- Unilateral pelvic pain in early pregnancym
- Vaginal bleeding present or absent
- Risk factor assessment
- Unilateral adnexal tenderness or mass
- Uterine size less than dates
- Quantitative human chorionic gonadotropin (hCG) and pelvic ultrasound
Ectopic pregnancy is the leading cause of pregnancy-related death in the first trimester. Patients with ectopic pregnancy are often encountered in the emergency department, and the disorder may be difficult to identify given the varied presentations that occur. Because ectopic pregnancy can be life threatening, it should be suspected in any patient presenting with amenorrhea, vaginal bleeding, and lower abdominal pain. For some women, the initial presenting symptom of an ectopic pregnancy is syncope. The most common presenting complaint is vaginal bleeding, often scant at first, with cramping lower abdominal pain.
The incidence of ectopic pregnancy is increased in women using an IUD and in those with a history of pelvic infection (eg, salpingitis), tubal surgery, infertility treatments, or previous tubal pregnancies. About 98% of ectopic pregnancies are tubal.
The clinical presentation of ectopic pregnancy is variable, ranging from the asymptomatic patient to the patient with hemorrhagic shock. Rupture of the fallopian tube followed by free intraperitoneal bleeding from tubal vessels is the principal cause of illness and death.
With improved resolution of ultrasound and rapidly available quantitative hCG assays, the diagnosis of ectopic pregnancy can be made more accurately and earlier than in the past (Figure 38–3).
Diagnostic algorithm for the patient with possible ectopic pregnancy. IUP, intrauterine pregnancy.
Patients have a history of the following: (1) missed or abnormal menses or vaginal bleeding—however, 30% of patients with ectopic pregnancy have no vaginal bleeding; (2) pelvic pain, which may be unilateral, following amenorrhea; and (3) possible intermittent pain; rupture of the fallopian tube may bring temporary relief of pain.
Symptoms of early pregnancy (eg, breast tenderness and nausea) may be present. Unilateral abdominal or pelvic pain may be present. Referred shoulder pain, syncope, or lightheadedness may also occur. Peritoneal pain may develop after tubal rupture with bleeding into the peritoneum.
In the early stages of ectopic pregnancy, the results of pelvic examination may be normal. Initially, symptoms may be completely nonspecific, because the tubal pregnancy producing them may be in the early stages of development. In advanced cases, a tender adnexal mass, enlarged uterus, or blood in the peritoneal cavity (eg, doughy cul-de-sac) may occur.
Obtain complete vital signs, including supine, sitting, and standing pulse and blood pressure measurements to look for supine or orthostatic hypotension.
Laboratory Tests and Special Examinations
The qualitative urine and serum pregnancy test may be positive at levels as low as 10 mIU/mL. Check with the laboratory. The most specific and sensitive test is the serum quantitative hCG. It may detect levels as low as 5 mIU/mL depending on laboratory assay. Quantitative hCG values are invaluable in the interpretation of pelvic ultrasound in this setting. In a normal intrauterine first-trimester pregnancy, the hCG level should double about every 1.5 days.
Endovaginal and transabdominal sonography have become key diagnostic tools in the differentiation of normal (see Figures 38–1 and 38–2) from abnormal early pregnancy (Figure 38–4). Occasionally, a mass can be seen in the adnexa or cul-de-sac, or products of conception can be visualized outside the uterine cavity, and ectopic pregnancy can be readily diagnosed (see Figure 38–4).
Ultrasound is often useful in excluding an ectopic pregnancy by ruling in an intrauterine pregnancy. If the patient reports a history of infertility treatments, avoid making premature conclusions because the possibility of a heterotopic pregnancy (ie, simultaneous intrauterine and ectopic) has been reported to be as low as 1 in 4000. With an hCG of 6000–6500 mIU/mL, an intrauterine pregnancy can be visualized transabdominally 94% of the time. Likewise, a yolk sac can be identified at the discriminatory hCG values of 1000–1500 mIU/mL utilizing endovaginal sonography. With endovaginal scanning, a small intrauterine collection of blood, or pseudosac, may be seen associated with an ectopic pregnancy. In very early pregnancy, at levels below the discriminatory values, the uterus may appear empty. Fluid in Morison's pouch on transabdominal scanning strongly suggests ruptured ectopic pregnancy, usually requiring operative intervention (Figure 38–5).
