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