Pediatric emergency medicine trisk 2117 2117
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many as 83% of patients meeting these criteria may experience spontaneous
abortion and resorption.
Although less common, those presenting with an acutely ruptured ectopic
pregnancy have an immediate life-threatening condition and providers should
maintain a high index of suspicion for this in any patient presenting with vaginal
bleeding and moderate to severe abdominal pain. These patients usually have a
history of abnormal vaginal bleeding and intermittent pelvic pain. On physical
examination, vital signs may reflect compensated or uncompensated shock, the
abdomen is tender, the uterus is tender and may be slightly enlarged, and an
adnexal mass may or may not be palpated after rupture has occurred. These
patients require immediate subspecialty consultation with either gynecology or
pediatric surgery, depending on the care setting. They should have continuous
vital sign monitoring, fluid resuscitation with normal saline, and packed red blood
cells as needed. Serial hemoglobin determination, coagulation profile, Rh
screening, and type and cross are important components of the laboratory
evaluation. Emergency surgical evaluation is the treatment of choice. Ultrasound
is contraindicated in the unstable patient and may delay surgical intervention.
However, a FAST ultrasound may be used to quickly assess for intraperitoneal
hemorrhage.
Finally, the possibility that sexual abuse may exist in teens concerned about
pregnancy and/or diagnosed with pregnancy in the ED needs to be considered and
explored. Healthcare providers are mandated to report significant concern for
sexual abuse in all patients younger than 18 years of age. It is also important to
assess safety issues and screen these teens for depression, substance abuse, and
suicide risk. Usually, a multidisciplinary approach is required to ensure that the
patient is safe, as well as able to obtain appropriate counseling and medical
follow-up.
Delivery. Patients presenting to the ED in active labor should be transferred to the
obstetrical unit as soon as possible. However, even in a PED, patients may
present when the newborn is crowning, making transfer impossible. Fortunately,
the majority of deliveries occur spontaneously, and the primary role of the
clinician is to control the process. However, a subspecialist should be called to the
ED to deliver the newborn whenever possible.
EMERGENCY CONTRACEPTION
The pregnancy rate in the United States is one of the highest, worldwide among
15- to 19-year-olds. Most of these pregnancies are unintended and pose a
significant burden leading to many negative social and economic consequences.