Laparoscopy or Laparotomy
Laparoscopy or laparotomy may be necessary to make a definitive diagnosis of ectopic pregnancy.
Endovaginal ultrasound clearly demonstrating an ectopic pregnancy. A: Longitudinal view of the uterus with a well-defined endometrial stripe and no intrauterine gestational sac. A gestational sac is noted posterior to the uterus. B: Transverse view of the uterus and right adnexa also demonstrating an extrauterine gestational sac. C: Longitudinal view demonstrating free fluid in the cul-de-sac.
Bedside transabdominal ultrasound of free fluid in Morison's pouch (hepatorenal space) secondary to a ruptured ectopic pregnancy.
Treatment and Disposition
Treatment of possible ectopic pregnancy is determined by the patient's risk factors for ectopic pregnancy (ie, infertility treatments, history of tubal ligation, or pelvic inflammatory disease), hemodynamic stability, and physical examination findings. Sonography is important in the evaluation of pregnant patients with either abdominal pain or vaginal bleeding (see Figure 38–3). Quantitative hCG results may help in the interpretation of ultrasound findings. In addition, Rh-negative mothers should receive Rho(D) immune globulin.
High Probability of Ectopic Pregnancy
Obtain emergency pelvic sonography if hemodynamic stability allows. If the quantitative hCG value is greater than 1500–2000 mIU/mL in a patient with an empty uterine cavity on endovaginal ultrasound, ectopic pregnancy should be strongly suspected. An adnexal mass or extrauterine products of conception may or may not be readily identified. A large amount of pelvic or intraperitoneal fluid is highly suggestive of ectopic pregnancy (Figures 38–4C and 38–5). If ultrasound is unavailable for evaluation of a patient with a positive pregnancy test, physical findings worrisome for ectopic pregnancy include adnexal tenderness or an adnexal mass. However, do not be misled by a lack of peritoneal signs during your examination.
Prevent or correct hemorrhagic shock by inserting 2 large-bore (≥16-gauge) intravenous catheters and infusing crystalloid solution for volume replacement. Type and crossmatch for 2–4 units of packed red blood cells. Insert a Foley catheter, and send urine for analysis.
Obtain emergency obstetric consultation, and prepare the patient for surgery. Obtain CBC, serum electrolyte, blood urea nitrogen, creatinine, coagulation profile, and other studies as required.
Ectopic Pregnancy Equivocal
Vaginal bleeding, pelvic pain, and tenderness without explanation may be present in a patient with a positive pregnancy test.
Insert an intravenous catheter, and send blood for CBC and crossmatching. Obtain pelvic sonogram. A transvaginal sonogram may not show definite evidence of an ectopic pregnancy, but worrisome signs include fluid in the cul-de-sac or an empty uterus with a quantitative hCG at or above the discriminatory zone. Urgent gynecologic consultation is recommended in these situations.
Low Probability of Ectopic Pregnancy
Vaginal bleeding or pelvic pain is present. The results of physical examination and laboratory studies are normal. Some authors have developed clinical criteria for prediction of ectopic pregnancy. Suggested low-risk clinical criteria (ectopic pregnancy risk <1%) for patients with pain or bleeding include absence of signs of peritoneal irritation on palpation, no cervical, adnexal, or uterine tenderness, and no abdominal or pelvic pain other than in the midline.
Send blood for quantitative hCG. If a pelvic sonogram demonstrates an intrauterine pregnancy, and the patient is at low risk for a heterotopic pregnancy (ie, no fertility medications or procedures), discharge the patient with 24–48 hours follow-up. Other patients who can be managed as outpatients with close gynecologic follow-up include those with quantitative hCG below the discriminatory zone (1000 mIU/mL) with an empty uterus and no abnormalities on endovaginal ultrasound suggestive of ectopic pregnancy. Patients with an isolated quantitative hCG below 1000 are not necessarily low risk because nearly one-third of patients with ectopic pregnancies have a quantitative hCG level below 1000 mIU/mL. A decision based only on a single hCG value below the discriminatory values lacks specificity and needs to be carefully evaluated.
Discharge the patient from the emergency department to outpatient care with a definitive follow-up appointment for reevaluation within 1–2 days. Give the patient written instructions explaining that ectopic pregnancy is a possible diagnosis and she must be alert to the following symptoms, which would require that she return to the hospital immediately: (1) increased vaginal bleeding, (2) increased pelvic or abdominal pain, or (3) syncope.
