Urgent considerations
See Differentials for more details
Ectopic pregnancy
Classic symptoms are abdominal pain, amenorrhoea, and vaginal bleeding.
The management of ectopic pregnancy may be expectant, medical (methotrexate), or surgical depending on specific criteria. Relevant guidelines should be consulted.[25][45][46][47]
Red flags include unstable vital signs or acute abdomen.
If the ectopic pregnancy has ruptured, treatment is dependent on the haemodynamic stability of the patient. Haemorrhage from a ruptured ectopic pregnancy rapidly leads to hypovolaemic shock. As such, the management of these patients involves stabilisation with emergency fluid resuscitation, blood transfusion as required, and immediate transfer to the operating theatre for definitive control of the bleeding.
Laparoscopic salpingectomy is the standard surgical approach for the treatment of an ectopic pregnancy in a haemodynamically stable patient (even in the presence of haemoperitoneum). In haemodynamically unstable patients the surgical approach will depend on the experience and judgement of the surgeon and will be decided on in consultation with the anaesthetist. Laparotomy may be appropriate.
Placental abruption
Usually presents with bleeding, abdominal pain, and contractions in the second or third trimester of pregnancy. For all women with placental abruption, initial treatment should consist of stabilisation and monitoring of the fetus and the mother. The goals are to prevent hypovolaemia, anaemia, and disseminated intravascular coagulopathy (DIC). Management includes:
Intravenous access with wide-bore cannulae
FBC for evidence of anaemia. Haematocrit (Hct) and haemoglobin (Hb) levels may be low
Coagulation profile looking for evidence of impaired coagulation. Low fibrinogen levels and a prolonged PT are suggestive of impaired coagulation due to DIC
Monitoring of the patient's haemodynamic status (BP, pulse, volume intake, and urine output)
Continuous fetal monitoring
Anti-D immunoglobulin in Rh-negative women
Fluid, blood, or blood product replacement, as indicated
Sonographic examination for placental location and for evidence of abruption. Placenta praevia found on sonography makes placental abruption unlikely.
Subsequent treatment depends on the gestational age and on the condition of the mother and fetus.
Sexual abuse
The possibility of sexual abuse must be considered in any patient with pre-pubertal vaginal bleeding.
Sexualised behaviour, depressive symptoms, aggression, sleep disturbance, regression, and frequent or persistent genitourinary complaints may indicate sexual abuse, although they are non-specific and the strength of association with child abuse is not quantified. Children and adolescents may present with somatic complaints such as headaches or recurrent abdominal pain.[48][49] Examination is normal or non-specific in most children who have been sexually abused.[50][51]
The child should be interviewed alone if possible and asked open ended questions in a neutral voice.[52]
If sexual abuse is suspected, follow local protocols for reporting suspected sexual abuse. In many countries specific sexual assault centres have been developed, with specially trained staff and facilities.
Use of this content is subject to our disclaimer