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Gynecologic Emergencies CEN Study Guide
Dysfunctional Uterine Bleeding
Abnormal uterine bleeding (AUB) is any bleeding from the uterus that is abnormal in volume or timing. This includes menses that occur irregularly, last for an abnormal number of days, or produce excessive blood loss. It occurs most often in adolescents and people approaching menopause. Common underlying causes of bleeding can be remembered with the mnemonic PALM-COEIN:
- Polyp
- Adenomyosis
- Leiomyoma (fibroids)
- Malignancy
- Coagulopathy
- Ovulatory disorder
- Endometrial
- Iatrogenic (e.g., IUD insertion)
- Not otherwise classified
Dysfunctional uterine bleeding (DUB) is irregular uterine bleeding with no underlying illness. It is usually the result of anovulation. Because no egg is released, the ovaries do not produce progesterone, leading to heavy, irregular periods. DUB is most common in adolescents and during perimenopause.
Physical Examination
- metrorrhagia and/or menorrhagia
- full gynecological and OB history to estimate volume of blood loss
- indicators of high volume of blood loss
- soaking more than 1 pad or tampon per hour
- changing pad or tampon frequently at night
- greater than 30 cc volume measured via menstrual cup
- passing clots > 1 in.
Diagnostic Tests
- pregnancy test
- CBC and coagulation profile
Management
- fluids or blood products as needed
- estrogen-progestin contraceptives (usually taken for 7 days)
- IV estrogen or tranexamic acid for severe bleeding
- nonemergent presentations: referred to a gynecologist/obstetrics specialist
Gynecological Infections
- Chlamydia is an STI caused by the bacteria Chlamydia trachomatis; left untreated, it can lead to PID, infertility, and ectopic pregnancy in women.
- Diagnosis: often asymptomatic, especially for men; discharge from site of infection; vaginal bleeding; dysuria; pruritis; NAAT performed on urine or swab
- Management: antibiotics (azithromycin [Zithromax], doxycycline); supportive treatment for symptoms
- Genital herpes is an STI caused by the two strains of the herpes simplex virus (HSV-1 and HSV-2). The first outbreak after the initial infection is the most severe; recurrent outbreaks, which vary in frequency and duration, will generally be less severe.
- Diagnosis: prodrome of itching, burning, or tingling at infection site; vesicles on genitalia, perineum, or buttocks; fever, adenopathy during Initial infection; PCRon swab of open lesion
- Management: antivirals; supportive treatment for symptoms
- Gonorrhea is an STI caused by the gram-negative diplococcus Neisseria gonorrhoeae; left untreated, it can lead to PID, infertility, and ectopic pregnancy.
- Diagnosis: usually asymptomatic; discharge from site of infection; dysuria; metrorrhagia; oropharyngeal erythema; culture or NAAT of swab
- Management: antibiotics (not fluoroquinolones); supportive treatment for symptoms
- Pelvic inflammatory disease (PID) is an infection of the upper organs of the female reproductive system, usually caused by an STI.
- Diagnosis: cervical, uterine, or adnexal tenderness; vaginal discharge; abdominal or low back pain; right scapular pain (Fitz-Hugh-Curtis syndrome); postcoital bleeding; metrorrhagia; dyspareunia; pleuritic URQpain; nausea and vomiting; fever; labs show infection
- Management: antibiotics; supportive treatment for symptoms
- Syphilis is an STI caused by the bacteria Treponema pallidum. The infection progresses through four stages: primary (3 - 90 days after infection), secondary (4- 10 weeks after infection), latent (3 months- 3 years after infection), and tertiary (> 3 years after infection).
- Signs and Symptoms (primary stage): firm, round, and painless chancres lasting 3-6 weeks
- Signs and Symptoms (secondary stage): rough, red rash on torso, hands, soles of feet; fever; lesions on mucous membranes; arthritis
- Signs and Symptoms (latent stage): asymptomatic
- Signs and Symptoms (tertiary stage): varies by affected system
- Diagnosis: positive VDRL, RPR, or specific treponemal antibody test
- Management: antibiotics; supportive treatment for symptoms
- Vulvovaginitis is inflammation of the vulva and vagina. It is usually the result of an infection by bacteria, yeast, or trichomoniasis (a protozoan parasite).