- Vaginal bleeding in early pregnancy
- Pelvic and back pain common
- Variable pelvic examination findings
- Quantitative hCG and pelvic ultrasound
- Exclude ectopic pregnancy
At least 20% of all pregnancies terminate in abortion, usually because of serious defects in the ovum. Half of abortions occur before the 8th week of gestation and another quarter before the 16th week. Many of these early spontaneous abortions go unnoticed as a delayed menstrual period. Nevertheless, early spontaneous abortions are also a common cause of visits to the emergency department.
Fetal demise and failed expulsion of the products of conception from the uterus, with a closed cervix, is termed missed abortion. If this state persists for longer than 4–6 weeks, the patient is at increased risk for infection and disseminated intravascular coagulation. Table 36–4 describes the various types of spontaneous abortion.
Table 38–4. Classification of Spontaneous Abortion. ||Download (.pdf)
Table 38–4. Classification of Spontaneous Abortion.
|Type||Symptoms and Signs|
|Threatened abortion||Mild, transient uterine cramps with minimal transient vaginal bleeding.|
|The cervix is long and closed.|
|Uterine size is compatible with the presumed length of pregnancy.a|
|Symptoms of pregnancy continue, and the conceptus remains viable|
|Inevitable abortion||Persistent uterine cramps and moderate vaginal bleeding.|
|The cervical os is open (ie, a 0.5-cm [3/16-in] diameter sponge stick passes easily).|
|Passage of some or all of the products of conception is inevitable or is about to occur; ie, fetal or placental tissue is found in the vagina or protrudes through the cervical os, or the patient gives a history of passage of tissue.|
|Symptoms and signs of pregnancy disappear.|
|Incomplete abortion||Uterine cramps and vaginal bleeding are persistent and excessive.|
|Symptoms of pregnancy may disappear.|
|Products of conception are noted in the vagina, or the patient gives a history of passage of tissue.|
|Complete abortion||Uterine cramps markedly diminish or stop.|
|Vaginal bleeding ceases.|
|The entire conceptus is expelled.|
|Symptoms of pregnancy disappear.|
|Missed abortion||The products of conception are retained.|
|Symptoms and signs of pregnancy abate, and results of pregnancy tests change to negative.|
|Brownish vaginal discharge (rarely, frank bleeding) occurs.|
|Uterine cramps are rare. Examination shows a small and irregularly softened uterus.|
|Ultrasonography fails to demonstrate a live fetus; ie, fetal heart motion is absent.|
Almost all patients have a history suggesting possible pregnancy:
- Sexual intercourse
- Period of amenorrhea or abnormal menses
- Nausea and vomiting; breast tenderness
- Uterine cramps and vaginal bleeding
- Passage of fetal or placental tissue (incomplete or complete abortion)
Caution: Pelvic examination should be performed on all patients with suspected abortion and on all pregnant patients with vaginal bleeding who have reached less than 20 weeks' gestation. Extreme care, however, must be exercised in examining patients in the second trimester; instruments should not be introduced into the cervical os. Beyond 20 weeks' gestation, pelvic examination should be done by an obstetrician because of the increasing risk of placenta previa.
Laboratory Tests and Special Examinations
In the first trimester of pregnancy, an hCG level that does not double in 48 hours suggests fetal demise or an abnormal pregnancy. Real-time ultrasonography, using abdominal or vaginal probes, can be diagnostic, for example, demonstrating a fetus without heartbeat or movement. Pathologic examination of tissue expelled by the uterus confirms passage of the products of conception.
Treatment and Disposition
Blood typing and antibody screening are required in all patients with abortion of any type. If patients are Rh-negative, give Rho(D) immune globulin (RhoGAM 300 mcg IM, many others), within 72 hours after any event in which fetal–maternal transfusion may occur, including abortion.
Advise the patient to rest. Do not use hormones, douches, or tampons. The patient should not engage in coitus. Ultrasound may reveal a gestational sac or evidence of fetal cardiac activity. Discharge instructions must include follow-up instructions and indications for return to the emergency department, including passage of fetal tissue, severe vaginal bleeding greater than one pad per hour, significant abdominal or pelvic pain, or fever. The patient should also be given adequate analgesia.
