Urgent considerations
See Differentials for more details
Ectopic pregnancy
Classic symptoms are abdominal pain, amenorrhea, 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 hemodynamic stability of the patient. Hemorrhage from a ruptured ectopic pregnancy rapidly leads to hypovolemic shock. As such, the management of these patients involves stabilization with emergency fluid resuscitation, blood transfusion as required, and immediate transfer to the operating suite for definitive control of the bleeding.
Laparoscopic salpingectomy is the standard surgical approach for the treatment of an ectopic pregnancy in a hemodynamically stable patient (even in the presence of hemoperitoneum). In hemodynamically unstable patients, the surgical approach will depend on the experience and judgment of the surgeon and will be decided on in consultation with the anesthesiologist. 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 stabilization and monitoring of the fetus and the mother. The goals are to prevent hypovolemia, anemia, and disseminated intravascular coagulopathy (DIC). Management includes:
Intravenous access with wide-bore intravascular catheters
CBC for evidence of anemia. Hematocrit (Hct) and hemoglobin (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 hemodynamic status (BP, pulse, volume intake, and urine output)
Continuous fetal monitoring
Rho(D) immune globulin in Rh-negative women
Fluid, blood, or blood product replacement, as indicated
Sonographic exam for placental location and for evidence of abruption. Placenta previa 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 prepubertal vaginal bleeding.
Sexualized behavior, depressive symptoms, aggression, sleep disturbance, regression, and frequent or persistent genitourinary complaints may indicate sexual abuse, although they are nonspecific 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 nonspecific 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 centers have been developed, with specially trained staff and facilities.
Use of this content is subject to our disclaimer