Gynaecological and obstetric emergencies
Anatomy and physiology
The female reproductive organs consist of:
They are situated outside the peritoneal cavity (Fig. 30.1).
Figure 30.1 The female reproductive system.
The uterus is located in the anterior pelvis above the bladder. It is a pear-shaped organ with thick walls, made up of three layers: an outer serous membrane, a middle layer of smooth muscle, and the mucosal inner layer of endometrium, which is extremely vascular. The top of the uterus is called the fundus; it is the height of this that is measured to determine the gestation of pregnancy (Fig. 30.2).
Figure 30.2 Change in fundal height during gestation.
The neck of the uterus is called the cervix. This opens into the vagina, the opening of which is called the os. The status of the os is an important consideration in assessing bleeding in early pregnancy. The ovaries sit bilaterally to the uterus, on the lateral pelvic wall, and are connected to the uterus by fallopian tubes. The fallopian tubes have a funnel-like opening below the ovaries, which collects the ova and transports them by peristalsis to the uterus. The tubes are made up of smooth muscle and mucous membrane. The vagina is an elastic tube leading to the external genitalia. There are two small glands either side of the vaginal opening called Bartholin’s glands which can be prone to cyst formation in some women (Bickley & Szilagyi 2003).
During child-bearing years, each ovary is 2.5–5 cm long, 1.5–3 cm wide, and 0.6–1.5 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 300 000–400 000 by puberty (Sanders Jordan 2009). The female reproductive cycle varies in length between 21 and 35 days, but for most the average cycle is 28 days. The cycle consists of ovulation and menstruation, and is governed by changes in hormone levels. The first 5–7 days of the cycle represent menstruation. This is followed by a 7–8-day follicular phase preparing the endometrium for implantation of a fertilized egg. At around days 14–15 of the cycle, ovulation occurs. Once the ovum is released from the follicle, the luteal phase then commences: the collapsed follicle becomes an endocrine gland called the corpus luteum. It secretes oestrogen and progesterone to support the egg if it is fertilized. If the egg is not fertilized the luteal phase is responsible for the degeneration of the corpus luteum, after which the thickened lining of the endometrium sheds and the cycle begins again. If the egg is fertilized, the corpus luteum continues to secrete hormones until about three months into the pregnancy when the placenta takes over.
Fertilization of the ovum takes place in the fallopian tube, and during the first few days it passes slowly towards the uterus while a series of cell divisions take place forming a mass of embryotic cells. The embryo reaches the uterus between 3 and 5 days after fertilization. It then begins to implant into the uterine wall by about 6–7 days after fertilization. The placenta forms around where the embryo is embedded and, after a few weeks, begins to provide oxygen and nutrients to support fetal growth for the rest of the pregnancy. By five weeks after implantation the fetal heart is pumping well, and nutrients pass from the maternal blood supply across the placental membrane to nourish the fetus.
The pregnancy is divided into trimesters of growth: in the first the internal organs develop; in the second the fetus grows in length and systems begin to mature; and in the last trimester the fetus fattens out and builds up reserves for birth. Physiological changes in pregnancy are plentiful, and an overview of key changes is given in Box 30.1; however, a detailed description is beyond the scope of this text and only those changes related to emergency care in ED will be discussed.
Emergency care of the non-pregnant woman
Obtaining an accurate history is vital to establish the severity of a patient’s condition. Because of the personal nature of gynaecological complaints, the nurse should ensure that assessment is carried out in private and in a sensitive and non-judgemental manner. Box 30.2 highlights the information that should be obtained.
Assessment
General assessment of the woman with a gynaecological condition should include baseline observations of pulse, respiration, blood pressure and temperature to detect signs of shock or infection. The level of pain should be determined, together with the exact location. Gentle abdominal examination will assist in this. If clinically indicated, a vaginal examination should be carried out once, either by the nurse or, more commonly, by the doctor. Assessment should include urinalysis to detect a urinary tract infection as a primary cause of pain. Initially this can be diagnosed by the presence of leucocytes, protein and blood in urine, but culture and sensitivity should follow to ensure appropriate antibiotic therapy. A pregnancy test should also be carried out routinely to exclude unknown pregnancy. Abdominal pain is often the primary reason women with gynaecological complaints attend ED. Conditions causing acute abdominal pain are shown in Box 30.3.
Menstrual pain
Mittelschmerz, from the German ‘middle pain’, is a periodic pain at mid-cycle due to irritation of the peritoneum by follicular fluid at the time of its rupture (Salhan 2011). It should only be diagnosed once other causes, such as ovarian cyst and pelvic inflammatory disease (PID), have been ruled out (Reedy & Brucker 1995). The condition is self-limiting, and therefore treatment involves symptom control and education. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are usually the most effective analgesia. The patient should be made aware of the cyclical nature of the condition, and the possibility of recurrence.
