Common

›Threatened miscarriage (O20.0)

›Cramping with vaginal bleeding

›Closed cervix on exam

›Round ligament pain (O26.89)

›Positional sharp groin pain

›No systemic illness

›UTI cystitis (O23.1)

›Dysuria and frequency

›Suprapubic discomfort

›Constipation and gas pain (K59.00)

›Reduced bowel movements

›Relief after stool or flatus

›Gastroenteritis (A09)

›Diarrhea and vomiting

›Sick contacts

Less common and mimics

›Nephrolithiasis (N20.0)

›Colicky flank to groin pain

›Hematuria may be absent

›Degenerating fibroid

›Localized uterine tenderness

›Fever can occur without infection

›Endometriosis flare

›Chronic pelvic pain history

›Dyspareunia history

›Cholecystitis (K81.0)

›RUQ pain with nausea

›Fever

›Pneumonia with referred pain (J18.9)

›Pleuritic symptoms

›Hypoxia

›Pulmonary embolism (I26.99)

›Dyspnea or pleuritic chest pain

›Syncope

09Past Medical History/pmh21

Obstetric and surgical history

›Prior pregnancies and outcomes

›Prior ectopic pregnancy

›Prior miscarriage

›Prior preterm birth

›Prior uterine surgery

›Cesarean delivery

›Myomectomy

›Dilation and curettage

Medical conditions

›Chronic diseases

›Hypertension (I10)

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›Hematologic conditions

›Sickle cell disease (D57.1)

