Identification and Management of Adolescent Gynecologic Emergencies in the Emergency Department

Table of Contents

 

The differential diagnosis for adolescent gynecologic complaints can be broad, and these cases are often 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. You will learn:

Obstetric and gynecologic causes of abdominal pain, pelvic pain, and abnormal uterine bleeding, including anatomic, infectious, and endocrine etiologies

Key aspects of history-taking for adolescent patients with gynecologic emergencies

When an external genitourinary examination or a pelvic examination is warranted

When a single hCG test is sufficient, and when serial testing is necessary

Recommendations for when laboratory screening (eg, a coagulation panel, endocrine workup, nucleic acid amplification testing, or urinalysis) and imaging studies are needed

Appropriate management for adolescent patients with an ectopic pregnancy, abnormal uterine bleeding, a Bartholin cyst or abscess, adnexal torsion, or an ovarian cyst or mass

Recommendations for management of adolescent patients with a sexually transmitted disease or pelvic inflammatory disease, as well as those who have experienced trauma or are a survivor of sexual assault

General guidelines regarding confidentiality issues associated with adolescent sexual health services

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
6. Epidemiology
7. Differential Diagnosis
   1. Obstetric and Gynecologic Causes of Abdominal and Pelvic Pain
      1. Obstetric Causes of Abdominal Pain, Pelvic Pain, and Vaginal Bleeding
         • Ectopic Pregnancy
         • Molar Pregnancy
         • Benign Vaginal Bleeding in Pregnancy
         • Spontaneous Abortion
         • Septic Abortion
      2. Gynecologic Causes of Abdominal and Pelvic Pain
         • Adnexal Torsion
         • Adnexal Cyst/Mass
         • Anatomic Abnormalities
         • Bartholin Gland Cyst/Abscess
         • Infections
         • Endocrine Etiologies
         • Foreign Body
   2. Abnormal Uterine Bleeding
      1. Endocrine Etiologies
      2. Bleeding Disorders
      3. Medications
      4. Systemic Disease
      5. Masses
      6. Trauma
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. External Genitourinary Examination
      2. Pelvic Examination
10. Diagnostic Studies
    1. Laboratory Testing
       1. Pregnancy
       2. Abnormal Uterine Bleeding
       3. Sexually Transmitted Infections
    2. Imaging Studies
       1. Ultrasound
          • Obstetric Ultrasound
          • Gynecologic Ultrasound
       2. Computed Tomography
       3. Magnetic Resonance Imaging
11. Treatment
    1. Pregnancy
    2. Abnormal Uterine Bleeding
    3. Bartholin Cyst or Abscess
    4. Adnexal Torsion
    5. Ovarian Cyst or Mass
    6. Sexually Transmitted Infection and Pelvic Inflammatory Disease
       1. Treatment of Sexually Transmitted Infections
       2. Treatment of Pelvic Inflammatory Disease
    7. Trauma
    8. Sexual Assault
       1. Reporting and Forensic Examination
       2. Treatment and Testing After Sexual Assault
12. Special Circumstances
    1. Consent and Confidentiality
    2. Patients With Special Healthcare Needs
13. Controversies and Cutting Edge
14. Disposition
15. Summary
16. Risk Management Pitfalls in the Management of Adolescent Patients With Gynecological Emergencies
17. Time- and Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway for Emergency Department Management of Abnormal Uterine Bleeding in Adolescent Patients
20. Tables and Figures
    1. Table 1. Differential Diagnosis of Obstetric/Gynecologic-Related Abdominal and Pelvic Pain
    2. Table 2. Differential Diagnosis of Abnormal Uterine Bleeding
    3. Table 3. Treatment of Sexually Transmitted Infection and Pelvic Inflammatory Disease
    4. Table 4. Prophylaxis After Sexual Assault
    5. Figure 1. Obstetric Point-of-Care Ultrasound
    6. Figure 2. Molar Pregnancy on Ultrasound
    7. Figure 3. Ovarian Torsion on Ultrasound
    8. Figure 4. Bartholin Gland Cyst or Abscess Incision and Drainage
21. References

Abstract

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.

Case Presentations

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?

Later in your shift, a 16-year-old girl presents to the ED with abdominal pain and vaginal discharge. She tells you that she recently started having sexual intercourse with her boyfriend and does not want her mother to know. On examination, she is well-appearing and has tenderness to the lower abdomen. Her vital signs are: blood pressure, 120/80 mm Hg; heart rate, 70 beats/min; respiratory rate, 15 breaths/min; and oxygen saturation, 100% on room air. What labs should you send for this patient? Should you treat her empirically with antibiotics? If you decide to treat her, what antibiotic regimen should you give? What is the law regarding confidentiality for this patient and how should you counsel her?

