Chapter 24. Gynecologic Emergencies. Introduction. The most obvious difference between men and women is that women are uniquely formed to conceive and give birth. This difference makes women susceptible to many conditions that do not occur in men. This chapter examines a few of those conditions.
Female anatomy is discussed first, followed by conditions that may be encountered in the pre-hospital setting. Vaginal bleeding causes are reviewed. Health concerns specific to the very young and the very old are discussed. The principles of treating a woman who has been the victim of sexual assault or rape, as well as recognizing the potential use of date rape drugs, are also discussed.
Anatomy and Physiology The female reproductive system includes internal and external structures. The external female genitalia consist of the vaginal opening just posterior to the urethral opening. The labia majora and labia minora are folds of tissue that surround the urethral and vaginal openings. At the anterior end of the labia is the clitoris, and at the posterior end is the anus. The perineum is the area of tissue between the vagina, and the anus.
The labia are extremely vascular and can be injured, but because of their location, they seldom are damaged except in cases of sexual abuse. In terms of internal structures, the ovaries are the primary female reproductive organ. The ovaries are located on each side of the lower abdomen, and produce an ovum, or egg, that, if fertilized, will develop into a fetus. The fallopian tubes connect each ovary to the uterus.
The uterus is the muscular organ where the fetus grows during pregnancy. The narrowest portion of the uterus, the cervix, opens into the vagina. The vagina is the outermost cavity of a woman's reproductive system and forms the lower part of the birth canal. When a female reaches puberty, she begins to ovulate and experience menstruation. Ovulation is the cycle in which the ovum is released.
The onset of menstruation is called menarche, and usually occurs between the ages of 11 and 16 years, although it can occur earlier or later. Any female who has reached menarche is capable of becoming pregnant. Women continue to experience the cycle of ovulation and menstruation until they reach menopause, which marks the end of menstrual activity. Women reach menopause at widely varying ages, but it commonly occurs around the age of 50 years. Each ovary produces an ovum during each menstrual cycle, although not necessarily in an orderly pattern that alternates back and forth between each ovary, and releases it into the fallopian tube.
Some women experience minor cramping pain during ovulation when an ovum is released. The pain is sometimes described as a dull pain on one side of the lower abdomen. The quality and severity of the pain vary for each woman. The process of fertilization begins in the vagina, where sperm from the male penis are deposited in the female reproductive tract. The sperm pass through the cervix into the uterus, and eventually up the fallopian tubes.
As the ovum moves slowly down the fallopian tube, sperm moving up the tube can surround it, and one sperm fertilizes it. When an ovum is fertilized in the fallopian tube, the developing embryo travels into the uterus, where the lining of the walls of the uterus has become engorged with blood in anticipation of receiving a fertilized ovum. Here, the embryo attaches to the uterine wall, and continues to grow.
If the ovum is not fertilized in the fallopian tube, it continues to travel into the uterus when fertilization has not occurred within about 14 days of ovulation the lining of the uterus begins to separate and menstruation occurs the menstrual flow consists of blood from the separated lining of the uterus and lasts about one week female hormones produced primarily in the ovaries control the process of ovulation and menstruation pathophysiology the causes of gynecologic emergencies are varied and range from sexually transmitted diseases to trauma you should recognize and properly manage female patients with any kind of abdominal or pelvic pain and consider problems that could be potentially life-threatening pelvic inflammatory disease pelvic inflammatory disease is an infection of the upper female reproductive organs specifically the uterus ovaries and fallopian tubes that occurs almost exclusively in sexually active women disease-causing organisms enter the vagina during sexual activity and migrate through the opening of the cervix and into the uterine cavity The infection may then expand to the fallopian tubes, and can cause scarring that can increase the risk of life-threatening conditions such as ectopic pregnancy or sterility. If the ovaries are affected, it can lead to the development of a life-threatening abscess. Although pelvic inflammatory disease itself is seldom a threat to life, it can lead to an ectopic pregnancy or an abscess, which can cause death. Ectopic pregnancy is a pregnancy that develops outside the uterus. most often in the fallopian tube the most common presenting sign of pelvic inflammatory disease is generalized lower abdominal pain other signs and symptoms include an abnormal and often foul-smelling vaginal discharge increased pain during sexual intercourse fever general malaise and nausea and vomiting risk factors associated with pelvic inflammatory disease include having multiple sex partners and or a partner who has had sex with multiple people having an untreated sexually transmitted disease having a past history of pelvic inflammatory disease being sexually active being younger than 26 years douching and using an intrauterine device for birth control sexually transmitted diseases sexually transmitted diseases can lead to more serious conditions For example, untreated gonorrhea and chlamydia often progress to pelvic inflammatory disease.