Dysmenorrhoea
In most cases, dysmenorrhoea (period pain) is self-diagnosed and treated at home; however, when symptoms are unusually severe, some women seek emergency care. Two types of dysmenorrhoea exist: primary and secondary dysmenorrhoea. In the former, uterine spasm involves A nerve fibres, responsible for acute pain, and C nerve fibres responsible for chronic and referred pain (see also Chapter 25). Primary dysmenorrhoea is most common in adolescents and young women who have not had children (Horne & Critchley 2012).
Diagnosis should be made only after other causes of pain and bleeding have been excluded. Management revolves around symptom control and the condition is self-limiting. NSAIDs are the analgesia of choice because they inhibit intrauterine synthesis of prostaglandin as well as decreasing pain. Small quantities of alcohol are effective in the treatment of dysmenorrhoea because it reduces oxytocin and vasopressor activity, therefore reducing uterine spasm. Ethically, however, this method of pain control should only be advocated for women who understand the potential dangers of alcohol ingestion and are legally old enough to use it (Reedy & Brucker 1995). Discharge information should include the commonality of dysmenorrhoea and, in the case of secondary dysmenorrhoea, information and advice about the predisposing condition.
Ovarian cyst
These usually result from a dysfunction in the menstrual cycle, when a collection of fluid forms around the corpus luteum. Cyst formation is more common in endometriosis and most are benign, self-limiting and asymptomatic. In some instances, the cyst increases in size and becomes symptomatic causing pelvic discomfort at about 8–10 cm diameter due to the stretching of the capsule, although most regress spontaneously over a period of 1–3 months (Sanders-Jordan 2009). Eventually, if growth persists, bleeding, rupture or torsion can occur. Ovarian cysts are uncommon in women using oral contraception.
Management
Cysts not causing haemodynamic compromise tend to be managed conservatively with follow-up investigation from a GP or gynaecological clinic. If adequate pain control cannot be achieved, hospital admission should be considered. If the patient has mild to moderate signs of hypovolaemia, intravenous fluid support should be established, and laparoscopic surgical decompression of the cyst should be considered. In cases of severe hypotension or torsion, fluid resuscitation and urgent surgical intervention are necessary. These women will need both information and psychological support during a time which potentially threatens their fertility.
Pelvic inflammatory disease
Pelvic inflammatory disease comprises a range of upper genital tract inflammatory disorders in women that usually result from microorganisms ascending from the cervix to the upper genital tract (French et al. 2011). Recurrent PID is associated with an increased risk for infertility and chronic pelvic pain (Trent et al. 2011). It is also linked to an increase in ectopic pregnancy. PID is a generic term used to describe infection of the pelvic peritoneum, connective tissue and reproductive organs – most commonly the fallopian tubes (also termed salpingitis). PID results from:
• sexually transmitted infections (STIs), particularly gonorrhoea and chlamydia
For most women, intrauterine contraceptive devices (IUCD) are a safe option. Upper genital tract infections occur when pathogenic microorganisms ascend from the cervix and invade the endometrium and the fallopian tubes, causing an inflammatory reaction (Martinez & Lopez-Arregui 2009). Sexually transmitted infections are the most common cause of PID, especially caused by Chlamydia trachomatis and Neisseria gonorrhoeae. The infection occurs in the genital area and spreads along mucosal surfaces, causing transient bouts of inflammation. Infection tends to settle in fallopian tubes, causing scar tissue and adhesions. This makes ovum passage more difficult and increases the likelihood of ectopic pregnancy because the fertilized egg is unable to pass to the uterus and implants in the tube. PID is most common in young women with multiple sexual partners, women who experienced their first sexual intercourse at a young age, or women with a high frequency of sexual intercourse, and within that group PID has a higher incidence in women from lower socioeconomic groups (Bryan 2004). The most common age group is 20–24 years of age (French et al. 2011), which has considerable implications for future healthcare and fertility therapy, as women with PID are at increased risk of chronic pelvic pain, ectopic pregnancy and infertility.
A patient with PID will present with moderate to severe abdominal pain, worse with urination, bowel action and intercourse. Because the pain increases with movement, patients characteristically shuffle, the ‘PID shuffle’. She may be tachycardic and will be pyrexic. If STI is the cause, the patient will have a thick vaginal discharge. If pelvic abscess or peritonitis is developing, the patient will also have nausea or vomiting. Lichtman & Parera (1990) highlighted three grades of PID (Box 30.4).
