Version May 2024
INTRODUCTION — As a result of their unique reproductive needs, adult females and girls are typically more negatively impacted by disasters compared with adult males and boys. Nonpregnant females in disaster settings may experience gynecologic emergencies; domestic violence, including sexual assault; limited access to contraception, emergency contraception, safe abortion, and skilled sexual assault examiners; and limited safety and security in evacuation shelters. Specific to disaster settings, injuries from blunt and penetrating trauma from domestic violence and sexual assault are very common. In addition, care is often delivered by providers untrained in sexual health, reproductive health, or pregnancy management.
This topic will review the unique gynecologic health needs of nonpregnant females during disasters. Care of pregnant patients is discussed separately. (See "Disaster settings: Care of pregnant patients".)
In this topic, we will use the terms "women" or "patient" as used in the studies below. However, we encourage the reader to consider the specific counseling needs of transgender and gender-expansive individuals.
DEFINITIONS
●Disaster setting – A disaster is defined by the World Health Organization as a situation or event that overwhelms local capacity and seriously disrupts the functioning of a community or society, necessitating a request at the national or international level for external assistance [1]. The types of disasters and their impact on women's health are presented in detail elsewhere:
•(See "Disaster settings: Care of pregnant patients", section on 'Definition'.)
•(See "Disaster settings: Care of pregnant patients", section on 'Epidemiology'.)
●Disaster response readiness – Disaster response planning and training occur at the levels of governments, teams, and individuals. Before responding to a disaster setting, health care providers need to be educated on caring for themselves and others in austere environments. (See "Disaster settings: Care of pregnant patients", section on 'Maintaining clinician readiness'.)
DISPARATE IMPACT OF DISASTERS ON FEMALES — From 2017 to 2019, the number of people affected by humanitarian crises rose from nearly 129 million to 134 million; approximately one-quarter of these were females of reproductive age [2-4]. The 2002 report of the World Health Organization, "Gender and Health in Disaster," explicitly states that there is a pattern of gender differentiation at all levels of the disaster process, including "exposure to risk, risk perception, preparedness, response, and physical and psychological impact" [5]. Emergency plans that specifically address the needs of women and girls during disasters are underdeveloped in many resource-limited settings. Women, children (particularly girls), and older adults are typically disproportionately affected in the response and recovery phases following a disaster and have higher death rates [6-9]. Representative studies include the following:
●In a population-based case-control study performed after an earthquake in California, individuals over the age of 65 had nearly three times the risk of injury compared with younger people, and women had 2.4 times greater risk of injury than men [7]. Sex and age were independent risk factors and were not impacted by seismic or building confounders. Possible explanations for the increased injury risk for females included decreased resiliency to injury (for older adults) or gender differences, such as responsibilities for children and differences in clothing and hair that may have increased susceptibility to injury and death [10].
●Differential mortality was reported after the 2005 Kashmir earthquake where women, children, and older adults were more likely to have died [8].
●A review of multiple earthquakes reported that female sex was associated with experiencing posttraumatic stress disorder (PTSD) [11]. Other factors associated with experiencing PTSD in the multivariate analysis included food and water shortages, loss of church, injuries, and low levels of perceived support.
●Other adverse reproductive health outcomes that disproportionately impact women include HIV acquisition, limited access to contraception and safe abortion, and gender-based violence [12]. (See 'Sexual violence' below.)
Resultant poor obstetric outcomes include, but are not limited to, early pregnancy loss, congenital anomalies, low birth weight, and preterm birth [13,14]. (See "Disaster settings: Care of pregnant patients", section on 'Epidemiology'.)
GYNECOLOGIC EMERGENCIES — Reproductive health emergencies include pregnancy-related bleeding, heavy vaginal bleeding unrelated to pregnancy, and infection.
Heavy vaginal bleeding — Heavy vaginal bleeding can be a result of pregnancy complications (incomplete pregnancy loss, ectopic pregnancy, unsterile abortion), heavy menstrual bleeding (eg, resulting from anovulatory bleeding or fibroids), or, less commonly, malignancy. Initial goals of care include treating hemodynamic instability, controlling the bleeding, and addressing the underlying cause.