Chlamydia is caused by the bacterium, chlamydia trachomatis. According to the Centers for Disease Control and Prevention, chlamydia is currently the most commonly reported sexually transmitted disease in the United States. Although the symptoms of chlamydia are usually mild or absent, some women may report lower abdominal pain, low back pain, nausea.
fever pain during sexual intercourse and or bleeding between menstrual periods chlamydia infection of the cervix can spread to the rectum leading to rectal pain discharge or bleeding if it is left untreated the disease can progress to pelvic inflammatory disease in rare cases chlamydia causes arthritis that may be accompanied by skin lesions and inflammation of the eye and urethra Bacterial vaginosis is the most common vaginal infection in women age 15 to 44 years, according to the Centers for Disease Control. In this infection, normal bacteria in the vagina are replaced by an overgrowth of other bacterial forms. Symptoms may include itching, burning, or pain and may be accompanied by a fishy, foul-smelling discharge.
Pregnant women with bacterial vaginosis may have premature babies or babies born with low birth weight. If it is left untreated, bacterial vaginosis can lead to more serious infections or result in pelvic inflammatory disease. Gonorrhea is caused by Neisseria gonorrhea, a bacterium that can grow and multiply rapidly in the warm, moist areas of the reproductive tract, including the cervix, uterus, and fallopian tubes in women, and in the urethra in women and men. The bacterium can also grow in the mouth, throat, eyes, and anus.
Symptoms, which are generally more severe in men than in women, appear approximately 2 to 10 days after exposure. Women may be infected with gonorrhea for months but not have any symptoms, or only mild ones, until the infection has spread to other parts of the reproductive system. When symptoms do appear in women, they generally present as painful urination, with associated burning or itching, a yellowish or bloody vaginal discharge, usually with a foul odor.
and blood associated with vaginal sexual intercourse more severe infections may present with cramping and abdominal pain nausea and vomiting and bleeding between menstrual periods these symptoms indicate that the infection has progressed to pelvic inflammatory disease rectal infections generally present with anal discharge and itching and occasional painful bowel movements with fecal blood spotting infection of the throat for which oral sex is the introducing factor usually results in mild symptoms consisting of painful or difficult swallowing sore throat swollen lymph glands and fever headache and nasal congestion may also be present if the infection is not treated the bacterium may enter the bloodstream and spread to other parts of the body including the brain vaginal bleeding because menstrual bleeding occurs monthly in most women vaginal bleeding that is the result of other causes may initially be overlooked Some possible causes of vaginal bleeding include abnormal menstruation, vaginal trauma, ectopic pregnancy, spontaneous abortion, miscarriage, cervical polyps, and cancer. Trauma to the internal female genitalia from any cause other than vaginal penetration is rare because these organs are located deep within the pelvis. Injuries to the vagina, and external genitalia are painful and serious because of the large number of nerves and blood vessels in this area. In contrast, internal bleeding from polyps or cancer, while also serious, may be relatively painless.
Ectopic pregnancy and spontaneous abortion are two conditions that can cause vaginal bleeding in women early in pregnancy who may not realize they're pregnant. These potentially life-threatening conditions are covered in Chapter 34, Obstetrics and Neonatal Care. All cases of vaginal bleeding should be taken seriously, and the patient should be evaluated by a physician for a thorough gynecologic examination.
Patient Assessment Obtaining an accurate and detailed patient assessment is critically important when dealing with gynecologic issues. You will be able to gain only a primary impression of the problem in the field, yet a thorough patient assessment will help determine just how sick the patient is, and whether you should initiate life-saving measures. This is especially true when dealing with abdominal pain. Women experience many of the same conditions that cause abdominal pain in men, for example, ulcers and appendicitis. In addition, there are numerous gynecologic causes of abdominal pain.
