Medical School · Year 3 · Emergency Medicine · includes a quiz and discussion video

Seminar 9: Obstetric and Gynecologic Emergencies

Emergency Medicine Clerkship

Learning Objectives

By the end of this seminar, students will be able to:

1. Diagnose ectopic pregnancy using clinical findings, beta-hCG levels, and transvaginal ultrasonography, and initiate appropriate surgical or medical management
2. Evaluate first trimester vaginal bleeding by differentiating threatened, inevitable, incomplete, complete, and missed abortion using ultrasound viability criteria
3. Manage third trimester emergencies including placenta previa, placental abruption, and eclampsia with evidence-based pharmacologic and obstetric interventions
4. Perform emergency vaginal delivery and manage complications including shoulder dystocia and cord prolapse using standardized maneuvers and protocols
5. Identify the causes of postpartum hemorrhage using the four T's mnemonic and implement stepwise management from uterine massage through surgical intervention
6. Approach sexual assault patients with trauma-informed care, perform forensic evidence collection, and administer appropriate prophylactic medical treatment

Seminar Outline

Section 1: Ectopic Pregnancy

Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity, most commonly in the fallopian tube. This condition represents a true gynecologic emergency because tubal rupture can lead to life-threatening hemorrhage. The strongest individual risk factor for ectopic pregnancy is a history of prior ectopic pregnancy, though pelvic inflammatory disease, prior tubal surgery, and current intrauterine device use also significantly elevate risk. Additional risk factors include in vitro fertilization treatments, infertility of any cause, and cigarette smoking, which impairs normal ciliary function within the fallopian tube and disrupts ovum transport.

The classic presentation of ectopic pregnancy includes vaginal bleeding that is typically light in volume, unilateral abdominal or pelvic pain, and a history of amenorrhea or missed menstrual period. On examination, the clinician may elicit adnexal tenderness and cervical motion tenderness. When rupture has occurred, the clinical picture becomes far more dramatic, with shoulder pain from diaphragmatic irritation by hemoperitoneum, hemodynamic instability including hypotension and tachycardia, and syncope. It is essential to recognize that any reproductive-age woman presenting with abdominal pain and vaginal bleeding should be considered to have an ectopic pregnancy until proven otherwise.

Diagnosis relies on the combination of a positive serum beta-hCG level and transvaginal ultrasound findings. The discriminatory zone concept holds that an intrauterine pregnancy should be visualized on ultrasound when the beta-hCG level exceeds approximately 1,500 to 3,000 mIU/mL, depending on the institution. If no intrauterine pregnancy is seen above this threshold, ectopic pregnancy must be strongly suspected. Ultrasound findings suggestive of ectopic pregnancy include an adnexal mass and free fluid in the cul-de-sac. When the beta-hCG is below the discriminatory zone and no intrauterine pregnancy is visualized, the term pregnancy of unknown location is applied, and serial beta-hCG measurements every 48 hours are required to assess viability and location.

Management depends on the clinical stability of the patient and the status of the ectopic pregnancy. Ruptured ectopic pregnancy with hemodynamic instability requires emergent surgical intervention with simultaneous resuscitation including large-bore intravenous access, crystalloid and blood product administration, and operative salpingectomy or salpingostomy. For unruptured, hemodynamically stable ectopic pregnancies, methotrexate is a medical alternative when specific criteria are met, including a stable clinical picture, beta-hCG levels below 5,000 mIU/mL, and absence of fetal cardiac activity. Serial beta-hCG monitoring after methotrexate administration continues until the level becomes undetectable, confirming resolution.

<image>Panel A: Transvaginal ultrasound demonstrating an empty uterine cavity with a complex adnexal mass and surrounding free fluid consistent with ectopic pregnancy. Panel B: Diagnostic algorithm showing beta-hCG discriminatory zone with decision pathways for values above and below 1,500-3,000 mIU/mL. Panel C: Laparoscopic image of a ruptured tubal ectopic pregnancy with active hemorrhage into the peritoneal cavity. Panel D: Management flowchart comparing indications for methotrexate therapy versus surgical intervention based on clinical stability and beta-hCG levels.</image>

Section 2: First Trimester Bleeding

First trimester vaginal bleeding is an extremely common emergency department presentation, occurring in approximately 25 percent of all pregnancies. The differential diagnosis encompasses a spectrum of conditions from the benign threatened abortion, in which bleeding occurs through a closed cervical os with a viable intrauterine pregnancy, to the more concerning incomplete abortion, where products of conception are found within the cervical canal. Inevitable abortion is characterized by vaginal bleeding with a dilated cervix, complete abortion involves passage of all products of conception with a subsequently empty uterus, and missed abortion describes a nonviable intrauterine pregnancy with a closed cervix and no active bleeding. Ectopic pregnancy must always remain on the differential when no intrauterine pregnancy is visualized on ultrasound.