Incomplete or Inevitable Abortion
Hospitalize the patient if hypovolemia or anemia is present or if the pregnancy is past the first trimester. Treat hypovolemia if present. An obstetrical or gynecological consult should be obtained to perform possible suction curettage or dilation and curettage.
The patient may be discharged to home care if vital signs and hematocrit are stable and if vaginal bleeding is clearly decreasing. Pain must also be clearly decreasing and the cervical os closed. A physician must differentiate a complete abortion from an incomplete abortion. Several clues can help the physician determine that a complete abortion has occurred:
- A reliable history.
- Ultrasound revealing a clean uterine stripe.
- The products of conception are brought to the physician and confirmed by pathology. If pathology is not readily available, a physician can differentiate between blood clots and products of conception by rubbing the specimen between a wet gauze pad. Unlike blood clots, true products of conception will not dissolve.
Missed Abortion (Retained Conceptus)
Obtain CBC, differential, and coagulation panel (platelet count, prothrombin time, and partial thromboplastin time). Obtain disseminated intravascular coagulation screening tests if abnormal values are found. Hospitalize the patient, and prepare to perform dilation and curettage if evidence indicates infection or disseminated intravascular coagulation or if the products of conception have been retained more than 4 weeks.
Outpatient management of early missed abortion is possible if the patient has close follow-up.
- History of gynecologic procedure or abortion
- Pelvic pain
- Systemic signs of infection
- Tender uterus
- Profuse, malodorous vaginal discharge
Septic abortion is a rare complication after some obstetric–gynecologic procedures. Septic abortion may also arise as a result of nonsterile nontherapeutic abortion. The usual cause of sepsis is incomplete evacuation of the products of conception. Infection is usually due to mixed aerobic and anaerobic bacteria (bacteroides, Prevotella, group B streptococci, Enterobacteriaceae, and C. trachomatis) and is rapidly progressive, extending quickly through the myometrium and involving the adnexa and pelvic peritoneum. Septic pelvic thrombophlebitis with or without septic pulmonary embolization is an uncommon but devastating complication.
Symptoms and signs are consistent with a history of recent pregnancy and induced abortion followed by pelvic pain and symptoms of infection. Nonjudgmental questioning in a private setting by a physician may be necessary to elicit a history of nontherapeutic abortion; in some cases, such a history is never obtained. Clinical findings include signs of infection (eg, fever and leukocytosis); diffuse pelvic tenderness; and profuse, foul vaginal discharge in most cases. Frank septic shock may be present.
Ultrasound or other imaging techniques (computed tomography [CT], magnetic resonance imaging) may show retained intrauterine material, uterine emphysema, or intraperitoneal air from uterine perforation.
Treatment and Disposition
Evacuation of the uterine contents and administration of broad-spectrum antibiotics are the mainstay of treatment.
Note: Although antibiotic therapy alone is effective in the earliest stage of infection, many patients require emergency hysterectomy. Death may occur despite the best treatment.
Hospitalize the patient at once, and start general measures for septic shock (Chapters 11 and 42). Obtain emergency surgical obstetric–gynecologic consultation.
Obtain samples of blood and uterine discharge for culture. Draw blood for CBC, hepatic and renal panels, serum electrolyte determination, prothrombin time, partial thromboplastin time, platelet count, and disseminated intravascular coagulation screening tests if initial findings are abnormal.
After taking specimens for culture of aerobic and anaerobic organisms, give antibiotics (eg, doxycycline, 100 mg IV every 12 hours, and one of the following: cefoxitin 2.0 g every 6–8 hours IV, piperacillin/tazobactam 4.5 g IV every 8 hours, ampicillin/sulbactam 3 g IV daily, or ertapenem 1 g IV daily. An alternate regimen consists of clindamycin 900 mg IV every 8 hours, plus ceftriaxone 1 g IV daily.
Carcinoma and Other Tumors
Although gynecologic cancers seldom present as emergency situations, the emergency physician should be aware of the various presenting symptoms and risk factors associated with gynecologic cancers. Vulvar cancers are rarely sudden in onset and usually occur in women over age 50 years. They are more common in women with a history of cervical dysplasia or cancer.