Early pregnancy-related bleeding — Patients may present with complications of a known early pregnancy or present with symptoms of bleeding and/or infection and then have early pregnancy diagnosed. For women who present with bleeding during pregnancy, we use the diagnostic approaches outlined in the algorithms and modify them, as needed, based on available laboratory and imaging resources (algorithm 1 and algorithm 2). Care of pregnant individuals in a disaster setting is reviewed in detail separately. (See "Disaster settings: Care of pregnant patients", section on 'Bleeding in pregnancy'.)
Patients with pregnancy-related heavy uterine bleeding typically require expedited surgical uterine evacuation. Unstable patients are not candidates for medical therapy. Procedures for uterine evacuation up to 12 weeks of gestation include mechanical vacuum aspiration or suction curettage.
●(See "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation".)
●(See "First-trimester pregnancy termination: Uterine aspiration".)
Heavy uterine bleeding
Trauma-related — Lower genital tract bleeding can occur from penetrative trauma or retained objects. Penetrative trauma can be direct (ie, rape, assault [15]) or secondary to pelvic fractures. Bleeding in these situations can lead to rapid hemodynamic decompensation [16,17] given the rich blood supply of the pelvic region [15]. Emergency evaluation and control of the bleeding sources are advised for these individuals. The accepted therapeutic modality for significant pelvic bleeding is preperitoneal pelvic packing into the space of Retzius.
●Pelvic fracture – In the setting of a suspected pelvic fracture, an external pelvic binder should be placed at the level of the greater trochanter [18].
•(See "Pelvic trauma: Initial evaluation and management".)
•(See "Severe pelvic fracture in the adult trauma patient".)
●Genital laceration – If a genital laceration is identified, management consists of suture ligation of bleeding vessels and vaginal laceration repair, which can be performed using local anesthesia and sterile equipment. Additional monitoring should be performed given the risk of occult bleeding.
•(See "Evaluation and management of female lower genital tract trauma".)
•(See "Repair of perineal lacerations associated with childbirth".)
●Sexual assault – In the setting of suspected or confirmed sexual assault, careful documentation of all the injuries and the patient's story is vital for future legal proceedings [19]. A trauma-informed approach to care is advised.
Abnormal uterine bleeding — Once trauma has been excluded as the likely source of bleeding, the PALM-COEIN classification (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and "not yet classified") of abnormal bleeding can be a useful diagnostic checklist for abnormal bleeding in the disaster setting (figure 1) [20]. Heavy uterine and lower genital tract bleeding can occur secondary to gynecologic causes that are structural or physiologic. A detailed history and physical examination will help make the diagnosis. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis".)
●Structural – Structural causes include uterine fibroids; prolapsing submucosal fibroids through a dilated cervical os; or uterine, cervical, or vaginal polyps. A pelvic speculum examination can identify polyps visualized in the cervix, and a bimanual examination with bedside ultrasound, if available, can presumptively diagnose fibroids. If a polyp or prolapsing fibroid can be easily removed in a clean and safe environment, this will reduce active bleeding.
●Physiologic – Physiologic bleeding occurs with anovulation and proliferative overgrowth of the endometrial lining. The standard intervention once pregnancy has been ruled out is treatment with tranexamic acid, progesterone-only pills, combined oral contraceptive pills, or a levonorgestrel-releasing intrauterine device. These are also appropriate medical options for bleeding secondary to polyps or fibroids if surgical intervention is unavailable. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management".)
Malignancy — As in the nondisaster setting, vaginal bleeding can be the initial presentation of gynecologic malignancy. Initial efforts to control related bleeding are made in the field, and the patient is then transferred to a Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facility or cancer care center, if available, for complete management.
●(See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis".)
●(See "Overview of resectable endometrial carcinoma".)
●(See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis".)
●(See "Vaginal cancer".)
●(See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment".)
