Every 6 days a woman is killed at the hands of her partner. Victims of intimate partner violence and domestic violence that we see in the ED typically involve an abuse story of repeated escalating violence over time that ends up in a crisis situation.
Universal Screening for Intimate Partner Violence
Start with a normalizing statement
“Because violence is so common in many women’s lives and because there’s help available for women being abused, I now ask every patient about domestic violence.”
The Partner Violence Screen
- Have you been hit, kicked, slapped, punched or otherwise hurt by someone in the past year?
- Do you feel safe in your current relationship?
- Is there a partner from a previous relationship who is making you feel unsafe now?
Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008).
Minimum criteria for clinical diagnosis (one or more of the following minimum clinical criteria should be present) are as follows:
- Bilateral lower abdominal (uterine) tenderness (sometimes radiating to the legs)
- Cervical motion tenderness – Positive cervical motion tenderness is defined as increased discomfort from a normal pelvic examination, as stated by the patient. Of note, cervical motion tenderness is neither sensitive nor specific for gynaecologic pathology, is a sign of nonspecific peritoneal inflammation,
- Bilateral adnexal tenderness (with or without a palpable mass)
One or more of the following additional criteria can be used to enhance the specificity of the minimum criteria and support a diagnosis of PID:
- oral temperature >101° F (>38.3° C);
- abnormal cervical or vaginal mucopurulent discharge;
- presence of abundant numbers of WBC on saline microscopy of vaginal fluid;
- elevated erythrocyte sedimentation rate;
- elevated C-reactive protein; and
- laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.
- Transvaginal ultrasound is the diagnostic tool of choice for tubal ectopic pregnancy.
- Tubal ectopic pregnancies should be positively identified, if possible, by visualising an adnexal mass that moves separate to the ovary.
- A serum beta-human chorionic gonadotrophin (β-hCG) level is useful for planning the management of an ultrasound visualised ectopic pregnancy.
- Expectant management is an option for clinically stable women with an ultrasound diagnosis of ectopic pregnancy and a decreasing β-hCG level initially less than 1500 iu/l.
- Systemic methotrexate may be offered to suitable women with a tubal ectopic pregnancy. It should never be given at the first visit, unless the diagnosis of ectopic pregnancy is absolutely clear and a viable intrauterine pregnancy has been excluded.
- Surgical methods of management are associated with a high failure rate and should be reserved for those women suffering life-threatening bleeding.
- Offer anti-D prophylaxis as per national protocol to all RhD-negative women who have surgical removal of an ectopic pregnancy, or where bleeding is repeated, heavy or associated with abdominal pain.
- The gravid uterus can mask the signs of peritoneal irritation (guarding, rigidity and rebound tenderness) by preventing the inflamed organ from contacting the peritoneum.
- Due to increased white blood cells that naturally occur during pregnancy, leukocytosis is not helpful in identifying acute pathology.
- A relative increase in blood volume can delay the development of tachycardia and hypotension in the truly ill patient.
- Consider appendicitis in the patient complaining of typical signs and symptoms of appendicitis even if confounded by right middle and upper quadrant abdominal pain, pyuria, urinary symptoms and subtle signs of peritonitis.
- HELLP syndrome is managed with blood pressure control, prevention of seizures, correction of coagulopathy, and delivery of the fetus.
- Radiological investigations, including abdominal plain films, can be safely undertaken during pregnancy and should always be considered so as to avoid delays and failures in diagnosing potentially life-threatening conditions.