Persistent unremitting vaginal pruritus is the single most common symptom of vulvar cancer and should never be dismissed as a frivolous complaint in the post-menopausal patient. Vaginal cancers are rare. Bleeding is typically the presenting complaint. The patient is usually of 50 years or older, but even teenagers have developed clear cell carcinoma (eg, girls whose mothers were given diethylstilbestrol during pregnancy). Patients with ovarian cancer may have abdominal distention from ascites, intestinal obstruction, or rarely, acute abdominal pain. Furthermore, ovarian carcinoma increases the risk for ovarian torsion.
Patients with gestational trophoblastic disease may present with heavy vaginal bleeding and symptoms similar to those of early miscarriage, but the following symptoms and signs suggest trophoblastic disease: (1) heavy vaginal bleeding with or without passage of tissue, or grape clusters of tissue aborted from the cervical os; (2) uterine size inappropriately large for dates; (3) profound anemia; (4) history of molar pregnancy; (5) first-trimester hypertension or preeclampsia; or (6) hCG remarkably elevated over the expected values. The diagnosis can be confirmed by ultrasound examination.
Any patient presenting with neurologic signs and with a recent history of molar pregnancy or trophoblastic disease may have cerebral metastasis. Central nervous system metastasis of trophoblastic disease represents a true oncologic emergency, because cerebral metastasis has the potential for cure as long as rapid growth or hemorrhage does not occur.
Patients with trophoblastic disease should be hospitalized for gynecologic consultation.
For any carcinoma, if the bleeding is severe, it is imperative to try to control the bleeding (ie, vaginal packing), volume resuscitate, and obtain emergency surgical and obstetrical consultation.
Vaginal bleeding is the most common symptom in cervical cancer. Patients may be in their late 20s to (most commonly) early 40s. Patients often complain of persistent watery discharge. Speculum examination reveals a necrotic friable lesion on the cervix.
Uncontrollable bleeding from the cervix may be treated with applications of ferric subsulfate solution or vaginal packing. Manipulation should be kept to a minimum. Biopsy of the lesion at its margin with normal tissue usually confirms the diagnosis, but this procedure should not be performed in an emergency department.
Carcinoma of the Endometrium
Postmenopausal bleeding is the most common symptom of endometrial carcinoma. Risk factors associated with endometrial carcinoma include ingestion of exogenous estrogens, obesity, infertility, polycystic ovarian syndrome, and age over 50 years.
The physician should not try to stop postmenopausal bleeding with administration of hormones (eg, estrogens or progesterone) without confirming the diagnosis beforehand. Consultation with a gynecologist should be obtained prior to discharge for further input.
Genital trauma in women almost always occurs as a result of sexual activity, either forced (rape) or voluntary. Penile thrusts rarely produce trauma unless it is the first sexual experience.
The most common presenting complaints are vaginal bleeding and pain or dyspareunia. Examination usually reveals bleeding from a tear in the genital mucosa or skin. Bleeding is rarely brisk enough to produce signs of hypovolemia, but if these are present, replace volume losses, and provide supportive care (Chapter 11). In prepubertal patients, general anesthesia may be required for adequate examination.
Treatment and Disposition
Determine whether rape has occurred, and proceed accordingly. Provide sedation or analgesia if necessary.
Treat hypovolemia if present. Control vaginal bleeding temporarily with a vaginal pack, or direct firm pressure if the bleeding is from the external genitalia. A urethrogram may be needed if urethral trauma is suspected.
Hospitalize the patient if bleeding cannot be easily and definitively controlled, and obtain gynecologic consultation. Small lesions at the introitus may be repaired in the emergency department under local anesthesia. However, small and seemingly minor vaginal tears may communicate with either the rectum or the peritoneum; consequently, such repairs are best performed by a gynecologist in an operating room with adequate anesthesia and good exposure.
- Sudden, moderate to severe unilateral pelvic pain
- Possible history of initial nausea, diaphoresis, nearsyncope
- Lack of systemic signs of infection
- Negative pregnancy test
- Unilateral adnexal tenderness without mass
- Pelvic ultrasound excludes significant hemorrhage
Ruptured ovarian cyst is associated with sudden, moderately severe pelvic or lower abdominal pain. The patient is afebrile, and leukocytosis is variable. Tenderness is found over the affected ovary, and there are no masses. A pregnancy test should be obtained because ectopic pregnancy is a possible diagnosis. Ultrasonography may show the presence of an ovarian cyst or free pelvic fluid and is useful to detect ectopic pregnancy.