The evaluation of first trimester bleeding begins with confirmation of pregnancy via beta-hCG testing, followed by transvaginal ultrasound to determine pregnancy viability and location. Rhesus status must be determined in all patients because Rh-negative women require RhoGAM administration to prevent alloimmunization. A complete blood count is indicated when significant bleeding is present to assess for anemia, and a type and screen should be obtained in any hemodynamically unstable patient in anticipation of potential transfusion. Additional laboratory evaluation may include a basic metabolic panel and coagulation studies depending on the clinical scenario and volume of blood loss.

Ultrasound viability criteria are essential for determining pregnancy outcome. The presence of fetal cardiac activity confirms viability, while a crown-rump length exceeding 7 millimeters without detectable heart activity indicates a nonviable pregnancy. Similarly, a mean gestational sac diameter greater than 25 millimeters without an identifiable embryo is diagnostic of an anembryonic gestation. When ultrasound findings are indeterminate and do not clearly establish viability or nonviability, a repeat ultrasound in 7 to 14 days is recommended to allow adequate time for embryonic development before a definitive diagnosis is made.

Management is tailored to the specific diagnosis. Threatened abortion is managed expectantly with activity precautions, reassurance, and close outpatient follow-up, as the majority of these pregnancies progress normally. Incomplete abortion may be managed with expectant observation, medical treatment with misoprostol to promote passage of retained products, or surgical evacuation via uterine aspiration. Ectopic pregnancy is managed as described previously. RhoGAM dosing is weight-adjusted to gestational age, with 50 micrograms administered for pregnancies less than 12 weeks gestation and the standard 300-microgram dose given for pregnancies beyond 12 weeks in Rh-negative women.

<image>Panel A: Transvaginal ultrasound images comparing a viable intrauterine pregnancy with fetal cardiac activity to a missed abortion with absent cardiac activity and crown-rump length exceeding 7 millimeters. Panel B: Speculum examination findings in threatened versus inevitable abortion, demonstrating closed versus dilated cervical os with visible products of conception. Panel C: Flowchart for first trimester bleeding evaluation from pregnancy confirmation through ultrasound assessment and viability determination. Panel D: Comparison chart of management strategies for threatened, incomplete, complete, and missed abortion including expectant, medical, and surgical options.</image>

Section 3: Third Trimester Emergencies

Placenta previa is defined as placental implantation that covers the internal cervical os, either partially or completely. The hallmark presentation is painless vaginal bleeding in the second or third trimester, often occurring without warning. Diagnosis is established by ultrasound, and it is absolutely critical that no digital vaginal examination be performed in any patient with suspected previa, as this can provoke catastrophic hemorrhage. Management requires hospital admission, continuous fetal monitoring, and delivery by cesarean section when the patient reaches term or when hemorrhage becomes hemodynamically significant at any gestational age.

Placental abruption refers to the premature separation of a normally implanted placenta from the uterine wall before delivery. Risk factors include chronic hypertension, prior abruption, abdominal trauma, cocaine use, and advanced maternal age. The classic presentation includes painful vaginal bleeding, a rigid and tender uterus described as board-like on palpation, and signs of fetal distress on cardiotocographic monitoring. Importantly, abruption is primarily a clinical diagnosis because ultrasound may appear normal in many cases, particularly with retroplacental hemorrhage that does not track to the cervical os. Severe abruption with hemodynamic instability or fetal distress necessitates immediate resuscitation and emergent delivery.

Preeclampsia is defined as new-onset hypertension with blood pressure at or above 140/90 mmHg after 20 weeks of gestation accompanied by proteinuria or evidence of end-organ dysfunction. Severe features include blood pressure at or above 160/110 mmHg, thrombocytopenia with platelets below 100,000, elevated liver transaminases to more than twice the upper limit of normal, renal insufficiency, and pulmonary edema. Eclampsia is the occurrence of generalized tonic-clonic seizures in the setting of preeclampsia. The HELLP syndrome, an acronym for hemolysis, elevated liver enzymes, and low platelets, represents a severe variant of preeclampsia that carries high maternal and fetal morbidity and may present with epigastric pain, nausea, and laboratory derangements even before blood pressure criteria are met.