Introduction

Adolescent patients comprise approximately 15% of all emergency department (ED) visits, accounting for nearly 15 million ED visits annually.^1,2 Teenagers who seek care in the ED tend to engage in high-risk behaviors, including risky sexual activity and substance use; they may also have mental health issues, which can place them at higher risk for health issues, comorbidities, and high-risk behaviors.² Pregnant adolescents account for an estimated 1% to 5% of pediatric ED visits, and this number is on the rise.³ Teens are less likely to seek care due to concerns about confidentiality, scheduling, transportation, cost, and embarrassment.⁴ When they do seek care, they are more likely to present to the ED than to a primary care provider. To better serve this high-risk population, it is important for emergency clinicians to be knowledgeable about adolescent reproductive health needs.

In an interview study of emergency physicians and nurses, the following barriers to providing gynecologic and obstetric healthcare to teens were described: parental presence, difficulty building rapport in the ED setting, lack of knowledge about long-term contraception, lack of knowledge about confidentiality laws, and differences in language, gender, and religious or cultural beliefs.⁵ Additionally, clinicians can have knowledge gaps and discomfort in managing adolescent health.^6,7 For example, Balamuth et al surveyed pediatric emergency clinicians and found an overall low level of knowledge about pelvic inflammatory disease (PID).⁸ One study of pediatric residents found that only 63% reported that teen pregnancy was adequately covered during residency.⁷ Many pediatric EDs are staffed largely by clinicians who have had minimal training in obstetrics.

This issue of Pediatric Emergency Medicine Practice reviews the gynecologic etiologies of abdominal/pelvic pain and vaginal bleeding, as well as first-trimester obstetric etiologies and complications in adolescent patients. The evaluation and management of these medical and surgical emergencies are discussed, along with the psychosocial and confidentiality issues pertaining to adolescents. For more information on the ED evaluation and management of common genital emergencies in girls, see the October 2018 issue of Pediatric Emergency Medicine Practice, “Diagnosing and Managing Common Genital Emergencies in Pediatric Girls.”

Critical Appraisal of the Literature

A literature search was performed in PubMed and the Cochrane Database of Systematic Reviews for articles and studies from 1992 to 2017 using the following search terms: adolescent pregnancy, vaginal bleeding, pediatric emergency department, ectopic pregnancy, pelvic inflammatory disease, adolescent gynecologic emergencies, pelvic pain, sexual assault, ovarian torsion, and confidentiality. The reference lists of the articles found were reviewed for additional relevant publications, and 76 articles were chosen for inclusion. The majority of the articles are review articles, in addition to retrospective and prospective studies.

Unfortunately, there is a dearth of emergency medicine clinical practice guidelines focusing on adolescent care. The guidelines cited in this issue are based on adult studies, but the recommendations can be extrapolated safely to adolescents as well. These include the United States Centers for Disease Control and Prevention (CDC) Sexually Transmitted Disease (STD) treatment guidelines⁹ and clinical practice guidelines on ectopic pregnancy.¹⁰

Risk Management Pitfalls in the Management of Adolescent Patients With Gynecological Emergencies

1. “The patient said she had never had sex before, so I didn’t do a pregnancy test.”

Adolescents often do not disclose sexual activity, due to concerns about confidentiality. Emergency clinicians should have a low threshold for pregnancy and STI testing in adolescent girls, regardless of the history provided by the patient.

5. “The girl came in with vaginal discharge after intercourse with a partner reporting an STI, so I tested her for gonorrhea and chlamydia. I told her to call back in 2 days for results.”

Studies have shown that adolescents have poor follow-up and can be difficult to contact after presentation to the ED. If there is clinical concern for an STI, treat empirically for both gonorrhea and chlamydia in the ED; do not wait for test results.

9. “I found out the patient was pregnant, so I updated her mom about my plan to transfer her to a hospital with obstetric services.”

Clinicians are prohibited by law from disclosing pregnancy to parents/guardians without the patient’s consent, unless there is concern that the patient will harm herself or someone else. Adolescents aged > 12 years can seek sexual health services for contraception, pregnancy care, STI treatment, and sexual assault care, as well as mental health and substance use services without parental consent. Laws vary by state, so emergency clinicians should be familiar with confidentiality regulations where they practice

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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