From the Guidelines
For a 20-year-old female who is asymptomatic except for secondary amenorrhea and a positive pregnancy test while taking Trivora oral contraceptive pills (OCPs), the recommended emergency department workup should include an estimation of gestational age and a pelvic examination if necessary, as well as providing information about the normal signs and symptoms of early pregnancy. This approach is based on the recommendations provided by the CDC and the U.S. Office of Population Affairs 1. The estimation of gestational age is crucial for appropriate counseling and to assess the risk of potential complications.
Key Components of the Workup
- Estimation of gestational age to determine the stage of pregnancy and potential risks
- Pelvic examination if the woman is uncertain about the date of her last normal menstrual period to help assess gestational age
- Providing information about the normal signs and symptoms of early pregnancy to educate the patient
- Instructing the patient to report any concerns to a provider for further evaluation
Considerations for Contraceptive Failure
Given that the patient is on Trivora (ethinyl estradiol and levonorgestrel) OCPs and still experienced a positive pregnancy test, it is essential to consider the potential for ectopic pregnancy or other pregnancy abnormalities, as the failure rate of OCPs can be associated with an increased risk of such complications 1.
Next Steps
Referral to appropriate providers of follow-up care should be made as needed, with every effort to expedite and follow through on all referrals, including assessing the client’s social support and referring her to appropriate counseling or other supportive services, as needed 1. Initial prenatal counseling should be provided in accordance with professional medical associations' recommendations, including discussing medications that might be contraindicated in pregnancy and the importance of prenatal vitamins, avoiding harmful substances, and necessary screenings and vaccinations.
From the Research
Diagnostic Approach
The diagnostic approach for a 20-year-old female with secondary amenorrhea and a positive pregnancy test despite taking oral contraceptive pills (OCP) involves several steps:
- Evaluating the patient's symptoms and medical history to determine the risk of ectopic pregnancy 2, 3, 4, 5
- Performing a pregnancy test to confirm the pregnancy 3, 5
- Conducting a quantitative serum hCG test to assess the level of human chorionic gonadotropin 2, 3, 5
- Performing an ultrasound, regardless of the hCG level, to locate the pregnancy and check for any abnormalities 2, 3, 4, 5
- If the patient is hemodynamically unstable, providing immediate resuscitation and consulting with obstetrics/gynecology 2, 3, 5
Special Considerations
- Even with a negative serum hCG test, ectopic pregnancy should not be excluded from the differential diagnosis in a woman of reproductive age 6
- The presence of a yolk sac or fetal pole in the uterus on ultrasound can help confirm an intrauterine pregnancy, while the absence of these findings may indicate a pregnancy of unknown location (PUL) 2
- Patients with a PUL who are stable and can reliably follow up may be managed with close specialist follow-up and repeat 48-hour hCG level testing 2
Risk Factors
- Risk factors for ectopic pregnancy include abnormalities of the fallopian tube, prior ectopic pregnancy, and age over 35 years, although many patients with confirmed ectopic pregnancy will not have an identifiable risk factor 2, 4
- The use of oral contraceptive pills (OCP) does not eliminate the risk of ectopic pregnancy, and patients taking OCP who present with symptoms suggestive of ectopic pregnancy should be evaluated accordingly 2, 3, 4, 5