Category: Obstetrics & Gynecology
Keywords: Mycoplasma genitalium, PID, cervicitis (PubMed Search)
Posted: 9/5/2024 by Michele Callahan, MD
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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.
https://www.cdc.gov/std/treatment-guidelines/toc.htm
Hufstetler, K., Llata, E., Miele, K., & Quilter, L. A. S. (2024). Clinical Updates in Sexually Transmitted Infections, 2024. Journal of women's health (2002), 33(6), 827–837. https://doi.org/10.1089/jwh.2024.0367
Category: Obstetrics & Gynecology
Keywords: breastfeeding, lactation (PubMed Search)
Posted: 8/7/2024 by Ashley Martinelli
(Emailed: 8/8/2024)
(Updated: 8/8/2024)
Click here to contact Ashley Martinelli
Breastfeeding provides a great nutrition source for infants, but early cessation is common for a wide variety of reasons. Notably, being asked to withhold breastmilk (“pump and dump”) due to safety concerns or illness increases rates of termination.
A recent paper is an invaluable reference on commonly used medications in the care of emergency department women of childbearing age and the lactation risk. It breaks down medications into clinical categories and then further highlights those that are safe, likely safe, and safe-but may reduce milk supply, and those to avoid.
The majority of commonly used medications in the ED are safe to use in breastfeeding. Only 3% of the medication analyzed should be avoided (aspirin [at doses > 325mg/day], dicyclomine, prochlorperazine, and benzonatate) and in most cases a safe alternative could be used.
Using these recommendations can help prescribe safe medications, prevent the recommendations to pump and dump, and relieve stress for the patient breastfeeding.
Consider adding the LactMed(R) app to your phone as well - This is a free database through the NIH to search individual medications to assess risk in lactation.
Premer C, Caruso K. Safety profile of the most ordered medications for breastfeeding patients in the emergency department. Am J Emerg Med. 2024;80:1-7.
Category: Obstetrics & Gynecology
Keywords: mastitis, breastfeeding, lactation (PubMed Search)
Posted: 8/1/2024 by Michele Callahan, MD
(Updated: 10/9/2024)
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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.
Louis-Jacques AF, Berwick M, Mitchell KB. Risk Factors, Symptoms, and Treatment of Lactational Mastitis. JAMA. 2023;329(7):588–589. doi:10.1001/jama.2023.0004
Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022
Katrina B. Mitchell, Helen M. Johnson, Juan Miguel Rodríguez, Anne Eglash, Charlotte Scherzinger, Kyle Widmer, Pamela Berens, Brooke Miller, and the Academy of Breastfeeding Medicine. Breastfeeding Medicine 2022 17:5, 360-376
Category: Obstetrics & Gynecology
Posted: 7/4/2024 by Michele Callahan, MD
(Updated: 10/9/2024)
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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.
Category: Obstetrics & Gynecology
Keywords: postpartum depression (PubMed Search)
Posted: 5/2/2024 by Michele Callahan, MD
(Updated: 10/9/2024)
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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.
Bauman BL, Ko JY, Cox S, et al. Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression — United States, 2018. MMWR Morb Mortal Wkly Rep 2020;69:575–581. DOI: http://dx.doi.org/10.15585/mmwr.mm6919a2
Category: Obstetrics & Gynecology
Keywords: postpartum, hemorrhage, pregnancy, maternal (PubMed Search)
Posted: 4/4/2024 by Michele Callahan, MD
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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.
Gallos I, Devall A, Martin J, et al. Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage. The New England Journal of Medicine. 2023 Jul;389(1):11-21. DOI: 10.1056/nejmoa2303966. PMID: 37158447.
Category: Obstetrics & Gynecology
Keywords: POCUS, OB, Ectopic Pregnancy (PubMed Search)
Posted: 7/31/2023 by Alexis Salerno, MD
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Ectopic pregnancy ranges from 3 to 13% in symptomatic first-trimester ED patients.
The discriminatory zone is defined as the level of Bhcg above which an intrauterine pregnancy can be reliably detected using ultrasound. (1,500 mIU/mL for transvaginal ultrasound and 3,000 mIU/mL for transabdominal ultrasound)
One study found that an intrauterine pregnancy was visualized with as low as 1,440 mIU/mL and patients with an interdeterminate pelvic ultrasound who were found to have an ectopic pregnancy had a Bhcg greater than 3,000 mIU/mL only 35% of the time.
Bottom Line: If you have a symptomatic patient with an empty uterus and a bhcg above the discriminatory zone, they have a higher risk for ectopic pregnancy. However, if your patient is symptomatic, they should still have further evaluation for ectopic pregnancy even if they have a bhcg lower than the discriminatory zone.
Wang R, Reynolds TA, West HH, Ravikumar D, Martinez C, McAlpine I, Jacoby VL, Stein JC. Use of a β-hCG discriminatory zone with bedside pelvic ultrasonography. Ann Emerg Med. 2011 Jul;58(1):12-20. doi: 10.1016/j.annemergmed.2010.12.023. Epub 2011 Feb 18. PMID: 21310509.
