{"id":3763,"date":"2024-05-29T19:01:00","date_gmt":"2024-05-29T19:01:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=3763"},"modified":"2025-10-01T11:39:35","modified_gmt":"2025-10-01T19:39:35","slug":"usmle-step-2-question-of-the-day-pelvic-pain","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Pelvic pain"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Learn about a USMLE Step 2 question involving a 28-year-old woman with a ruptured ectopic pregnancy, presenting with severe pelvic pain, hypotension, and a positive hCG. Understand the significance of emergent laparoscopy to control bleeding and remove damaged tissue.<br><\/em><\/strong><br>A 28-year-old woman comes to the emergency department for evaluation of right-sided pelvic pain for the last week and light vaginal spotting. Today, the pain became severe, and the patient subsequently developed lightheadedness. The patient has not had a fever or vomiting. She had pelvic inflammatory disease two years ago and is currently sexually active with one biologically male partner. Her periods are irregular, and she reports that her last normal menstrual cycle was three months ago. Temperature is 37.0\u00b0C (98.6\u00b0F), pulse is 132\/min, respiratory rate is 22\/min, blood pressure is 88\/62 mmHg, and oxygen saturation is 98% on room air. On examination, the patient appears pale and in pain. There is diffuse abdominal tenderness with rebound tenderness and guarding. Serum hCG is 3,900 IU\/L. Ultrasound shows evidence of an adnexal mass and free fluid in the pelvis. There is no intrauterine pregnancy visualized. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Which of the following is the <em>best <\/em>next step in management?\u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.&nbsp;Laparoscopy<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B.&nbsp;Methotrexate&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;&nbsp;Local feticidal injection&nbsp;<br><\/strong><br><strong>D.&nbsp;Salpingostomy<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E.&nbsp;Hysterectomy&nbsp;&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Scroll down for the correct answer!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.\u00a0Laparoscopy<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B.&nbsp;<\/strong><strong>Methotrexate<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>&nbsp;Methotrexate can be used in a small subset of patients with ectopic pregnancy who meet the following criteria: hemodynamic stability, no suspicion of impending or active tubal rupture, low and declining serum hCG levels, no fetal cardiac activity, capability of close follow up, and no contraindications to methotrexate therapy. This patient is hemodynamically unstable with signs of a tubal rupture and is therefore not a candidate for methotrexate therapy.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Local feticidal injection<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Feticidal injection is occasionally used to manage an unruptured ectopic pregnancy when there is a concurrent intrauterine pregnancy which is being preserved. This patient is unstable with a likely ruptured ectopic pregnancy requiring emergent surgery.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D.&nbsp;Salpingostomy&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Salpingostomy involves incising the fallopian tube and removing the tubal pregnancy while leaving the remaining tube intact. Salpingostomy is an option for patients with an unruptured ectopic pregnancy. This patient has evidence of tubal rupture.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E.&nbsp;Hysterectomy&nbsp;&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>A hysterectomy is not routinely indicated for patients with a ruptured ectopic pregnancy.&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" height=\"569\" width=\"1024\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_3ab135.png?w=1024\" alt=\"hCG POSITIVE\nUS\n1. Absence of intrauterine pregnancy.\n2. Free fluid or adnexal mass --&gt; Considered ruptured ectopic pregnancy --&gt; Operative laproscopy --&gt; Ruptured ectopic pregnancy\nAn image of an ultrasound showing all three factors is included.\" class=\"wp-image-3765\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_3ab135.png 1774w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_3ab135.png?resize=300,167 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_3ab135.png?resize=768,427 768w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_3ab135.png?resize=1024,569 1024w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_3ab135.png?resize=1536,854 1536w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents with severe pelvic pain, hypotension, and a positive hCG&nbsp;without the presence of an intrauterine pregnancy&nbsp;on ultrasound. These findings, along with free fluid in the pelvis, suggest a&nbsp;ruptured ectopic pregnancy.&nbsp;Emergent laparoscopy&nbsp;is indicated to control the bleeding and remove the damaged tissue. The patient\u2019s preceding symptoms of unilateral pelvic pain and vaginal bleeding were likely symptoms of the ectopic pregnancy prior to rupture. Previous&nbsp;pelvic inflammatory disease&nbsp;is a&nbsp;risk factor for ectopic pregnancy.