What is the necessary workup for a 20-year-old female with amenorrhea and a positive pregnancy test despite taking Trivora (Ethynodiol Diacetate and Ethinyl Esteradiol) OCP (oral contraceptive pills)?

From the Guidelines

For a 20-year-old female with amenorrhea and a positive pregnancy test despite taking Trivora (Ethynodiol Diacetate and Ethinyl Esteradiol) OCP, a comprehensive workup should be initiated to confirm pregnancy and assess the patient's health, but routine examinations and tests are not necessary before starting contraception, as stated in the CDC guidelines 1.

Initial Assessment

The patient's positive pregnancy test should be confirmed with quantitative serum beta-hCG testing to rule out false positives. A detailed history should be taken to assess the patient's pregnancy risk and contraceptive use, as recommended by the CDC guidelines 1.

Necessary Examinations and Tests

According to the CDC guidelines, blood pressure should be taken before initiating combined hormonal contraception, but in this case, the patient is already taking Trivora OCPs 1.

• A pelvic examination is not necessary unless an intrauterine device (IUD) is being inserted or a diaphragm is being fitted, but it may be considered in this case to evaluate for any abnormalities.
• Cervical cytology, clinical breast exam, HIV screening, and laboratory tests for lipid, glucose, liver enzyme, and hemoglobin levels or thrombogenic mutations are not needed routinely to provide contraception safely to a healthy client 1.
• Weight measurement is not needed to determine medical eligibility for any method of contraception, but measuring weight and calculating BMI at baseline might be helpful for monitoring any changes and counseling women who might be concerned about weight change perceived to be associated with their contraceptive method 1.

Focused Workup

A transvaginal ultrasound should be scheduled to determine gestational age, confirm intrauterine pregnancy, and rule out ectopic pregnancy, which is a medical emergency.

• The patient's medication history should be reviewed for any drugs that might reduce OCP effectiveness, like certain antibiotics, antiseizure medications, or St. John's wort.
• The patient should be counseled on pregnancy options (continuation, adoption, termination) and initiated prenatal care if she chooses to continue the pregnancy, including prenatal vitamins with folic acid.
• Assessing vital signs and performing a physical examination, including a pelvic exam, may be considered to evaluate for any abnormalities, but this is not routinely necessary for contraceptive use, as stated in the CDC guidelines 1.

From the Research

Necessary Workup for Amenorrhea and Positive Pregnancy Test

• A 20-year-old female with amenorrhea and a positive pregnancy test despite taking Trivora (Ethynodiol Diacetate and Ethinyl Esteradiol) OCP requires a thorough workup to rule out ectopic pregnancy, as the presentation of ectopic pregnancy can be highly variable 2.
• The workup should begin with a sensitive beta hCG qualitative test, followed by sonography, first transabdominally, then transvaginally, in stable patients 3.
• In cases where the transvaginal ultrasound does not show intrauterine or ectopic gestation, the patient should be followed up until an outcome is obtained, with serial serum hCG levels and serum progesterone levels used as biomarkers to determine the viability and location of the pregnancy 4.
• The discriminatory zone, which is the value of serum hCG above which an intrauterine gestational sac should be visible on ultrasound, should be used to guide the diagnosis and management of the patient 4, 5.
• Serial beta hCG levels can demonstrate atypical trends in some cases, and interpretation of these results should be done in conjunction with clinical and sonographic findings to arrive at a correct diagnosis 6.

Diagnostic Modalities

• Transvaginal ultrasound is able to identify an ectopic pregnancy with a sensitivity ranging from 87% to 94% and a specificity ranging from 94% to 99% 4.
• Serum progesterone levels are a satisfactory marker of pregnancy viability, but they are unable to predict the location of a pregnancy of unknown location 4.
• Quantitative beta hCG testing can be used to determine the discriminatory zone and guide the diagnosis and management of the patient 3, 5.

Management Strategy

• The management strategy for a patient with a suspected ectopic pregnancy should be based on the hospital protocol and should take into account the patient's clinical presentation, sonographic findings, and serum hCG and progesterone levels 6.
• Expectant management with serial serum hCG levels and serum progesterone levels, as well as transvaginal ultrasound, can be used in low-risk cases, while active treatment may be necessary in situations where progressive intrauterine pregnancy is excluded and a high possibility of ectopic pregnancy exists 4.