Pediatric emergency medicine trisk 2153 2153

of polycystic ovarian syndrome include hirsutism, acne, obesity, and acanthosis
nigricans (an indication of insulin resistance). The clinician may choose to
perform a speculum examination to note for the presence of bleeding from the
cervical os, an incomplete abortion, cervicitis, a retained foreign body, and to rule
out anomalies of the lower genital tract. A bimanual examination may be
performed to assess for uterine tenderness and adnexal masses. If necessary,
rectoabdominal palpation can be substituted for the standard vaginal bimanual
examination.
A complete blood count should be ordered to assess the hemoglobin,
hematocrit, and platelet count. Iron studies should be considered. A reticulocyte
count may be helpful as an indicator of bone marrow response to the blood loss.
Screen sexually active adolescents with a pregnancy test as well as a vaginal
swab or urine collection for a NAAT for N. gonorrhoeae and C. trachomatis. Be
aware that many adolescents may not be forthcoming about their sexual history;
routine pregnancy testing can aid in narrowing the differential diagnosis.
Coagulation disorders—such as von Willebrand disease, thrombocytopenia, or
platelet dysfunction—should be considered in adolescents who present with
heavy bleeding at menarche or who bleed heavily with each menses. Coagulation
studies to send in addition to a complete blood count include prothrombin time,
partial thromboplastin time, fibrinogen, and a von Willebrand panel—consisting
of von Willebrand factor (antigen), von Willebrand multimers, ristocetin cofactor
activity, factor VIII activity, and fibrinogen. The von Willebrand panel should be
drawn prior to the administration or 7 days after discontinuing any hormonal
medications, particularly those containing estrogen, as the estrogen may raise the
von Willebrand factor into normal range. Bleeding may also be related to liver
disease (which affects production of coagulation factors), or use of medications,
such as anticoagulants or platelet inhibitors. TSH should also be sent, as
hyperthyroidism and hypothyroidism may cause menstrual irregularities. An
evaluation for polycystic ovarian syndrome may include laboratory studies for
FSH, LH, DHEAS, free and total testosterone, androstenedione, though these
results will not be available to the emergency physician, but will likely be useful

to the patient’s outpatient provider. If there are concerns for a prolactinoma,
including signs of visual field deficits, a prolactin level may be sent. Adolescents
with androgenic signs and clitoromegaly may be evaluated for congenital adrenal
hyperplasia by sending 17-hydroxyprogesterone.

Management
For patients with brisk hemorrhage or hemodynamic instability, hospitalization
and prompt volume resuscitation are necessary as well as possible blood