Treatment and Disposition
The physician should provide adequate analgesics, including narcotics if needed. The patient should be observed and may require hospitalization if the diagnosis is uncertain or if relief is required for severe pain not relieved by narcotics. Surgery is rarely required unless there is a significant hemoperitoneum from the rupture of a hemorrhagic corpus luteum cyst with hemodynamic instability.
- Extremes of age
- Single or recurrent moderate unilateral pelvic pain
- Negative pregnancy test
- Pelvic mass
- Pelvic ultrasound
Torsion of ovary is associated with a history of attacks of severe unilateral pain in the lower abdomen. There is a bimodal age distribution which includes the adolescent and postmenopausal women older than 50. The symptoms may be gradual, or occur suddenly if there is accompanying intraovarian bleeding. Physical examination can be unreliable, therefore imaging studies, usually ultrasonography, is needed. Doppler studies can detect decreased or absent blood flow to the torsed ovary. If other intra-abdominal pathology is suspected, computed tomography may be the better imaging modality.
Treatment and Disposition
Hospitalize the patient, and obtain urgent gynecologic consultation. Laparoscopy is frequently required. Laparotomy is indicated if the diagnosis is confirmed or if the patient's condition deteriorates.
- Recurrent pelvic, flank, or abdominal pain with menses
- Negative pregnancy test
The patient with endometriosis gives a history of attacks of crampy lower abdominal pain associated with menstruation. Symptoms may be gradual, or sudden if bleeding is present. Acquired dysmenorrhea is most commonly due to endometriosis. Other symptoms include painful defecation and dyspareunia.
Treatment and Disposition
Refer the patient for further gynecologic evaluation. Definitive diagnosis usually requires laparoscopy. Provide oral analgesia as needed.
- Painful menstruation
- Negative pregnancy test
- Exclude pelvic infection
Many women experience painful menstruation (dysmenorrhea). The pain is cramping in nature, may be debilitating, and is usually relieved by menses. The pain occurs because of elaboration of excessive quantities of prostaglandins by the endometrium with subsequent increased uterine tone. It is not psychological in origin.
Idiopathic dysmenorrhea usually begins at menarche and is probably more common than the acquired form. Acquired dysmenorrhea, occurring in the late teens and early 20s, may suggest endometriosis and is common in chronic pelvic inflammatory disease.
Treatment and Disposition
Both types of dysmenorrhea may be seen by the emergency physician and may be treated by prostaglandin inhibitors (eg, ibuprofen, 400 mg orally every 6 hours; naproxen, 250–500 mg twice daily; or controlled release, 750–1000 mg every day). Local application of heat to the lower abdomen may be helpful.
Midcycle pain (mittelschmerz) is common in women with regular menstrual periods who are not taking birth control pills. These patients may commonly have mid-cycle spotting caused by an estrogen surge. There is no fever and no other abnormal bleeding such as that resulting from trauma to the cervix (eg, coitus and douching). Pain usually occurs over several cycles. There is no history of intermittent lower abdominal pain. Examination at the time of mittelschmerz may reveal some lower quadrant tenderness with or without rebound. Bimanual examination may show localized tenderness. A palpable ovary may be present, but a history of regular menses, lack of fever, and negative pregnancy tests confirm the diagnosis.
Mild analgesics and reassurance are usually adequate for these patients.
- Prior vaginal deliveries
- History of pelvic heaviness, low back pain
- Patient may present with urinary retention
- Firm, muscular mass in or protruding from vagina
Uterine prolapse typically occurs because of muscular defects in the pelvic floor arising from childbirth. Prolapse is characterized by variable symptoms of pelvic heaviness or a dragging sensation and lower back pain. Urinary retention of sudden onset may be a presenting complaint. Examination reveals a firm, muscular mass in the vagina or protruding from the vagina (procidentia) and having the shape and size of the uterus and cervix. Cystocele, rectocele, and enterocele are commonly associated with procidentia.
Treatment and Disposition
Uterine prolapse associated with delivery requires immediate obstetric–gynecologic consultation, as significant hemorrhage and hemodynamic instability may occur. Reversion of the uterus should be attempted by manual pressure, directing the fundus back through the introitus. Tocolytics may be used to relax the uterus if needed. After repositioning, oxytocin is given to facilitate uterine contraction and prevent further prolapse. Patients with acute urinary retention or procidentia should have urgent gynecologic consultation. Patients with mild prolapse should be referred within 5–7 days for gynecologic evaluation and possible surgery.