An old medical axiom states, anyone who neglects to consider a gynecologic cause in a woman of childbearing age who reports abdominal pain will miss the diagnosis at least 50% of the time. Missing the diagnosis may be fatal for the patient. Scene size up.
Every emergency call, including calls involving gynecologic emergencies. begins with a thorough scene size up is the scene safe will you need assistance how many patients do you have what is the nature of illness or mechanism of injury have you taken standard precautions gynecologic emergencies can be messy sometimes involving significant amounts of blood and body fluids contaminated with organisms that can potentially cause communicable diseases where and in what position is the patient found If she is at home, what is the condition of the residence? Is it clean or dirty?
Do you see evidence of a fight? Is there evidence of alcohol, tobacco products, or drug use present? Does the patient live alone or with other people?
All of the information you obtain contributes to your assessment of the patient's overall health, and the safety of the scene. In the case of a crime scene, you may also be required to testify in court regarding the conditions on your arrival your documentation needs to be accurate and thorough involve law enforcement if any type of assault is suspected in cases of sexual assault it is important to have a female emergency medical technician provide patient care if possible so consider calling for a female provider early if you and your partner are both men often The nature of illness or mechanism of injury in patients with gynecologic emergencies will be understood from the dispatch information, such as in cases of sexual assault. In other patients, the exact nature of the condition will not emerge until you gather patient history information.
For example, your patient may present with vague symptoms such as abdominal pain, and you will not be able to determine the exact nature of the problem until you gather more information during the patient history. Primary assessment. The general impression is an important aspect of all patient assessments.
As you approach the patient, you should quickly determine if her condition is stable or unstable. Use this information to help you as you proceed further with the assessment. Use the awake and alert verbal stimuli pain unresponsive scale to determine the patient's level of consciousness. Always evaluate the airway and breathing immediately to ensure they're adequate and treat any airway or breathing problem that is identified according to established guidelines and local protocol. Identifying and treating life threats takes precedence over all other assessment and treatment.
It is important to carefully assess circulation in all patients, palpate a pulse, and evaluate skin color, temperature, and moisture to help identify the patient who might have blood loss. Because skin paleness can be difficult to detect in patients with dark skin, check for pale mucous membranes inside the inner lower eyelid or slow capillary refill. On general observation, the patient may appear ashen or gray.
If the patient has experienced significant blood loss because of vaginal bleeding, she may not demonstrate obvious signs of shock but may still be hypovolemic. If the patient has a weak or rapid pulse or has pale, cool, or diaphoretic skin, place the patient in a supine position. Cover the patient to keep her warm, and then transport to the nearest appropriate hospital for treatment.
Most cases of gynecologic emergencies are not life-threatening. However, if signs of shock exist because of bleeding, then rapid transport is necessary. The remainder of the assessment can be performed en route to the hospital.
History taking. Begin by asking about the patient's chief complaint, but realize some of the questions you must ask may be considered extremely personal. Be sensitive to the patient's feelings, and ensure that her privacy and dignity are protected.
Gynecologic emergencies can be highly embarrassing for the patient, and many women may be extremely uncomfortable with discussing their sexual history in front of strangers or even close family members. An adolescent girl may want to keep her sexual history from her parents. For a report of abdominal pain, ask specific questions about onset, duration, quality, and radiation.
Provoking or relieving factors, and associated symptoms such as syncope, lightheadedness, nausea, vomiting, and fever are also relevant. For a report of vaginal bleeding, ask about onset, duration, quantity. number of sanitary pads or tampons soaked and associated symptoms such as syncope and lightheadedness obtain a sample history beginning with the current symptoms make note of any allergies she has or any over-the-counter or prescription medications she is taking such as birth control pills and any birth control devices she uses ask the patient about medical conditions and ask specifically about her last menstrual period this will help determine if the patient is possibly pregnant not every woman has a menstrual cycle every month which may make determining the possibility of pregnancy challenging do not let your guard down by ruling out pregnancy as a possibility ask about the possibility of sexually transmitted diseases and the possibility of pregnancy find out when she last eight or drank and what events led up to her calling for emergency medical service use her history of events, her chief complaint, and her answers to your other questions to lead further questioning.