The management of eclampsia centers on magnesium sulfate, which is the first-line agent for both seizure treatment and prophylaxis. The loading dose is 4 to 6 grams administered intravenously over 15 to 20 minutes, followed by a continuous infusion of 1 to 2 grams per hour. Blood pressure control is achieved with labetalol administered as intravenous boluses, hydralazine, or nicardipine infusion, with a target of reducing severe-range blood pressures to below 160/110 mmHg. Delivery is the definitive treatment for preeclampsia and eclampsia and should be pursued after the patient has been stabilized. Magnesium toxicity manifests in a predictable sequence beginning with loss of deep tendon reflexes, followed by respiratory depression, and ultimately cardiac arrest, and is treated with calcium gluconate.

<image>Panel A: Ultrasound images demonstrating complete placenta previa with the placenta entirely covering the internal cervical os. Panel B: Illustration comparing the clinical presentations of placenta previa (painless bleeding) and placental abruption (painful bleeding with rigid uterus), showing concealed versus revealed hemorrhage patterns. Panel C: Diagnostic criteria table for preeclampsia with and without severe features, eclampsia, and HELLP syndrome. Panel D: Eclampsia management protocol showing the sequence of magnesium sulfate loading, maintenance infusion, blood pressure control targets, and signs of magnesium toxicity with calcium gluconate as the antidote.</image>

Section 4: Emergency Delivery

Recognition of imminent delivery is a critical skill for the emergency physician, as precipitous deliveries may occur before an obstetrician can arrive. Signs of imminent delivery include an uncontrollable urge to push, crowning with the fetal head visible at the vaginal introitus, frequent and strong uterine contractions, and full cervical dilation if a vaginal examination is performed. When these signs are present, the emergency physician must be prepared to manage the delivery in the emergency department with the available resources, as transfer to a labor and delivery suite may not be feasible.

The normal spontaneous vaginal delivery proceeds in a systematic fashion. The clinician should prepare by donning gloves and assembling essential supplies including towels, two cord clamps, scissors, bulb suction, and warm blankets. As the head delivers, the perineum is supported with gentle counterpressure to prevent uncontrolled extension and laceration. The clinician should then check for a nuchal cord by sliding a finger around the infant's neck; if a cord is palpated, it should be reduced over the head if loose, or doubly clamped and cut if tight. Delivery of the shoulders follows, with gentle downward traction on the head to deliver the anterior shoulder, then upward traction to deliver the posterior shoulder. After complete delivery, the cord is clamped in two locations and divided between the clamps, and the placenta is delivered with gentle traction after signs of separation. Uterine massage is performed immediately after placental delivery to promote contraction and prevent uterine atony.

Shoulder dystocia is an obstetric emergency that occurs when the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of the head. It is recognized by the turtle sign, in which the delivered fetal head appears to retract against the perineum. The first-line maneuver is the McRoberts maneuver, which involves sharply hyperflexing the maternal thighs toward the abdomen, thereby straightening the sacrum and increasing the anteroposterior diameter of the pelvis. Simultaneous suprapubic pressure is applied by an assistant from above to dislodge the anterior shoulder from behind the symphysis. If these measures fail, an episiotomy may be performed to allow additional room for internal maneuvers, which include the Woods screw maneuver and the Rubin maneuver involving rotational pressure on the fetal shoulders. The Zavanelli maneuver, which involves replacing the fetal head into the vagina for emergent cesarean delivery, is considered a last resort. Fundal pressure must absolutely be avoided as it worsens the impaction.

Umbilical cord prolapse occurs when the umbilical cord presents ahead of the fetal presenting part, resulting in cord compression and potential fetal asphyxia. It is recognized when the cord is palpated or visualized in the vagina below the presenting part, often following rupture of membranes. The immediate management involves elevating the presenting part off the cord by placing a gloved hand into the vagina and applying continuous upward pressure on the fetal head or buttock. The patient should be positioned in knee-chest or steep Trendelenburg position to use gravity to relieve cord compression. Under no circumstances should the clinician attempt to push the cord back into the uterus or allow any compression. Emergent cesarean section is the definitive treatment, and the clinician must maintain manual elevation of the presenting part during transport to the operating room.