Gestational trophoblastic disease — Individuals with gestational trophoblastic disease typically present with an enlarged uterus, a positive human chorionic gonadotropin, and an enlarged and hydropic placenta on ultrasound evaluation. A normal fetus may or may not be present. Evacuation of the uterus is the standard intervention. Progression to malignancy is rare; however, women should be appropriately counseled and referred to a CEmONC facility for complete management.
●(See "Gestational trophoblastic disease: Pathology".)
●(See "Initial management of low-risk gestational trophoblastic neoplasia".)
●(See "Initial management of high-risk gestational trophoblastic neoplasia".)
●(See "Management of resistant or recurrent gestational trophoblastic neoplasia".)
Lower genital tract malignancy — Malignancies of the lower genital tract, including vulvar, vaginal, and cervical cancers, can lead to heavy bleeding. A careful pelvic examination can quickly identify these lesions. If available, a Foley catheter should be inserted to drain the bladder, followed by a vaginal pack to tamponade the bleeding. If available, acetone is applied to the pack prior to placement as an adjunct to packing [21]. The patient should then be expediently transferred to a CEmONC facility for further management.
Uterine cancer — Uterine cancer is the most common gynecologic malignancy in North America [22]. Uterine bleeding is the most common presenting symptom, and advanced stage uterine cancers can present with frank hemorrhage. Interventions in an austere setting include fluid resuscitation, vaginal or uterine packing, transfusion if available, and referral to a cancer center. (See "Overview of resectable endometrial carcinoma".)
Infections with or without sepsis
●Common etiologies – Common gynecologic causes of infection and/or sepsis include pelvic inflammatory disease, tubo-ovarian abscess, septic abortion, and retained foreign object [23].
•(See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)
•(See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)
●Polymicrobial infection – Genital tract sepsis is a polymicrobial infection in which aerobic and anaerobic bacteria are presumed to ascend from the lower genital tract into the fallopian tubes and pelvic peritoneum. In addition to untreated sexually transmitted infections (STIs), common pathogens identified in genital tract sepsis are beta-hemolytic Streptococcus pyogenes, Lancefield group A Streptococcus, Escherichia coli, Enterococcus faecalis, Pseudomonas, Staphylococcus aureus, Proteus, Streptococcus pneumoniae, Morganella morganii, Citrobacter koseri, Acinetobacter, and Listeria. Mixed infection with two or more organisms can also occur. Methicillin-resistant S. aureus (MRSA) infection can develop in some women during a prolonged stay in a clinical environment unit [24].
●Presenting symptoms – Sepsis ranges from infection and bacteremia to septic shock, multiple organ dysfunction syndrome, and death. Indicators of infection and/or sepsis include fever (>38°C) or hypothermia, tachypnea, tachycardia, leukocytosis, and/or leukopenia. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis".)
●Management – Specific recommendations on the management of infections in patients with sepsis and septic shock are mainly derived from studies on bacterial sepsis in high-income settings and are not necessarily applicable elsewhere due to differences in etiology and diagnostic or treatment capacity. However, the tenets of treatment do not differ in disaster environments and consist of supportive care, antipyretics, empiric broad spectrum antibiotics (parenteral or oral), fluid replacement, and control of the infection source.
•Initial interventions – Field management is primarily clinical and based on the patient's history, vital signs, and physical examination. Investigative capacity is often limited; chest radiograph, other imaging studies, and blood cultures may not be available. Interventions in the field focus on oral and intravenous antibiotics. Drug choice is driven by the suspected pathogen(s) since culture-directed antibiotic selection may not be possible. In disasters, wounds are often polymicrobial, and thus, broad spectrum regimens are typically initiated.
Choice of drug combination is driven by availability and suspected underlying etiology. One commonly used regimen for patients with pelvic infection, including septic abortion, is gentamicin (5 mg/kg/day intravenously) plus ampicillin (2 g intravenously every four hours) plus clindamycin (900 mg intravenously every eight hours). Treatment of patients with suspected pelvic inflammatory disease often use a cephalosporin combined with doxycycline (algorithm 3).
-(See "Evaluation and management of suspected sepsis and septic shock in adults".)
-(See "Pelvic inflammatory disease: Treatment in adults and adolescents".)
-(See "Management and complications of tubo-ovarian abscess".)
