Abdominal pain in an adult
In any woman of childbearing age with abdominal pain, think of pregnancy first. A ruptured ectopic pregnancy can bleed into the abdomen before she knows she is pregnant, and the first sign may be fainting. The decision that saves her is made at the health centre: recognise shock, start fluids and send her to an operating theatre.
- Setting: Rural health centre with no theatre, 90 minutes by road from the district hospital
- For clinical officers, nurses and doctors at first-level facilities
- Reviewed October 2026
The presentation
Mariam, 24, felt sudden pain low in her abdomen while at the market this morning. She fainted and was brought in by a neighbour. She has had light spotting for 2 days. She is pale and lying very still.
| Vital sign | Value |
|---|---|
| Pulse | 118 per minute, weak |
| Blood pressure | 90/58 mmHg |
| Breathing rate | 24 per minute |
| Temperature | 36.9 °C |
| Capillary refill | 3 seconds, hands cool |
| Conscious level (AVPU) | Alert, anxious |
Tests at hand: Urine pregnancy test · Haemoglobin (Hb) · Urine dipstick · Blood glucose (finger-prick) · Malaria rapid diagnostic test (RDT)
- Ruptured ectopic pregnancy Must not missStill possible
- Miscarriage or complicated (septic) abortion Must not missStill possible
- Other surgical abdomen (perforation, obstruction) Must not missStill possible
- AppendicitisStill possible
- Pelvic inflammatory diseaseStill possible
- Ovarian cyst: rupture or torsionStill possible
- Kidney infectionStill possible
- MalariaLess likely
Work through it
Read each question and decide your own answer first. Then open the model answer and see how the differential changes.
- Step 1 of 7 · Look
Start with ABCDE. Is Mariam in shock, and what do you do in the first five minutes?
Model answer
A pulse of 110 or more with a systolic BP below 90 is how WHO defines shock in a woman of reproductive age. Mariam's pulse is 118, her BP is 90/58, her hands are cool and she is breathing fast. Treat her as shocked now, and expect her to get worse.
- Shout for help. Lie her flat with the legs raised; keep her warm.
- Put in two large-bore IV cannulas. Take blood for haemoglobin and cross-match before the fluids run.
- Give normal saline or Ringer's lactate fast: 1 litre in 15 to 20 minutes, then reassess pulse, BP and breathing.
- Nothing to eat or drink: she may need an operation.
- Check glucose if she becomes confused.
Think ectopicShock with abdominal pain in a woman who might be pregnant is a ruptured ectopic pregnancy until proved otherwise. Do not wait for a test result to start fluids or arrange transfer.Differential now- Ruptured ectopic pregnancy Must not missLeading (moved up)
- Miscarriage or complicated (septic) abortion Must not missStill possible
- Other surgical abdomen (perforation, obstruction) Must not missStill possible
- AppendicitisStill possible
- Pelvic inflammatory diseaseStill possible
- Ovarian cyst: rupture or torsionStill possible
- Kidney infectionStill possible
- MalariaSet aside for now (moved down)
- Step 2 of 7 · Ask
While the fluids run, what do you ask? Which answers point to which cause?
Model answer
- Last menstrual period, and is she sexually active? A period more than a month late suggests pregnancy.
- Vaginal bleeding: how much (a pad soaked in under 5 minutes is heavy), clots, anything passed.
- Where the pain started, and pain in the shoulder tip (blood under the diaphragm).
- Fever, foul vaginal discharge, or anything done to end a pregnancy (septic or unsafe abortion).
- Vomiting, distension, no stool or wind (obstruction); pain that began around the navel and moved to the right (appendicitis).
- Burning urine and loin pain (kidney infection).
- Previous ectopic pregnancy, pelvic infection, tubal surgery, or an IUD.
Her last period was 7 weeks ago. The spotting is light and dark. The pain started on the left and is now across the lower abdomen, and her right shoulder hurts when she lies down. No fever, no discharge, nothing taken or done to end a pregnancy. Bowels opened yesterday. She was treated for a pelvic infection 2 years ago.
Differential now- Ruptured ectopic pregnancy Must not missLeading
- Other surgical abdomen (perforation, obstruction) Must not missStill possible
- Ovarian cyst: rupture or torsionStill possible
- Miscarriage or complicated (septic) abortion Must not missLess likely (moved down)
- AppendicitisLess likely (moved down)
- Pelvic inflammatory diseaseLess likely (moved down)
- Kidney infectionLess likely (moved down)
- MalariaSet aside for now
- Step 3 of 7 · Test
Which bedside tests help now, and how far can you trust them?