<image>Panel A: Sequential illustration of normal spontaneous vaginal delivery including head delivery with perineal support, nuchal cord check, anterior and posterior shoulder delivery, and cord clamping. Panel B: Demonstration of the McRoberts maneuver showing hyperflexion of maternal thighs to the abdomen with simultaneous suprapubic pressure application for shoulder dystocia. Panel C: Photograph of the turtle sign where the fetal head retracts against the perineum indicating shoulder dystocia. Panel D: Illustration of cord prolapse management showing a gloved hand elevating the presenting part off the compressed umbilical cord with the patient in knee-chest position.</image>

Section 5: Postpartum Hemorrhage

Postpartum hemorrhage is defined as blood loss exceeding 500 milliliters following vaginal delivery or exceeding 1,000 milliliters following cesarean section, though quantitative blood loss measurement is increasingly used as a more accurate assessment. The causes of postpartum hemorrhage are organized using the four T's mnemonic. Tone refers to uterine atony, which is the most common cause, accounting for approximately 70 to 80 percent of cases. Trauma encompasses genital tract lacerations, cervical lacerations, and uterine rupture. Tissue refers to retained placental fragments or membranes that prevent adequate uterine contraction. Thrombin represents coagulation disorders including disseminated intravascular coagulation and pre-existing bleeding diatheses.

Multiple risk factors predispose to postpartum hemorrhage, and these should be identified antepartum whenever possible. A history of prior postpartum hemorrhage is among the strongest predictors. Prolonged labor leads to uterine fatigue and increases the risk of atony. Overdistension of the uterus from multiple gestation, polyhydramnios, or fetal macrosomia also predisposes to inadequate uterine contraction after delivery. Chorioamnionitis, an intrauterine infection, weakens the myometrium's ability to contract effectively. Additionally, magnesium sulfate, used therapeutically in preeclampsia management, causes uterine smooth muscle relaxation and may contribute to postpartum hemorrhage.

The management of postpartum hemorrhage follows a stepwise approach beginning with bimanual uterine massage as the first-line intervention for uterine atony. This involves placing one hand on the fundus abdominally and a fist in the vagina against the anterior uterine wall, compressing the uterus between the two hands. Simultaneously, the lower genital tract should be inspected for lacerations that may require repair. If retained products of conception are suspected, manual exploration of the uterine cavity or surgical evacuation should be performed. Transfusion should be initiated early in significant hemorrhage, and activation of a massive transfusion protocol with balanced blood product administration should be considered when ongoing hemorrhage is anticipated. Uterine tamponade with a Bakri balloon may be employed when medical management fails to control bleeding.

Uterotonic medications are the pharmacologic mainstay of postpartum hemorrhage treatment. Oxytocin is the first-line agent, administered as 10 to 40 units intravenously or intramuscularly, and has no significant contraindications. Methylergonovine at a dose of 0.2 milligrams intramuscularly promotes sustained uterine contraction but is contraindicated in hypertensive patients due to its vasoconstrictive properties. Carboprost, a prostaglandin F2-alpha analog, is given as 250 micrograms intramuscularly and is contraindicated in patients with asthma because it can induce bronchospasm. Misoprostol at a dose of 800 to 1,000 micrograms administered rectally has no absolute contraindications and serves as a readily available alternative. When all medical and mechanical interventions fail, surgical options include the B-Lynch compression suture, uterine artery ligation, and ultimately hysterectomy as the definitive life-saving procedure.

<image>Panel A: Diagram illustrating the four T's of postpartum hemorrhage (Tone, Trauma, Tissue, Thrombin) with the relative frequency of each cause. Panel B: Demonstration of bimanual uterine massage technique with one hand on the fundus and a fist compressing the anterior uterine wall through the vagina. Panel C: Stepwise management algorithm from uterine massage through uterotonics, tamponade with Bakri balloon, and surgical interventions. Panel D: Summary of uterotonic medications showing oxytocin, methylergonovine, carboprost, and misoprostol with their doses, routes, and contraindications.</image>

Section 6: Pelvic Inflammatory Disease

Pelvic inflammatory disease is an ascending polymicrobial infection of the female upper genital tract involving the uterus, fallopian tubes, ovaries, and surrounding pelvic structures. The typical presentation includes bilateral lower abdominal pain that is often described as dull and constant, mucopurulent vaginal discharge, and fever, although the absence of fever does not exclude the diagnosis. The hallmark physical examination finding is cervical motion tenderness, which is elicited by gently rocking the cervix during bimanual examination and reproducing the patient's pain. Risk factors include multiple sexual partners, history of sexually transmitted infections, lack of barrier contraceptive use, and prior pelvic inflammatory disease.

