EMS Protocol of the Week - Obstetric Complications

Short cooldown email for today’s EMS PotW (EMS-PoW? Is that catchier?). Protocol 540 – Obstetric Complications, attached below, shockingly addresses potential complications with the obstetric patient. For context, NYC REMAC is using a 160/110 cutoff for severe preeclampsia, associated with some sort of symptomatology. The protocol opens with reference to BLS procedures, which in this case is essentially just checking ABC’s, calling for ALS if needed, and considering IVC syndrome, moving the patient into a left lateral position if indicated. At this point, the only SO ALS intervention is IV access and fluids, and ultimately an OLMC call to you fine folks for discuss magnesium administration.

The MCO for magnesium is written as a 2 gram IV dose over 10-20 minutes, with a repeat dose of 2 grams if needed. Seeing as we normally start at 4 grams for our preeclampsia/eclampsia patients, this allows for an early start for the loading dose at a lower rate while getting the patient to the ED for further eval. Generally, I tend to have a low threshold for authorizing the magnesium, assuming the crew paints a picture of a patient who could benefit from it.

www.nycremsco.org and the protocol binder, both there for you when you need them most.

David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

Intrauterine Devices

Studies show that about 10% of US women aged 15-49 use long acting reversible contraception (LARCs) and many of those happen to be intrauterine devices, or IUDs.

IUDs are a small flexible T-shaped piece of plastic that sit in the uterus and are used for contraception.

What do we as Emergency providers have to know about IUDs and when is it an emergency?

There are 2 categories of IUDs: copper and hormonal.

5 brands are approved for use in the US.

ParaGard (copper)

works by causing an inflammatory response which impairs movement and viability of sperm and diminishes the ability of a fertilized egg to implant

can be used for 10 years

women experience heavy periods/more cramping

string color is clear or white

Mirena, Liletta, Skyla, Kyleena (hormone)

works by releasing a progestin hormone which thickens the cervical mucus, thins uterine wall, and impairs binding of sperm to the egg

can be used for 3-5 years depending on the brand

women experience lighter periods/less cramps

string color is blue or brown

Complications are most commonly see within 1 month of placement and include PID, expulsion, perforation of uterus.

 How to evaluate a patient with an IUD coming in with lower abdominal/pelvic complaints:

 On exam, look for the IUD strings. There are 2 but they can appear as 1. They are generally 2.5cm in length.

 If the strings are too short or not visible at all:

The strings might be curled up in the cervix. Take a cytobrush or Q-tip and sweep the os to see if you can uncurl the strings.

If you still can't see the strings, perform a bedside ultrasound.

If the IUD is in the right location but there are no strings visible, provide outpatient OBGYN follow up.

If the IUD is visible on ultrasound but not in the right location, it might have perforated the uterus. Call OBGYN to evaluate the patient.

If the IUD is not visible on ultrasound, it might have perforated entirely through the uterus. Perform a KUB to make sure it is not somewhere else in the abdomen. If you see it on KUB, again call OBGYN.

If you don't see it on KUB, it's possible that the IUD has fallen out of the uterus. Provide outpatient OBGYN follow up.

If the strings are too long or absent and the IUD is partially out, remove the IUD completely.

If the patient has PID, treat it the same way you would if the patient did not have an IUD and provide OBGYN follow up. Although not removing an IUD in this case goes against logical sense, studies have shown that women who retained their IUDs had similar or better outcomes than women who had their IUDs removed.

Definitely still perform a pregnancy test. There is a 0.1-1.5% risk of pregnancy, depending on which brand of IUD. If the patient is pregnant, be very worried about an ectopic pregnancy and evaluate for it!

If the patient wants to keep her pregnancy and you see an IUP on ultrasound, keep the IUD in and provide OBGYN follow up, assuming patient is otherwise stable and ready to be discharged. Removing the IUD may actually disrupt the pregnancy.

If there is no IUP and patient is stable, asymptomatic, and being discharged, be sure to provide urgent OBGYN follow up.

To remove the IUD, you can use a pair of forceps to pull on the strings. There should be no resistance. If you meet any resistance, stop and call OBGYN.

When removing an IUD, remember to tell your patient that they can become fertile again within a couple days. If they recently had intercourse, sperm can be viable for 5 days, so offer them a Plan B pill.

Rhogam?

Rhogam. 

What is Rhogam?

• an immunoglobulin which suppresses Anti-D antibody formation in an Rh- mother with possible Rh+ infant. Rhogam decreases the risk of antibody formation from ~12% to ~1%

• We'll refer to the brand name (Rhogam) as its shorter to type than repetitively typing anti-D immunoglobulin

What are we trying to accomplish?

•  Prevention of maternal sensitization and Hemolytic Disease of the Fetus and Newborn (HDFN).

• If an Rh- mother is exposed to fetal Rh D antigen she may develop antibodies which will cross the placenta in subsequent pregnancies attack fetal RBC's.

• While there is a spectrum of HFDN, in its most severe case it can lead to hydrops fetalis and fetal death

What are the reccomendations regarding the administration of Rhogam?

• They vary

• ACEP:

  • administer 50mcg of Rhogam to all Rh- women experiencing first trimester loss of established pregnancy

  • level C recommendation to consider administering Rhogam in case of minor abdominal trauma

  • insufficient evidence to recommend for or against its use in treating threatened abortion or ectopic pregnancy

• ACOG

  • All Rh- negative women receiving instrumentation for a miscarriage should receive Rhogam

  • Recommended for-

    • all cases of ectopic pregnancy 

    • Rh- women experiencing antenatal hemorrhage after 20 weeks of gestation

    • Rh- women who experience abdominal trauma

    • Rh- women who experience fetal demise in the 2nd or 3rd trimester

  • Although the risk of alloimmunization is low, the consequence can be significant and administration of Rh D immune globulin should be considered in cases of spontaneous first-trimester miscarriage, especially those that are later in the first trimester.

• Cochrane Review

  • Interesting conclusion:

  • “There are insufficient data available to evaluate the practice of anti-D administration in an unsensitised Rh-negative mother after spontaneous miscarriage. Thus, until high-quality evidence becomes available, the practice of anti-D Immunoglobulin prophylaxis after spontaneous miscarriage for preventing Rh alloimmunization cannot be generalized and should be based on the standard practice guidelines of each country.”

• Contrast the American reccomendations with those of the NICE Guidelines (United Kingdom)

  • Do not offer Rhogam to women who receive solely medical management for an ectopic pregnancy or miscarriage, have a threatened miscarriage, have a complete miscarriage, or have a pregnancy of unknown location

  • Offer Rhogam to all Rh- women who have a surgical procedure to manage an ectopic pregnancy or miscarriage

Are there any risks of administering Rhogam?

• Typically not. 

• Side effects include fever, headache, injection site pain, and RBC breakdown (minor)

• There have also been cases of allergic reactions, AKI, and viral infection

• RBC breakdown may be significant in those with ITP 

What is the cost of Rhogam

• ~$200 for a treatment

In conclusion.

• Recommendations vary

• We currently are aggressive in how we administer Rhogam

• However side effects are few and the cost is not prohibitively expensive

-Elly

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