Management
If the woman is pregnant or has not responded to, or complied with, oral antibiotics, hospital admission should be considered. If the patient is discharged from the ED, it is essential that she has appropriate health education to enable her to recognize a recurrence and get treatment. This is important in reducing potential long-term health problems, including chronic pelvic pain, dyspareunia and infertility. If the PID originates from an STI, the patient’s partner should be encouraged to attend an STI clinic and advice should be given about the use of barrier methods of contraception during intercourse. Patients with PID, gonorrhoea, or chlamydial infection should also have serological testing and be offered confidential counselling and testing for HIV infection (Sacchetti 2009).
Bartholin’s cyst
The Bartholin’s glands lie on either side of the vagina and secrete fluid onto the surface of the labia. In normal health these cannot be seen or palpated. If the duct becomes blocked, a small cyst forms; these are usually benign and self-limiting. They can, however, become infected with Escherichia coli or STIs such as gonorrhoea. Bartholin’s cyst/abscess affects 2 % of women (Haider et al. 2007). If infection occurs, the labium becomes inflamed and oedematous to the extent that the patient may have difficulty walking. This is a painful and distressing condition, which is resolved by early excision and drainage of the cyst. This is usually performed as an inpatient procedure. Antibiotic therapy is also indicated (Wechter et al. 2009).
Sexually transmitted infections
Patients may present to ED because of its relative anonymity compared with GP attendance. Many people are still unaware of the existence and accessibility of STI clinics. Broadly, common symptoms of STI are genital irritation or pain, infection, discharge and sometimes bleeding. Specific symptoms and management are shown in Table 30.1.
The role of the ED nurse in caring for patients with STIs is twofold: first, to provide immediate therapy to resolve the acute episode with appropriate STI clinic follow-up; and second, to provide non-judgemental health education aimed at preventing the spread of STIs. All direct sexual contacts of the patient should be advised to have a health check. It is not possible for the ED nurse to personally follow up patient contacts, but the nurse can support the patient in informing a current partner, and information can then be cascaded to anyone else who may be involved. Patients should refrain from sexual activity until the infection is clear. Advice about barrier contraception should also be given and where appropriate, opportunities for serological testing, confidential counseling and testing for HIV infection (Sacchetti 2009).
Emergency contraception
Progesterone-based pills
The most widely used emergency contraception is that containing levonorgestrel. While it was initially prescribed in two divided doses, a single dose is now the preferred method of administration (Black 2009). Administration of the drug which should be taken within 72 hours of unprotected intercourse. Nausea and vomiting are significant side-effects of oral postcoital contraception and some doctors prefer to prescribe prophylactic anti-emetic drugs with the pill. Follow-up care should be sought around three weeks after postcoital contraception. It is because these facilities are not available in ED that some consultants choose not to offer emergency postcoital contraception. Most women will commence menses within 21 days of the postcoital pill. If this does not happen, a pregnancy test should be performed; however, the failure rate of the postcoital pill is less than 2 % if taken within 72 hours of coitus (Task Force on Postovulatory Method of Fertility Regulation 1998).
Intrauterine contraceptive device
The IUCD may be used up to five days after ovulation, or after unprotected intercourse if the date of ovulation is not known. It also works by preventing implantation, and failure is rare at 0–0.2 % (Black 2009). There are disadvantages to its use in nulligravida women because of pain associated with insertion. It is not ideal for women with existing pelvic infection as it could exacerbate this. Irregular vaginal bleeding is also common after IUCD insertion. The advantage of this method is that it provides longer-term contraception. The use of prophylactic antibiotics may be considered for women who are at increased risk of sexually transmitted infection if an IUCD is to be inserted before results of tests are available (French et al. 2004).
Rape and sexual assault
In England and Wales, under the Sexual Offences Act 2003 (Home Office 2003), the definition of rape is the non-consensual penetration of vagina, mouth or anus by a penis. Sexual assault by penetration is the non-consensual, intentional insertion of an object other than the penis into the vagina or anus. The Act also treats any sexual intercourse with a child under the age of 13 as rape and defines the age of consent as 16 (College of Emergency Medicine 2011).
Rape and sexual assault are violent crimes. Police forces are increasingly caring for physically injured survivors of rape in dedicated rape suites equipped for the privacy and comfort of women who have been assaulted. In the UK and Ireland, Sexual Assault Referral Centres (SARCs)/Sexual Assault Treatment Units (SATUs) are located at most major hospitals providing an integrated response to adult survivors of rape and sexual assault. The services provided include forensic and medical examination, one-to-one counselling, screening for sexually transmitted diseases, postcoital contraception and 24-hour information and support (Lovett et al. 2004, Lovett & Kelly 2009
