Pediatric emergency medicine trisk 390

Classification

HgB level

Estrogen option

Mild

>/ = 12
mg/dL

No hormone replacement indicated
Close follow-up and monitoring of cycle
calendar
30–35 μg ethinyl Norethindrone 0.35 mg
estradiol with
daily
0.3 mg of an
androgenic
progestin
(norgestrel or
levonorgestrel)
1 pill daily for 6
mo
OCP taper:
Medroxyprogesterone
acetate 10 mg every 6
1 pill every 6 hrs
hrs until bleeding
for 4 days
stops, then begin

1 pill every 8 hrs
taper:
for 3 days
1 pill twice daily 4 times daily for 4 days
3 times daily for 3 days
for 2 days
Twice daily for 2 days
1 pill daily
1 pill daily
(Do not take
placebo pills
-ORduring taper ) Norethindrone 5–10 mg
daily until bleeding
stops then use taper.
High doses of
norethindrone will
peripherally convert
into ethinyl estradiol
50 μg ethinyl
Medroxyprogesterone
estradiol with
acetate
0.5 mg
10 mg every 4–6 hrs
norgestrel
until bleeding stops
every 6 hrs
followed by taper
-OR-

Moderate with NO 10–12
active bleeding
mg/dL

Moderate with
active bleeding

Severe and
<10 mg/dL
hemodynamically
stable

Progesterone option


Severe and
hemodynamically
unstable

30–35 μg ethinyl
estradiol with
0.3 mg
norgestrel
every 4 hrs
until bleeding
stops followed
by taper
Conjugated
estrogen 25 mg
IV every 4–6

hrs for 24 hrs
followed by
OCP taper


FIGURE 79.4 Diagnostic approach to abnormal uterine bleeding after menarche—pregnant
patients. β-hCG, β-human chorionic gonadotropin.

The urine pregnancy test usually detects at β-hCG levels of ≥20 mIU/mL and
will permit the detection of a normal pregnancy within about 10 days of
conception. Serum β-hCG can be detected at lower levels (range of 1–2
mIU/mL). Ectopic pregnancies often produce abnormally low levels of β-hCG
compared to an intrauterine pregnancy of the same gestational age (see Chapter
119 Genitourinary Emergencies ). If the β-hCG is positive or if there is clinical
suspicion of pregnancy, a pelvic ultrasound should be performed to evaluate
whether the pregnancy is intrauterine or ectopic. Early intrauterine pregnancies
and ectopic pregnancies are best visualized by transvaginal ultrasound, though the
clinician may want to perform a speculum examination to assess if the cervical os


is open before obtaining a transvaginal ultrasound. Obstetrical evaluation is
frequently necessary for any adolescent with bleeding during pregnancy.

Bleeding During Early Pregnancy
Among adults in the first trimester of pregnancy presenting to an ED with
abdominal pain or vaginal bleeding, approximately 60% have normal
pregnancies, 30% have nonviable intrauterine pregnancies, and 10% have ectopic
pregnancies. In a pregnant patient with abdominal pain or vaginal bleeding in the
first trimester, symptoms that favor an intrauterine pregnancy (rather than
ectopic) include mild pain, pain located in the midline, and uterine size greater

than 8 weeks. On examination, the diagnosis of incomplete spontaneous abortion
is straightforward if the internal cervical os is open or tissue fragments are visible.
A normal intrauterine pregnancy should be visible on transabdominal
ultrasound when the β-hCG level reaches about 6,000 mIU per mL at the sixth or
seventh gestational week (4 to 5 weeks after conception) and should be visible on
transvaginal ultrasound when the level reaches between 1,000 and 2,000 mIU per
mL at approximately the fifth week of gestation (3 weeks after conception).
Visibility on the ultrasound is also operator dependent. It should be remembered
that β-hCG levels for any given gestational age are higher in twin pregnancies.
Failure to visualize a gestational sac on transvaginal ultrasound in a patient
whose β-hCG level exceeds 3,000 mIU per mL strongly suggests a nonviable
pregnancy. Among patients with vaginal bleeding, no intrauterine gestational sac
on transvaginal sonography, and a β-hCG level of 2,000 mIU per mL or higher,
about 40% will miscarry, about 55% will have ectopic pregnancies, and roughly
5% will have normal intrauterine pregnancies. The likelihood of ectopic
pregnancy is increased in symptomatic patients whose β-hCG levels are less than
1,500 mIU per mL. Spontaneous abortion includes threatened, incomplete,
complete, septic, and missed abortions. During a threatened abortion, the patient
has experienced vaginal bleeding but the cervical os remains closed. In the case
of a threatened abortion, the pregnancy may still be viable and requires close
follow-up by an obstetrician. Incomplete, complete, and missed abortions occur
when a spontaneous miscarriage is occurring or has already occurred. The
obstetrician or emergency physician may need to complete the evacuation of the
products of conception in the case of an incomplete abortion. During management
for spontaneous abortion, the patient will need close follow-up with an
obstetrician and may require admission to the hospital. In a normal pregnancy,
between days 5 and 42 after conception and above an initial level of 100 mIU per
mL, the β-hCG level doubles approximately every 2 days. A decline in β-hCG