POTD: Emergency Contraception

I wanted to touch on emergency contraception and the modalities available to emergency physicians. It’s been surprising to me that this request has not come up more often in residency. Remember, you want to initiate emergency contraception as soon as possible for higher efficacy.

What does “emergency contraception” mean?

Emergency contraception refers to the products that prevent pregnancy from occurring after an episode of unprotected intercourse or a failure of alternate forms of contraception.

Emergency contraception can be in the form of oral medications or IUDs.

Oral medications:

Technically, the FDA has only approved two forms of emergency contraception: oral levonorgestrel and oral ulipristal acetate.

Oral levonorgestrel – 1.5mg PO (one dose)

• Must be initiated within 72 hours, maximum up to 5 days for moderate efficacy

• Relative risk reduction (RRR) of pregnancy: 89% if initiated within 48h

• Brand names: Plan B, Plan B One Step, My Way, Next Choice

• Mechanism of action: progestin (aka synthetic progesterone)

• prevents fertilization by inhibiting ovulation, and it thickens cervical mucus

• Side effects: heavy/irregular vaginal bleeding, GI symptoms

• Available OTC for ~$40 out of pocket, (or $10 with GoodRx)

• Not recommended if patient’s BMI > 25

• There is a long list of drug interactions
  

Oral ulipristal acetate – 30 mg (one dose)

• Must be initiated within 5 days

• May be more effective for overweight patients

• Brand name: Ella

• Mechanism of action: progestin

• Delays or inhibits ovulation and prevents implantation by altering the endometrium

• Recommended to discard breast milk x 24 hours after ingestion

• Side effects: GI symptoms, headache

• Available OTC for ~$50 out of pocket, (or $40 with GoodRx)

IUDs:

• IUDs are the most effective forms of emergency contraception

• They must be inserted within 5 days of unprotected intercourse

• 99+% RRR of pregnancy

• No weight limit!

• Traditionally, the copper IUD (e.g. ParaGard) was considered the gold standard.

• However, recent literature shows that hormonal IUDs (e.g. Mirena, Liletta), are just as effective forms for emergency contraception. (See the NEJM study below.) Personally, I think this is a game changer.

• Emergency contraceptive users have an incidence of ~10% of pregnancy within 1 year

• Contraindicated in patients with PID or with active gonorrhea/chlamydia

• Consider an OB/GYN consult if you think an IUD might be the best option for your patient.
  

Yuzpe Method:

• Lastly, in lower-resource areas where access is a concern, you can consider the “Yuzpe” method, which is a combination estrogen/progesterone treatment.

• 100mcg ethinyl estradiol (aka synthetic estrogen) + 0.5 mg levonorgestrel Q12h for one day

• RRR of pregnancy is ~75%

• Recommended within 5 days
  

Should you find yourself in a pickle overseas, this Wikipedia article has information regarding EC availability by country. I thought it was interesting!

https://en.wikipedia.org/wiki/Emergency_contraceptive_availability_by_country

Resources:

1. https://www.uptodate.com/contents/emergency-contraception?search=emergency%20contraception&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

2. https://wikem.org/wiki/Emergency_contraception

3. https://www.nejm.org/doi/full/10.1056/NEJMoa2022141 https://www.mayoclinic.org/drugs-supplements/levonorgestrel-oral-route/before-using/drg-20074413

POTD: Abnormal Vaginal Delivery Part 2

Shoulder Dystocia - present in 0.2-3.0% of all deliveries. Anterior shoulder becomes impacted against mother’s pubic symphysis. Be concerned if there is obstructed labor with the head not passing through the vaginal canal

-       Risk factors: More likely to occur if mother is small/baby is big

o   Small maternal stature, pelvis

o   Macrosomia

o   >42 weeks gestation

o   Maternal BMI > 40

o   Diabetes

o   Previous shoulder dystocia

-       There is no consensus on which maneuvers are best/should be done first. An extremely helpful/unhelpful tip an OB/GYN attending gave me is to “do the maneuver that best matches how the baby is trying to move”. Ultimately, it seems like you give each maneuver one, gentle attempt and if that doesn’t fix the dystocia to move onto the next one.  