•Source control – Source control includes identification and removal of any foreign object from the lower genital tract, uterine exploration if retained products are suspected, and abdominal drainage for pelvic abscesses (table 1). Bedside ultrasound is invaluable in identifying fluid collections and/or abscesses that may require surgical drainage. High-dose penicillin and clindamycin should be given if there is concern for beta-hemolytic S. pyogenes, a common causative organism in toxic shock syndrome, or other infection resulting from retained or foreign objects [25].
-(See "Staphylococcal toxic shock syndrome".)
-(See "Toxic shock syndrome due to Paeniclostridium sordellii".)
●Impact of HIV infection – During a disaster or conflict, individuals with HIV infection may be unable to access usual medications and thus develop life-threatening complications from HIV infection. A scoping review of reproductive health services after rapid-onset disasters and humanitarian crises identified gaps in care focused on STI screening and treatment and services for women with HIV [26]. A case study of antiretroviral therapy delivery after the 2010 earthquake in Haiti showed a rapid drop in treatment followed by a rebound in prescriptions with infrastructure recovery [27]. Clinicians in the field must be aware of the need to evaluate for STIs and a history of HIV and have a plan with the pharmacy associated with the group to provide appropriate antibiotics and antiretroviral therapy.
OTHER COMMON GYNECOLOGIC ISSUES
Abnormal uterine bleeding — As above, abnormal uterine bleeding from fibroids or anovulatory cycles can result in heavy bleeding requiring emergency evaluation and treatment. By contrast, uterine bleeding can also be of lesser volume and/or a chronic condition as a result of several underlying conditions (figure 1). This is a diagnosis of exclusion after emergency causes, pregnancy, and genital tract bleeding from nonuterine sources have been excluded (table 2). Full evaluation and treatment of patients who present with nonemergency bleeding that appears chronic in nature can be deferred to the post-acute phase setting. Iron supplementation should be offered to reduce the risks of anemia until a full evaluation can be performed.
●(See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis".)
●(See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management".)
Contraception and abortion services — Earthquakes and other disasters are associated with reductions in access to sexual and reproductive health (SRH) services, which can further exacerbate existing health care inequities [28-32]. While it is increasingly recognized that SRH care is an integral part of disaster response, it has historically been absent from humanitarian agendas, particularly abortion care [33]. SRH neglect can lead to "preventable maternal and newborn deaths, sexual violence and subsequent trauma, sexually transmitted infections (STIs), unwanted pregnancies, unsafe abortions, and the possible spread of HIV" [34].
The Inter-Agency Working Group (IAWG) on Reproductive Health in Crises has created a Minimal Initial Services Package (MISP) and multilingual quick reference to improve implementation of SRH care during disaster response. Services should include pregnancy, delivery, and postpartum care; counseling and provision of contraception, including emergency contraception; abortion and postabortion care; evaluation and care of rape survivors; and counseling, testing, and treatment for STIs [35]. Supplies include obstetric delivery kits, male and female condoms, oral and injectable contraceptives, medications and devices for treating pregnancy loss, and testing and treatment for STIs [34]. Tetanus vaccination may be relevant, particularly for survivors of rape or unsafe abortion [35]. To help guide contraceptive selection, the World Health Organization Medical Eligibility Criteria for Contraceptive Use and the US Medical Eligibility Criteria for Contraceptive Use are freely available and provide contraceptive prescribers with definitive guidance on safety across a broad range of conditions for different patient populations. It is important that contraception is provided free of coercion and on a strictly voluntary basis.
Detailed discussions addressing contraceptive selection, abortion care, and management of pregnancy loss are presented separately.
●(See "Contraception: Counseling and selection".)
●(See "Overview of pregnancy termination".)
●(See "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation".)
