to the editor: In response to this article, I would like to present a different type of case: a newly-diagnosed pregnant patient who presents to the emergency department (ED) reporting sudden-onset bleeding and cramping, yet has a normal workup, including normal ultrasound and no bleeding on examination.

I have learned from at-risk/transient youth patients that, after a positive pregnancy test, a woman (with possible encouragement by friends or family) may sometimes decide to proceed directly to the ED solely to obtain a copy of the ultrasound. Once at the ED, she may simply formulate a history of sudden-onset of cramping, spotting, and concern about miscarriage. This usually results in the patient receiving a complimentary copy of the ultrasound to take home.

In our youth-at-risk culture, seeing an ultrasound as proof of pregnancy “as soon as possible” may be a priority because the ultrasound is treated like a “baby picture” to show to family and friends. From past experience, however, after the pregnant adolescent has a copy of the ultrasound, she is then less likely to keep her regular obstetrics appointments, less likely to receive continuing prenatal education, and more likely to use the ED for further medical care.

To ensure that the patient receives proper obstetric care if a positive pregnancy test is obtained at our free adolescent clinic, I now ask the patient if she will agree to the following: sign a release form to allow communication with the local EDs; make an appointment for prenatal care with a health care professional while here (transportation can be arranged); and sign that she understands that if for any health reason she goes to the ED, and if consequently ultrasonography is performed, the ED will forward a copy of the ultrasound to her family physician's or obstetrician's office, where she can see it at her first pre-natal appointment.

Most patients have been fine with this arrangement, and it has allowed for further discussion of the proper use of the health care system. Hopefully, this practice of formulating a history of bleeding during pregnancy is rare, but I remain ever thankful to my patients for educating me about it.