1)    McRobert’s – hyperflexion of legs to abdomen with mild abduction and external rotation (fixes 40% of time)

+

2)    Rubin’s – suprapubic pressure POSTERIORLY and laterally (these 2 will fix the majority of shoulder dystocia)

3)    Wood’s Corkscrew – essentially attempting to rotate the baby into a more oblique position (push the posterior aspect of the anterior shoulder towards baby’s face)

4)    Attempt to delivery posterior shoulder first – bring posterior arm across chest, fetal hand to chin, grasp, and gently pull out

5)    Gaskin’s – roll patient onto all fours and attempt to deliver

6)    Can attempt an episiotomy by first injecting lidocaine, then making a 2-3cm cut (45 degrees from midline, cut mediolaterally)

And last resort maneuvers…

7)    Break the clavicle – direct pressure on middle of clavicle. Reduces shoulder-shoulder width. I tried to find out which clavicle you’re supposed to break, it sounds like you just break one if not both…

8)    Zavanelli – the infamous “push baby back into vaginal canal and C-section”. Although if you’ve personally reached this stage its likely because you don’t have OB/GYN at bedside…

Breech Delivery – call OB :’)? When the presenting part is the buttocks instead of the head

-       Requires heavy coaching and encouragement on mother to push with contractions - NEVER pull or squeeze, just support the baby

-       Deliver legs as they emerge (around level of umbilicus)

-       Push arms medially to facilitate delivery (around level of nipples/axilla)

-       Mariceau Maneuver: Rotate baby with sacrum up, gentle pressure on baby’s head to flex and facilitate delivery of head

Hand/Foot/Arm/Leg/Umbilical Prolapse

-       Unfortunately, these just need OB/GYN and stat C-section

-       Umbilical Prolapse – will feel a pulsating mass

o   Attempt to elevate presenting fetal part to remove pressure on the umbilical cord

o   You will remain this way until patient reaches the OR

-       If there are major delays to OR, can consider tocolytics

o   Terbutaline 0.25mg subQ

o   Nitroglycerin 50-200mcg IV

o   Magnesium sulfate 4g IV over 15 min, then 1-4g/hour IV

Just ending with a very helpful infographic by Dr. Reuben Strayer from emupdates.

TL;DR from emdocs

• To relieve shoulder dystocia, avoid excess traction, hyper flex the mothers legs and apply suprapubic pressure, then progress to fetal maneuvering as needed.

• During breech delivery, allow the delivery to happen spontaneously without traction while supporting the fetal body, then prevent excess neck extension while delivering the head.

• If cord prolapse occurs, do not manipulate the cord. Minimize pressure on the cord with maternal knee-chest positioning and elevation of presenting parts while preparing for emergency cesarean section.

https://emupdates.com/wp-content/uploads/2020/06/Precip_HI.jpg

https://wikem.org/wiki/Emergent_delivery

https://wikem.org/wiki/Shoulder_dystocia

https://wikem.org/wiki/Breech_delivery

https://first10em.com/the-difficult-delivery-breech-presentation/

http://www.emdocs.net/the-complicated-delivery-what-do-you-do/

POTD: Vaginal Delivery Part 1

Part 1 will be on normal vaginal delivery. 

Normal Delivery

1)    Preparation

a.     Call for help!! OB/GYN, NICU, pediatrics

b.     Place patient in dorsal lithotomy position. You can have the patient push their feet against your upper arm if the bed is not equipped for this (like in our ED)

c.     Put on PPE

d.     Get suction, warmer, airway equipment, sterile gloves/clamps/scissors

2)    Delivery – NORMALLY the head should be the presenting part

a.     Gentle countertraction once the head emerges  prevents expulsive delivery and reduces tears and lacerations.

b.     Check for nuchal cord

                                               i.     If present, attempt to place finger between cord and neck to slip over baby’s head

                                             ii.     If that fails, clamp and cut cord

c.     Gentle downward force to deliver anterior shoulder first

d.     Gentle upward force to deliver posterior shoulder

e.     Clamp and cut cord ~2-3cm from baby

f.      Suction, dry, warm and stimulate baby in warmer. If baby is well can give to mother.

3)    Placental delivery – don’t forget! This will occur soon after delivery. Prolonged placental delivery increases risk of postpartum hemorrhage (>18-20min)

a.     Maintain manual suprapubic pressure

b.     Using clamps, provide very gentle cord traction. There will be a gush of blood and abrupt lengthening as the placenta separates. Have a bucket ready to catch the placenta. 

c.     Inspect for missing parts. An easy way the OB/GYNs told me is to check for any tears in the lining of the placenta (it looks like it’s in a bag)

d.     Check the perineum for any tears

e.     Start oxytocin (10U IM)

4)    Check frequently within first hour of delivery. Highest risk of postpartum hemorrhage is in this first hour.

Sounds easy. What can go wrong? 😰