Consideration of pregnancy and pregnancy-related complications on the differential diagnosis for adolescent females Rapid stabilization of unstable patients Identification of appropriate resources to ensure adequate treatment and followup Attention to consent and confidentiality issues CLINICAL PEARLS AND PITFALLS The symptoms of pregnancy in teenagers are highly variable It should be considered in the differential diagnosis for almost every chief complaint among postpubertal adolescent girls This is true even if using contraception since adolescents are more likely to use short-acting methods (daily pills, weekly patches, monthly vaginal ring, or quarterly shot) that require frequent dosing; they are also more likely than adult women to use these methods incorrectly and inconsistently Physicians should remember to include the possibility of pregnancy in teens with chronic illness and disability One study of sexual behaviors in teenagers with chronic conditions demonstrated that they are as sexually active as their otherwise healthy counterparts Confidentiality and Legal Issues Confidentiality should be maintained throughout the visit to encourage autonomy, protect privacy, promote necessary medical follow-up, and guard the teen from any physical harm or humiliation that may result from disclosing pregnancy status to family members The results of a pregnancy test are best shared with the adolescent alone initially This allows the practitioner to assess the adolescent’s attitudes towards the pregnancy privately and counsel around options as needed It also allows the provider to encourage the teen to share the information with a trusted adult and to engage in a shared decision-making process to determine which trusted adult—parent, family member, or friend—the adolescent deems acceptable to offering support and assistance during subsequent follow-up The teen may choose to share this information with those that have accompanied her to the ED or her partner, or may want to contact another adult A nonjudgmental and compassionate approach will assist the teen in choosing the option that suits her life situation best because she is the one who will be most affected by that choice However, there are certain situations in which disclosure is required, regardless of the teen’s wishes It is important to be cognizant of state laws regarding age of legal consent for sexual activity, criteria for emancipated minor status, and the health provider’s status as mandated reporter in the case of suspected physical or sexual abuse and suicidal or homicidal ideation; some states include pregnancy in women younger than 13 years old in the definition of abuse Current Evidence According to the Youth Risk Behavior Survey, approximately 40% of high school students have been sexually active; of those who are currently sexually active, 54% report condom use and 21% report birth control use during their last sexual encounter In 2017, there were 194,377 teen births which was 7% down from the year prior Despite this decrease, the United States still has one of the highest teen birth rates in the world Clinical Considerations Clinical Recognition A recent study found that only 20% of adolescent females seen in an ED underwent pregnancy testing Among those patients with a chief complaint potentially related to pregnancy, the proportion who underwent pregnancy testing was higher (44.5%) but still represented the minority of cases The most common presenting complaint associated with early pregnancy is a missed or abnormal menstrual period However, the menstrual history is particularly unreliable in teenage women secondary to high rates of anovulatory cycles Other symptoms commonly associated with pregnancy include fatigue, dizziness, breast tenderness, weight gain, nausea, and morning sickness Many adolescents report nonspecific complaints related to the gastrointestinal or genitourinary tracts Less commonly, the presenting symptom is associated with complications of early pregnancy, including vaginal bleeding, hyperemesis, hypertension, headache, hyperglycemia, vaginal discharge, or dysuria Clinical Assessment It is important to consider offering a pregnancy test to all teenage women seeking care Even if a pregnancy test is unrelated to the presenting symptoms, there are several advantages to the patient in identifying pregnancy as early as possible: earlier initiation of prenatal care if childbirth is desired, earlier detection of lifethreatening complications such as ectopic pregnancy, opportunity for consideration of options such as therapeutic abortion or adoption, and increased time for counseling, regardless of the patient’s ultimate choice If the pregnancy test is negative and pregnancy is suspected, repeat testing should be done in weeks In the ED, it is imperative to recognize those patients who are immediately at risk for life-threatening complications and require acute resuscitation and emergent evaluation by a surgical subspecialist Pregnant patients who present with vaginal bleeding (with or without abdominal pain) represent a high-risk group First-trimester vaginal bleeding occurs in 20% to 25% of patients Common etiologies include ectopic