1. GYNECOLOGICAL EMERGENCIES

2. OBJECTIVES Upon completion, the student will be able to: 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 emergency 5. Describe the general care for any patient experiencing a gynecological emergency.

3. OBJECTIVES 6. Describe the pathophysiology, assessment, and management of the following gynecological emergencies: a) Pelvic inflammatory disease b) Ruptured ovarian cyst c) Cystitis d) Mittelschmertz e) Endometritis f) Endometriosis g) Ectopic pregnancy h) Vaginal hemorrhage

4. OBJECTIVES 7. 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.

5. Gynecology Branch of medicine that deals with female reproductive tract. Branch of medicine that deals with female reproductive tract. Most patients will complain of either abdominal pain or vaginal bleeding. Most patients will complain of either abdominal pain or vaginal bleeding.

6. Menstrual Cycle Monthly hormonal changes that prepares the uterus to receive the fertilized egg. Monthly hormonal changes that prepares the uterus to receive the fertilized egg. Starts when a girl is approximately 12-14 years of age. Starts when a girl is approximately 12-14 years of age. Beginning of menses is termed menarche. Beginning of menses is termed menarche. Cycle influenced by estrogen and progesterone. Cycle influenced by estrogen and progesterone.

7. Menstrual Cycle A normal cycle varies from one individual to another. 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. Day 1 is the day on which bleeding starts. Flow usually lasts from 3-5 days. Average cycle lasts approximately 28 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) 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)

8. Menstrual Cycle At day 14, LH causes the release of an egg from the ovary, (ovulation). 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. 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. 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 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. If the egg is not fertilized, estrogen levels fall and the uterine lining sloughs away.

9. Menstrual Cycle This will start a new menstrual cycle, (menstrual phase). This will start a new menstrual cycle, (menstrual phase). Absence of a period should raise the suspicion of pregnancy. 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). Menstrual periods usually stop in a woman in her 40’s or 50’s, (menopause).

10. Assessment Includes the standard initial and focused exams. Includes the standard initial and focused exams. Particular attention should be paid during your SAMPLE History. Particular attention should be paid during your SAMPLE History. Usually patients will complain of abdominal pain or discomfort and/or vaginal bleeding. Usually patients will complain of abdominal pain or discomfort and/or vaginal bleeding.

11. History You will need to gather an obstetric history. Also remember to role out other problems that do not have a gynecological 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). 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. Also question about cesarean section, pelvic surgeries, abortion procedures. Determine and document the patient’s last menstrual period (LMP). Determine and document the patient’s last menstrual period (LMP).

12. History Was the last period normal or was the flow heavier or lighter. Are the patient’s periods regular. 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 using birth control, what kind? Is the patient having vaginal discharge: What is the color? Presence of blood? Is there an associated odor? 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. Be aware of the fact that the patient may feel uncomfortable about discussing these problems with you. Do not push the issue.

13. Physical Examination Initial, focused, and detailed as always. 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. 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!!!!! DO NOT PERFORM AN INTERNAL VAGINAL EXAM IN THE FIELD!!!!!

14. MEDICAL GYNECOLOGICAL EMERGENCIES

15. Pelvic Inflammatory Disease Most common cause of nontraumatic abdominal pain. Most common cause of nontraumatic abdominal pain. Infection of the female reproductive tract. Infection of the female reproductive tract. Usually involves the uterus, fallopian tubes, and ovaries. Usually involves the uterus, fallopian tubes, and ovaries. Common causes: gonorrhea and chlamydial infections. Common causes: gonorrhea and chlamydial infections. Staph or strep can also be causative agents. Staph or strep can also be causative agents. May be either acute or chronic. May be either acute or chronic. May develop into sepsis if left untreated. May develop into sepsis if left untreated. Adhesions can occur, causing organs to stick together. 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. Adhesions is a common cause of chronic pelvic pain and also increase the frequency of ectopic pregnancies.