Sexual assault and sexually transmitted infections — Increases in sexual violence and transactional sex have been reported in crisis settings [36,37]. As a result, sexual counseling, as well as testing and treating STIs, are now considered key components of crisis care [34]. Médecins Sans Frontières (Doctors Without Borders) has produced publicly available guidelines that address clinical care and treatment of genital infections and victims of sexual violence. Victims of sexual violence require social, mental, and medical support. Medical care of survivors of sexual trauma includes treatment of physical injuries and prophylactic medication for prevention of HIV transmission (algorithm 4), pregnancy (ie, emergency contraception (algorithm 5)), and STIs [38]. Suggested vaccinations include tetanus (for wounds) and hepatitis B (table 3). Detailed information on the initial evaluation and care of sexual violence survivors is presented separately. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department".)
It is important for clinicians in the field to screen for sexual assault as survivors may not volunteer this information. The National Sexual Violence Resource Center has published online guidelines and worksheets for predisaster planning, interventions, and response to sexual assault [39].
Access to routine STI testing and treatment is often limited during disaster situations. In 2012, HIV testing rates declined across areas impacted by Hurricane Sandy, presumably as a result of disrupted access to care [40]. A health care organization operating during political unrest in Kenya in 2008 reported that initiation of highly active antiretroviral therapy had to be temporarily stopped [41].
Counseling, testing, and treating STIs in routine settings are discussed separately.
●(See "Screening for sexually transmitted infections".)
●(See "Sexually transmitted infections: Issues specific to adolescents".)
●(See "Prevention of sexually transmitted infections".)
Care for gynecologic malignancy — Challenges to cancer care that are commonly encountered in disaster settings include damage to infrastructure, loss of or limited communication (including medical records), and disruption or cessation of treatment [42]. A 2018 systematic review of 85 studies reported a substantial disruption of oncology services during a disaster [42]. The authors advised predisaster planning of how to manage cancer patients during a disaster. Clinicians and responders may find themselves faced with delivering supportive care only to patients with advanced and symptomatic malignancies. Predisaster training should also involve learning how to give bad news and administer supportive care, including psychological first aid [43].
SEXUAL VIOLENCE
Background — Tragically, sexual violence often accompanies disaster, and therefore, the initial disaster response should include a comprehensive strategy to prevent and mitigate interpersonal violence. Disasters increase women's vulnerabilities and susceptibility to exploitation and violence [44]. As an example, reports of sexual violence increased 300-fold following the Loma Prieta earthquake [45]. Similarly, accounts of "disaster rape" emerged on day 1 of Hurricane Katrina, during which gender-based violence (GBV) increased from a baseline of 4.6 to 16.3 reported cases per 100,000 per day [46-48]. Such acts reflect the failure of the disaster response to include protocols for the prevention of sexual violence, particularly through safety and security.
Types
●Individual acts of sexual violence – Sexual violence has been widely reported during all phases of disaster. A qualitative study found reports of rape during all phases of Hurricane Katrina in New Orleans (warning, impact, emergency, recovery, and reconstruction) [46]. A different study on sexual violence related to Hurricanes Katrina and Rita reported nearly one-third of assaults occurred in evacuation sites or shelters [49]. A 2001 United Nations report noted circumstances contributing to sexual violence following disaster events included male perpetrators' dominance over female victims, psychological strains in refugee camps, absence of support systems for protection, crowded facilities, lack of physical protection, general lawlessness, alcohol and drug abuse, politically motivated violence against refugees, and separation of single females from male family members [50]. A 2018 assessment of male-to-female violence in the Philippines following Super Typhoon Haiyan reported that increased GBV following the typhoon was a result of both the crisis and the preexisting "social construction of gender" in that country [51].
●Targeted or strategic sexual violence – Systematic or targeted rape and sexual violence have been used as strategic weapons during conflicts and genocide efforts [52-54]. Providers who will be working in a disaster zone must understand the cultural and political context of the region. Some areas have been in chronic conflict prior to the onset of the natural disaster. Part of the acts of targeted violence have included sexual exploitation and abuse. One example is the Democratic Republic of Congo (DRC), where it is estimated that there are 200,000 females who have survived rape [55]. In 2018, the DRC experienced an Ebola outbreak [56]. Médecins Sans Frontières (Doctors Without Borders) deployed a hospital to help. The group not only had to manage Ebola but also the consequences of the trauma that women experienced there.
