Pediatric emergency medicine trisk 2115 2115
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In the ED, it is imperative to recognize those patients who are immediately at
risk for life-threatening complications and require acute resuscitation and
emergent evaluation by a surgical subspecialist. Pregnant patients who present
with vaginal bleeding (with or without abdominal pain) represent a high-risk
group. First-trimester vaginal bleeding occurs in 20% to 25% of patients.
Common etiologies include ectopic pregnancy, spontaneous and incomplete
abortion, missed or threatened abortion, sexually transmitted infections, and
trauma.
The initial laboratory workup should include a complete blood count, both to
assess the amount of blood loss and to provide a baseline if bleeding continues. A
urinalysis can detect the presence of white blood cells, bacteria, glucose, or
protein. If unknown, Rh determination is indicated if there is vaginal bleeding and
those who are Rh-negative should receive Rh immunoglobulin.
Ectopic pregnancy is the leading cause of maternal mortality in the United
States during the first half of pregnancy; therefore, timely recognition and
treatment is imperative. The prevalence of ectopic pregnancy among women
presenting to an ED with first-trimester bleeding and/or pain ranges from 6% to
16%. Although the overall incidence of ectopic pregnancy in teenagers is low,
this group has the highest mortality rate, largely due to a tendency to delay
seeking care. Risk factors for ectopic pregnancy include prior ectopic pregnancy,
tubal abnormalities, prior genital tract infection, and assisted reproduction. The
diagnosis of ectopic pregnancy must be considered in any patient with vaginal
bleeding and/or abdominal pain. Patients can present with a wide spectrum of
symptoms, including abnormal vaginal bleeding; intermittent crampy, lower
abdominal pain; or acute abdominal pain associated with shock (with or without
vaginal blood loss). Fortunately, most patients with ectopic pregnancy present
before rupture has occurred.
Spontaneous abortion is another cause of vaginal bleeding in the pregnant
teenager, which can be septic, threatened (or missed), inevitable, or complete.
Spontaneous miscarriage is very common in early pregnancy; up to one-half of all
fertilized ova that implant into the endometrium are lost. Most spontaneous
abortions occur during the first trimester, although a small number occur after 20
weeks’ gestation. Vaginal bleeding can indicate threatened abortion, when the
patient’s external cervical os is closed, or an inevitable abortion, when the
external os is open. If products of conception are found in the vaginal vault of a
patient with an inevitable abortion and the cervix is closed, the abortion is most
likely complete; however, an ultrasound is helpful for confirming that no products
are retained in the uterus.
