CHAPTER 43. Gynecologic Emergencies
Kathleen Sanders Jordan
ANATOMY AND PHYSIOLOGY
Gynecologic emergencies can affect any organ in the internal or external female reproductive system. The internal reproductive organs include the vagina, cervix, uterus, fallopian tubes, and ovaries. The external genitalia include the mons pubis, labia majora and minora, clitoris, vestibular glands, hymen, vaginal orifice, urethral orifice, and the ducts of Bartholin’s and Skene’s glands. The perineum is the triangular area between the posterior portion of the vestibule and the anus that supports portions of the urogenital and gastrointestinal tracts.
The ovaries, fallopian tubes, and uterus are located inside the peritoneal cavity. The ovaries are bilateral oval structures, located between the uterus and lateral pelvic wall. During childbearing years, each ovary is 2.5 to 5 cm long, 1.5 to 3 cm wide, and 0.6 to 1.5 cm thick. Size diminishes significantly after menopause. The number of ova present in the ovaries also decreases with age—from approximately 2 million at birth to 300,000 to 400,000 by puberty. During ovulation each ovary releases a single ovum that is transported down the fallopian tubes to the uterus. The fallopian tubes (approximately 10 cm long) transport the ovum to the uterus through smooth muscle contraction. These bilateral tubes are not contiguous with the ovaries; consequently, the ovum can migrate into the peritoneal cavity. This is the basic mechanism that leads to endometriosis and to ectopic pregnancy in the peritoneal space.
The uterus is a thick-walled organ shaped like an inverted pear. It is suspended in the anterior pelvis above the bladder and in front of the rectum. Length in nulliparous women is 6 to 8 cm. After pregnancy the uterus lengthens to 9 to 10 cm. A layer of peritoneum covers the superior portion of the uterus and forms the serous layer of the uterine wall. The middle layer of the uterine wall consists of smooth muscle with an inner mucous lining called the endometrium. The lower portion of the uterus is referred to as the cervix and provides entrance into the uterus. It is located in the vagina between the bladder on the anterior aspect and the rectum posteriorly. The top of the uterus is called the fundus.
The female reproductive cycle consists of ovulation and menstruation, with each cycle determined by the level of female hormones. Changes in hormone levels prepare the endometrium for implantation of a fertilized ovum. If the ovum is not fertilized, the endometrium sheds the inner lining as menstrual flow. A normal menstrual cycle occurs every 21 to 45 days (average of 28 days for most females) with menstruation lasting from 2 to 7 days; an average of 35 to 150 mL of blood is lost with each cycle.
ASSESSMENT
An accurate history is critical to the assessment process. A patient’s behavior during the assessment process may provide important clues as to the patient’s feelings and attitudes regarding her illness. Pain and emotions related to one’s reproductive organs and sexuality may cause a great deal of anxiety and fear for patients. It is important that the ED nurse create an environment to establish rapport and ensure confidentiality with each individual patient to facilitate the discussion of this sensitive material. Essential components of the history include chief complaint, pain assessment (i.e., provocation, quality, radiation, severity, and timing), presence of vaginal bleeding, presence of vaginal discharge, menstrual history, obstetric history, sexual history, medical/surgical history, medications and allergies. All female patients of reproductive age should be considered pregnant until pregnancy has been ruled out through a urine or serum pregnancy test. Box 43-1 summarizes essential interview questions for this patient population.
Box 43-1
I nterview Q uestions for G ynecologic E mergencies
When was your last menstrual period? Was it normal?
How long does your period normally last?
Are you bleeding now? How much are you bleeding? How many pads or tampons have you used in the last hour? Are there any clots or tissue?
Is there a possibility you are pregnant?
How many pregnancies have you had? How many children do you have?
Do you normally have a vaginal discharge? Is there anything different about your discharge today?
Do you have any swelling, itching, redness, or pain?
Are you having other symptoms or problems?
Are you sexually active?
Do you have sex with men, women, or both?
In the past 2 months, how many partners have you had sex with?
What type of birth control do you use? Do you consistently use it?
