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GYN
CMECNE

Medical Evaluation of the Rape Victim

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Name the blood tests, urine tests and cultures that should be obtained from the victim
2. List the medications for STD prophylaxis

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Sexual assault is unfortunately not an uncommon event, with the National Intimate Partner and Sexual Violence Survey providing a statistic of 1.3 million rape-related physical assaults per year. Some centers have a team trained and available to identify and assist rape victims. However, this is not universal and women’s healthcare providers may be either part of such a team, or may be the initial point of contact and care provider. Important points to consider are as follows:

  • Ask for help if not familiar with performing an examination as proper evidence collection is necessary to prosecute a case
  • Tell a sexual assault victim, if outside the hospital or clinic, to come to a medical facility directly and avoid bathing, cleansing, eating, changing her clothes, urinating, defecation, washing her mouth, cleaning her fingernails, smoking, eating or drinking
  • Obtain history including circumstances of the attack, patient activities after the attack (including bathing, douching), last menstrual period, contraceptive history, previous coitus
  • Physical exam
    • Noting genital and nongenital trauma, foreign material (stains, hair, dirt, etc) colposcopy if available
    • Collect samples of clothing, hair, semen, blood from the patient
    • Collect urine, saliva, buccal mucosa smear, fingernail clipping and scraping, other specimens as indicated
    • Vaginal test for acid phosphatase, saline mount for sperm, trichomonads, bacterial vaginosis, semen analysis for blood group
  • Initial STD exam (CDC)
    • NAATs for C. trachomatis and N. gonorrhoeae at the sites of penetration or attempted penetration
    • NAATs from a urine or vaginal specimen or point-of-care testing (i.e., DNA probes) from a vaginal specimen for T. vaginalis
    • Point-of-care testing and/or wet mount with measurement of vaginal pH and KOH application for the whiff test from vaginal secretions should be done for evidence of BV and candidiasis, especially if vaginal discharge, malodor, or itching is present
    • A serum sample for evaluation of HIV, hepatitis B, and syphilis infections.
  • STD prophylaxis (CDC)
      • Ceftriaxone 125 mg IM (gonorrhea) and
      • Metronidazole 2 gm po (trichomonaisis and BV) or Tinidazole 2 g po and
    • Azithromycin 1 g po (chlamydia)
  • Hepatitis B
    • Assailant HepB status unknown and survivor is unvaccinated
      • HepB vaccine without HBIG
    • Assailant HepB positive and survivor is unvaccinated
      • HepB vaccine and HBIG
    • Administer
      • At initial exam
      • 1-2 months and 4-6 months after first dose
    • If survivor previously vaccinated but did not receive postvaccination testing
      • single vaccine booster
  • HPV
    • HPV vaccination is recommended for female survivors aged 9–26 years and male survivors aged 9–21 years
    • Administer vaccine to sexual assault survivors at the time of the initial examination with follow-up dose administered at 1–2 months and 6 months after the first dose

HIV Prophylaxis (PEP)

  • Best if started as soon as possible after penetration | Do not give if >72 hours
  • Preferred PEP regimen  (4 weeks)
    • Tenofovir 300 mg PO daily + Emtricitabine 200 mg PO daily plus
    • Raltegravir 400 mg PO twice daily or Dolutegravir 50 mg PO daily
  • CDC guidance (see ‘Learn More – Primary Sources Below) provides further regimen considerations when
    • Source in known to be HIV-infected | Dose adjustments for renal insufficiency | Drug-drug interactions | Recommended alternative regimens
  • Urine for drug screen and pregnancy
      • Offer emergency contraception (see ‘Related ObG Topics’ below)
    • Repeat pregnancy test in 2 weeks

SYNOPSIS:

Nearly 20% of women report having been raped at some time in their lives, according to the CDC 2010 survey. Goals of the rape investigation include: medical assessment and treatment; pregnancy and STD prevention/treatment; collection of forensic data; and psychologic evaluation and support. A form is used to record legal evidence and findings. This may be introduced in court, so should be legible and nontechnical. Some states have programs with designated hospitals, training sites and forensic examiners.

KEY POINTS:

Follow Up

Psychosocial 

  • Psychologic support should be started at presentation; the full effects may not be evident initially
    • Follow-up is important and ideally handled by a specialist trained in rape crisis intervention

STD Follow Up 

    • If initial tests negative and no treatment
      • Repeat STD tests within 1–2 weeks of the assault
    • If treated during the initial visit (regardless of whether testing was performed)
      • Only do post-treatment testing if symptomatic
    • Follow up exam at 1–2 months to look for anogenital warts
    • Syphilis
        • Repeat serologic tests for syphilis if initial test results were negative and infection in the assailant cannot be ruled out
      • Repeat serologic tests for syphilis at 4–6 weeks and 3 months
  • HIV testing
    • Repeat at 6 weeks and at 3 and 6 months using methods to identify acute HIV infection
  • Diagnosis Code: ICD-10-CM: Z04.41

Learn More – Primary Sources:

ACOG Committee Opinion 777: Sexual Assault

CDC: National Intimate Partner and Sexual Violence Survey, 2010 Summary Report

CDC Violence Prevention: Sexual Violence

CDC: Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016

CDC: Sexual Assault and Abuse and STDs

Take a post-test and get CME credits

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Related ObG Topics:

Chlamydia: CDC Recommendations for Diagnosis and Treatment
Gonorrhea: New CDC Diagnosis and Treatment Guidelines
Trichomoniasis: CDC Diagnosis and Treatment Guidelines
Emergency Contraception: What, When and How?
Screening for Sexual Assault

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Media - Internet

Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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