›Thrombophilia

Prior procedures and devices

›Gynecologic procedures

›Tubal surgery

›IUD history

›Recent procedures

›Pelvic instrumentation

›Recent abdominal surgery

10Physical Exam/exam32

Vitals and general

›Vital signs pattern

›Fever

›Tachycardia

›Hypotension

›Tachypnea

›General appearance

›Toxic or ill appearing

›Pallor

›Diaphoresis

Abdominal and pelvic

›Abdominal exam

›Focal tenderness location

›Guarding

›Rebound

›Distension

›CVA tenderness

›Pelvic exam when indicated

›Speculum bleeding source

›Cervical os open or closed

›Cervical motion tenderness

›Adnexal tenderness or mass

Pregnancy assessment

›Uterine findings

›Fundal height approximation

›Uterine tenderness

›Fetal assessment if viable gestation

›Fetal heart rate

›Contraction pattern

Pitfalls and subtle findings

›Pregnancy physiologic changes

›Baseline mild tachycardia

›Leukocytosis in pregnancy

›Pain localization shifts with gestational age

›Appendix displacement

›Reduced peritoneal signs late pregnancy

11Lab Studies/labs27

Pregnancy and bleeding labs

›Pregnancy confirmation if status uncertain

›Urine pregnancy test

›Serum beta hCG

›Type and screen

›Transfusion planning if bleeding

›Rh status documentation

›CBC

›Hemoglobin trend

›Leukocytosis context

Infection and urinary labs

›Urinalysis

›Nitrites and leukocyte esterase

›Hematuria

›Urine culture

›Pyelonephritis concern

›Recurrent UTI history

›Blood cultures

›Fever and suspected sepsis

›Before antibiotics when feasible

Metabolic and other labs

›CMP

›Creatinine for imaging and dosing

›AST and ALT if RUQ pain

›Lactate

›Sepsis risk stratification

›Shock monitoring

›Lipase

›Epigastric pain with vomiting

›Pancreatitis mimic

12Imaging/img32

Scoring Systems

›Appendicitis risk tools in pregnancy

›Alvarado score limitations in pregnancy

›Use as adjunct only with imaging pathway

›Ectopic pregnancy risk stratification

›Pregnancy of unknown location framework

›Follow up and repeat testing pathway

MRI

›MRI abdomen pelvis without gadolinium

›Suspected appendicitis with nondiagnostic ultrasound

›Suspected adnexal pathology with unclear ultrasound

›MRI considerations in pregnancy

›Avoid gadolinium unless benefits outweigh risks

›Claustrophobia and positioning

›CT abdomen pelvis

›Use when MRI unavailable and urgent diagnosis needed

›High concern appendicitis or alternate surgical diagnosis

›CT pregnancy considerations

›Radiation risk discussion and documentation

›Minimize dose with protocol optimization

›Contrast use based on maternal benefit and renal function

Ultrasound

›Transvaginal ultrasound

›Intrauterine pregnancy confirmation

›Adnexal mass evaluation

›Free fluid assessment

›Transabdominal ultrasound

›Dating and viability

›Later pregnancy placenta location

›Ovarian torsion ultrasound with Doppler

›Enlarged ovary and peripheral follicles

›Doppler limitations with intermittent torsion

›Renal ultrasound

›Hydronephrosis

›Distinguish physiologic from obstructive when possible

13Special Tests/spec15

Bedside and pelvic testing

›Pelvic wet mount testing

›Trichomonas

›Bacterial vaginosis

›NAAT for STIs

›Chlamydia

›Gonorrhea

›Cervical evaluation

›Products of conception visible

›Cervical dilation

Fetal and uterine monitoring

›Fetal monitoring when viable gestation

›Continuous fetal heart rate tracing

›Contraction monitoring

›Tocolysis decision support

›Local protocol dependent thresholds

›Contraindications in infection or abruption concern

14ECG/ecg7

Indications and high risk patterns

›ECG indications in pelvic pain presentations

›Syncope or presyncope

›Significant tachycardia with unclear source

›High risk ECG findings

›Ischemic changes

›Tachyarrhythmia

›QT prolongation with antiemetic use

15Assessment/ax22

Problem representation and risk

›Pelvic pain in pregnancy working frame

›Gestational age category

›Hemodynamic stability

›Presence of vaginal bleeding

›Presence of fever

›Pregnancy location status

›Confirmed intrauterine pregnancy

›Pregnancy of unknown location

›Confirmed ectopic pregnancy

Severity and complications

›Severity stratification

›Stable with mild pain

›Stable with severe pain

›Unstable or shock

›Complications to rule out

›Ruptured ectopic pregnancy

›Torsion with threatened ovarian viability

›Appendiceal perforation

›Sepsis from pyelonephritis

Diagnostic uncertainty

›Alternative diagnoses

›Non obstetric surgical abdomen

›Urinary obstruction

›Gastrointestinal infection

16Plan/plan51

First 5 minutes critical pathway

›Immediate stabilization

›Cardiac monitor and pulse oximetry

›Two large bore IV lines if unstable or heavy bleeding

›Crystalloid bolus if hypotensive

›Massive transfusion protocol if exsanguinating hemorrhage local protocol dependent

›Immediate tests

›Point of care glucose if altered mental status

›Bedside ultrasound for free fluid if unstable

Analgesia and symptom control

›Analgesia

›Acetaminophen PO or IV

›PO 1000 mg once

›Maximum 3000 mg per day typical

›Opioid for severe pain

›Morphine IV 2 mg

›Repeat every 5 to 10 minutes to effect

›Avoid NSAIDs in third trimester

›Ductus arteriosus constriction risk

›Oligohydramnios risk

›Antiemetic

›Doxylamine pyridoxine if mild

›Local protocol dependent dosing

›Sedation caution

›Ondansetron if refractory

›QT risk

›Use lowest effective dose

Diagnostic sequencing

›Labs based on risk

›CBC and type and screen with bleeding or instability

›Urinalysis and culture with urinary symptoms or fever

›Imaging sequence

›Transvaginal ultrasound early pregnancy

›MRI without gadolinium for suspected appendicitis after nondiagnostic ultrasound

›CT only if urgent diagnosis needed and MRI unavailable

Condition specific treatments

›Rh immune globulin when indicated

›Rh negative with bleeding or pregnancy loss concern

›Dose by gestational age local protocol dependent

›Pyelonephritis treatment

›IV antibiotics

›Ceftriaxone IV 1 g daily

›Adjust per culture and local resistance

›Admission for IV therapy and monitoring

›STI and cervicitis treatment

›Pregnancy compatible regimens

›Partner treatment and public health reporting local protocol dependent

Consultation and reassessment loop

›Consult triggers

›OB for suspected ectopic pregnancy or pregnancy loss

›Surgery for suspected appendicitis or peritonitis

›Urology for obstructing stone with infection

›Reassessment loop

›Pain score and abdominal exam every 30 to 60 minutes in ED

›Repeat vitals every 15 minutes if unstable

›Repeat hemoglobin if ongoing bleeding or clinical deterioration

17Disposition/dispo23

ICU and inpatient criteria

›ICU criteria

›Ongoing vasopressor requirement

›Massive transfusion

›Severe sepsis with organ dysfunction

›Inpatient admission

›Suspected ectopic pregnancy requiring intervention

›Ovarian torsion

›Appendicitis

›Pyelonephritis

›Uncontrolled pain or vomiting

Observation pathway

›Observation appropriate

›Stable pregnancy of unknown location with reliable follow up

›Nondiagnostic imaging with improving symptoms

›Mild dehydration responsive to fluids

Discharge criteria and follow up

›Discharge criteria

›Hemodynamic stability

›Pain controlled with oral medications

›No peritonitis

›Clear follow up plan and reliability

›Follow up timing

›OB follow up within 24 to 48 hours for pregnancy of unknown location

›Repeat beta hCG timing per local protocol

›Return for repeat ultrasound per risk

18Discharge Instructions/di22

Copy discharge instructions

›You were evaluated for pelvic pain during pregnancy

›Your tests today did not show an emergency cause that requires admission right now

›Some pregnancy related problems can develop over time and need repeat testing

›Medicines

›Use acetaminophen as directed on the label

›Avoid NSAIDs unless your pregnancy care team tells you it is safe

›If you were given an opioid, do not drive and avoid alcohol

›Activity

›Rest as needed

›Avoid heavy lifting until you are feeling better

›Follow up

›Follow up with your obstetric clinician within 1 to 2 days

›If you were told you have pregnancy of unknown location, you need repeat blood work and possibly repeat ultrasound

›Return to the emergency department now for

›Fainting or severe dizziness

›Worsening abdominal pain

›New shoulder pain

›Heavy vaginal bleeding

›Fever

›Trouble breathing

›Persistent vomiting or inability to keep fluids down

›Decreased fetal movement if you are far enough along to feel movement

19References/r18

Guidelines and key sources

›ACOG, Ectopic Pregnancy Practice Bulletin, 2018

›Diagnostic framework for ectopic pregnancy

›Management options and follow up

›ACOG, Early Pregnancy Loss Practice Bulletin, 2018

›Threatened and early pregnancy loss pathways

›Rh immune globulin considerations

›ACOG, Urinary Tract Infections in Pregnant Individuals, Clinical Consensus, 2023

›Pyelonephritis admission and IV antibiotics

›Culture guided therapy

›ACR, Appropriateness Criteria, Acute Pelvic Pain in the Pregnant Patient, most recent version

›Ultrasound first imaging strategy

›MRI preferred after nondiagnostic ultrasound for appendicitis concern

›ACEP, Clinical Policy and emergency ultrasound guidance for early pregnancy evaluation, 2017 to 2020 era updates

›POCUS role in intrauterine pregnancy confirmation

›Limitations in ruling out ectopic pregnancy

›Project instructions

›Evidence based clinical reference generator rules

›Formatting and structure constraints

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.