Teen Pregnancies in the ED: Handling Complications
This is a summarized version of the full in-depth article on Relias Media.
Author
Daniel Migliaccio, MD, FPD, FAAEM
Clinical Associate Professor, Division Director of Emergency Ultrasound, Ultrasound Fellowship Director, Department of Emergency Medicine, University of North Carolina at Chapel Hill
Peer Reviewer
Katherine Baranowski, MD, FAAP, FACEP
Chief, Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark
Introduction
Although the teen birth rate in the United States has declined in recent years, adolescent pregnancy rates remain significantly higher compared to other developed nations. Adolescents who are pregnant face unique challenges and barriers when seeking emergency care. In this article, we will discuss the medical and obstetrical complications that may arise in adolescent pregnancies, including trauma, preeclampsia, HELLP syndrome, venous thromboembolism (VTE), precipitous delivery, and postpartum hemorrhage.
Trauma in Pregnancy
Trauma is the leading cause of non-obstetric, pregnancy-associated maternal death in the U.S., with motor vehicle collisions, falls, and assaults as the most common causes. Complications of trauma in pregnancy include preterm labor, placental abruption, uterine rupture, and fetal demise, among others.
- Maternal Resuscitation: As always, maternal survival takes priority in trauma management, as fetal survival is dependent on it. Initial management follows Advanced Trauma Life Support (ATLS) principles, with additional considerations for anatomic and physiologic changes of pregnancy.
- Placental Abruption: Abruption can occur even with minor trauma. Symptoms include uterine tenderness, contractions, and vaginal bleeding. Continuous fetal monitoring is essential, as abruption can lead to serious complications like disseminated intravascular coagulation (DIC) and fetal-maternal hemorrhage.
- Perimortem Cesarean Delivery: In the event of maternal cardiac arrest, perimortem cesarean delivery may be necessary, particularly if the uterus is at or above the umbilicus, indicating a gestational age of ≥ 20 weeks. The procedure should be performed within four minutes of arrest to optimize both maternal and fetal outcomes.
Preeclampsia, Eclampsia, and HELLP Syndrome
Hypertensive disorders, including preeclampsia and eclampsia, affect 10% of pregnancies worldwide. Early recognition and management of these conditions are critical to preventing maternal and fetal complications.
- Preeclampsia: Defined by new-onset hypertension and proteinuria after 20 weeks’ gestation. Severe preeclampsia includes signs of end-organ damage such as liver dysfunction, renal insufficiency, or neurologic symptoms. Management involves antihypertensive therapy (e.g., labetalol or hydralazine) and magnesium sulfate for seizure prophylaxis.
- Eclampsia: This severe form of preeclampsia is characterized by seizures. Immediate treatment with magnesium sulfate and antihypertensive agents is required. Delivery of the fetus is often the definitive treatment.
- HELLP Syndrome: A life-threatening variant of preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelet count. HELLP can lead to serious complications like DIC, hepatic rupture, and placental abruption. Management typically involves corticosteroids for fetal lung maturity, magnesium sulfate for seizure prevention, and antihypertensives. In severe cases, delivery is indicated.
Venous Thromboembolism in Pregnancy
Pregnancy increases the risk of VTE tenfold due to the hypercoagulable state, venous stasis, and vascular damage that occurs. VTE is a leading cause of maternal death, and evaluation can be challenging because symptoms such as dyspnea and leg swelling are common during normal pregnancy.
- Diagnosis: Compression duplex ultrasound is the preferred diagnostic tool for deep vein thrombosis (DVT) because it is noninvasive and poses no radiation risk to the fetus. For suspected pulmonary embolism (PE), a CT pulmonary angiogram (CTPA) or ventilation-perfusion (V/Q) scan may be considered. Both carry similar fetal radiation risks, but the decision should involve shared decision-making with the patient.
- Management: Treatment begins with stabilization, followed by therapeutic anticoagulation with low molecular-weight heparin (LMWH). Therapy should continue for at least six weeks postpartum and for a minimum of three to six months.
Precipitous Delivery and Postpartum Hemorrhage
Precipitous labor is labor that lasts less than three hours and can result in rapid delivery without medical preparation.
- Uncomplicated Delivery: In the event of an emergency delivery, the clinician should assist the delivery using the “hands-on” approach to guide the fetal head and shoulders. After delivery, the placenta is delivered with the aid of uterotonic agents, such as oxytocin, to minimize the risk of hemorrhage.
- Postpartum Hemorrhage (PPH): This is one of the most serious complications of delivery, defined as blood loss of ≥1,000 mL accompanied by hypovolemia. The most common cause is uterine atony. Initial management includes uterotonic agents (e.g., oxytocin) and bimanual uterine massage. In severe cases, advanced interventions such as blood transfusions or surgical interventions may be necessary.
Adolescent pregnancies are associated with higher risks of obstetrical complications, such as trauma, hypertensive disorders, VTE, and postpartum hemorrhage, all of which require prompt recognition and management. Emergency medicine providers must be prepared to stabilize both mother and fetus, recognizing that the mother’s well-being takes priority. Effective communication, multidisciplinary collaboration, and appropriate use of resources are essential in optimizing outcomes for both mother and child.
Read the full in-depth article on Relias Media
We discuss teen pregnancies in the ED in more detail and include detailed charts and tables in our full write-up on Relias Media.