16. Assessment of PID Most common complaint is abdominal pain. Most common complaint is abdominal pain. It is a diffuse pain and located at the along the lower abdomen. It is a diffuse pain and located at the along the lower abdomen. Moderate to severe. Moderate to severe. Hard to distinguish from appendicitis. Hard to distinguish from appendicitis. Pain may intensify during menstrual period Pain may intensify during menstrual period Pain may also intensify during sexual intercourse. Pain may also intensify during sexual intercourse. Walk in a shuffling gait, which decreases the pain. Walk in a shuffling gait, which decreases the pain. May be accompanied by fever, chills, nausea, and vomiting. May be accompanied by fever, chills, nausea, and vomiting. Vaginal discharge: yellow Vaginal discharge: yellow

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

18. Ectopic Pregnancy Implantation of a growing fetus in a place where it does not belong. Implantation of a growing fetus in a place where it does not belong. Most common site is within the fallopian tubes. Most common site is within the fallopian tubes. This is a surgical emergency This is a surgical emergency Rupture can occur with resultant hemorrhage. Rupture can occur with resultant hemorrhage. Patients present with one-sided abdominal pain, late or missed period, occasionally with vaginal bleeding. Patients present with one-sided abdominal pain, late or missed period, occasionally with vaginal bleeding.

19. Ovarian Cysts Cysts are fluid-filled pockets. When in the ovary they can rupture and be a source of abdominal pain. 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. 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.

20. Appendicitis Difficult to distinguish from PID or ectopic pregnancy. Difficult to distinguish from PID or ectopic pregnancy. Abdominal pain that develops around the navel and moves to the RLQ. Abdominal pain that develops around the navel and moves to the RLQ. Pain may be associated with anorexia, fever, nausea, vomiting, or shock. Pain may be associated with anorexia, fever, nausea, vomiting, or shock.

21. Cystitis Bladder infection. Bladder infection. Because the bladder lies anterior to the reproductive organs, it causes pain above the symphysis pubis once inflamed. Because the bladder lies anterior to the reproductive organs, it causes pain above the symphysis pubis once inflamed.

22. Mittleschmertz Abdominal pain during menstrual cycle. Abdominal pain during menstrual cycle. This pain is referred to as mittleschmertz, and is associated with the release of an egg from the ovary. This pain is referred to as mittleschmertz, and is associated with the release of an egg from the ovary.

23. Management Significant abdominal should be treated and transported. Significant abdominal should be treated and transported. Oxygen Oxygen IV: crystalloid of choice. IV: crystalloid of choice. Position of comfort Position of comfort

24. TRAUMA GYNECOLOGICAL EMERGENCIES

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

26. Gynecological Trauma Injuries to the external genitalia should be managed by simple pressure over the laceration. Injuries to the external genitalia should be managed by simple pressure over the laceration. IV crystalloid if bleeding is severe. IV crystalloid if bleeding is severe. Monitor hemodynamic state Monitor hemodynamic state MAST (local protocol) MAST (local protocol) NEVER PACK THE VAGINA!!!!! NEVER PACK THE VAGINA!!!!! Rapid Transport Rapid Transport

27. Sexual Assault One of the fastest growing crimes in the USA. One of the fastest growing crimes in the USA. 60% are not even reported. And sexual abuse of children is reported even less. 60% are not even reported. And sexual abuse of children is reported even less. There is no “typical victim” There is no “typical victim” Defined: sexual contact without the consent of the person assaulted. Vary from state to state. 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. Rape: penetration of the vagina or rectum of an unwilling female or the rectum in an unwilling male.

28. Sexual Assault In most states penetration must occur for an act to be classified as rape. 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. 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. Most victims know the assailant. Motivation is unclear, control of the victim, desire to inflict pain, aggression have been implicated.

29. Assessment of the Assault Victim Patients SHOULD NOT be questioned about the incident in the field. Patients SHOULD NOT be questioned about the incident in the field. Do not inquire about the patient’s sexual practices. Do not inquire about the patient’s sexual practices. Victim may be withdrawn or hysterical. Victim should be approached calmly and professionally. Victim may be withdrawn or hysterical. Victim should be approached calmly and professionally. Respect the victim’s modesty and explain all procedures. 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. Avoid touching the victim, unless necessary for exam. DO NOT examine genitalia unless there is life-threatening hemorrhage.

30. Management of the Assault Victim Psychological and emotional support is the most important help you can offer. Psychological and emotional support is the most important help you can offer. Maintain a nonjudgmental attitude. Maintain a nonjudgmental attitude. Assure confidentiality. Assure confidentiality. Same sex rescuer if possible. Same sex rescuer if possible. Provide safe environment (well lit area). Provide safe environment (well lit area). Respond to victim’s feelings and respect their wishes. Respond to victim’s feelings and respect their wishes. Always get permission to treat before touching the patient. Always get permission to treat before touching the patient.

31. Management Preservation of physical evidence is important: Preservation of physical evidence is important: 1. Handle clothing as little as possible 2. Do not examine the perineal area 3. Do not use plastic bags for blood-stained articles 4. Bag each item separately 5. Do not allow patients to comb their hair or clean their fingernails

32. 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