Gynecological Emergencies

Gynecological emergencies manifest as severe pelvic pain, bleeding, or both:

1. Sexual assault.
2. Infections, e.g., STIs, tubo-ovarian abscesses.
3. Trauma, e.g., straddle injuries in children.
4. Dysfunctional uterine bleeding due to hormonal cycle abnormalities.
5. Malignancy or benign fibroid tumors.
6. Complications to undiagnosed or first-trimester pregnancy, i.e., ectopic pregnancy.

 

Sexual Assault

Sexual assault can cause vaginal bleeding from forced penetration resulting in lacerations and other trauma to the vagina and surrounding area. Consensual sex allows for lubrication and elasticity of vaginal tissues, which the lack thereof is fraught with tearing (lacerations) which can extend deeply and involve arterial vessles.

Since rape is an act of violence, there may be other injuries as well, such as internal abdominal trauma or a post-concussion status. The emotional component can often make the patient uncooperative, silent, or even combative. Younger or sexually immature victims will present additional psychological challenges that may interfere with your care.

EMS providers should support the ABC’s and take every effort to maintain any evidence needed by law enforcement, should advise the patient to refrain from cleaning the affected area or showering, and should attempt to stop bleeding with topical pressure only. If at all possible, have a female EMS responder take the lead role.

Be alert to evidence of alcohol consumption in the environment and note it, i.e, empty liquor, beer, or wine bottles, the smell of alcohol, etc. (Even drug paraphernalia is pertinent to note.) One of the likely legal arguments used to disprove assault is "consent," that is, that the sexual activity was consensual, but if alcohol or drugs are involved, the argument of consent could arguably be eliminated. This makes prudent a blood alcohol level (and toxicology screen) upon arrival at the appropriate facility.

 

Infections

Infections such as yeast and bacterial vaginosis can cause vaginal bleeding due to increased irritation and inflammatory changes in mucous membranes. This is usually nothing more than spotting and usually will not be severe enough to summon EMS services. (There are no bacterial vaginosis emergencies!)

Sexual trauma and even digital and foreign body trauma can result in secondary bacterial infections causing pain severe enough to call for EMS responders.

Exaggerated scratching of minor vaginal irritations (e.g., yeast infection) can result in bleeding and secondary bacterial infection. Minor bleeding should be managed by placing a sterile gauze pad over the area which can be held in place by the patient herself. I

In cases of serious infection, pain and discomfort are usually the presenting complaints, with vaginal bleeding a secondary complaint. Nevertheless, EMS providers should wear proper PPE and apply topical pressure to control any significant bleeding. Vaginal discharge, however, may be the superficial symptoms of a much more serious internal pelvic/abdominal infectious process that could result in an acute abdomen or sepsis.

Therefore, pelvic pain should be assessed and treated like any abdominal pain, since the internal pelvis is continuous with the rest of the abdomen. Adequate support of the ABC’s is always indicated.

STIs: Sexually transmitted infections (alternately, STDs) may cause vaginal bleeding or bleeding from the area around the vagina due to open sores, changes in the mucous membranes, digital trauma, and other reasons.

EMS providers should wear proper PPE and apply topical pressure to control significant bleeding. Vaginal pain, discharge, and discomfort are usually the presenting complaints, with vaginal bleeding a secondary complaint. However, always keep in mind a more serious condition higher up (into the pelvis/abdomen). Minor bleeding should be managed by placing a sterile gauze pad over the affected area that the patient can hold herself. Adequate support of the ABC’s is always indicated.

 

Special Populations: Pediatric and Geriatric

PEDIATRIC

Menarche: Pediatric patients from ages 8-16 may be experiencing vaginal bleeding due to the onset of menarche. This is more unsettling to the patient and/or her parent(s) than actually dangerous.

Trauma: Traumatic straddle injuries (playground or gym equipment) can sometimes cause significant bleeding in a child. Inspection of the vulva area, even without physically touching the patient, usually demonstrates an obvious injury.

►Call to Action: TRANSPORT

Without knowing how far up the bleeding or laceration(s) extend, transport is necessary in any child with a straddle injury (including boys) for possible surgical pre-operative evaluation since there may be arterial bleeding that can dissect up tissue planes leading to hemorrhagic effects (hypovolemia, hypotension).

GERIATRIC AND MENOPAUSAL WOMEN

Atrophic Vaginitis: Geriatric or menopausal women can experience spotting and bleeding from thinning of the vaginal tissues due to lack of estrogen support of this tissue. This is termed "atrophic vaginitis" and seldom, if ever, is an emergency.

