GYNECOLOGICAL EMERGENCIES

OBJECTIVES Upon completion, the student will be able to:1. Review the anatomic structures and physiology of the

female reproductive system.2. Identify the normal events of the menstrual cycle.3. Describe how to assess a patient with a gynecological

complaint.4. Explain how to recognize a gynecological emergency5. Describe the general care for any patient experiencing a

gynecological emergency.

OBJECTIVES6. Describe the pathophysiology, assessment, and management

of the following gynecological emergencies:a) Pelvic inflammatory diseaseb) Ruptured ovarian cystc) Cystitisd) Mittelschmertze) Endometritisf) Endometriosisg) Ectopic pregnancyh) Vaginal hemorrhage

OBJECTIVES7. Describe the assessment, care and emotional support of the

sexual assault patient.8. Given several scenarios involving gynecological patients,

provide the appropriate assessment, management, and transportation.

Gynecology Branch of medicine that deals with female

reproductive tract. Most patients will complain of either

abdominal pain or vaginal bleeding.

Menstrual Cycle Monthly hormonal changes that prepares the

uterus to receive the fertilized egg. Starts when a girl is approximately 12-14

years of age. Beginning of menses is termed menarche. Cycle influenced by estrogen and

progesterone.

Menstrual Cycle

A normal cycle varies from one individual to another.

Day 1 is the day on which bleeding starts. Flow usually lasts from 3-5 days.

Average cycle lasts approximately 28 days. First two weeks of the cycle is dominated by

estrogen. Causes lining of the uterus to thicken and to become engorged with blood vessels. (Proliferative Phase)

Menstrual Cycle At day 14, LH causes the release of an egg from

the ovary, (ovulation). The egg moves to the fallopian tubes, and then

swept towards the uterus. Fertilization may take place, if sexual intercourse

has taken place within 24 hours. If fertilization takes place the egg will implant in

the thickened lining of the uterus, (secretory phase).

If the egg is not fertilized, estrogen levels fall and the uterine lining sloughs away.

Menstrual Cycle This will start a new menstrual cycle,

(menstrual phase). Absence of a period should raise the suspicion

of pregnancy. Menstrual periods usually stop in a woman in

her 40’s or 50’s, (menopause).

Assessment Includes the standard initial and focused

exams. Particular attention should be paid during your

SAMPLE History. Usually patients will complain of abdominal

pain or discomfort and/or vaginal bleeding.

History You will need to gather an obstetric history.

Also remember to role out other problems that do not have a gynecological history.

You need to ask question regarding the number or pregnancies (gravida), and the number of pregnancies that have produced a viable infant (para).

Also question about cesarean section, pelvic surgeries, abortion procedures.

Determine and document the patient’s last menstrual period (LMP).

History Was the last period normal or was the flow heavier

or lighter. Are the patient’s periods regular. Is the patient using birth control, what kind? Is the patient having vaginal discharge: What is

the color? Presence of blood? Is there an associated odor?

Be aware of the fact that the patient may feel uncomfortable about discussing these problems with you. Do not push the issue.

Physical Examination Initial, focused, and detailed as always. Any abdominal complaint should be

examined carefully because of the number of problems that could be associated with abdomen that do not have a gynecological component.

DO NOT PERFORM AN INTERNAL VAGINAL EXAM IN THE FIELD!!!!!

MEDICAL GYNECOLOGICAL

EMERGENCIES

Pelvic Inflammatory Disease Most common cause of

nontraumatic abdominal pain.

Infection of the female reproductive tract.

Usually involves the uterus, fallopian tubes, and ovaries.

Common causes: gonorrhea and chlamydial infections.

Staph or strep can also be causative agents.

May be either acute or chronic.

May develop into sepsis if left untreated.

Adhesions can occur, causing organs to stick together.

Adhesions is a common cause of chronic pelvic pain and also increase the frequency of ectopic pregnancies.

Assessment of PID Most common complaint

is abdominal pain. It is a diffuse pain and

located at the along the lower abdomen.

Moderate to severe. Hard to distinguish from

appendicitis. Pain may intensify during

menstrual period

Pain may also intensify during sexual intercourse.

Walk in a shuffling gait, which decreases the pain.

May be accompanied by fever, chills, nausea, and vomiting.

Vaginal discharge: yellow

Management of PID Primary treatment is antibiotics, IV infusion. Make the patient comfortable.

Ectopic Pregnancy Implantation of a growing fetus in a place

where it does not belong. Most common site is within the fallopian

tubes. This is a surgical emergency Rupture can occur with resultant

hemorrhage. Patients present with one-sided abdominal

pain, late or missed period, occasionally with vaginal bleeding.

Ovarian Cysts Cysts are fluid-filled pockets. When in the

ovary they can rupture and be a source of abdominal pain.

When ruptured, a small amount of blood is spilled into the abdomen causing irritation to the peritoneum and the cause of abdominal pain and rebound tenderness.

Appendicitis Difficult to distinguish from PID or ectopic

pregnancy. Abdominal pain that develops around the

navel and moves to the RLQ. Pain may be associated with anorexia, fever,

nausea, vomiting, or shock.

Cystitis Bladder infection. Because the bladder lies anterior to the

reproductive organs, it causes pain above the symphysis pubis once inflamed.

Mittleschmertz Abdominal pain during menstrual cycle. This pain is referred to as mittleschmertz, and

is associated with the release of an egg from the ovary.

Management Significant abdominal should be treated and

transported. Oxygen IV: crystalloid of choice. Position of comfort

TRAUMA GYNECOLOGICAL

EMERGENCIES

Causes of Gynecological Trauma Straddle Injury (bicycle) Blows to the perineal area Foreign body insertion into the vagina Attempts at abortion Lacerations following childbirth Sexual assault

Gynecological Trauma Injuries to the external genitalia should be

managed by simple pressure over the laceration.

IV crystalloid if bleeding is severe. Monitor hemodynamic state MAST (local protocol) NEVER PACK THE VAGINA!!!!! Rapid Transport

Sexual Assault One of the fastest growing crimes in the

USA. 60% are not even reported. And sexual

abuse of children is reported even less. There is no “typical victim” Defined: sexual contact without the

consent of the person assaulted. Vary from state to state.

Rape: penetration of the vagina or rectum of an unwilling female or the rectum in an unwilling male.

Sexual Assault

In most states penetration must occur for an act to be classified as rape.

Sexual assault is a crime of violence with serious physical and psychological implications.

Most victims know the assailant. Motivation is unclear, control of the victim, desire to inflict pain, aggression have been implicated.

Assessment of the Assault Victim

Patients SHOULD NOT be questioned about the incident in the field.

Do not inquire about the patient’s sexual practices.

Victim may be withdrawn or hysterical. Victim should be approached calmly and professionally.

Respect the victim’s modesty and explain all procedures.

Avoid touching the victim, unless necessary for exam. DO NOT examine genitalia unless there is life-threatening hemorrhage.

Management of the Assault Victim

Psychological and emotional support is the most important help you can offer.

Maintain a nonjudgmental attitude. Assure confidentiality. Same sex rescuer if possible. Provide safe environment (well lit area). Respond to victim’s feelings and respect

their wishes. Always get permission to treat before

touching the patient.

Management Preservation of physical evidence is

important:1. Handle clothing as little as possible2. Do not examine the perineal area3. Do not use plastic bags for blood-stained

articles4. Bag each item separately5. Do not allow patients to comb their hair or

clean their fingernails

Management

6. Do not allow patients to change their clothes, bathe, or douche before the medical examination

7. Do not clean wounds, if at all possible