pregnancy, spontaneous and incomplete abortion, missed or threatened abortion, sexually transmitted infections, and trauma The initial laboratory workup should include a complete blood count, both to assess the amount of blood loss and to provide a baseline if bleeding continues A urinalysis can detect the presence of white blood cells, bacteria, glucose, or protein If unknown, Rh determination is indicated if there is vaginal bleeding and those who are Rh-negative should receive Rh immunoglobulin Ectopic pregnancy is the leading cause of maternal mortality in the United States during the first half of pregnancy; therefore, timely recognition and treatment is imperative The prevalence of ectopic pregnancy among women presenting to an ED with first-trimester bleeding and/or pain ranges from 6% to 16% Although the overall incidence of ectopic pregnancy in teenagers is low, this group has the highest mortality rate, largely due to a tendency to delay seeking care Risk factors for ectopic pregnancy include prior ectopic pregnancy, tubal abnormalities, prior genital tract infection, and assisted reproduction The diagnosis of ectopic pregnancy must be considered in any patient with vaginal bleeding and/or abdominal pain Patients can present with a wide spectrum of symptoms, including abnormal vaginal bleeding; intermittent crampy, lower abdominal pain; or acute abdominal pain associated with shock (with or without vaginal blood loss) Fortunately, most patients with ectopic pregnancy present before rupture has occurred Spontaneous abortion is another cause of vaginal bleeding in the pregnant teenager, which can be septic, threatened (or missed), inevitable, or complete Spontaneous miscarriage is very common in early pregnancy; up to one-half of all fertilized ova that implant into the endometrium are lost Most spontaneous abortions occur during the first trimester, although a small number occur after 20 weeks’ gestation Vaginal bleeding can indicate threatened abortion, when the patient’s external cervical os is closed, or an inevitable abortion, when the external os is open If products of conception are found in the vaginal vault of a patient with an inevitable abortion and the cervix is closed, the abortion is most likely complete; however, an ultrasound is helpful for confirming that no products are retained in the uterus Management Pregnancy Once the diagnosis of pregnancy has been made, the goals of the ED evaluation include (i) dating the pregnancy, (ii) recognizing symptoms that require immediate referral for obstetric or gynecologic evaluation, (iii) identifying and treating presenting and potential nonsurgical complications, (iv) assessing chronic medical conditions, (v) providing appropriate counseling, and (vi) securing appropriate and timely follow-up These goals can be tailored to specific settings, depending on consultant availability and access to close follow-up for the patient The approach to management of patients diagnosed with pregnancy includes subspecialty consultation, quantitative serum β-hCG levels, serum progesterone levels, abdominal and/or transvaginal ultrasound, depending on the practice setting, as well as close follow-up Ideally, schedule a primary care or adolescent medicine specialist follow-up visit in to days so that counseling about options can be repeated in a less rushed, less chaotic environment It is also important to review the patient’s medical insurance and link her to eligible coverage/resources The need to arrange close follow-up and to facilitate connection to care following the ED visit should not be underestimated In a normal singleton pregnancy, serial serum β-hCG levels should increase by 67% every 48 hours during the first month of pregnancy Levels that not rise or rise more slowly than expected are indicative of an abnormal pregnancy (usually an ectopic pregnancy or a pregnancy that is destined to spontaneously abort) Ultrasound is used to visualize the uterine cavity to assess for the presence of a gestational sac When the β-hCG level reaches the discriminatory zone, a gestational sac should be visible within the uterus The discriminatory zone varies based on local transvaginal ultrasound expertise, but is generally around a β-HCG of 2,500, or a gestational age of weeks If no sac is seen and the β-HCG is beyond the discriminatory zone, the pregnancy is presumed to be ectopic If the discriminatory zone has not been reached or the pregnancy dates (by last menstrual period, for example) is less than weeks, the patient should have a repeat β-HCG within 48 hours and the ultrasound repeated if the β-HCG is at or above the discriminatory zone For patients diagnosed with ectopic pregnancy, conservative medical management may be appropriate in adolescents who are stable, have no evidence of any bleeding, have a hemoglobin of greater than g/dL and a gestational sac less than cm, who are not immunocompromised, and not have a bleeding diathesis, or liver, or renal disease, and if close follow-up can be secured As ... the practice setting, as well as close follow-up Ideally, schedule a primary care or adolescent medicine specialist follow-up visit in to days so that counseling about options can be repeated