6.3 Gynecologic Emergencies and Sexual-Assault Care

Ectopic Pregnancy: The Bleeding Clock

Ectopic pregnancy is implantation outside the uterine cavity, most often in the fallopian tube, and is the leading cause of first-trimester maternal death. The classic triad is abdominal/pelvic pain, vaginal bleeding, and a positive pregnancy test with amenorrhea. A ruptured ectopic causes intraperitoneal hemorrhage: severe pain, referred shoulder pain from diaphragmatic irritation by free blood, syncope, and hemorrhagic shock.

The diagnostic rule the exam loves: a positive beta-hCG with no intrauterine pregnancy seen on transvaginal ultrasound is an ectopic until proven otherwise. The discriminatory zone — the beta-hCG above which an intrauterine pregnancy should be visible (roughly 1,500-2,000 mIU/mL transvaginally) — is a guide, not a rule-out; ruptured ectopics occur at very low beta-hCG levels, so clinical suspicion drives imaging regardless of the number.

Management splits by stability:

• Unstable / ruptured: large-bore IV access, crystalloid, type and crossmatch, and emergent surgery (laparoscopy/laparotomy). This patient does not wait.
• Stable, early, unruptured: may be eligible for methotrexate (a folate antagonist that stops trophoblast growth) with serial beta-hCG follow-up.

Ovarian Torsion, PID, and Abnormal Bleeding

Ovarian torsion twists the ovary on its vascular pedicle, cutting off blood flow — the female analog of testicular torsion. It causes sudden, severe, unilateral pelvic pain, often with nausea and vomiting, frequently associated with an ovarian cyst or mass. Doppler ultrasound may show reduced flow or a 'whirlpool sign'; treatment is surgical detorsion to salvage the ovary, so it is another surgical clock.

Pelvic inflammatory disease (PID) is ascending infection of the upper genital tract (usually gonorrhea/chlamydia). The CDC minimum criteria call for empiric treatment in an at-risk patient with pelvic pain and one or more of: cervical-motion tenderness ('chandelier sign'), uterine tenderness, or adnexal tenderness. Because untreated PID causes infertility, ectopic pregnancy, and tubo-ovarian abscess, the exam answer is to treat empirically rather than wait for cultures. A severe walled-off tubo-ovarian abscess may need admission and drainage.

For abnormal vaginal bleeding, quantify blood loss, check hemodynamic stability and beta-hCG, and remember pregnancy-related causes (miscarriage, ectopic) always come first in a positive-hCG patient.

Sexual-Assault Care and the SANE Role

A Sexual Assault Nurse Examiner (SANE) provides trauma-informed care that is simultaneously medical and forensic. The medical priorities are treating injuries, then offering prophylaxis: empiric antibiotics for gonorrhea, chlamydia, and trichomonas; HIV post-exposure prophylaxis (PEP) started ideally within 72 hours; and emergency contraception, effective up to 120 hours but most effective early.

The forensic priorities protect evidence and the survivor's choices:

• Timeframe: the forensic evidence kit is generally valid up to 120 hours (5 days) after the assault for adolescents/adults; oral and anal swab windows are shorter.
• Chain of custody: every specimen must be sealed, labeled, signed, and continuously accounted for; never leave collected evidence unattended. A break in chain of custody can void the evidence in court.
• Consent and autonomy: the survivor consents to each step and may decline the exam, treatment, or reporting; care proceeds at the survivor's pace.
• Preserve evidence: discourage bathing, urinating, or changing clothes before collection when feasible; collect clothing per protocol.

The exam reliably tests chain of custody and the 120-hour evidence window, plus the principle that the survivor's emotional safety and informed consent guide every decision.

First-Trimester Bleeding and Shock Recognition

Not all early-pregnancy bleeding is ectopic, and CEN expects you to recognize the spectrum of miscarriage while never dropping ectopic from the differential. The terminology is testable:

• Threatened abortion — bleeding with a closed cervical os; the pregnancy may continue.
• Inevitable abortion — bleeding with an open os; loss is unavoidable.
• Incomplete abortion — some products of conception passed, some retained; risk of ongoing bleeding.
• Complete abortion — all products passed, os closing, bleeding subsiding.
• Missed abortion — fetal demise without expulsion; the os is closed.
• Septic abortion — retained products with infection: fever, foul discharge, uterine tenderness — a true emergency needing antibiotics and evacuation.

For any bleeding pregnant patient, the nursing priorities are the same: assess hemodynamic stability, send beta-hCG, type and Rh, and CBC, and remember Rh-negative patients need Rho(D) immune globulin (RhoGAM) after significant bleeding to prevent isoimmunization.

Recognizing hemorrhagic shock is the highest-yield skill across this whole domain. The exam tests the early, compensated picture: a young patient with a ruptured ectopic may maintain blood pressure while becoming tachycardic, anxious, pale, and diaphoretic, with delayed capillary refill — then decompensate suddenly. Orthostatic vital-sign changes, referred shoulder pain, and a rigid or distended abdomen are warning signs of intraperitoneal hemorrhage.

The nursing response to suspected hemorrhagic shock is reflexive: two large-bore IVs, isotonic crystalloid, type and crossmatch, activate massive transfusion if unstable, and move toward the OR. Do not anchor on a 'normal' blood pressure in a young, bleeding patient — by the time it falls, blood loss is already substantial. This vigilance separates safe emergency nursing from a missed catastrophe.