Emergency contraception comes in multiple forms, all of which have their own side effects and best case use scenarios that emergency medicine providers should be aware of to offer the best counseling.
Consider your patient before advising - if their BMI is > 25, consider ulipristal. If they want the most effective method, that'll be a copper IUD - but make sure they can get an appointment within 5 days of the unprotected intercourse! If they cannot afford ulipristal or levonorgestrel (which can both be $50 without insurance), but they already have OCPs, combining OCPs to the total noted above can be a method of emergency contraception that is still very effective.
So you have a patient who is pregnant and has abdominal pain. You, as the astute provider you are, decide to do an ultrasound to rule out an ectopic, and low and behold! You see a gestational sac and a yolk sac within the uterus! You show your patient, you both breathe a sigh of relief, and you discharge them…
But they return two weeks later, now hypotensive, excruciating pain, and extremely pale. On an emergent bedside ultrasound, you see copious amounts of free fluid, and OBGYN tells you, after they rush your patient to the OR, that it was an ectopic - but how? The pregnancy was in the uterus!
Welcome everyone to the world of interstitial and angular pregnancies, pregnancies that are much closer to the endometrium than normal ectopic pregnancies and therefore have a much higher chance of progressing further before they rupture, meaning that when they do, they are devastating!
To evaluate for these ectopics, make sure that you get a mantle distance on every pregnancy ultrasound you do looking for an ectopic. Mantle distance is measured from the end of the gestational sac to the outer edge of the thinnest side of endometrium. If your value is >0.8cm, you should be okay. If it's less than <0.5cm, you most likely have an ectopic. Between 0.5cm and 0.8cm, consult OB urgently or have extremely close follow up for your patient.
In the last few months, there have been multiple articles published regarding the use of prophylactic TXA to prevent postpartum hemorrhage. While almost none of us want to ever be in the situation where we have to deliver a baby in the ED, we need to be prepared for all outcomes.
A meta-analysis by Ker et. al (Oct 2024) and a RCT, blinded study by Zhang et. al (Dec 2024) both demonstrated that giving 1g TXA immediately after delivery of a baby can reduce the rate of severe postpartum hemorrhage in patients with risk factors. These studies had a wide variety in what they considered risk factors, but a few that showed particular significance included: hx of postpartum hemorrhage, history of anemia, gestational diabetes, and placental adhesion.
So next time you've scooped that screaming baby out into your already chaotic emergency department, ask your patient (not the baby) a few questions about their birth history and think about giving 1g of TXA to prevent a horror show for whoever is coming on for you next.
Caveat: These studies were done in delivery rooms and not emergency rooms, but I think we can extrapolate since it would be very hard to find enough patients to conduct a study like this in the emergency department.