Model answer
- Urine pregnancy test: positive confirms she is pregnant. A negative test does not completely exclude an ectopic pregnancy, so the clinical picture still decides.
- Haemoglobin from the cannula sample: a baseline for the hospital. Early in acute bleeding the Hb can still look nearly normal.
- Urine dipstick: nitrites and white cells would support a urinary source, but they do not explain shock with a positive pregnancy test.
- Glucose only if her conscious level falls. A malaria RDT does not help here: she has no fever.
Results: pregnancy test positive. Hb 8.9 g/dL. Urine: no nitrites, no leucocytes.
Differential now- Ruptured ectopic pregnancy Must not missLeading
- Other surgical abdomen (perforation, obstruction) Must not missStill possible
- Miscarriage or complicated (septic) abortion Must not missLess likely
- AppendicitisLess likely
- Pelvic inflammatory diseaseLess likely
- Ovarian cyst: rupture or torsionLess likely (moved down)
- Kidney infectionSet aside for now (moved down)
- MalariaSet aside for now
- Step 4 of 7 · Look
What do you look for on examining the abdomen and pelvis, and what must you be careful about?
Model answer
- Distension, and shifting dullness: free blood in the abdomen.
- Tenderness, guarding and rebound: peritoneal irritation, a sign of a surgical abdomen.
- Bowel sounds: absent in peritonitis or obstruction.
- Speculum: amount of bleeding, whether the cervix is open, tissue in the os.
- If you are trained to do a bimanual examination, do it gently: an ectopic pregnancy ruptures easily. Cervical motion tenderness and a tender mass to one side support ectopic pregnancy. Do not let the examination delay transfer.
The abdomen is slightly distended and tender across the lower half, worst on the left, with guarding and rebound. Bowel sounds are quiet. A little dark blood at a closed cervix. Gentle bimanual examination: marked cervical motion tenderness.
Differential now- Ruptured ectopic pregnancy Must not missLeading
- Other surgical abdomen (perforation, obstruction) Must not missLess likely (moved down)
- AppendicitisLess likely
- Ovarian cyst: rupture or torsionLess likely
- Miscarriage or complicated (septic) abortion Must not missSet aside for now (moved down)
- Pelvic inflammatory diseaseSet aside for now (moved down)
- Kidney infectionSet aside for now
- MalariaSet aside for now
- Step 5 of 7 · Do
What is the working diagnosis, and what does she need that you cannot give?
Model answer
Ruptured ectopic pregnancy: 7 weeks without a period, positive pregnancy test, light bleeding, acute lower abdominal pain, shoulder-tip pain, peritoneal signs, a fast weak pulse and low BP. This matches the WHO description of rupture: collapse, a pulse of 110 or more, hypotension, acute abdominal and pelvic pain, distension and pallor.
The treatment is an immediate laparotomy, with blood. WHO advises not waiting for blood before surgery. Your job is to keep her alive until she reaches a theatre: this is an immediate referral.
After the first litre: pulse 108, BP 96/62. Fluids buy time; they do not stop the bleeding.
Differential now- Ruptured ectopic pregnancy Must not missLeading
- AppendicitisLess likely
- Miscarriage or complicated (septic) abortion Must not missSet aside for now
- Other surgical abdomen (perforation, obstruction) Must not missSet aside for now (moved down)
- Pelvic inflammatory diseaseSet aside for now
- Ovarian cyst: rupture or torsionSet aside for now (moved down)
- Kidney infectionSet aside for now
- MalariaSet aside for now
- Step 6 of 7 · Do
How do you organise the transfer so that she arrives alive?
Model answer
- Phone or send word ahead so the hospital prepares theatre and blood. Ask relatives to go too.
- Keep both IV lines running and continue fluids, reassessing pulse, BP and breathing after each litre; slow them if she becomes breathless.
- A health worker travels with her and checks pulse, BP and conscious level every 15 minutes, lying flat and kept warm.
- Handover note: last period, pregnancy test result, Hb, vital signs over time, fluids given with times.
- If the vehicle is delayed, keep reassessing and giving fluids; do not send her home or to wait in a queue.
You are pregnant, but the pregnancy is growing outside the womb and it is bleeding inside your belly. You need an operation at the hospital now. We are going with you.
