TLDR: Being on antidepressants (specifically SSRIs and SNRIs) does not increase the risk of miscarriage in the first trimester if started before pregnancy, while starting them during pregnancy might present a small increase in risk of miscarriage in that first trimester.
Researchers in the UK looked at patient data from 1996-2018, with almost a million pregnancies evaluated, to look for an association between antidepressant use and first trimester miscarriage, because studies in the past have been iffy about this whole thing. They looked at exposed patients, who were split into two categories: prevalent (started antidepressants at least 3 months prior to pregnancy) and incident (started antidepressants during pregnancy), and nonexposed patients.
The data was analyzed raw and then also after taking out what they felt like would be important confounders (including hx of miscarriage, smoking hx, antipsychotic/seizure medication use, age). Data analyzed after the confounders were taken out of the equation showed that there was no statistical difference in first trimester seizures among patients who were not exposed to SNRIs/SSRIs and prevalent users (or patients who started before pregnancy).
Among incident users, there was a small increase in risk, though the researchers noted that they were concerned about “reserve causation” or patients being started on antidepressants after they had had a miscarriage, which could have screwed with these numbers. The absolute increase in risk was 0.5% (13.1% in non-exposed, and 13.6% in exposed).
Takeaways: Given that we cannot ethically do RCTs on our pregnant patients, this is probably one of the largest population studies to date looking at this issue, and it provides reassuring data. For our patients who are on SSRIs/SNRIs before they get pregnant, you can reassure them that there is good data saying that they are not putting the fetus at increased risk of miscarriage in that first trimester. For patients who need to start on SSRIs/SNRIs during pregnancy, counsel closely, but let them know that our data shows a relatively small absolute risk increase for first trimester miscarriage.
At this point, we've likely all encountered a patient who is on aspirin as a preventative for a history of pre-eclampsia or high risk pregnancy, but what about for low risk patients who have not yet had any children?
This meta-analysis came out in August of this year looking at RCTs that examined giving low dose aspirin to low-risk (no pre-eclampsia, gestational DM/HTN, autoimmune or renal disease), nulliparous individuals during pregnancy and found that while not all doses of aspirin at all ages were helpful, a planned subgroup analysis showed that giving 100mg of aspirin daily starting before 16 weeks cut the odds of preterm birth before 37 weeks in about half (RR 0.45).
That's not to say that we should all be starting aspirin for our patients in the emergency department just yet - but this might be why you're seeing aspirin pop up on more of our pregnant patients' medication list (or why your OB might be recommending it to you or your family/friends).
Sickle cell disease is one of the notorious inherited blood disorders, with the abnormal hemoglobin shapes creating abnormal blood cells that can create clots and cause problems in just about every organ system - so it should surprise no one that this hold true in pregnancy.
Published just in June 2025, the below article looked retrospectively at Medicaid patients in California, Georgia, Tennessee, and Michigan from 2010-2018. In total, this study included 1286 patients, 90% of whom were Black. They followed ~800 of these patients for a year postpartum to look for the most common complications.
Aside from vaso-occlusive crisis being extremely common (~40% of patients experienced at least one crisis during or in the year after pregnancy), ~25% of patients with sickle cell had antepartum hemorrhage and preterm delivery, while ~10% had preeclampsia or eclampsia.
Keep in mind that this is a retrospective cohort study that did not have any comparisons, so this is really just observational data. While we can't draw any conclusions about just how much more dangerous sickle cell disease makes pregnancy, I think the numbers are concerning enough that we should keep an even closer eye than normal on our patients who have concurrent sickle cell and pregnancy.
Pain, bleeding, fever - what symptoms actually mean something when it comes to ovarian torsion?
Well, in this retrospective case-control study looking at 221 patients from 2011 to 2022, Aiob et. al looked at a ton of history, physical exam, and ultrasound findings to see which ones correlated most strongly with ovarian torsion. They found that vomiting and reports of localized pain (v diffuse pain) were highly associated with surgery-confirmed ovarian torsion. In multivariate analysis, localized pain had an odds ratio of 4.36 and vomiting had an odds ratio of 2.38.
Additionally, on ultrasound findings, ovarian edema was much more likely to be present in torsion cases, with an odds ratio of 5.29.
This is a retrospective single center study that comes with all the limitations that these studies always come with, but let this be a reminder of what should trigger your Spidey-senses!
Additional note: We all know that torsion is a diagnosis that can only be confirmed by surgery, no matter what Doppler flow looks like, and this study just adds onto that pile of evidence: Doppler flow was not significantly different between patients who ended up having torsion and those who didn't. >60% of patients who ended up having torsion had normal flow, so like always, remember that a normal Doppler does not exclude torsion in a patient who you're worried about! Talk to OBGYN!
Everyone clenches up when an imminent delivery shows up at the ED bay doors, even though most of these deliveries will not need intervention. Still, there are catastrophic ways delivery can go wrong, so today, let's talk about a new study on breech delivery.
The Study: Bogner et. al conducted a prospective single-center observational cohort study from 2006-2021 looking at breech deliveries in ~230 patients, with 92 of them being delivered in the traditional, supine way, while 140 of them delivered on all-fours. The only difference found between the two groups was that the all-fours group had heavier babies with bigger heads.
The Results: Over half (51.4%) of the patients in the all-fours position required no additional interventions from the provider compared to 11.9% of the supine group, and there were fewer perineal injuries. There was no increase in neonatal outcomes or NICU referrals in the all-fours group as compared to the supine group.
Limitations: Single center, no randomization, 11 patients started in all-fours and then had to switch to supine due to difficulty with delivery and prolonged second stage of labor, excluded footling breech
Takeaways: All-fours may be a position to consider for your patient with a breech delivery - especially if you haven't brushed up on your breech maneuvers recently.
Despite its name, we're not really sure what's happening in amniotic fluid embolisms. We think that some amniotic fluid and fetal cells gets into the parental blood vessels, and this causes a cytokine storm that leads to systemic vascular collapse, but we're still figuring it out. This is a clinical diagnosis, and while rare (1-3/100000), it can be extremely fatal, ranging anywhere from 10%-60% mortality depending on what study you're looking at. Even worse, some studies show that up to 80% of patients arrest at some point after their diagnosis, many within 5 minutes of their symptoms beginning.
Key times to look for this are postpartum AND post-abortion (though post-abortion is even rarer).
What you're looking for:
Often times, there will be neurological symptoms like AMS, seizures, and confusion.
There is no cure, so we treat the symptoms: use your vasopressors! Norepinephrine is our go-to, but keep your inotropic agents close, because of your right heart failure (dobutamine, milrinone). You can also try iNO therapy, MTP, and ECMO if you're at a facility capable of it.
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.