The diagnosis of pelvic inflammatory disease is primarily clinical, as no single test is both highly sensitive and specific. The minimum diagnostic criteria established by the Centers for Disease Control and Prevention require pelvic or lower abdominal pain plus at least one of the following on pelvic examination: cervical motion tenderness, uterine tenderness, or adnexal tenderness. Supportive findings that increase diagnostic specificity include fever above 38.3 degrees Celsius, elevated white blood cell count, and elevated erythrocyte sedimentation rate or C-reactive protein. Definitive diagnosis by laparoscopy is rarely required in the emergency department. Testing for Neisseria gonorrhoeae and Chlamydia trachomatis should be performed, along with HIV and syphilis screening when appropriate.

Outpatient treatment is appropriate for the majority of patients who are not severely ill and can tolerate oral medications. The recommended regimen consists of ceftriaxone 500 milligrams intramuscularly as a single dose plus doxycycline 100 milligrams orally twice daily for 14 days plus metronidazole 500 milligrams orally twice daily for 14 days to provide coverage for anaerobic organisms. Indications for inpatient treatment include tubo-ovarian abscess, pregnancy, severe systemic illness with high fevers or inability to tolerate oral medications, and failure of outpatient therapy. Inpatient regimens include cefoxitin plus doxycycline or clindamycin plus gentamicin, with transition to oral therapy after clinical improvement.

The long-term complications of pelvic inflammatory disease are significant and underscore the importance of prompt diagnosis and treatment. Tubo-ovarian abscess is a serious acute complication that may require percutaneous or surgical drainage in addition to antibiotic therapy. Tubal scarring and damage increase the risk of subsequent ectopic pregnancy and may cause infertility, with the risk increasing with each episode of pelvic inflammatory disease. Chronic pelvic pain may develop as a result of adhesion formation. Fitz-Hugh-Curtis syndrome, characterized by perihepatitis with right upper quadrant pain from inflammation of the liver capsule, is a recognized complication that may mimic biliary disease and should be considered in the differential diagnosis of right upper quadrant pain in young women.

<image>Panel A: Illustration of the ascending spread of infection in pelvic inflammatory disease from the cervix through the endometrium to the fallopian tubes and ovarian structures. Panel B: Clinical photograph demonstrating the technique for eliciting cervical motion tenderness during bimanual pelvic examination. Panel C: Treatment algorithm distinguishing outpatient from inpatient management criteria with specific antibiotic regimens for each setting. Panel D: Diagram of long-term complications including tubo-ovarian abscess, tubal damage leading to ectopic pregnancy and infertility, and Fitz-Hugh-Curtis perihepatitis with violin-string adhesions on the liver capsule.</image>

Section 7: Ovarian Torsion

Ovarian torsion occurs when the ovary and often the fallopian tube twist on the infundibulopelvic ligament, compromising venous and eventually arterial blood supply to the ovary. The characteristic presentation is the sudden onset of severe, unilateral lower abdominal or pelvic pain that is frequently accompanied by nausea and vomiting. Risk factors include the presence of an ovarian mass or cyst, which acts as a lead point for torsion, as well as pregnancy and fertility treatment, both of which can cause ovarian enlargement. On examination, adnexal tenderness is typically present, and a mass may be palpable. An important clinical clue is the history of intermittent episodes of similar pain that resolve spontaneously, suggesting torsion-detorsion events.

Pelvic ultrasound with Doppler flow assessment is the primary imaging modality for suspected ovarian torsion. Classic findings include an enlarged ovary, often exceeding 5 centimeters, and absent or markedly decreased blood flow on Doppler examination. However, it is critically important to recognize that the presence of normal Doppler flow does not exclude torsion, as intermittent torsion may allow restoration of blood flow, and dual arterial supply from the ovarian and uterine arteries may maintain some perfusion even in the setting of torsion. Computed tomography may demonstrate an enlarged ovary with a twisted vascular pedicle and surrounding inflammatory changes. A pregnancy test should always be obtained in reproductive-age women to evaluate for concurrent pregnancy.

