Pediatric emergency medicine trisk 389

Chapter 92 Gynecology Emergencies . Every sexually active patient with
abnormal vaginal bleeding should be screened for N. gonorrhoeae and C.
trachomatis genital tract infections. Cervicitis or pelvic inflammatory disease
may also be caused by Mycoplasma genitalium or Ureaplasma urealyticum,
though commercial testing for these pathogens is not widely available. Bleeding
genital warts should not be treated with topical podophyllin because toxic
amounts of the resin can be absorbed systemically (see Chapter 92 Gynecology
Emergencies ). Referral to a specialist is recommended.
Trauma
The evaluation and management of victims of sexual assault are discussed in
detail in Chapter 127 Sexual Assault: Child and Adolescent . Hymenal tears
produced by coitus rarely require treatment beyond reassurance. More significant
trauma may occur necessitating a careful physical examination. Retained foreign
body such as a tampon or condom can cause vaginal bleeding. Evaluation via
bimanual examination, speculum examination, or ultrasound may be helpful.
Hematologic
Hematologic causes of AUB are relatively rare. The most common hematologic
cause of excessive menstrual bleeding is thrombocytopenia caused by idiopathic
thrombocytopenic purpura, hematologic malignancy, or chemotherapeutic agents.
Clotting factor disorders produce heavy bleeding much less frequently than does
thrombocytopenia, but von Willebrand disease should be considered in the
differential diagnosis, especially when heavy bleeding has been present since
menarche.

Treatment Options
The treatment for adolescents with AUB depends on the underlying cause and the
severity of the bleeding. AUB is categorized as mild, moderate, or severe based
on the measured hemoglobin level. Mild bleeding (hemoglobin >12 mg/dL) can
be managed by close monitoring via a menstrual calendar and careful follow-up.
The treatment goals of more moderate (hemoglobin 10 to 12 mg/dL) or severe
(hemoglobin <10 mg/dL) AUB is to stop the bleeding and correct any anemia.

The mainstay of therapy is monophasic combined hormone oral contraceptive pill
(OCP) if there are no contraindications to estrogen therapy (see Table 79.3 ).
Treatment regimens containing estrogen tend to stop bleeding more quickly and
with higher reliability, however progesterone-only regimens can be very effective
and should be used when estrogen is contraindicated. Consider hospitalization for
adolescents with severe, ongoing blood loss, orthostatic hypotension or other


symptoms of anemia, and/or hemoglobin less than 8 g per dL (see Table 79.4 for
detailed treatment guidelines at all severity and stability levels). Antiemetics are
recommended for patients receiving OCPs more than once daily due to associated
nausea with the estrogen-containing medications. All patients with anemia should
receive iron replacement, typically ferrous sulfate 325 mg orally three times daily
and a stool softener should be considered.
TABLE 79.3
CONTRAINDICATIONS TO ESTROGEN THERAPY
Migraine with aura
Acute VTE or history of VTE
Inherited prothrombotic disorders
Lupus with positive or unknown antiphospholipid antibodies
Hypertension (SBP >160 mm Hg or DBP >100 mm Hg)
Current and history of certain heart conditions
Certain liver diseases
Postpartum (<21 days)
Stroke
Current diagnosis of breast cancer
For a complete list of contraindications see the CDC’s US Medical Eligibility Criteria for Contraceptive Use.

.

BLEEDING IN THE PREGNANT PATIENT
The emergency physician should consider complications of pregnancy in any
adolescent that presents with vaginal bleeding ( Fig. 79.4 ). A β-hCG test should
be performed in all adolescent females with vaginal bleeding. A pregnancy test
should be obtained even if the patient with an episode of abnormal bleeding has
had regular menstrual periods because approximately 25% of patients with
ectopic pregnancies do not report having missed a menstrual period, and
recollection of menstrual history dates are often not reliable. The emergency
physician should obtain the social history from the patient in a confidential
setting, separate from the parent. There is often a hesitancy to share sexual
activity with a healthcare provider in the emergency setting due to fear of
disclosure to her parent. The patient also may not be forthcoming with the
information if she has been a victim of sexual abuse or sexual violence.


Adolescents tend to present to a healthcare provider with concerns of pregnancy
much later than women in their 20s and 30s. In addition to the above disclosure
concerns, an adolescent may be less knowledgeable about recognizing early signs
of pregnancy such as nausea, breast tenderness, or fatigue. Menstrual cycles are
often irregular among adolescents, so the patient may not notice a missed period.


TABLE 79.4
TREATMENT GUIDELINES FOR THE ADOLESCENT WITH
ABNORMAL UTERINE BLEEDING