Patients with gynecologic emergencies can experience significant blood loss and hypovolemia. The physical examination must include a general survey consisting of the patient’s general appearance; vital signs; skin color, moisture, and temperature; and cardiovascular and respiratory status. A focused assessment should include examination of the abdominal and genitourinary systems. The abdomen should be inspected, bowel sounds auscultated, and the entire abdomen palpated for areas of tenderness, masses, and signs of peritonitis. A complete pelvic examination should be performed, including assessment of the external genitalia, vagina, and bimanual examination of the uterus and ovaries; a speculum examination is commonly performed. Specimens should be obtained for sexually transmitted infection (STI) screening (e.g., chlamydial infection, gonorrhea, and trichomoniasis) and wet mount (i.e., normal saline and potassium hydroxide [KOH]).
Diagnostic tests indicated for the patient with a gynecologic emergency should include a urinalysis and urine or serum pregnancy test. A catheterized urine specimen should be obtained if the patient is bleeding from the vagina. Other laboratory tests that may be indicated include a complete blood count (CBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), serum electrolyte levels, blood type and crossmatch, and C-reactive protein. Ultrasonography, abdominal and pelvic computed tomography (CT), and magnetic resonance imaging (MRI) may also be useful diagnostic tests for evaluating masses and abscesses.
SPECIFIC GYNECOLOGIC EMERGENCIES
Vaginal Bleeding/Dysfunctional Uterine Bleeding
Vaginal bleeding in the nonpregnant patient can be due to a variety of causes, including hormonal imbalance; vaginal, cervical, or uterine disorders; trauma; infection; malignancies; systemic disease; medications; or blood dyscrasias. Eating disorders, excessive weight loss, stress, and exercise can also cause abnormal vaginal bleeding or amenorrhea. More than 8 saturated pads per day or 12 tampons per day is considered excessive bleeding, although blood loss is difficult to estimate depending on the frequency of pad or tampon changes. Vaginal bleeding is abnormal in prepubertal females and necessitates a full diagnostic workup. Terms used to define abnormal uterine bleeding are listed inBox 43-2.
Box 43-2
T erms U sed to D efine A bnormal U terine B leeding
Amenorrhea—no menstruation
Oligomenorrhea—too few episodes of bleeding
Menorrhagia—too much blood loss
Metrorrhagia—too many episodes of bleeding
Menometrorrhagia—too much and too many episodes of bleeding
Dysfunctional uterine bleeding (DUB) is the most common cause of vaginal bleeding during a woman’s reproductive years. The diagnosis of DUB is a diagnosis of exclusion and should only be made when other organic and structural causes for the abnormal bleeding have been ruled out.
Approximately 90% of DUB results from anovulation, which causes failure of the corpus luteum to develop. This leads to failure of normal progesterone secretion, resulting in continuous unopposed production of estrogen. Unopposed estrogen causes endometrial hyperplasia and irregular endometrial shedding, which can be excessive, prolonged, and life threatening. 13
DUB may occur at any age; however, given the fact that most cases are due to anovulation, it is most common at the extremes of the reproductive years. Most cases in adolescent girls occur during the first 18 months after the onset of menstruation because of immaturity of their hypothalamic-pituitary axis. 7 In the perimenopausal period, DUB may be an early manifestation of ovarian failure. Vaginal bleeding in the postmenopausal patient should be considered a malignancy until this is ruled out.
Assessment of the nonpregnant patient with vaginal bleeding includes a detailed history followed by an abdominal and pelvic examination. The history should include the amount and duration of bleeding the patient has experienced. The patient with an established menstrual history should be asked to compare the number of pads used per day in a normal menstrual cycle to the number used at this time. The average tampon holds 5 mL of blood, the average pad 5 to 15 mL of blood. Additional information should be obtained regarding the presence or absence of pain; date of last normal menstrual period (LNMP), including duration and flow; menstrual regularity; obstetric history; contraceptive use; and sexual history. Additional information should be obtained regarding comorbidities and medications taken.
A physical examination should be conducted to assess volume status, hemodynamic stability, and extent of bleeding. Laboratory specimens should be obtained for urinalysis, urine or serum pregnancy test, and CBC. Other laboratory tests that may be indicated include PT, aPTT, liver function tests (in the presence of liver disease), and type and crossmatch. A pelvic or intravaginal ultrasound examination may be obtained to evaluate for structural abnormalities.