Management of ovarian torsion is surgical and time-sensitive, as prolonged torsion leads to ovarian necrosis and irreversible loss of ovarian function. Emergent operative detorsion is the standard of care, with ovarian preservation attempted whenever the tissue appears viable. Even ovaries that appear dusky or edematous at the time of surgery may recover function after detorsion, so oophorectomy is reserved for clearly necrotic tissue. If an ovarian cyst or mass is identified as the lead point, cystectomy may be performed concurrently. Surgical consultation should not be delayed for additional imaging when clinical suspicion is high, as the diagnosis is ultimately confirmed intraoperatively.

Ruptured ovarian cyst is an important differential diagnosis that shares features with ovarian torsion but has distinct management implications. Cyst rupture typically presents with acute pelvic pain that may follow sexual intercourse or vigorous physical activity. Ultrasound demonstrates free fluid in the pelvis, often with a collapsed or partially collapsed cyst. The majority of ruptured ovarian cysts are managed conservatively with analgesia, observation, and outpatient follow-up. However, hemorrhagic cyst rupture with hemodynamic instability requires surgical intervention. The distinction between torsion and ruptured cyst is important because torsion demands emergent surgery while most ruptured cysts resolve spontaneously.

<image>Panel A: Pelvic ultrasound with Doppler demonstrating an enlarged ovary with absent blood flow consistent with ovarian torsion, compared with a normal contralateral ovary with preserved flow. Panel B: Intraoperative photograph showing a torsed ovary with the twisted vascular pedicle and edematous, congested ovarian tissue. Panel C: Ultrasound image of a ruptured hemorrhagic ovarian cyst with surrounding free fluid in the cul-de-sac. Panel D: Clinical decision algorithm for acute unilateral pelvic pain differentiating ovarian torsion from ruptured cyst based on Doppler findings, clinical stability, and surgical indications.</image>

Section 8: Vaginal Bleeding in the Non-Pregnant Patient

Abnormal vaginal bleeding in the non-pregnant patient encompasses a wide differential diagnosis that can be broadly categorized by etiology. Structural causes include uterine fibroids (leiomyomas), endometrial and cervical polyps, and gynecologic malignancies including endometrial, cervical, and vaginal carcinoma. Infectious causes include cervicitis and pelvic inflammatory disease. Coagulopathies, whether from inherited bleeding disorders such as von Willebrand disease or from therapeutic anticoagulation, can manifest as heavy or prolonged vaginal bleeding. Traumatic causes include genital lacerations and retained vaginal foreign bodies. Hormonal etiologies, particularly anovulatory bleeding, are common in adolescents and perimenopausal women. A pregnancy test must always be obtained first, as pregnancy and its complications remain the most important cause to exclude.

The emergency department evaluation begins with a pregnancy test in all reproductive-age women, followed by a complete blood count to assess for anemia and thrombocytopenia. Coagulation studies including prothrombin time and partial thromboplastin time should be obtained when a bleeding disorder is suspected. A thorough speculum examination is essential to identify the source of bleeding, which may originate from the cervix, vaginal walls, or uterine cavity. Sexually transmitted infection testing should be performed when cervicitis or pelvic inflammatory disease is suspected. Additional workup including thyroid function tests and endometrial biopsy may be appropriate for outpatient evaluation.

Stabilization of the hemodynamically significant bleeding patient requires establishment of intravenous access with large-bore cannulation and initiation of crystalloid resuscitation. Blood transfusion is indicated for symptomatic anemia or hemodynamic instability, and a type and crossmatch should be obtained early. Hormonal therapy can be employed to achieve medical hemostasis; high-dose intravenous conjugated estrogen or high-dose oral progestins can stabilize the endometrium and reduce bleeding. Vaginal packing may be used as a temporizing measure in cases of uncontrolled lower genital tract hemorrhage. Obstetrics and gynecology consultation should be obtained urgently for uncontrolled bleeding that does not respond to initial resuscitative measures.

Disposition depends on the severity of bleeding and the patient's hemodynamic stability. Hemodynamically stable patients with mild to moderate bleeding can be discharged with close outpatient follow-up with a gynecologist for further evaluation and definitive management. Hemodynamically unstable patients or those with severe ongoing hemorrhage require hospital admission, continued transfusion support, and subspecialty consultation. Postmenopausal vaginal bleeding warrants particular attention because it may represent endometrial carcinoma; these patients should be referred urgently for endometrial biopsy and gynecologic evaluation even when bleeding is minimal and the patient is hemodynamically stable.