- Step 7 of 7 · Ask
What will she need after the operation, and what do you tell her when she returns?
Model answer
- Treatment of anaemia: WHO advises ferrous sulfate or ferrous fumarate 60 mg by mouth daily for three months.
- A follow-up visit at about four weeks.
- Counselling about future fertility; the risk of another ectopic pregnancy is higher, so she should come early in any future pregnancy.
- Family planning if she wishes, started before discharge.
- Emotional support: loss of a pregnancy can bring grief and low mood.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Ruptured ectopic pregnancy | Woman of childbearing age, missed period or not sure, abdominal pain, light bleeding, fainting, shoulder-tip pain, pulse 110 or more, low BP, distended tender abdomen. | Two IV lines, take blood first, 1 litre fast and reassess, nothing by mouth; immediate transfer for laparotomy and blood. |
| Complicated or septic abortion | Bleeding with fever, foul discharge, tender uterus, open cervix, or an unsafe procedure. | IV fluids, first doses of IV/IM antibiotics, refer urgently for evacuation of the uterus. |
| Surgical abdomen (perforation, obstruction, appendicitis) | Severe pain not relieved by analgesia, guarding and rebound, distension, absent bowel sounds, vomiting, no stool or wind. | Nothing by mouth, IV fluids, analgesia, refer the same day or now if shocked. |
| Shock from any cause | Fast weak pulse, low BP, cold hands, capillary refill over 3 seconds, fast breathing, confusion. | ABCDE; IV fluids; treat the cause; transfer. |
Decision at first-level care
Mariam has a ruptured ectopic pregnancy with early shock: 7 weeks' amenorrhoea, positive pregnancy test, peritoneal signs, pulse 118 and BP 90/58. She is resuscitated with IV fluids through two lines and transferred immediately, accompanied, for laparotomy and blood transfusion.
Source: WHO Managing complications in pregnancy and childbirth (2017); WHO and ICRC Basic emergency care (2018); IMAI district clinician manual, volume 2 (2011).
- Mild pain with burning urine and a positive dipstick, not pregnant, no fever or loin pain: treat as cystitis.
- Upper abdominal burning pain related to food, no danger sign, not pregnant: treat as dyspepsia and review.
- Light bleeding with mild cramps in early pregnancy, closed cervix, stable vital signs and no tenderness to one side (threatened miscarriage): review, with clear return advice, and refer if bleeding persists or pain develops.
- Non-specific pain with normal vital signs and a soft abdomen: review within hours, or the next day.
- Shock, or a positive pregnancy test with abdominal pain and tenderness to one side: now.
- Peritoneal signs, distension, or vomiting with no stool or wind: now.
- Fever with tender uterus or foul discharge after a miscarriage or abortion: after first antibiotic doses, now.
- Pain not relieved by analgesics, or increasing on review.
Key learning points
- In every woman of childbearing age with abdominal pain, ask about the last period and do a pregnancy test.
- A pulse of 110 or more with systolic BP below 90 is shock: start fluids through two large lines, taking blood first.
- A ruptured ectopic pregnancy needs a theatre; fluids at the health centre only buy time.
- Examine gently: an unruptured ectopic pregnancy is easily ruptured by a rough bimanual examination.
- A suspected surgical abdomen means nothing by mouth and early referral.
Sources
- World Health Organization. Managing complications in pregnancy and childbirth: a guide for midwives and doctors, 2nd edition. 2017. Shock (pulse 110 or more, systolic below 90; 1 L in 15 to 20 minutes; blood before fluids); vaginal bleeding in early pregnancy, Table S-1; ectopic pregnancy signs, Table S-7; gentle bimanual examination; immediate laparotomy without waiting for blood; iron 60 mg daily for 3 months; follow-up at 4 weeks; complications of abortion, Table S-2.
- World Health Organization and International Committee of the Red Cross. Basic emergency care: approach to the acutely ill and injured. Participant workbook. 2018 (ISBN 9789241513081). Module 4, shock: severe abdominal pain as a sign of bleeding; ectopic pregnancy in any woman of childbearing age; IV fluids and referral for transfusion and obstetric care.
- World Health Organization. IMAI district clinician manual: hospital care for adolescents and adults, volume 2. 2011. Section 10.7a, abdominal pain: surgical abdomen signs, nothing by mouth, pregnancy test for all; ectopic pregnancy (pregnancy test may be negative).
- World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd edition. 2015. Heavy bleeding: pad or cloth soaked in under 5 minutes.