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.