<image>Panel A: Speculum examination images demonstrating common causes of vaginal bleeding including cervical polyp, cervicitis, and cervical malignancy. Panel B: Algorithm for emergency department evaluation of abnormal vaginal bleeding beginning with pregnancy test and proceeding through laboratory studies, speculum examination, and imaging. Panel C: Transvaginal ultrasound images showing structural causes of bleeding including submucosal fibroid and thickened endometrial stripe suggestive of malignancy. Panel D: Stepwise stabilization approach for hemodynamically significant vaginal bleeding from intravenous access and resuscitation through hormonal hemostasis, vaginal packing, and gynecologic consultation.</image>

Section 9: Sexual Assault

The emergency department evaluation of the sexual assault patient demands a trauma-informed approach that prioritizes the patient's sense of safety, dignity, and autonomy. The patient should control the pace of the evaluation, and all procedures should be explained in advance with explicit consent obtained before proceeding. A private examination room should be provided, and a trained chaperone should be present throughout the encounter. Documentation must be objective, detailed, and non-judgmental, describing findings without interpretation. The decision to involve law enforcement belongs entirely to the patient, and the medical evaluation should proceed regardless of the patient's choice regarding reporting. The clinician's primary obligation is to the medical and psychological welfare of the patient.

The medical evaluation begins with a thorough history that includes the circumstances of the assault, any injuries sustained, and specific details regarding the type of assault for purposes of guiding evidence collection and prophylactic treatment. A comprehensive physical examination should be performed from head to toe, with particular attention to the genitourinary region. Photographic documentation of injuries should be obtained with the patient's consent, and a body diagram should be completed. It is important to recognize that injuries may be subtle or entirely absent, and the absence of visible trauma does not indicate that an assault did not occur. Mental health status should be assessed, including immediate safety concerns, suicidal ideation, and the need for crisis support services.

Forensic evidence collection should be performed by a Sexual Assault Nurse Examiner when available, as these specially trained providers have expertise in both evidence collection and compassionate care. The sexual assault evidence kit should be collected within 72 to 120 hours of the assault, depending on jurisdictional protocols, though earlier collection yields higher-quality evidence. Kit contents typically include swabs from relevant body sites, the patient's clothing, pubic hair combings, and fingernail scrapings. Strict chain of custody must be maintained throughout the process to ensure the legal admissibility of collected evidence. Patient consent is absolutely required before evidence collection proceeds, and the patient retains the right to decline any portion of the examination.

Medical treatment addresses the immediate and potential long-term consequences of the assault. Sexually transmitted infection prophylaxis is administered empirically and typically includes ceftriaxone for gonorrhea, azithromycin or doxycycline for chlamydia, and metronidazole for trichomoniasis. Emergency contraception should be offered and provided if desired; levonorgestrel (Plan B) or ulipristal acetate may be given up to 5 days after the assault, with copper intrauterine device placement as an additional option. HIV post-exposure prophylaxis should be considered based on risk assessment and initiated if indicated, ideally within 72 hours. Hepatitis B vaccination should be administered if the patient is not already immune. Follow-up should be arranged within 1 to 2 weeks for sexually transmitted infection test results, additional counseling, and referral to ongoing support services.

<image>Panel A: Diagram of a trauma-informed approach to sexual assault care showing the principles of patient autonomy, privacy, consent, objective documentation, and patient-directed law enforcement involvement. Panel B: Body diagram template used for documenting the location and characteristics of injuries during the forensic medical examination. Panel C: Sexual assault evidence kit contents including swabs, specimen containers, clothing bags, and chain of custody documentation forms. Panel D: Summary of prophylactic medical treatments including STI prophylaxis regimens, emergency contraception options with timing windows, HIV PEP indications, and hepatitis B vaccination.</image>

Section 10: Other Gynecologic Emergencies

A Bartholin gland abscess develops when the duct of the Bartholin gland, located at the posterior aspect of the labia majora at approximately the 5 and 7 o'clock positions, becomes obstructed and secondarily infected. The patient presents with a painful, unilateral labial swelling that is tender, fluctuant, and warm to palpation. The definitive emergency department treatment is incision and drainage with placement of a Word catheter, which is a small balloon-tipped catheter inserted into the abscess cavity and inflated to maintain the drainage tract and promote epithelialization of a new duct opening. Systemic antibiotics are not routinely required unless surrounding cellulitis is present, and the patient should follow up with gynecology for Word catheter removal in approximately 4 to 6 weeks.

