IMild   analgesics   and   antispasmodic   may   be administered,  and  for  severe  and  incapacitating pain, light duty and bed rest for 1 or 2 days may be indicated. Refer the patient to a medical treat- ment facility for evaluation if the dysmenorrhea is  interfering  with  the  performance  of  duties. Amenorrhea Menstrual  cycles  that  are  absent  or  more  than 6 months apart are considered to be amenorrhea. The  causes  of  amenorrhea  include  ovarian  or uterine  tumors,  obstruction,  endocrine  function abnormalities, and pregnancy, which is discussed elsewhere   in   this   chapter.   Refer   nonpregnant patients  with  primary  amenorrhea  for  evaluation. In addition to amenorrhea, any other type of abnormal  uterine  bleeding  patterns  should  be referred  as  soon  as  possible  for  definitive diagnosis  and  treatment. Pregnancy A  woman  will  usually  suspect  that  she  is pregnant before coming to sick call for confirma- tion. The physical changes that occur in pregnancy are variable and may not hold true in all cases, so make sure that a false diagnosis is not made. The  patient  will  normally  reveal  a  history  of recent  coitus  with  subsequently  missed  periods. The  classic  symptom  of  morning  sickness  is common.  Pelvic  examination  may  reveal  a  soft, enlarged uterus (detectable at or about the sixth week)  and  a  purplish  hue  to  the  cervix  and  the surrounding   vaginal   mucosa.   There   may   be frequency  of  urination  and  some  amount  of  breast enlargement  and  tenderness.  Laboratory  diagnosis is  accomplished  by  means  of  several  tests  that  are available through the Federal Stock Catalog and are complete with instructions. In the event of a pregnancy  aboard  ship,  consult  NAVMEDCOM and  NAVMILPERSCOM  instructions  for  dispos- ition. Refer the patient for an obstetric workup. Emergency Conditions in Pregnancy l  Ectopic  Pregnancy—This  condition  results when a fertilized ovum is implanted and develops outside  of  the  uterine  cavity.  Ectopic  gestation occurs  in  approximately  1  out  of  every  200 pregnancies.  Most  of  the  time  the  implantation occurs  in  the  fallopian  tube. SYMPTOMS—The   patient   will   reveal   a history   of   amenorrhea   or   irregular   menses, followed  by  a  sudden  onset  of  bleeding.  There may   or   may   not   have   been   a   previously diagnosed  pregnancy.  She  may  complain  of  severe abdominal cramping pain in the lower quadrant. The pain is nonradiating, and a soft, tender pelvic mass  may  be  palpable.  The  decidual  tissues may  pass  and  the  patient  may  show  signs  of shock. TREATMENT—Transfer   the   patient   to   a medical  facility  as  soon  as  possible.  Surgical  treat- ment  is  required. .  Spontaneous  Abortion—This  is  termina- tion   of   gestation   before   the   24th   week   of pregnancy.  Most  spontaneous  abortions  are  the result  of  ovular  or  sperm  defects.  It  may  be  the result  of  anatomic  malformation  of  the  fetus  or diet  deficiencies. SYMPTOMS—The   patient   will   reveal   a history  of  amenorrhea  or  irregular  menses.  A previous  diagnosis  of  pregnancy  mayor  may  not have  been  established.  The  usual  signs  and symptoms  of  pregnancy  are  often  lacking.  An abortion  is  classified  as  follows: .  Threatened—This  is  any  time  vaginal bleeding  or  cramping  occurs  after  conception. .  Imminent—Bleeding  is  heavier  and cervical effacement of dilation is present, and it may  be  accompanied  by  cramping  pain. l   Inevitable—The   membranes   are ruptured and portions of tissue may be visible at the cervical  OS. .   Incomplete—Some   tissue   has   been passed,  and  the  remainder  of  the  conceptus  re- mains in the uterus. . Complete—There is total passage of all parts  of  the  conceptus,  the  uterus  has  returned to  normal  size,  and  the  cervix  has  closed. . Missed—The viability of the pregnancy has  been  terminated  for  at  least  1  month,  but the concept us has been retained. TREATMENT—Place  the  patient  on  com- plete bed rest until the transfer is completed. If bleeding  is  severe,  replace  fluids  and  treat  for shock. Analgesics may be administered to relieve pain.  Administer  antibiotics  if  signs  of  infection are  present.  Transfer  the  patient  to  a  medical facility  as  soon  as  possible. Sexual Assault/Rape Sexual   offenses,   including   rape,   may   be associated  with  serious  injury,  pregnancy,  and 2-39