Approaching Gynecological Emergencies
Gynecological emergencies can be challenging for EMS providers due to the sensitive nature of the complaints, the potential for embarrassment on the part of both patient and provider, and the wide differential diagnosis for pelvic pain and vaginal bleeding. Professional, empathetic communication is essential. Use proper medical terminology, maintain the patient's privacy and dignity, and explain every aspect of your assessment before performing it. These patients deserve the same thorough assessment and clinical care as any other emergency.
When assessing female patients with abdominal or pelvic complaints, always determine pregnancy status. Many gynecological and obstetric emergencies present similarly, but management differs significantly. Ask about the last menstrual period (LMP), possibility of pregnancy, and any pregnancy testing. A positive pregnancy test changes the differential diagnosis and may indicate an ectopic pregnancy or other obstetric emergency.
Vaginal Bleeding
Vaginal bleeding can range from minor to life-threatening. Assess the volume by asking how many pads or tampons the patient has used and how quickly they are soaking through. One soaked pad per hour is considered heavy bleeding. Assess for signs of hemorrhagic shock: tachycardia, hypotension, pale and diaphoretic skin, and altered mental status.
Common causes of non-pregnancy-related vaginal bleeding include menorrhagia (heavy menstrual bleeding), uterine fibroids, endometriosis, ovarian cysts, and malignancy. Pregnancy-related causes include miscarriage (spontaneous abortion), ectopic pregnancy, placenta previa, and placental abruption. The prehospital provider does not need to determine the cause; focus on assessing hemodynamic stability, providing IV fluid resuscitation for signs of shock, and transporting to an appropriate facility.
Pelvic Pain Differential
Acute pelvic pain in female patients has a broad differential:
- Ovarian torsion: Sudden, severe unilateral pelvic pain from twisting of the ovary on its pedicle. A surgical emergency.
- Ruptured ovarian cyst: Sudden sharp pelvic pain, often midcycle. Usually self-limiting but can cause significant intraperitoneal bleeding.
- Pelvic inflammatory disease (PID): Bilateral lower pelvic pain with fever, vaginal discharge, and pain with movement. Caused by ascending infection, often from sexually transmitted organisms.
- Ectopic pregnancy: Unilateral pelvic pain with vaginal bleeding in a woman of childbearing age. Life-threatening if ruptured.
Sexual Assault Response
When responding to a sexual assault, prioritize the patient's emotional and physical safety. Treat any injuries, but be aware that evidence preservation is important. Discourage the patient from bathing, changing clothes, eating, drinking, or using the bathroom if possible (without making them feel responsible for evidence preservation). Do not examine the genital area unless medically necessary for hemorrhage control. Transport to a hospital with a SANE (Sexual Assault Nurse Examiner) program. Document objectively: record the patient's statements in quotes, note physical findings without interpretation, and avoid language that implies consent or judgment. Provide emotional support and connect the patient with victim advocacy resources.