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Vaginal Bleeding

A 23-year-old woman presents to the emergency department (ED) with irregular menstrual bleeding. She denies any abdominal pain, dizziness, or palpitations. Her last menstrual period (LMP) was 2 weeks ago with normal flow and duration. Which of the following ancillary tests is most critical in defining the differential diagnosis for this patient?

a. Type and screen

b. Coagulation panel

c. β-Human chorionic gonadotropin (β-hCG)

d. Complete blood count (CBC)

e. Orthostatic vital signs

The answer is c. A urine or serum β-hCG should be one of the first ancillary tests ordered in any female of reproductive age, especially in those presenting with vaginal bleeding or abdominal pain regardless of their sexual, contraceptive, and menstrual history. A follow-up serum quantitative β-hCG is warranted if the urine test is positive. A positive urine or serum β-hCG in the setting of vaginal bleeding or abdominal pain warrants additional evaluation to determine the status of the pregnancy and to exclude ectopic pregnancy. Determining if a patient is pregnant may also distinguish between an emergent cause of vaginal bleeding (ie, ectopic pregnancy) versus a nonemergent cause (ie, pathologic cervical lesion).

Although a type and screen (a) may be necessary in a patient with severe vaginal bleeding and hemodynamic instability, this patient is currently stable. A type and screen is also indicated if the patient is found to be pregnant in order to determine her Rh status. A coagulation panel (b) may be considered later in determining if the vaginal bleeding is induced by conditions such as von Willebrand disease, a relatively common cause of menorrhagia. A CBC (d) may be helpful in distinguishing such conditions as idiopathic thrombocytopenia purpura and to evaluate for anemia. Orthostatic vital signs (e) may help determine if the patient is hypovolemic, however is not likely to guide treatment decisions nor is it the best first test. Remember the most important initial step is to determine pregnancy status.

A 30-year-old G2P2 woman with a history of Chlamydia presents to the ED with acute onset of severe lower abdominal pain associated with vaginal bleeding that began 2 hours prior to arrival. She denies any prior medical history but does report having a tubal ligation after the birth of her second child. Her vitals are significant for a blood pressure (BP) of 90/60 mm Hg and heart rate (HR) of 120 beats/minute. On physical examination, her cervical os is closed and she has right adnexal tenderness with blood in the posterior vaginal vault. Given this patient's history and physical examination, which of the following is the most likely diagnosis?


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