In the presence of hemodynamic instability, nursing interventions should be directed at immediate resuscitation and stabilization. If bleeding is severe and the patient is not responsive to initial fluid resuscitation, a 25-mg dose of intravenous (IV) conjugated estrogen (Premarin) should be administered. Repeat doses every 2 to 4 hours may be administered as needed. A course of oral estrogen therapy (Premarin) may also be prescribed for cessation of bleeding. Perimenopausal women may be treated with cyclic oral contraceptives 4 times per day for a period of 7 days to control and regulate bleeding. 12 A gynecology consultation should be obtained for all patients with hemodynamic instability while the patient is in the ED. Patients who are discharged should be given a referral to a gynecologist for further workup. All patients with anemia should be advised to take an iron supplement.
Pelvic Pain
Pelvic pain is a common presenting chief complaint in patients seeking care in the ED. Pain in the lower abdomen or pelvis may be due to a variety of causes. The uterus, cervix, and adnexa share the same visceral innervation as the lower ileum, sigmoid colon, and rectum. Therefore it may be difficult to distinguish pain originating in the gynecologic organs from pain originating in the gastrointestinal organs. Poorly localized visceral pain originates in organs and viscera innervated by autonomic nerves. This may be caused by distention of a hollow viscus (e.g., fallopian tube or bowel), distention of the capsule of a solid organ, or stretching of pelvic ligaments or adhesions. In contrast, pain that is well localized originates from somatic nerve irritation, such as irritation of the peritoneum caused by an inflamed organ (e.g., endometritis, appendicitis) or the presence of blood or purulent fluid (e.g., ruptured ectopic pregnancy or ovarian cyst). 6 Pelvic pain is classified as acute, chronic, or cyclic. Box 43-3 outlines the causes of pelvic pain originating from the reproductive organs. An accurate history and physical examination is crucial in this patient population because the condition causing the pain may be life threatening.
Box 43-3
C auses of P elvic P ain of G ynecologic O rigin
ACUTE PELVIC PAIN
Abortion (threatened or incomplete)
Ectopic pregnancy
Ovarian cyst
Ovarian torsion
Acute pelvic inflammatory disease
Tuboovarian abscess
Endometritis
Degenerating fibroid
CYCLIC PELVIC PAIN
Mittelschmerz
Endometriosis
Dysmenorrhea
Adenomyosis
CHRONIC PELVIC PAIN
Adhesions
Chronic pelvic inflammatory disease
Dysmenorrhea
Pain with menstruation is a common gynecologic complaint, particularly in adolescents and young women. Primary dysmenorrhea is defined as pelvic pain during menstruation in the absence of other pelvic pathologic condition. It typically develops 1 to 3 years after menarche with an increasing incidence through the early to mid twenties as ovulatory cycles are established. Primary dysmenorrhea is the most common form of pain during menstruation. This problem may be significant, causing up to 10% of women to miss school or work days. 13 It is most severe in young, nulliparous women. Primary dysmenorrhea is characterized by crampy, low midline pain, which occurs secondary to progesterone-mediated uterine contractions and arteriolar vasospasm. The pain typically precedes menstrual flow by up to 24 hours and subsides after menses begins. There may be associated nausea, vomiting, back pain, headache, and irritability. 13
Secondary dysmenorrhea is cyclic menstrual pain associated with a pelvic pathologic condition. This is most frequently caused by endometriosis or pelvic inflammatory disease (PID). Other causes include intrauterine devices, adhesions, and benign tumors of the uterus.
Management of primary dysmenorrhea includes the use of nonsteroidal antiinflammatory drugs (NSAIDs) to inhibit the synthesis of prostaglandins; narcotics should be avoided. To maximize pain relief, NSAIDs should be administered before the onset of menses. If NSAIDs fail to provide relief, cyclic oral contraceptives (COCs) should be started to inhibit ovulation, which will decrease the amount of menstrual pain and bleeding. If dysmenorrhea persists despite the use of COCs, a secondary cause of dysmenorrhea should be considered and an appropriate diagnostic workup should be pursued. 7 Sympathetic reassurance is helpful after other causes of acute pelvic pain have been ruled out. Gynecologic follow-up is indicated.
Endometriosis
Endometriosis is a common cause of cyclic pain in menstruating women. Endometrial tissue develops outside of the uterus, causing pain with menses. Organs involved may include the ovaries, posterior cul de sac, fallopian tubes, and uterosacral ligaments. Despite the abnormal location of endometrial tissue growth, the tissue sloughs and bleeds just as the uterine tissue does. As the disease progresses, pelvic adhesions may develop. Pain is cyclic or constant and may vary in character and intensity. It is generally worse just before or during menses. The character of the pain may range from midline pelvic cramping to severe diffuse pain.
