Identification and Management of Adolescent Gynecologic Emergencies in the Emergency Department
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Identification and Management of Adolescent Gynecologic Emergencies in the Emergency Department -

Publication Date: February 2019 (Volume 16, Number 2)

CME: This issue includes 4 AMA PRA Category 1 Credits™; 4 ACEP Category I credits; 4 AAP Prescribed credits; and 4 AOA Category 2-A or 2-B CME credits. Included as part of the 4 credits, this CME activity is eligible for 0.5 Infectious Disease, 0.5 Pharmacology, and 0.25 Sexual Assault CME credits, subject to your state and institutional approval. CME expires 02/01/2022. 


Tatyana Vayngortin, MD
Assistant Clinical Professor of Pediatrics, University of California San Diego School of Medicine, Rady Children's Hospital San Diego, San Diego, CA
Shruti Kant, MD, FAAP
Associate Professor of Emergency Medicine and Pediatrics, Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
Peer Reviewers
Geri Hewitt, MD
Chief, Obstetrics and Gynecology, Nationwide Children’s Hospital; Professor of Obstetrics/Gynecology and Pediatrics, The Ohio State University, Columbus, OH
Beth W. Rackow, MD
Associate Professor of Obstetrics & Gynecology and Pediatrics, Columbia University Medical Center, New York, NY

In the emergency department, gynecologic complaints are common presentations for adolescent girls, who may present with abdominal pain, pelvic pain, vaginal discharge, and vaginal bleeding. The differential diagnosis for these presentations is broad, and further complicated by psychosocial factors, confidentiality concerns, and the need to recognize abuse and sexual assault. This issue provides recommendations for the evaluation and management of obstetric and gynecologic emergencies including infectious, anatomic, and endocrine etiologies. Offering adolescents evidence-based guidance and treatment for sexually transmitted infection and avoiding unwanted pregnancy can help to mitigate the high-risk behavior that can affect their wellness and future fertility.

Excerpt From This Issue

A 15-year-old girl presents to the ED with vaginal bleeding that has persisted for 1 month. Over the last few days, she has had to change pads every hour. The patient says she feels fatigued and is unable to go to school. Her vital signs are: blood pressure, 110/70 mm Hg; heart rate, 110 beats/min; respiratory rate, 16 breaths/min; and oxygen saturation, 100% on room air. On examination, she appears pale and fatigued. She has a systolic flow murmur with clear lungs, and her abdomen is soft and nontender. What labs should you order? Are imaging studies warranted and, if so, which would be best? Does this patient need a transfusion? Should she be admitted or can she be treated as an outpatient?

You are then called to the resuscitation room for a 17-year-old girl who was found unresponsive at home. On examination, she is ill-appearing, lethargic, has cool distal extremities, normal heart sounds, and clear lungs, and her abdomen is soft but tender in the left lower quadrant. Her vital signs are: blood pressure, 80/40 mm Hg; heart rate, 130 beats/min; respiratory rate, 25 breaths/min; and oxygen saturation, 95% on room air. What are the immediate first steps in managing this patient? What testing is needed for evaluation and management? What is the appropriate disposition?

Product Reviews
- 09/06/2019
ED treatment of abnormal vaginal bleeding was highlighted by these questions and readings and will encourage me to intervene medically in the ED and stress the importance of OB/Gyn follow up to the patients and family.
- 09/05/2019
I will have the more aggressive evaluation of ovarian pathology.
- 09/04/2019
I will have more aggressive evaluation of ovarian pathology
- 09/03/2019
I will adhere to evidence based guidelines for prompt recognition and management.
- 09/02/2019
I will routinely consider STI testing in adolescent patients with urinary complaints
- 08/30/2019
I now have more comfortable dealing with adolescent issues in a hospital that may not have OB / GYN in the house.
- 08/29/2019
I can now anticipate disposition more quickly based on exam and pregnancy testing.
- 08/27/2019
I will be able to treat patients more effectively based on this article.
- 08/07/2019
I will consider using Azitho 1 gm q week x2 after reading this issue.
- 08/05/2019
I have a better understanding of how to manage adolescents with gynecological problems.
- 08/01/2019
I now have a higher index of suspicion for ob-Gyn etiologies in adolescent females presenting with abdominal pain.
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