For example, if she answers that she is sexually active, ask her about birth control, and about symptoms of pregnancy. If she has vaginal bleeding, ask how many sanitary pads or tampons she is using per hour. This information can help create an estimate of blood loss.
Secondary Assessment The secondary assessment may be performed on scene, en route to the emergency department, or, in some instances, not at all. If the patient is critically ill or injured or the transport time is short, you may not have time to conduct this part of the patient assessment process. Pertinent secondary assessment findings should include vital signs, blood pressure, pulse, skin color, orthostatic vital signs, abdomen. distension and tenderness, genitourinary, visible bleeding, neurologic, mental status. Your physical examination of a gynecologic patient should be limited and professional.
Only examine the genitalia if it is necessary to do so to treat the patient. Protect the woman's privacy during the physical examination. Few women are comfortable with having their body exposed to a crowd of family, neighbors, emergency medical technicians, police officers, or firefighters. Limit the personnel present to only those required to perform the necessary tasks.
Show the patient you respect her by being an advocate for her modesty. You also serve as a role model for other emergency medical service providers when you act this way. The population of women older than 65 years is increasing, and although they are past their childbearing years, many will have other gynecologic problems they may have concerns specific to hormone replacement therapy have an increased risk of cancer or could be suffering from internal physical changes in the female organs associated with aging for example pelvic floor prolapse and urinary incontinence although these problems cannot be treated in the pre-hospital environment perform and record a thorough assessment and treat any of the patient's immediate needs Focus your physical examination on the history of events and the patient's chief complaint. If vaginal bleeding is present, you should ask about its quality and quantity. You need to look at vaginal bleeding when it is sufficient to cause shock.
Questioning suggests less aggressive bleeding, and no evidence of shock. Privacy takes precedence, and examination is deferred to the emergency department. Use external sanitary pads to absorb the bleeding, and keep the possibility of hypoperfusion or shock in mind. Always ask if there is pain associated with the vaginal bleeding or discharge. Never insert anything into the vagina to control bleeding, including a tampon.
Vaginal discharge is a condition that does not need to be visualized if no bleeding is noted by the patient. Make observations about the discharge and ask the patient about any qualities she noticed, and the history of the discharge. A transport decision is based on the patient's vital signs, which, if they're normal, confirm that visualizing is not necessary. Fever, nausea, vomiting are common with many medical conditions but should be considered especially significant with gynecologic emergencies fever should always be considered a sign of an infectious process any report of syncope on the part of the patient especially if she reports vaginal bleeding is considered significant treat the patient reporting this symptom as being in shock until proven otherwise assess the patient's vital signs including heart rate rhythm and quality, respiratory rate, rhythm, and quality, skin color, temperature, and condition, capillary refill time, and blood pressure.
Consider obtaining orthostatic vital signs if bleeding is known or suspected. Pay special attention to the presence of tachycardia and hypotension, which could indicate hemorrhagic shock. Monitor the patient's condition frequently to watch for changes in vital signs and mental status. Consider using non-invasive blood pressure monitoring to continuously track the patient's blood pressure.
Remember, pulse oximetry readings may not be accurate in the setting of hypovolemia. Reassessment. Repeat the primary assessment.
Reassess the patient's vital signs, and the chief complaint. Reassess the patient's vital signs every 5 minutes to identify hypoperfusion from excessive blood loss. If the patient shows signs of shock, begin treatment and rapid transport. How is the patient's condition improving with the interventions?
Identify and treat any changes in the patient's condition. For example, if the patient appears to be losing consciousness, position her in the supine position and reassess. Finally, pay specific attention to the needs of your patient, and respect her desire for conversation or silence.
Provide her with calm reassurance. Explain to her that the hospital staff will be sympathetic to her condition, and will be well qualified to treat her. There are a few interventions that can or should be done for a patient with a gynecologic emergency.
If the patient has vaginal bleeding, treat her for hypoperfusion or shock. Keep her warm, place her in a supine position, and provide her with supplemental oxygen even if she is not experiencing difficulty breathing. Consider advanced life support intercept for fluid replacement depending on transport times and local protocols, then transport to the nearest appropriate receiving facility. Notify staff at the receiving hospital of all relevant information, including the possibility of pregnancy, so a proper response can be prepared. Carefully document the patient's condition, her chief complaint, the scene, and all interventions, especially in cases of sexual assault.