- Signs and Symptoms (general): dyspareunia, dysuria, vulvovaginal pruritis
- Signs and Symptoms (bacterial vaginosis): malodorous white-grey vaginal discharge
- Signs and Symptoms (vulvovaginal candidiasis): thick, white vaginal discharge with no odor (often described as “cottage cheese" like)
- Signs and Symptoms (trichomoniasis): frothy, green-yellow vaginal discharge; vaginal inflammation ("strawberry cervix")
- Diagnosis: culture or wet mount
- Management: antibiotic, antifungal, or antiprotozoal as indicated
Ovarian Disorders
Pathophysiology
Ovarian cysts form in the ovaries, usually a result of an unreleased egg (follicular cyst) or failure of the corpus luteum to break down (corpus luteum cyst). Ovarian cysts are usually asymptomatic and are often found during assessments related to other conditions. However, the cysts can rupture, causing intense pain. Symptoms of rupture are usually self-limiting, but rupture of corpus luteum cysts may lead to severe bleeding.
Ovarian torsion is twisting of the ovary or fallopian tube twists, usually secondary to ovarian cysts. It is a medical emergency that requires surgery to prevent further ischemia.
Risk Factors
- endometriosis
- infertility treatment
- hormonal imbalances
- hypothyroidism
- tubal ligation
- pelvic infection or inflammation
- smoking
Physical Examination
- cyst
- often asymptomatic
- pelvic pain, feeling of fullness, or discomfort
- dyspareunia
- irregular menstrual cycle
- rupture: sudden, severe, unilateral pelvic pain
- torsion
- acute, unilateral pelvic pain
- nausea and vomiting
- low fever
Diagnostic Tests
transvaginal ultrasound to diagnose
Management
- analgesics
- fluids or blood products (for severe hemorrhage)
- surgical intervention in rare cases of continued bleeding or large cyst
- torsion: surgical intervention required
Sexual Assault and Battery
Sexual assault is any unwanted sexual or physical contact or behavior that occurs without the explicit consent of the recipient. Victims of sexual assault can be male or female, adult or pediatric. It is a significantly underreported crime, and many victims know the assailant. Any patient presenting with a report of sexual assault should be treated with respect and dignity.
Management
- Assess for serious or emergent conditions that may require immediate treatment.
- For female patients, take a complete OB/GYN history.
- The physician or a certified sexual assault nurse examiner (SANE) may perform a sexual assault medical forensic exam (also called a sexual assault forensic exam or “rape kit") to document injuries and collect evidence.
- Follow hospital protocols for STI screening (some hospitals requireit while others do not).
- All patients reporting sexual assault should be offered post-exposure prophylaxis.
- emergency contraception (after negative hCG test)
- antibiotics and antiprotozoals (ceftriaxone, metronidazole, azithromycin and/or doxycycline)
- HIV postexposure prophylaxis (PEP)
- HPV vaccine
- Provide emotional support to patient.
- Provide patient with access to available resources for survivors of sexual assault, including hospital counselors and community sexual assault centers.
Legal Considerations
- Nurses should keep in mind that patients’ medical records are legal documents that may be used in criminal or civil court proceedings.
- All interactions with patients should be carefully documented.
- Nurses who are asked to testify in court should confer with the hospital’s legal team.
Gynecological Trauma
Pathophysiology
Patients presenting with complaints of genital pain or bleeding should undergo a thorough history and physical examination. External trauma can usually be identified easily; however, internal examination will be required to evaluate for deeper injury. Vulvar injuries may include lacerations and hematomas, while vaginal trauma may present with lacerations. Uterine and cervical injuries are generally associated with pregnancy; however, they can also be caused by vaginal or abdominal trauma. Undiagnosed vaginal trauma may result in secondary issues including dyspareunia, pelvis abscesses, and fistula formations.
Physical Examination
- pain (vaginal, external, or visceral)
- vaginal bleeding
- external laceration, ecchymosis, or mutilation
- hematuria or dysuria
- foul-smelling vaginal discharge
- labial edema
- visible wound, penetration injury, or embedded object
Diagnostic Tests
- urinalysis for hematuria
- CT scan and pelvic/vaginal ultrasound to assess the integrity of reproductive organs
Management
- pain management (analgesics, cold compresses)
- sutures for lacerations
- remove foreign object(s)
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