UMEM Educational Pearls - By Michele Callahan

Historically, there has been limited and inconclusive data regarding the utility of Rh (D) immunoglobulin (RhIg) in preventing alloimmunization for patients with early pregnancy loss or abortion at <12 weeks gestation. Although previous guidelines recommended routine administration of RhIg in Rh(-) patients after abortion of pregnancy loss at <12 weeks gestation, updated recommendations have been published as of September 2024. 

The following are the updated recommendations from ACOG for patients who are less than 12 0/7 weeks gestation and undergoing abortion (managed with uterine aspiration or medication) or experiencing pregnancy loss  (spontaneous or managed with aspiration or medication):

-ACOG recommends forgoing routine Rh testing and RhIg prophylaxis

-Rh testing and administration of RhIg can be considered on an individual basis with the help of shared-decision making regarding potential risks and benefits

These updated recommendations are based on recent studies that show a very low likelihood (although not entirely zero) of Rh alloimmunization associated with these populations. Many other Obstetric expert guidelines (such as those from the World Health Organization, Royal College of Obstetricians and Gynaecologists, and the Society of Family Planning) mirror these recommendations. 

Summary: Consider shared decision-making regarding RhoGAM administration in patients who have an abortion or early pregnancy loss  at <12 weeks  gestation.

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Mycoplasma genitalium (M.genitalium, or Mgen) is a pathogen that is increasingly associated with cervicitis, pelvic inflammatory disease, preterm labor, spontaneous abortion, and infertility. Although many are asymptomatic, M.genitalium can be found in 10-30% of women with symptoms/exam findings of cervicitis. 

NAAT testing for M.genitalium is FDA-approved for use with urine and urethral, penile meatal, endocervical, and vaginal swab samples.

According to CDC guidelines, women with recurrent or persistent cervicitis should be tested for M.genitalium, and testing should be considered among women with PID.  It is not recommended to test for asymptomatic infections at this time, even in pregnancy.

High rates of macrolide resistance in this pathogen make 1 g of Azithromycin insufficient. The recommended regimen for NAAT-positive M.genitalium infections is:  Doxycycline 100 mg PO BID x 7 days to reduce bacterial load, followed by moxifloxacin 400 mg PO daily x 7 days.

Overall, more studies are needed to truly determine the clinical relevance of this pathogen. 

Consider testing for M.genitalium in patients presenting with recurrent or persistent cervicitis or pelvic inflammatory disease, as this may not respond to typical antibiotic regimens.

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Lactational mastitis (inflammation of the breast in individuals who are lactating) affects up to 20% of breastfeeding individuals. It is characterized by localized breast pain with erythema, edema,  and systemic symptoms such as fever/chills and malaise. Supportive treatment measures include the use of NSAIDS, heat and/or ice, and continued feeding or emptying of the breast (stagnant milk can allow for progression of infection). If there is no response to supportive measures within 24 hours, pursuing antibiotic therapy is appropriate.  Staphylococcus and Streptococcus species are common organisms responsible for bacterial mastitis; first-line treatment options include Dicloxacillin 500 mg QID or Cephalexin 500 mg QID for 10-14 days. If there is a concern for MRSA, Clindamycin or Bactrim may be used but are considered second-line. Bactrim should be avoided in breastfeeding individuals with infants <1 month or infants who are jaundiced or premature. 

Complications of mastitis can include early termination of breastfeeding, breast abscess, and systemic infection if untreated. Ultrasound can be used to assess for breast abscess in patients who do not respond appropriately to antibiotics.

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Spontaneous coronary artery dissection (SCAD) occurs when there is an intimal tear that develops within the wall of an epicardial coronary artery, leading to intramural hematoma and false lumen formation with compromised coronary blood flow.  This tear develops in the absence of atherosclerosis, trauma, or iatrogenic injury. SCAD is believed to account for 4% of acute coronary syndromes, and has been found to be the cause of ACS in 35% of women under the age of 50. Women comprise the majority of cases of SCAD( 87-95%). 

Patients with Pregnancy-associated SCAD (P-SCAD) will often present with higher-risk features and more severe presentations compared with non-pregnancy related SCAD. They are more likely to present with STEMI (>>NSTEMI), impaired left ventricular function, left main and multivessel disease, and shock than other cohorts of SCAD patients.

The peak timing of P-SCAD is within the first month postpartum (with the highest incidence within the first week), although cases can occur throughout all trimesters of pregnancy or many months postpartum.

Keep SCAD in your differential for patients without typical risk factors who present with signs/symptoms of ACS. A strong index of suspicion is necessary to prevent bad outcomes and improve morbidity and mortality from this disease entity.

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Perinatal mental health problems are unfortunately quite common: according to the World Health Organization, approximately 10% of women in high-income countries and approximately 30% in low- or middle-income countries are affected.

It's important to be able to distinguish “baby blues” from more significant mental health issues. Typical symptoms of the “baby blues” include mild and short-lived changes in mood, as well as feelings of exhaustion, worry, and unhappiness in the weeks that follow giving birth.

Symptoms that are more severe or lasting >2 weeks post-partum should prompt further investigation and discussion with a mental health professional. Symptoms of perinatal depression may include: feeling persistently sad, feelings of hopelessness, loss of interest or pleasure in hobbies/activities, trouble bonding with the infant, appetite changes, and can even become as severe as wanting to harm onself or one's child. There are specific DSM-5 Criteria used to diagnose postpartum depression.

Universal screening for all pregnant and postpartum patients is highly recommended, and can be life-saving.

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Postpartum hemorrhage (defined as >500 mL blood loss after birth by the WHO and >1000 mL blood loss within 24 hours of birth by ACOG), accounts for 27% of maternal deaths worldwide. It is the leading cause of maternal complications and death worldwide, with approximately 70,000 deaths globally.

In a randomized trial published in the NEJM in 2023, they implemented a bundle of first-response treatments including uterine massage, uterotonic medications, and tranexamic acid and compared this intervention group with a control group providing "usual care". They concluded that early detection of PPH and use of bundled treatment led to a lower risk of postpartum hemorrhage, lower need for laparotomy for bleeding, or lower risk of death from bleeding compared with usual care amongst patients having a vaginal delivery.  

This study confirms the already widely-published recommendations for prevention of PPH with active management of the third stage of labor using prophylactic uterotonic medication (most commonly Oxytocin), uterine massage for atony, early cord clamping, and controlled cord traction for delivery of the placenta. Prompt escalation to more aggressive management (including blood transfusion, TXA, and more invasive treatments such as uterine tamponade or surgical intervention) should occur when initial treatments fail.

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