●Intimate partner violence (IPV) – A study comparing IPV rates in four Indian provinces following a tsunami in 2004 reported a 41 to 98 percent increased risk of IPV in severely impacted states compared with those moderately or indirectly impacted [57].
Interventions
System level — Across organizations and disciplines, protocols that address evacuee safety in emergency shelters are imperative. For those deploying who are also part of the organizational board, a reference for how to construct protocols can be referenced online.
The majority of clinicians deployed will be evaluating victims of sexual violence. In a nondisaster setting, one in three women experiences IPV [58]. After a disaster, the incidence increases dramatically. As a result, clinicians should assume that the females they are treating may have experienced sexual assault.
The Inter-Agency Standing Committee (IASC) is the forum for the Global Health cluster that is led by the World Health Organization. The Global Protection Cluster (GPC) is responsible for managing programs and training on GBV. The GPC develops training on GBV for health workers, police, and judges. The IASC has developed GBV guidelines for humanitarian actors working in both conflict and natural disaster settings [59].
Individual care
●Warning signs – Screening for GBV can be complicated in a disaster setting because of cultural differences and lack of time and resources. Screening strategies can be universal or targeted, either to patients who present with specific complaints (table 4) or to high-risk populations. The choice of screening strategy will depend in part on available resources and the surrounding environment. Regardless of formal screening guidelines, clinicians should be concerned about GBV, including human trafficking and IPV, for patients who present with warning signs (table 5).
●Approach to clinical encounter and examination – We take the following approach to lessen the potential of exacerbating sexual harm:
•Ensure the presence of adequately trained GBV personnel as members of the initial deployment team.
•Ensure that clinicians are trained on sexual assault response procedures and the possibility that the clinical examination may cause retraumatization.
•Ensure that patients are screened for sexual violence during clinical encounters.
•Ensure that a member of the team is trained in sexual assault forensic examination and that necessary medical equipment is available.
In addition to mental health counseling, gynecologic services that should be provided include emergency contraception, sexually transmitted infection (STI) screening and STI prophylaxis, and postexposure HIV prophylaxis. (See 'Sexual assault and sexually transmitted infections' above.)
Additional resources on gender-based violence — There are several online training modules on sexual exploitation, abuse, and GBV for disaster responders and humanitarian aid workers.
●Inter-Agency Working Group (IAWG) – Minimum Initial Service Package (MISP) for Sexual and Reproductive Health in Crisis Situations: A Distance Learning Module
•This self-instructional learning module is based on the 2018 Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings and includes core elements of sexual and reproductive health in humanitarian settings, as well as a resource to order sexual and reproductive health kits.
●IAWG – Resources of the Women's Refugee Commission
●Inter-Agency Standing Committee (IASC) – Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian Action
●International Federation of Red Cross and Red Crescent Societies (IFRC) – Unseen, unheard: Gender-based violence in disasters – Global study
●Humanitarian Practice Network (HPN) – Provides online content addressing gender-based violence globally.
●United Nations Population Fund (UNFPA) – Managing Gender-based Violence Programmes in Emergencies
●United Nations High Commissioner for Refugees (UNHCR) – Reach Out: A refugee protection training project
●DisasterReady.org – Access to online courses, including:
•GBV in emergencies
•Prevent sexual exploitation and abuse
●EuroGender – Online certificate course in GBV training (fee of USD $300).
●List of free online courses addressing GBV [60].
GYNECOLOGIC CARE IN AUSTERE ENVIRONMENTS
Gynecologic evaluation — The type of disaster, phase of the disaster response, austerity of the environment, available physical resources, and the availability of interpreters all impact the health care provider's ability to obtain a history, perform a physical examination, and make an assessment. General considerations for effective sexual and reproductive health interventions include attention to privacy, respectful examination, cultural sensitivity, and appropriate health care supplies. Camp geography should foster both patient privacy and security during sensitive examinations. A safe and physically protected location should be used to conduct the interview and perform the examination.