Salpingitis and Tubo-Ovarian Abscess
Proper care of the reported rape victim requires concern for the social and emotional consequences of the event as well as for the medical sequelae. The best care fulfills the requirements of the law while providing proper support and reassurance to the patient. Every state has its own laws and regulations concerning rape; however, some general principles apply. The physician's responsibilities include the following:
- recognizing and managing life-threatening trauma (eg, hemorrhagic shock);
- obtaining informed written consent for physical examination, collection of evidence, photographic documentation, and treatment;
- shielding the rape victim from other patients, bystanders, and visitors;
- accurately diagnosing and treating all physical injuries, both genital and nongenital;
- recording a detailed and explicit history of the event in the patient's own words;
- carefully collecting specimens for evidence, with accurate documentation and protection of the chain of evidence;
- providing psychological support and follow-up;
- offering prophylaxis against pregnancy and sexually transmitted disease;
- the physician should avoid judgmental or conclusive language;
- being willing to testify in court;
- ensuring that discharge from the emergency department is to a safe place;
- encouraging a physical examination even if the patient declines forensic examination.
- Unless required to do so by statute, the emergency physician does not have a legal obligation to notify the police when providing treatment to a victim of the rape. Notifying the police is appropriate when the patient has consented (preferably in writing) to such notification. The physician may wish to refer the patient to a counseling organization that aids rape victims.
- The responsibilities described above may be fulfilled by having a multidisciplinary team who follows an established protocol.
Management of the Rape Victim (Man or Woman)
If required by law or with the patient's consent, inform the police (see below). Obtain written informed consent for examination.
Obtain and record the history in the patient's own words. Obtain answers to other specific questions including the specific time in which the reported rape occurred (if they have not already been answered). A detailed account of the events leading up to the assault, however, is not helpful and should not be documented. Record the victim's general appearance and demeanor, and note whether clothing is torn or stained.
Collect and label relevant evidence following your state and local protocol, use a rape kit if available and protect the chain of evidence. Your examination should be complete and thorough but guided by the history of the assault to include all pertinent evidence. Most evidence includes but is not necessarily limited to
scrapings under the fingernails;
collecting any other loose hairs or dried blood;
dried slides of vaginal contents as well as vaginal secretions;
specimens from oral cavity or rectum if penetration has occurred;
photograph all external lesions, but only with the patient's written consent.
Thoroughly examine the patient for other signs of bodily trauma or bleeding; record the results of the examination; and photograph all lesions (the last only with the patient's written consent). Examine the mouth and the rectum for injuries. Proctoscopy may be advisable if penetration has occurred and if foreign objects were used, because peritoneal perforation may occur from rectal trauma.
Look carefully for signs of trauma to the external genitalia. Note and record whether the hymen is intact and whether any hymenal tags are fresh (indicating trauma) or healed.
Using a warm, water-moistened speculum, carefully examine the vagina for lacerations. Topical application of toluidine blue may enhance identification of genital skin tears. Colposcopy enhances the identification of traumatic injury. Rarely, peritoneal perforation may occur. If examination must be delayed for a short while, some methods to enhance future collection include insertion of tampon (send tampon with evidence) and do not have the patient urinate, douche, or defecate.
Obtain blood for chemistry studies (if indicated), a serologic test for syphilis, and blood typing (to compare the alleged assailant's type with that of the victim). Blood sampling may also be used for hepatitis B and C and human immunodeficiency virus (HIV) serologic testing. Rapid HIV testing in the perpetrator should also be sought if advisable. To exclude pregnancy, a urine pregnancy test is indicated.
The physician should be empathic and concerned, never skeptical or judgmental.
Prevent Sexually Transmitted Disease
Treatment for gonorrhea, C. trachomatis, and syphilis (Chapter 40) should be offered. Only about 3% of rapes result in gonorrhea and only about 0.1% result in syphilis. Follow-up cultures for Neisseria gonorrhoeae are essential. Perform follow-up serologic tests for syphilis 1 and 3 months after the rape.
Prevent Infectious Diseases
Offer the hepatitis B vaccine as well as follow-up in 3–4 weeks for repeat hepatitis vaccination and testing. HIV is also of concern. Offer postexposure prophylactic medications based on risk factors with a follow-up for repeat HIV testing.
