levels on serial measurement or an increase of less than 66% in 48 hours suggests a nonviable fetus Septic abortion may complicate an intrauterine infection from a spontaneous abortion or from an induced abortion The patient may have signs of fever, severe pelvic pain, and leukocytosis Retained products of conception may still be present and will require surgical evacuation Broad-spectrum parenteral antibiotics should be initiated to cover for gram-positive and gram-negative bacteria Infections may also occur from polymicrobial organisms, anaerobic bacteria, and fungi Consultation with a specialist is imperative Bleeding During an Ectopic Pregnancy An ectopic pregnancy is a pregnancy that is not intrauterine Nearly all ectopic pregnancies occur in the fallopian tubes Adolescents who have had pelvic inflammatory disease, tubal surgeries, or previous ectopic pregnancies are at risk of having ectopic pregnancy, though many patients with ectopic pregnancy will present with no risk factors Sharp pain, lateralized pain, and pain of moderate to severe intensity favor ectopic pregnancy Examination findings that favor ectopic pregnancy include cervical motion tenderness, lateral pelvic tenderness, and signs of peritoneal irritation β-hCG levels may be low compared to an intrauterine pregnancy of the same gestational age If an intrauterine pregnancy is not seen on ultrasound, a transvaginal ultrasound should be performed to look for an ectopic pregnancy Sonographic signs suggestive of ectopic pregnancy include a solid or complex adnexal mass, a pelvic mass, particulate fluid in the fallopian tube, an endometrial pseudogestational sac, and cul-de-sac fluid that is either moderate to large in volume or echogenic Ultrasound and serial β-hCG testing are the main diagnostic studies for ectopic pregnancy, though in rare circumstances obtaining a serum progesterone concentration may be helpful; serum progesterone levels are usually higher in intrauterine pregnancies than in ectopic and nonviable pregnancies If an ectopic pregnancy is diagnosed, an obstetrician/gynecologist or other appropriate surgical service should be called to manage the patient The mainstay of treatment is surgery, though early ectopic pregnancies may be managed medically with the administration of methotrexate Patients who present with ruptured ectopic pregnancy must be monitored closely for signs of hemodynamic instability, sepsis, and shock in the hospital Bleeding During Late Pregnancy If the patient is 20 weeks pregnant or more by history or abdominal examination, potential causes of bleeding that must be identified urgently are placenta previa (placenta close to or overlying cervical os), abruptio placentae (premature separation of the placenta), uterine rupture, and vasa previa (fetal vessels traversing closely to cervical os) An obstetrician should be consulted at the earliest opportunity regarding further ED management of the pregnant patient with second- or third-trimester bleeding Digital vaginal examination in a female in late pregnancy presenting with vaginal bleeding should initially be avoided because uncontrollable hemorrhage may be provoked in a patient with placenta previa Vital signs, physical examination, and laboratory studies should be obtained to evaluate for hemodynamic instability A transabdominal ultrasound should be performed to assess for the location of the placenta A transvaginal ultrasound may also need to be performed to better visualize the placenta location in relation to the cervical os The fetal heart rate should be monitored, and a large-bore intravenous catheter should be inserted Initial laboratory evaluation should include determinations of the blood type and antibody screen, hematocrit, platelet count, fibrinogen level, and coagulation studies to screen for disseminated intravascular coagulation, which may be present in moderate and severe abruption Bleeding With Shock If the patient with vaginal bleeding is in the first or early second trimester of pregnancy and has shock or early signs of cardiovascular instability (pallor, perspiration, vomiting), ruptured ectopic pregnancy or septic abortion must be ruled out Because of the urgency of the situation, treatment of shock and diagnostic measures should be undertaken simultaneously Pelvic examination is performed and obstetric consultation should be obtained rapidly Emergency surgery may be necessary for critically ill patients with ectopic pregnancy Fluid resuscitation and antibiotics should be administered for patients with suspected septic abortion If the patient is ≥20 weeks of gestation, hypovolemic shock should be suspected from placenta