Clinicians should be aware that, in many cultures, male health care providers are not allowed to examine women, and therefore, having female chaperones may improve acceptability of physical examination in these settings. Supplies should include an appropriate examination table, emergency obstetric and midwifery supplies, urine dipsticks, and sanitary and reproductive health supplies. As demonstrated following the 2005 Pakistani earthquake, care delivery, quality, and effectiveness are improved if conducted in a culturally sensitive manner [61].
Focused history and physical examination — In a crisis situation, the components of history and physical examination are focused to address the immediate complaint with the resources available (both personnel and equipment). A complete gynecologic history and physical examination, including the pelvic examination, are detailed separately. (See "The gynecologic history and pelvic examination".)
Regardless of the presenting complaint, key components that apply to most patients include:
●Trauma-informed care – Individuals presenting for care may have experienced sexual or physical violence, neglect, or physical trauma. Providers of health services must understand the impact of trauma (especially directly experienced physical or sexual trauma) and posttraumatic stress disorder (or similar symptoms) on women and female-bodied patients, as well as the unique needs of trauma survivors who are accessing reproductive and general health care. Additionally, clinical care providers are at risk for secondary trauma from the intensity of this work. Briefings and debriefings, both in the field and upon return home, may help health care providers heal from this experience.
Discussions of physical examination and trauma-informed care are presented elsewhere.
•Preparing for and examining patients with a history of trauma or posttraumatic stress disorder – (See "Health care for female trauma survivors (with posttraumatic stress disorder or similarly severe symptoms)".)
•Trauma-informed care – (See "Human trafficking: Identification and evaluation in the health care setting".)
●History
•Chief complaint – Details of the chief complaint are obtained in an expedited fashion. Common gynecologic problems and questions for a focused history are reviewed elsewhere. (See "The gynecologic history and pelvic examination", section on 'Problem focused history'.)
•Last menstrual period and likelihood of pregnancy – The date of the last menstrual period is determined to assess likelihood of pregnancy. However, the last menstrual period only correlates well with pregnancy for patients with regular menstrual cycles (typically defined as 21 to 45 days apart). Clinical symptoms and diagnosis of early pregnancy are discussed in detail separately. (See "Clinical manifestations and diagnosis of early pregnancy".)
•Use of contraception – For patients who are sexually active, pregnancy likelihood can be modified by regular use, or nonuse, of contraception. Emergency contraception can be offered following unprotected vaginal intercourse, whether consensual or forced.
•Surgical history – Obtaining information on prior uterine, tubal, and pelvic surgeries is particularly important for delineating risk of ectopic pregnancy.
•General medical history – Baseline medical conditions, particularly those that could be life-threatening if untreated, such as hypertension, diabetes, and kidney disease, are identified.
•Medications and allergies
•Social history – We include questions about the individual's living conditions; employment; access to clean water, food, and transportation; intimate partner violence/domestic violence; and issues for safety in her surroundings.
●Physical examination – When possible to complete safely, vital signs are measured and a full pelvic examination with focused physical examination is performed. Presence of tachycardia and hypotension should lead to urgent placement of intravenous lines for fluid resuscitation and evaluation for internal bleeding. Physical examination assesses for obvious injury, such as contusions, abrasions, or burns. The pelvic examination includes inspection of external genitalia, a speculum examination of the vagina and cervix, and a bimanual examination of the cervix, uterus, and adnexa. If relevant, evidence of trauma, abuse, and injury is documented when possible. For patients with abdominal trauma, a focused portable ultrasound is performed. If available and appropriate for the patient's presenting complaint, testing for sexually transmitted infections is performed.
Components of complete gynecologic examination and evaluation of sexual assault survivors are reviewed elsewhere.
•(See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)
Imaging — Imaging in these settings is often limited to portable ultrasonography. Handheld portable ultrasounds are easy to transport and are an invaluable tool in a field hospital. If available, ultrasound (typically transabdominal) can be used to confirm pregnancy presence, intrauterine location, viability, and estimated gestational age. While large lesions of the adnexa or uterus may be visualized with transabdominal ultrasound, a transvaginal probe is typically needed to see small lesions, evaluate pregnancy of unknown location, and look for anatomic causes of heavy menstrual bleeding (eg, uterine fibroids, malpositioned intrauterine device).