Emergency medical care. Whenever you care for patients with gynecologic emergencies, you must maintain the patient's privacy as much as possible. If the patient is in a public place, move her to the ambulance.
Gain the patient's confidence by communicating appropriately. If possible, have a female emergency medical technician participate in the patient's care. Excessive internal vaginal bleeding can have many causes. and can possibly lead to hypoperfusion or shock determining the cause of the bleeding should be considered less important than treating for shock and transporting the patient to an appropriate facility use sanitary pads on the external genitalia to absorb the blood most women will use sanitary pads before you arrive so you may continue that approach document the number of sanitary pads that were saturated with blood If the woman has a tampon in place. it is not necessary to have a remove it vaginal bleeding is really significant enough to cause hemorrhagic shock but the patient should be treated for shock nevertheless apply oxygen keep the patient supine and warm and promptly transport to the hospital the genitals have a rich nerve supply making injuries very painful treat any external lacerations abrasions and tears with sterile compresses using local pressure to control bleeding and a diaper type bandage to hold the dressings in place leave any foreign bodies in place after stabilizing them with bandages under no circumstances should you pack or place dressings inside the vagina continue to assess the patient while transporting her to the emergency department contusions and other blunt trauma will require careful in-hospital evaluation assessment and management of specific conditions pelvic inflammatory disease a patient with pelvic inflammatory disease will report abdominal pain the pain generally starts during or after normal menstruation so inquiring about the date of the patient's last menstrual period is an important detail of the patient's history the pain may be described as achy and may be made worse by walking other symptoms may include vaginal discharge fever and chills and pain or burning on urination patients often present with a distinctive gate that appears as a shuffle when they walk pre-hospital treatment is limited and non-emergency transport is usually recommended As stated earlier, pelvic inflammatory disease itself is seldom life-threatening, but it is serious enough to require transport and evaluation in the hospital.
Sexual assault and rape Unfortunately, sexual assault and rape are all too common occurrences. According to a government survey, approximately 18% of women, or 1 in 5, in the United States reported being raped during their lifetime. and one in every three have been sexually abused in some form often before the age of 12 years emergency medical technicians called to treat a victim of sexual assault sexual abuse or actual or alleged rape face many complex issues ranging from obvious medical ones to serious psychological and legal issues you may be the first person the victim has contact with after the encounter and how you manage the situation from first contact throughout treatment and transport may have a lasting effect for the patient and you being professional respectful and sensitive is important when performing your assessment be aware of information suggesting the potential use of date rape or club drugs the patient may or may not be aware of the use of drugs in the assault but an inability to remember the event should create suspicion while alcohol is the most frequently used date rape drug Drugs such as Rohypnol, phenetrazepam known as roofies gamma hydroxybutyric acid known as liquid ecstasy Kettler ketamine known as special K clonopin clonase Pam methylene dioxamethamphetamine known as ecstasy and Xanax El Praslam are drugs typically used during sexual assault and rape for the intended purpose of incapacitating a person drugs that are added into a person's drink may go undetected because they often do not have a color smell or taste the effects may be immediate and are made more active with alcohol the person may become weak and confused and may even have a loss of consciousness these drugs cause muscle relaxation and loss of muscle compliance which may make the victim more compliant during a sexual assault if these drugs are still in the patient system during your assessment you may see hypotension bradycardia abdominal complaints difficulty breathing seizures, coma, and even death.
Because sexual assault and rape are crimes, you can generally expect law enforcement to be involved early in the situation. In many cases, emergency medical service may be called by law enforcement. Police officers generally have basic medical training, many states require at least basic training at the first responder, emergency medical responder, level.
Nevertheless, Primary training for police officers focuses on crime investigation, not patient care. A rape victim has just experienced a major trauma of the body and mind. The last thing a victim wants to do is give a concise, detailed report of what has just occurred.
If you attempt to gather patient information in this manner, it will most likely cause the victim to shut down. Whenever possible, a female rape victim should be given the option of being treated by a female emergency medical technician, because the patient may be experiencing mixed feelings toward men. These feelings will hinder the patient assessment, and the patient's well-being. The job of law enforcement is to solve the crime, arrest the perpetrator, and see justice served.
