GYNECOLOGICAL
EMERGENCIES
OBJECTIVES
1.
2.
3.
4.
5.
Upon completion, the student will be able to:
Review the anatomic structures and physiology of the
female reproductive system.
Identify the normal events of the menstrual cycle.
Describe how to assess a patient with a gynecological
complaint.
Explain how to recognize a gynecological emergency
Describe the general care for any patient experiencing a
gynecological emergency.
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
OBJECTIVES
7.
8.
Describe the assessment, care and emotional support of the
sexual assault patient.
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 40s or 50s, (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 patients last
menstrual period (LMP).
History
Was the last period normal or was the flow heavier
or lighter. Are the patients 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
May be either acute or
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.
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.
Victim
Patients SHOULD NOT be questioned
about the incident in the field.
Do not inquire about the patients sexual
practices.
Victim may be withdrawn or hysterical.
Victim should be approached calmly and
professionally.
Respect the victims 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 victims 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 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
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