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The first step in assessing patients with&nbsp;acute pelvic pain&nbsp;is to establish stability. Findings of&nbsp;hypotension&nbsp;and&nbsp;tachycardia&nbsp;are concerning for&nbsp;internal bleeding&nbsp;from an etiology such as a ruptured ectopic pregnancy.&nbsp;Ectopic pregnancy&nbsp;represents one of the true gynecologic emergencies that can cause acute pelvic pain in a biological female. It occurs when an embryo implants outside of the uterine cavity, usually in the&nbsp;fallopian tube. As the fetus grows, the fallopian tube is unable to accommodate the growing fetus, leading to rupture. Patients typically present with significant abdominal and pelvic pain,&nbsp;syncope or lightheadedness, with or without recent&nbsp;vaginal bleeding. In the presence of rupture, the abdominal exam typically shows rebound tenderness and guarding.&nbsp;Emergent surgery is the only option for management after rupture occurs; however, less invasive treatment with&nbsp;methotrexate&nbsp;may be considered if the ectopic pregnancy is found prior to rupture in select circumstances.&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" height=\"555\" width=\"1024\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_6c0c0b.png?w=1024\" alt=\"illustration of the difference between intrauterine pregnancy and ectopic pregnancy, showing the embryo implanted normally on the left, and ectopically on the right.\" class=\"wp-image-3766\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_6c0c0b.png 1958w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_6c0c0b.png?resize=300,163 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_6c0c0b.png?resize=768,417 768w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_6c0c0b.png?resize=1024,555 1024w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/image_6c0c0b.png?resize=1536,833 1536w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Acute management of a patient with a ruptured ectopic pregnancy consists of stabilizing the patient and emergent laparoscopy.&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Mullany K, Minneci M, Monjazeb R, C Coiado O. Overview of ectopic pregnancy diagnosis, management, and innovation. Womens Health (Lond). 2023 Jan-Dec;19:17455057231160349. doi: 10.1177\/17455057231160349. PMID: 36999281; PMCID: PMC10071153.\u00a0<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/www.osmosis.org\/create\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/02\/Blog_Display_Ads_GENERAL2_2023.png\" alt=\"\" class=\"wp-image-5441\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/02\/Blog_Display_Ads_GENERAL2_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/02\/Blog_Display_Ads_GENERAL2_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more \u00a0USMLE\u00ae Step 2 CK practice questions?\u00a0Try Osmosis by Elsevier today! Access your\u00a0<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>\u00a0and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Learn about a USMLE Step 2 question involving a 28-year-old woman with a ruptured ectopic pregnancy, presenting with severe pelvic pain, hypotension, and a positive hCG. Understand the significance of emergent laparoscopy to control bleeding and remove damaged tissue.A 28-year-old woman comes to the emergency department for evaluation of right-sided pelvic pain for the last [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":3764,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,1370,45],"tags":[],"class_list":["post-3763","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-step-2-questions","category-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Pelvic pain - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Pelvic pain - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Learn about a USMLE Step 2 question involving a 28-year-old woman with a ruptured ectopic pregnancy, presenting with severe pelvic pain, hypotension, and a positive hCG. Understand the significance of emergent laparoscopy to control bleeding and remove damaged tissue.A 28-year-old woman comes to the emergency department for evaluation of right-sided pelvic pain for the last [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain\" \/>\n<meta property=\"og:site_name\" content=\"Osmosis Blog\" \/>\n<meta property=\"article:published_time\" content=\"2024-05-29T19:01:00+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2025-10-01T19:39:35+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/2024-09-19T130157.707.webp\" \/>\n\t<meta property=\"og:image:width\" content=\"1080\" \/>\n\t<meta property=\"og:image:height\" content=\"1080\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/webp\" \/>\n<meta name=\"author\" content=\"Marina Horiates Kerekes, MD &amp; Team\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":[\"Article\",\"BlogPosting\"],\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain#article\",\"isPartOf\":{\"@id\":\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-pelvic-pain\"},\"author\":{\"name\":\"Marina Horiates Kerekes, MD &amp; 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