Endometriosis may be strongly suspected, but it is not a diagnosis made in the ED. Diagnostic studies include a pregnancy test, CBC, and urinalysis. Laparoscopy is the standard modality used to definitively diagnosis endometriosis. ED management focuses on pain control through the use of NSAIDs and possibly short-term narcotics. Further therapy depends on the severity of symptoms, stage of the disease, and desire for future fertility. Hormonal therapy may be used to mimic pseudopregnancy, chronic anovulation, and pseudomenopause.
Mittelschmerz
Pain with ovulation, referred to as mittelschmerz, is a transient, midcycle pelvic pain that occurs during or just after ovulation. The cause is increasing ovarian capsular pressure before the follicle erupts and leakage of prostaglandin-containing follicular fluid associated with ovulation. Mittelschmerz is characterized by sudden, sharp, and unilateral pelvic pain. Treatment includes antiprostaglandin therapy with NSAIDs for pain relief. Sympathetic reassurance is helpful after other causes of acute pelvic pain have been ruled out.
Ovarian Cyst
An ovarian cyst is a fluid-filled or semi–fluid-filled sac in an ovary that can develop at any time from the neonatal period to postmenopause. For most patients ovarian cysts cause no symptoms and are an incidental finding during ultrasonography performed for another reason. Follicle cysts of the ovary are the most common cystic structure found in healthy ovaries, and they develop during the first 2 weeks of the menstrual cycle. This type of cyst results from either failure of the mature follicle to rupture or failure of an immature follicle to undergo the normal maturation process. A follicular cyst may grow to a size of 8 to 10 cm, and stretching of the capsule is the cause of pelvic discomfort. Most of these cysts regress spontaneously over 1 to 3 months. Follicular cysts are thin walled and may rupture during sexual intercourse or strenuous exercise. The symptoms of a ruptured follicular cyst include sharp pelvic pain of sudden onset that resolves over a few days.
Corpus luteal cysts are much less common than ovarian cysts. These cysts develop during the latter half of the menstrual cycle during the luteal phase, and most regress at the end of the menstrual cycle. However, persistent corpus luteal cysts are blood filled and may rupture, producing sharp pelvic pain, intraperitoneal irritation, and bleeding, which may progress to anemia and hypovolemia. Bleeding from a ruptured corpus luteal cyst is usually self-limited but in rare cases may progress to hemorrhage and hypovolemic shock. 13
Diagnostic studies include a pregnancy test, urinalysis, and CBC. Definitive diagnosis is made through pelvic ultrasonography and/or laparoscopy. Treatment of ruptured ovarian cysts is directed at pain control with NSAIDs and/or narcotics and treatment of complications, including hypovolemia and hemorrhage. Patients may need admission for observation and serial hematocrit determinations to monitor bleeding. Surgical intervention is usually not required except for the rare case of continued intraperitoneal hemorrhage.
Ovarian Torsion
Twisting of the ovary or fallopian tube is referred to as torsion. Most ovarian torsions result secondary to an ovarian cyst (most commonly dermoid cysts). The pain associated with this disorder is due to ischemia and is usually described as acute, severe, and unilateral. Pain may be intermittent or constant. Associated symptoms commonly include nausea and vomiting, low-grade fever, and leukocytosis. Diagnostic studies include a pregnancy test, CBC, and pelvic ultrasonography. Patients with torsion require hospital admission for surgical intervention. If untreated, an ovarian torsion can lead to infertility, infection, and eventual necrosis of the affected ovary or fallopian tube.
Vaginal Discharge and Vaginitis
Discharge from the vagina that is odorless and clear to milky in color is normal and the body’s physiologic way of keeping the vagina healthy. A complex and intricate balance of microorganisms maintain the normal vaginal flora. Factors that can influence and alter the composition of the vaginal flora include age, stress, hormonal balance, sexual activity, contraceptives, hygiene products, antibiotics, and general health status. 10 Any change in the amount, color, odor, and/or associated symptoms of itching, burning, or irritation may indicate a change in this chemical balance in the vagina and lead to an infection. Vaginitis is common in postpubertal adolescents and adult women, but relatively uncommon in prepubertal females. The most common cause of vaginitis is bacterial vaginosis (40% to 50%), followed by Candida albicans (20% to 25%), and Trichomonas vaginalis (15% to 20%). 6
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