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