1. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Paramedic Care: Principles & Practice Volume 3 Medical Emergencies

2. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 13 Gynecology

3. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Anatomy and Physiology of the Female Reproductive Organs The Menstrual Cycle Assessment of the Gynecological Patient Management of Gynecological Emergencies Specific Gynecological Emergencies

4. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction Gynecology –Branch of medicine that deals with the health maintenance and the diseases of women. Mainly reproductive organs Most patients that you will encounter will be experiencing either abdominal pain or vaginal bleeding.

5. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Female Reproductive Organs

6. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Female Reproductive Organs External Genitalia –Accessory functions Protect body openings Important role in sexual functioning Internal Genitalia –Most important organs of reproduction –The ovaries, fallopian tubes, uterus, and vagina

7. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ External Genitalia Perineum –Muscular tissue that separates the vagina and the anus Mons Pubis –Fatty layer of tissue over the pubic symphysis Labia –Structures that protect the vagina and the urethra

8. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ External Genitalia Clitoris –Vascular erectile tissue that lies anterior to the labia minora Urethra –Drains the urinary bladder

9. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Internal Genitalia Vagina –Female organ of copulation –Birth canal –Outlet for menstruation Uterus –Site of fetal development

10. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Internal Genitalia Fallopian Tubes –Transports the egg from the ovary to the uterus –Fertilization usually occurs here Ovaries –Primary female gonads

11. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Uterus Provides a site for fetal development Two major parts: –Body (or corpus) –Cervix (or neck) Tissue layers –Endometrium –Myometrium –Perimetrium

12. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Female Reproductive Anatomy Click here to view an animation on female reproductive anatomy.here

13. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Menstrual Cycle

14. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Menstrual Cycle Monthly hormonal cycle, usually 28 days –Estrogen and progesterone Influenced by FSH and LH Prepares the uterus to receive a fertilized egg The onset of menses, known as menarche –Usually occurs between the ages of 10 and 14 Menopause

15. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Phases of the Menstrual Cycle The Proliferative Phase The Secretory Phase The Ischemic Phase The Menstrual Phase

16. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Proliferative Phase First two weeks of the menstrual cycle –Dominated by estrogen –Uterine lining will gradually thicken and become engorged with blood Day 14 –Surge in leutenizing hormone (LH) –Ovulation occurs –Follicle develops the corpus luteum If fertilization occurs, egg implants in uterus –If not, the endometrium sheds in normal menses

17. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Secretory Phase Stage immediately surrounding ovulation –If the egg is not fertilized, the woman’s estrogen level drops sharply –Progesterone dominant hormone during this phase

18. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Ischemic Phase Estrogen and progesterone levels fall without fertilization The endometrium breaks down –Vascular changes cause the endometrium to become pale and small blood vessels to rupture

19. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Menstrual Phase Menstruation –Ischemic endometrium is shed, along with a discharge of blood, mucus, and cellular debris –A “normal” menstrual cycle depends on the regular pattern Premenstrual syndrome (PMS) –Symptoms include: Breast tenderness or engorgement, transient weight gain or bloating, excessive fatigue, and/or cravings for specific foods, migraine headaches

20. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Menstrual Phase Menopause –Menstruation occurs until a woman is 45 to 55 –Menopause signals the cessation of ovarian function and the cessation of estrogen secretion Periods decline in frequency and length until they ultimately stop Surgical menopause –Hormone replacement therapy

21. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Assessment of the Gynecological Patient

22. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Assessment of the Gynecological Patient The most common emergency complaints of women in the childbearing years are abdominal pain and vaginal bleeding. –Often due to problems of the reproductive organs. Conduct an initial assessment, focused history, and physical exam as normal. Conduct yourself professionally. If patient is reluctant to discuss, transport while treating any life-threats.

23. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ History Initial Assessment—SAMPLE Does the patient complain of pain? Use OPQRST –Dysmenorrhea/dyspareunia Associated signs or symptoms Has she ever been pregnant? –Gravida/parity/abortion Document last menstrual cycle Medications—Contraceptives

24. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Contraceptive Methods

25. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Physical Exam Respect patient’s privacy Be professional and explain all procedures Observe patient Check vital signs Assess bleeding or discharge: –Do not perform an internal vaginal exam in the field Abdominal examination

26. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of Gynecological Emergencies

27. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of Gynecological Emergencies General management of gynecological emergencies is focused on supportive care –Administer oxygen or assist ventilation as necessary –Treat for shock if indicated Intravenous therapy Cardiac monitoring PASG consideration –Hemorrhage control Do not pack dressings in the vagina

28. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Specific Gynecological Emergencies

29. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Specific Gynecological Emergencies Gynecological Abdominal Pain –Pelvic Inflammatory Disease –Ruptured Ovarian Cyst –Cystitis –Mittelschmerz –Endometriosis –Ectopic Pregnancy

30. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pelvic Inflammatory Disease An infection of the female reproductive tract –Bacterial, viral, fungal –The most common causes of PID are gonorrhea (Neisseria gonorrhoeae) or chlamydia (Chlamydia trachomatis) © Phototake NYC

31. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pelvic Inflammatory Disease Predisposing factors –Multiple sexual partners, prior history of PID, recent gynecological procedure, or an IUD –Infertility results from scarring of the fallopian tubes Signs and symptoms –Abdominal pain (may intensify either before or after the menstrual period) Worsens during intercourse –Patients may walk with a shuffling gait –A yellow, foul-smelling vaginal discharge –Midcycle bleeding

32. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pelvic Inflammatory Disease Physical Exam –Appearance reveals ill or toxic patient –Moderate to severe abdominal pain Worse with palpation Rebound tenderness may be present –Fever may or may not be present Treatment –Definitive treatment is IV antibiotics –Prehospital treatment is supportive

33. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ruptured Ovarian Cyst Cyst is a fluid-filled pocket –Usually the result of a ruptured follicle Corpus luteum cyst, is often left in its place Blood causes irritation of peritoneum –Results in pain © Phototake NYC

34. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ruptured Ovarian Cyst Physical Exam –Moderate to severe unilateral abdominal pain May radiate to back –Dyspareunia, irregular bleeding, or a delayed menstrual period Cyst may rupture during sexual activity or physical activity –Vaginal bleeding may be present

35. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cystitis Urinary bladder infection –Usually result of bacteria May progress to kidneys Signs and Symptoms –Abdominal pain –Urinary frequency, pain or burning with urination (dysuria) –Low-grade fever

36. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Mittelschmerz Mid-cycle abdominal pain –Peritoneal irritation during follicular rupture –Usually self-limited Signs and Symptoms –Unilateral lower quadrant pain –Low-grade fever Treatment is symptomatic

37. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Endometritis An infection of the uterine lining –Results from miscarriage, childbirth, or gynecological procedures Dilation and Curettage (D & C) Signs and Symptoms –Mild to severe lower abdominal pain –Bloody, foul-smelling discharge –Fever (101°F to 104°F) –Onset of symptoms usually 24-48 hours post- procedure Complications of endometritis may include sterility, sepsis, or even death

38. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Endometriosis Condition in which endometrial tissue is found outside of the uterus –Most commonly in abdominal cavity and pelvic cavity –Tissue responds to the hormonal changes associated with the menstrual cycle –Usually seen in women between the ages of 30 to 40 Signs and Symptoms –Dull, cramping pelvic pain, dyspareunia, abnormal uterine bleeding, painful bowel movements

39. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ectopic Pregnancy Implantation of a fetus outside of the uterus –Most commonly the fallopian tubes Signs and symptoms –Severe, unilateral pain with referred shoulder pain on the same side –Shock –A late or missed period © Phototake NYC

40. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of Gynecological Abdominal Pain Administer oxygen and establish intravenous access if indicated Make the patient comfortable and transport

41. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Non-Traumatic Vaginal Bleeding Rarely seen in the field unless it is severe –Obtain history Menorrhagia –Excessive menstrual flow –Be alert for signs of shock Spontaneous abortion (miscarriage) –Most common cause of non-traumatic bleeding –Often associated with cramping abdominal pain and the passage of clots and tissue Other causes –Cancerous lesions, PID, or the onset of labor

42. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Non-Traumatic Vaginal Bleeding Management –Will depend on the severity of the situation Initiation of oxygen therapy and intravenous access –Absorb blood flow Never pack the vagina –Transport any blood or tissue to hospital

43. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Traumatic Gynecological Emergencies Causes of Gynecological Trauma –Blunt Trauma –Sexual Assault –Blunt force to Lower Abdomen –Foreign Bodies Inserted in Vagina –Abortion Attempts

44. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management of Gynecological Trauma Apply direct pressure over laceration –Source of bleeding may not be readily apparent –Apply cold pack to hematoma Establish IV if patient is severe or signs of shock present Potential organ rupture may lead to peritonitis Transport

45. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Sexual Assault The most rapidly growing violent crime in America –60 percent of all sexual assaults are never reported –Male victims represent 5 percent of reported sexual assaults –No “typical victim” of sexual assault Most victims know assailants –Sexual assault is a crime of violence

46. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Sexual Assault Assessment –Patient needs emergency medical treatment and psychological support –Legal concerns –Victims of sexual abuse should not be questioned about the incident in the field –Respect the patient’s modesty

47. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management Considerations Protect the scene Handle clothing as little as possible If removing clothing, bag each item separately Do not cut through any tears or holes in clothing Place bloody articles in brown paper bags

48. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Management Considerations Do not examine the perineal area Do not allow patient to change clothes, bathe, or douche Do not allow patient to comb hair, brush teeth, or clean fingernails Do not clean wounds, if possible

49. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Documentation State patient remarks accurately Objectively state your observations of patient’s physical condition, environment, or torn clothing Document evidence turned over to hospital staff Do not include your opinions as to whether rape occurred

50. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Summary Anatomy and Physiology of the Female Reproductive Organs The Menstrual Cycle Assessment of the Gynecological Patient Management of Gynecological Emergencies Specific Gynecological Emergencies