Laboratory testing — Access to laboratory testing is typically limited in crisis settings and depends, in part, on the preexisting health infrastructure of the region. In our experience, laboratory data are often limited to point-of-care testing (complete blood count, glucose, rapid HIV). Ideally, urine pregnancy tests are available; however, the clinician most often relies on clinical information obtained from the patient's history and physical examination to diagnose pregnancy. (See "Disaster settings: Care of pregnant patients", section on 'Evaluating the pregnant patient'.)
Documentation — Documentation and record keeping can be extremely difficult in resource-scarce settings. Options may range from paper records handed to patients in plastic bags to system-wide electronic health records. These issues are discussed in detail separately. (See "Disaster settings: Care of pregnant patients", section on 'Documentation'.)
Intrauterine procedures — Procedures that may need to be performed for urgent gynecologic issues include uterine evacuation (manual or vacuum aspiration) and dilation and curettage. Preprocedure preparation for both can include cervical preparation.
●(See "First-trimester pregnancy termination: Uterine aspiration".)
●(See "Dilation and curettage".)
●(See "Pregnancy termination: Cervical preparation for procedural abortion".)
Information on materials and procedure completion in resource-challenged settings is available through the Médecins Sans Frontières (Doctors Without Borders) manual on Essential Obstetric and Newborn Care.
DISASTER RESPONSE TEAM AND FACILITIES — A successful disaster response requires training and preparedness for individuals, teams, hospitals, and health care systems. Introductory discussions of these issues are presented in related content.
●(See "Disaster settings: Care of pregnant patients", section on 'Maintaining clinician readiness'.)
RESOURCES FOR PATIENTS AND CLINICIANS — The following organizations provide online resources to the public at no cost:
●Centers for Disease Control and Prevention (CDC) – Crisis and Emergency Risk Communication (CERC) Manual
●United Nations (UN) – United Nations Office for Disaster Risk Reduction
●World Health Organization (WHO) – Disaster Management Guidelines: Emergency Surgical Care in Disaster Situations
●Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis – Resources
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Disaster management: Links to UpToDate resources and society guidelines".)
SUMMARY AND RECOMMENDATIONS
●Impact of disaster settings on reproductive health – As a result of their unique reproductive needs, adult females and girls are typically more negatively impacted by disasters compared with adult males and boys. Nonpregnant females in disaster settings may experience gynecologic emergencies; domestic violence, including sexual assault; limited access to contraception, emergency contraception, safe abortion, and skilled sexual assault examiners; and limited safety and security in evacuation shelters. In addition, care is often delivered by providers untrained in sexual health, reproductive health, or pregnancy management. (See 'Disparate impact of disasters on females' above.)
●Reproductive health emergencies – Reproductive health emergencies include pregnancy-related bleeding, heavy vaginal bleeding unrelated to pregnancy, and infection. Following evaluation, initial management steps often include fluid resuscitation, control of bleeding, and initiation of broad spectrum antibiotics. (See 'Gynecologic emergencies' above.)
●Ongoing care needs – Common ongoing gynecologic problems that continue to require care despite disruption of services from disaster or conflict include abnormal uterine bleeding, contraception and abortion services, care for sexual assault and sexually transmitted infections, and treatment of malignancy. (See 'Other common gynecologic issues' above.)
●Sexual violence – Sexual violence often accompanies disaster, and therefore, the initial disaster response should include a comprehensive strategy to prevent and mitigate interpersonal violence. Disasters increase women's vulnerabilities and susceptibility to exploitation and violence. Gender-based violence includes intimate partner violence, individual acts of violence, and targeted or strategic use of sexual violence. (See 'Sexual violence' above.)
●Care provision in austere environment – While not different from non-disaster settings, resource-austere environments heighten the need for sexual and reproductive health providers to consider attention to privacy, respectful examination, cultural sensitivity, and appropriate health care supplies. Camp geography should foster both patient privacy and security during sensitive examinations. A safe and physically protected location should be used to conduct the interview and perform the examination. (See 'Gynecologic care in austere environments' above.)
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