Vaginal foreign body is an underrecognized cause of gynecologic symptoms in the emergency department, and patients may not volunteer the history due to embarrassment. The most commonly encountered retained object is a forgotten tampon, which may be retained for days to weeks before the patient presents with foul-smelling vaginal discharge, pain, and occasionally vaginal bleeding. Other foreign bodies encountered in clinical practice include contraceptive devices, sexual objects, and, in pediatric patients, small objects inserted during exploration. Treatment involves careful removal of the foreign body, which can usually be accomplished with ring forceps under direct visualization; however, sedation or anesthesia may be required for deeply retained objects or in pediatric patients.

Hyperemesis gravidarum represents the severe end of the spectrum of nausea and vomiting in pregnancy, defined by persistent vomiting that results in weight loss exceeding 5 percent of pre-pregnancy weight, dehydration, and ketonuria. Complications include electrolyte abnormalities, particularly hypokalemia and hyponatremia, metabolic alkalosis from hydrochloric acid loss, and rarely Wernicke encephalopathy from thiamine deficiency. Emergency department management centers on intravenous fluid resuscitation, thiamine supplementation (which should be administered before dextrose-containing fluids to prevent precipitating Wernicke encephalopathy), and antiemetic therapy with ondansetron, metoclopramide, or promethazine. Hospital admission is indicated for patients with severe dehydration, persistent inability to tolerate oral intake, significant electrolyte derangements, or signs of thiamine deficiency.

Ovarian hyperstimulation syndrome is an iatrogenic complication that occurs following fertility treatments, particularly after ovulation induction with gonadotropins and human chorionic gonadotropin trigger. The syndrome results from massive ovarian enlargement with increased capillary permeability leading to fluid shifts from the intravascular compartment into the peritoneal and pleural spaces. Mild cases present with abdominal bloating and mild discomfort, while severe cases develop tense ascites, pleural effusions, hemoconcentration, renal failure from decreased renal perfusion, and electrolyte abnormalities. Management is primarily supportive, with careful fluid resuscitation to maintain intravascular volume without worsening third-spacing, paracentesis for symptomatic ascites, and thromboprophylaxis because these patients are at markedly increased risk for venous thromboembolism. Ovarian torsion is a feared complication due to the massively enlarged ovaries, and any acute change in pain character should prompt urgent evaluation.

<image>Panel A: Anatomical illustration showing the location of the Bartholin glands at the vaginal introitus with a photograph of a fluctuant Bartholin abscess and the Word catheter device used for drainage and marsupialization. Panel B: Speculum examination demonstrating removal of a retained vaginal foreign body (tampon) using ring forceps. Panel C: Clinical features of hyperemesis gravidarum showing laboratory findings of ketonuria, electrolyte derangements, and the management algorithm from intravenous fluids through antiemetic therapy. Panel D: Pelvic ultrasound demonstrating massively enlarged ovaries with multiple large follicles in severe ovarian hyperstimulation syndrome, alongside a CT image showing ascites and bilateral pleural effusions.</image>

Summary

• Ectopic pregnancy presents with positive beta-hCG, no intrauterine pregnancy on ultrasound, and adnexal findings; ruptured ectopic requires emergent surgery while stable patients may receive methotrexate
• The discriminatory zone holds that an intrauterine pregnancy should be visible on ultrasound when beta-hCG is between 1,500 and 3,000 mIU/mL
• Placenta previa presents with painless third trimester bleeding; digital vaginal examination must never be performed, and ultrasound is the diagnostic modality
• Placental abruption presents with painful bleeding and a rigid uterus; this is a clinical diagnosis as ultrasound may appear normal
• Eclampsia is managed with magnesium sulfate at a 4 to 6 gram loading dose followed by 1 to 2 grams per hour infusion; delivery is the definitive treatment
• Shoulder dystocia is managed with the McRoberts maneuver and suprapubic pressure; fundal pressure must be avoided
• The four T's of postpartum hemorrhage are Tone (uterine atony, most common), Trauma, Tissue, and Thrombin
• Pelvic inflammatory disease requires cervical motion tenderness plus pelvic pain for diagnosis; outpatient treatment is ceftriaxone plus doxycycline plus metronidazole
• Ovarian torsion presents with sudden unilateral pain and requires emergent surgical detorsion; normal Doppler does not exclude the diagnosis
• Sexual assault patients receive trauma-informed care, forensic evidence collection, STI prophylaxis, and emergency contraception

Key Terms

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