Category: Obstetrics & Gynecology
Keywords: Morning Sickness, Pregnancy (PubMed Search)
Posted: 9/21/2013 by Michael Bond, MD
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Treatment:
Consider these therapies the next time you see a pregnant with persistent nausea and vomiting in her 1st
--Yemi
Niebyl, Jennifer MD. Nausea and Vomiting in Pregnancy. The New England Journal of Medicine. Oct 2010. 363:16.
Category: Obstetrics & Gynecology
Keywords: Rhogam, Pregnancy (PubMed Search)
Posted: 8/22/2009 by Michael Bond, MD
(Updated: 10/9/2024)
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Rhogam Dosing:
Though most textbooks recommend Micro-Rhogram (50mcg) for woman that have miscarried and are less than 12 weeks gestation, you might find it a real challenge to get that dose from your pharmacy or blood bank.
The cost difference between microRhogram and Rhogam is minimal so most hospitals have decided to only stock full dose (300 mcg) Rhogam. The full dose can be given to woman in their 1st trimester without any deleterious effects.
Just remember if you are giving it as a result of a delivery you should order a Kleihauer-Betke test to determine if additional doses of Rhogam are needed.
Category: Obstetrics & Gynecology
Keywords: postpartum, headache (PubMed Search)
Posted: 7/25/2009 by Michael Bond, MD
(Updated: 7/26/2009)
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Postpartum Headaches:
Category: Obstetrics & Gynecology
Keywords: metronidazole, pregnancy, safety (PubMed Search)
Posted: 12/14/2008 by Michael Bond, MD
(Updated: 10/9/2024)
Click here to contact Michael Bond, MD
It seems to come up about once or twice a month about the safety of metronidazole in pregnancy. This has been very controversial over the years, but the current stance is that it is safe in pregnancy. In fact, untreated vaginal infections, bacterial vaginosis and trichomonas, have been associated with miscarriages and preterm labor, so the benefits outweigh the risks.
Below are two good references to add to your file in case you get into a debate with somebody quoting old data.
Organization of Teratology Information Specialists Information on Flagyl and Pregnancy
Safety of metronidazole during pregnancy: a cohort study of risk of congenital abnormalities, preterm delivery and low birth weight in 124 women. J Antimicrob Chemother 1999; 44: 854-855 http://jac.oxfordjournals.org/cgi/content/full/44/6/854
Category: Obstetrics & Gynecology
Posted: 11/23/2008 by Michael Bond, MD
(Updated: 10/9/2024)
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Third Trimester Bleeding:
Category: Obstetrics & Gynecology
Keywords: Bacterial Vaginosis, Treatment, Pregnancy (PubMed Search)
Posted: 4/5/2008 by Michael Bond, MD
(Updated: 10/9/2024)
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Bacterial Vaginosis
Category: Obstetrics & Gynecology
Keywords: Ultrasound, ectopic, pregnancy (PubMed Search)
Posted: 2/24/2008 by Michael Bond, MD
(Updated: 10/9/2024)
Click here to contact Michael Bond, MD
Ultrasound in Pregnancy
Category: Obstetrics & Gynecology
Keywords: Rhogam, Pregnancy (PubMed Search)
Posted: 2/9/2008 by Michael Bond, MD
(Updated: 10/9/2024)
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Rhogam
Dosing:
Trivial Fact: Rhogam is Pregnancy Class C
Category: Obstetrics & Gynecology
Keywords: Migraines, Pregnancy (PubMed Search)
Posted: 1/27/2008 by Michael Bond, MD
(Updated: 10/9/2024)
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Migraines and Pregnancy
Category: Obstetrics & Gynecology
Keywords: Placenta, Abruption, Vaginal Bleed, Third Trimester (PubMed Search)
Posted: 10/20/2007 by Michael Bond, MD
(Updated: 10/9/2024)
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Placental Abruption
Category: Obstetrics & Gynecology
Keywords: Delivery, Imminent, Dystocia (PubMed Search)
Posted: 7/10/2007 by Michael Bond, MD
(Emailed: 7/8/2007)
(Updated: 10/9/2024)
Click here to contact Michael Bond, MD
Category: Obstetrics & Gynecology
Keywords: Erb's Palsy, Dystocia, Legal (PubMed Search)
Posted: 7/14/2007 by Michael Bond, MD
(Emailed: 7/8/2007)
(Updated: 10/9/2024)
Click here to contact Michael Bond, MD
In follow up to my Shoulder Dystocia Pearl
Dr. DePriest Whye has some legal pearls for us:
Erbs Palsy( Brachial Plexus Injury) is a known complication of shoulder dystocia and is due to traction on the arm that causes stretching of the brachial plexus.
Erb's Palsy cases are difficult to defend. They are impossible to defend with improper documentation.
Category: Obstetrics & Gynecology
Keywords: Pre-eclampsia, eclampsia, HELLP (PubMed Search)
Posted: 7/12/2007 by Michael Bond, MD
(Emailed: 7/8/2007)
(Updated: 10/9/2024)
Click here to contact Michael Bond, MD