Leiomyomata: Uterine fibroids (leiomyomata; singular, leiomyoma) are benign space-occupying swirls of fibromuscular tissue that can attain pregnancy-like sizes in the uterus; they prevent the muscular uterus from effectively clamping down on its venous sinuses so that even a normal menstrual period can become a life-threatening hemorrhage. Even with normal and stable vital signs, heavy bleeding from fibroids can cause the vital signs to deteriorate suddenly, so it warrants transport.

Malignancy: The sudden onset of heavy bleeding, even hemorrhage, in an older woman--menopausal or not--should prompt suspicion of a gynecological malignancy which may have vaginal bleeding as its initial symptom.

These are often hemorrhagic emergencies, and the EMS provider should treat it like any other case of severe hypovolemic, hypotensive, and imminent shock. 

Hypotension is hypotension, and shock is shock, no matter the cause. It is sometimes possible to be distracted from the seriousness of the event due to the exotic or intimate nature some assign to gynecological problems.

COMPLICATIONS OF PREGNANCY

Anyone pregnant may experience vaginal bleeding due to complications with the pregnancy, anytime, from conception to delivery. First trimester (weeks 1-12) conditions are usually assigned as gynecologic as opposed to obstetrical.

First-trimester emergencies are usually:

1. Threatened spontaneous abortion. a threatened spontaneous abortion can present during early pregnancy with lower quadrant abdominal pain or vaginal bleeding. Almost 25% of pregnancies have some degree of vaginal bleeding during the first two trimesters (threatened spontaneous abortion), and almost HALF of the 25% who have bleeding progress to an actual abortion. The bleeding in a threatened abortion is usually mild to moderate. The abdominal pain may present as intermittent cramps, suprapubic pain, pelvic pressure, or lower back pain.

2. Complications of an elective abortion. In the context of delivering health care and being your patient's advocate, focus on the patient and her health. There are health risks and complications that can arise post-procedure.

• Common Complications: Excessive bleeding, infection, incomplete abortion.
• Recognize signs of complications. Get good history of symptoms and progression.
• Stabilize, manage shock if present, rapid transport.
• Ensure privacy, and maintain a supportive and non-judgmental demeanor.

3. ECTOPIC PREGNANCY:  the fertilized egg implants in tissue other than the uterus--that is, in tissue not designed to expand with its growth, and sooner or later, rupture at the implant site will occur. This can be in the tube, at the ovary, or even in the abdomen itself.

• Even though the uterus is the correct place for a fertilized egg to implant, there are areas--even there--where a pregnancy is at risk for loss:
• the UTERINE CORNU. These are the two corners of the uterus, thinner than the body of the uterus and prone to rupture.
• the CERVIX. Implantation near the exit out of the uterus, at the cervix, involves embedding in non-muscular tissue. Thus, bleeding is difficult to contain without the right muscular tone around it to close off bleeding areas.
• PREVIOUS IMPLANTATION SITES: Every successful pregnancy has a placenta and an attachment site, which ends up with a poorly vascularized scar. The more pregnancies a woman has, the more scar tissue and the more likely a subsequent pregnancy will attempt attachment there, which would prove to be a less-than-desirable vascular bed for normal growth.

Any of these can cause hemorrhage and even infection → shock, but whereas the infection is usually a smoldering process, hemorrhage can occur fairly early in the pathological process.

►Call to Action: TRANSPORT

Any woman of childbearing age, especially a young woman naive (in her first pregnancy) who suddenly experiences syncope, should be assumed to have a ruptured ectopic and hypotensive from internal bleeding till proven otherwise = rapid transfer and volume/fluid support.

 

When in Doubt...Transport

Depending on the severity of the gynecological emergency and the clinical presentation of the patient, emergent transport to a hospital is often necessary.

Because what is occurring internally is often hidden, the outward signs and symptoms can be misleading. It is better to err on the side of caution in decisions for transport. In cases of sexual assault, the patient should be transported to a hospital that has the capability of forensics via a sexual assault kit. (That window of opportunity closes quickly.)

Because many gynecological emergencies involve otherwise young and, moments earlier, healthy women, the discordance between what is perceived by the family before and after can have severe emotional consequences, especially in matters of a sexual nature, so the responder should be reassuring and of a calm demeanor at all times and be prepared for exaggerated emotional outbursts that can interfere with care.

Gynecological emergencies require communication with the hospital or other healthcare providers directly involved with the treatment of the patient in accordance with, and maintaining of, all ethical and moral standards. Documentation should be thorough and include all pertinent findings, objective and subjective information, treatment, response to treatment, vital signs, and condition upon arrival at the facility. Most states require mandatory reporting to law enforcement of sexual assault.