Treatment for the prevention of pregnancy should be offered. Only about 1% of rapes result in pregnancy; the chances are much less if the victim is using an effective method of contraception. Levonorgestrel 0.75 mg, two tablets taken 12 hours apart, or Levonorgestrel 1.5 mg taken as a single dose, is approved for emergency contraception. Accepted alternate regimens include ethinyl estradiol, 200 μg, and norgestrel, 2 mg, orally over 12 hours in two divided doses (eg, norgestrel [Ovral], two tablets orally, repeating in 12 hours) to prevent implantation if it is certain that the patient is not already pregnant. Advise the patient that nausea and vomiting may occur. Give an antiemetic 40 minutes prior to the oral contraceptives.
Caution: Existing pregnancy is an absolute contraindication to the use of oral contraceptives. Warn the patient that this regimen may not be effective, and explain that a return visit within 1–2 weeks is essential for another pregnancy test.
If required by law or if the patient consents, report the incident to the proper authorities before the patient leaves the emergency department because the police will want to question her. If the reported victim is a child, the incident should be reported to the appropriate child welfare authorities (Chapter 50).
Start Rape Counseling Immediately
Preferably, counseling should be directed by experienced personnel who are part of an established rape counseling program.
A definite appointment (time, place, and physician or clinic) should be made.
In the emergency department, the most common problem relating to these devices is the “lost” IUD. Check to see if the IUD is still properly placed by looking for the removal string protruding from the cervix (most women soon learn to feel for it with a finger). If no string can be found, the IUD may be located by uterine sonography or abdominal X-ray (for metallic IUDs). The IUD may be in an extrauterine position, in which case it should be removed surgically by laparoscopy or laparotomy.
The principal indication for removal of an IUD in the emergency department is infection (salpingitis, endometritis, pyosalpinx, or pelvic peritonitis). The incidence of endometritis, salpingitis, and tubal abscess is increased in women using IUDs. Any of these conditions requires removal of the IUD so that infection can be completely cleared. If possible, the patient should be started on appropriate antibiotics before the device is removed (see Salpingitis section in Chapter 40).
Persistent vaginal bleeding or pelvic pain usually requires removal of an IUD but not often on an emergency basis. Referral to the physician who inserted the device is preferable.
If referral is impractical, grasp the string of the IUD with a Kelly clamp or other long grasping forceps and pull with gentle but increasing force until the IUD emerges from the uterus. Do not jerk the string, because it may detach from the device and make removal more difficult. If the string is not easily seen after manipulation with a speculum, use a special IUD remover to locate and grasp the string.
Serious But Rare Problems
Perforation of the Uterus
Perforation of the uterus is a probable diagnosis in patients with IUDs who have symptoms of endometritis, salpingitis, or peritonitis. Physical examination, an abdominal X-ray, and sonography show that the IUD is embedded in the uterine wall or free in the peritoneum. Emergency hospitalization is required.
Pregnancy with IUD In Place
If pregnancy is confirmed by a positive pregnancy test, and an IUD is still in place, seek emergency obstetric consultation. Ectopic pregnancy is a distinct possibility in the pregnant patient with an IUD still in place.
Postcoital Emergency Contraception
Postcoital emergency contraception, also known as the morning-after pill, can be given to prevent implantation. The US Food and Drug Administration has approved plan B (levonorgestrel 0.75 mg) within 72 hours of intercourse and repeated again 12 hours later. Several prescriptive equivalents are available. Nausea and emesis frequently occur, and an antiemetic should be prescribed. Although the morning-after pill is reported to be 98% effective, a pregnancy test should be performed if menstruation does not occur within 21 days of treatment.
Disorders of the Vulva and Vagina
Vaginal and vulvar cancers and other lesions are discussed earlier in this chapter. Vaginitis, gonorrhea, genital herpes virus infection, and genital abscesses are discussed in Chapter 42.
Warning About Discontinuing Contraception
Treatment of gynecologic problems in the emergency department may require discontinuing the patient's current form of contraception. The emergency physician advising this course of action must warn the patient of the possibility of pregnancy and offer appropriate contraceptive advice. Discontinuation of oral contraceptives or IUD use because of treatment in the emergency department should not result in an unwanted pregnancy.