Your job, as the emergency medical technician, is to handle the medical and psychological aspects of the case, and to act as the patient advocate. In this capacity, it is important for you to focus on several key components. The first component is the medical treatment of the patient. Is the victim physically injured?
Are any life-threatening injuries present? Does the patient report any pain? The second component is your psychological care of the patient.
Do not cross-examine the patient or attempt to obtain information for the benefit of the police. These issues will be handled later by the hospital staff and police. Do not pass judgment on the patient, and protect the patient from the judgment of others on the scene. A crime may have been committed, and you need to remain aware of that fact. Many women report feeling violated when subjected to interrogation, criticism, or disbelief.
Last. Remember that you are at a crime scene, and the victim's body is part of that crime scene. Although your job is to treat the medical aspects of the incident, and not to collect evidence, you still have a responsibility to preserve evidence.
Do not cut through any clothing or throw away anything from the scene. Place blood-stained clothing and anything else that could be evidence in separate paper, not plastic, bags. Obtain evidence bags from the police if necessary.
paper bags allow wet items to dry naturally whereas plastic allows mold to grow and may destroy biologic evidence it may be necessary to gently discourage the patient from cleaning herself victims tend to want to wash away the humiliation and embarrassment of the assault valuable evidence can be destroyed in this process also discourage the patient from urinating changing clothes moving her balls or rinsing out her mouth she will be photographed and examined by nurses trained in sexual assault examination and management sometimes called sexual assault nurse examiners or law enforcement personnel as well and the evidence needs to be as accurate as possible if you cannot discourage the patient from taking these actions respect her feelings some patients may refuse transport altogether and they have the right to do so in such cases Follow your system's refusal of treatment policy or procedure for sexual assault victims without judging or talking down to the patient. Your compassion is the best tool you have to gain the patient's confidence and encourage her to get help. If the patient refuses transport, offer to call the local rape crisis center for her.
Many communities have rape crisis centers with victim advocacy hotlines. Having a professional advocate at the scene may help the patient deal with the trauma, and the advocate can better explain in more compassionate detail the necessity of preserving evidence. Many victim advocates are rape trauma survivors themselves. They can provide support to the patient in the hospital during any additional physical examinations.
Take the patient's history, and limit any physical examination to a brief survey for life-threatening injuries. Treat all other injuries such as contusions or lacerations according to the appropriate procedures and protocols for your emergency medical service system. Follow standard precautions.
Expose and examine the vaginal area only if there is evidence of bleeding that needs to be treated. Cover and protect the patient from curious onlookers. Examine and interview the patient with a minimum of people present. Move her to the ambulance if necessary. The patient report is a legal document and, should a case result in an arrest, and subsequent trial, may be subpoenaed.
Keep the report concise, and record only what the patient stated in her own words. Use quotation marks to indicate you are reporting the patient's version of events. Do not insert your own opinion as to whether the patient was sexually assaulted or raped or offer any conclusions that would prove or disprove the patient's account of the event. Focus on the facts. Record all of your observations during the physical examination, the patient's emotional state, the condition of her clothing, obvious injuries, and so forth.
Remember that rape is a legal diagnosis, not a medical diagnosis. The medical team can establish only whether sexual intercourse occurred. A court must decide whether sexual intercourse was forcibly inflicted against her will.
Table 24-1 lists the treatment principles you should use when dealing with a victim of sexual assault. Often the most important intervention for sexual assault patients is comforting reassurance, and transport to a facility that has employees who are certified to perform the proper physical examination in this type of case. reminding the patient that she is safe with you and that the hospital staff and the police will take good care of her may help reassure her. Sometimes just the presence of a female emergency medical technician can be emotionally helpful.
Do not insist that the patient talk to you, but listen carefully and do not be judgmental if she does want to talk. Remember that victims of sexual assault may also need medical assistance. Therefore, treat the medical injuries.
but also remember to ensure the patient's privacy and provide her with emotional support although most cases have sexual assault are on women by men it is important to remember that it is possible for a man to be sexually assaulted or for the assailant to be either a woman or a man the principles of care above still apply and the likelihood of psychological trauma is just as strong