previa, abruption placenta, uterine rupture, or vasa previa Appropriate measures should be taken to provide volume resuscitation, and obstetrics must evaluate urgently Suggested Readings and Key References General Boyle C, McCann J, Miyamoto S, et al Comparison of examination methods used in the evaluation of prepubertal and pubertal female genitalia: a descriptive study Child Abuse Negl 2008;32:229–243 Vaginal Bleeding During Childhood Daniels RV, McCuskey C Abnormal vaginal bleeding in the nonpregnant patient Emerg Med Clin North Am 2003;21:751–772 Dwiggins M, Gomez-Lobo V Current review of prepubertal vaginal bleeding Curr Opin Obstet Gynecol 2017;29(5):322–327 Guthrie B Vaginal bleeding in the prepubescent child Clin Ped Emerg Med 2009;10:14–19 Kondamudi NP, Gupta A, Watkins A, et al Prepubertal girl with vaginal bleeding J Emerg Med 2014;46(6):769–771 Lacy J, Brennand E, Ornstei M, et al Vaginal laceration from a high-pressure water jet in a prepubescent girl Pediatr Emerg Care 2007;23:112–114 Poindexter G, Morrell DS Anogenital pruritus: lichen sclerosus in children Pediatr Ann 2007;36:785–791 Scheidler MG, Shultz BL, Schall L, et al Mechanisms of blunt perineal injury in female pediatric patients J Pediatr Surg 2000;35:1317–1319 Striegel AM, Myers JB, Sorenson MD, et al Vaginal discharge and bleeding in girls younger than years J Urol 2006;176:2632–2635 Sugar NF, Feldman KW Perineal impalements in children: distinguishing accident from abuse Pediatr Emerg Care 2007;23:605–616 Tsanadis G, Avgoustatos F, Sotiriadis A, et al Isolated menses: a benign, selflimited process J Obstet Gynaecol 2002;22(3):323 Vaginal Bleeding During Pregnancy Barnhart KT, Casanova B, Sammel MD, et al Prediction of location of a symptomatic early gestation based solely on clinical presentation Obstet Gynecol 2008;112:1319–1326 Cox JE Teen pregnancy In: Emans SJ, Laufer MR, eds Pediatric and Adolescent Gynecology 6th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2012:474–486 Dart R, Ramanujam P, Dart L Progesterone as a predictor of ectopic pregnancy when the ultrasound is indeterminate Am J Emerg Med 2002;20:575–579 Doubilet PM, Benson CB, Bourne T, et al Diagnostic criteria for nonviable pregnancy early in the first trimester N Engl J Med 2013;369(15):1443–1451 Kohn MA, Kerr K, Malkevich D, et al Beta-chorionic gonadotropin levels and the likelihood of ectopic pregnancy in emergency department patients with abdominal pain or vaginal bleeding Acad Emerg Med 2003;10:119–126 Maturen KE, Deshmukh SP, Dudiak KM, et al ACR appropriateness criteria In: Brown DL, Packard A, Maturen KE, et al., eds American College of Radiology Expert Panel on Women’s Imaging: First trimester vaginal bleeding 2017 https://acsearch.acr.org/docs/69460/Narrative/ Norwitz ER, Park JS Overview of the etiology and evaluation of vaginal bleeding in pregnant women UpToDate Online Version 14.0 https://www.uptodate.com/contents/overview-of-the-etiology-and-evaluationof-vaginal-bleeding-in-pregnant-women Accessed 2019 Sinha P, Kuruba N Ante-partum haemorrhage: an update J Obstet Gynecol 2008;28:377–381 Vaginal Bleeding in the Nonpregnant Adolescent Bennett AR, Gray SH What to when she’s bleeding through: the recognition, evaluation, and management of abnormal uterine bleeding in adolescents Curr Opin Pediatr 2014;26:414–419 Hillard PJA Menstruation in adolescents: what’s normal, what’s not Ann N Y Acad Sci 2008;1135:29–35 James A, Matchar DB, Myers ER Testing for von Willebrand disease in women with menorrhagia: a systematic review Obstet Gynecol 2004;104:381–388 American College of Obstetricians and Gynecologists Management of acute abnormal uterine bleeding in non-pregnant reproductive-aged women Committee Opinion No 557 Obstet Gynecol 2013;121:891–896 Seravalli V, Linari S, Peruzzi E, et al Prevalence of hemostatic disorders in adolescents with abnormal uterine bleeding J Pediatr Adoles Gynecol 2013;26:285–289 Strickland JL, Wall JW Abnormal uterine bleeding in adolescents Obstet Gynecol Clin North Am 2003;30:321–335 ... simultaneously Pelvic examination is performed and obstetric consultation should be obtained rapidly Emergency surgery may be necessary for critically ill patients with ectopic pregnancy Fluid resuscitation... 2007;36:785–791 Scheidler MG, Shultz BL, Schall L, et al Mechanisms of blunt perineal injury in female pediatric patients J Pediatr Surg 2000;35:1317–1319 Striegel AM, Myers JB, Sorenson MD, et al Vaginal... presentation Obstet Gynecol 2008;112:1319–1326 Cox JE Teen pregnancy In: Emans SJ, Laufer MR, eds Pediatric and Adolescent Gynecology 6th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2012:474–486