Identification and Management of Adolescent Gynecologic Emergencies in the Emergency Department

Points and Pearls Excerpt

• Maintain a high suspicion for obstetric or gynecologic causes of abdominal pain in adolescent girls. Give special consideration to ectopic pregnancy, ovarian torsion, and pelvic inflammatory disease (PID).
• Obtain a thorough sexual history in adolescent girls presenting with abdominal pain or genitourinary complaints. Ask the patient if she is sexually active, when her last sexual activity occurred, whether it was consensual, if she has male and/ or female partners, if she is using condoms or other forms of contraception, if she has had a sexually transmitted infection (STI) or has been tested before, and if she has ever been pregnant.
• The following symptoms should raise concern for a bleeding disorder: bleeding longer than 7 days, soaking 1 pad or tampon every hour, passing clots larger than 1 inch in diameter, and soaking through clothing or onto bedding.
• Indications for pelvic examination include lower abdominal/pelvic pain or urinary symptoms in a sexually active girl or pelvic pain in the setting of irregular bleeding, dyspareunia, and vaginal discharge.

Most Important References

• Brunham RC, Gottlieb SL, Paavonen J. Pelvic inflammatory disease. N Engl J Med. 2015;372(21):2039-2048. (Review article) 
• Brown J, Fleming R, Aristzabel J, et al. Does pelvic exam in the emergency department add useful information? West J Emerg Med. 2011;12(2):208-212. (Prospective study; 183 patients)
• Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy? The rational clinical examination systematic review. JAMA. 2013;309(16):1722-1729. (Systematic review; 14 studies, 12,101 patients)
• Wilkinson C, Sanderson A. Adnexal torsion -- a multimodality imaging review. Clin Radiol. 2012;67(5):476-483. (Review article)
• Crawford-Jakubiak JE, Alderman EM, Leventhal JM, et al. Care of the adolescent after an acute sexual assault. Pediatrics. 2017;139(3). (Review article)