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.
A study published in the NEJM (March 2025) looked at recurrence of bacterial vaginosis at 12 weeks in two groups: a control group where women received standard treatment but male partners were not treated, and a partner-treatment group. In the partner-treatment group, women received standard treatment, and the male partner received both oral and topical treatment. Male partners in this study received Metronidazole 400 mg BID x 7 days in addition to 2% topical clindamycin cream applied to penile skin BID x 7 days. The trial was actually stopped early as it was found that only treating the female was inferior to treatment of both.
This study concluded that treatment of both the female and male partners led to significantly decreased recurrence of bacterial vaginosis within 12 weeks (35% with dual treatment vs. 65% with female-only treatment). This study suggests that we should consider offering treatment to both sexual partners for patients presenting with bacterial vaginosis.
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.
Perinatal HIV transmission in the U.S. can approach rates of <1% if appropriate interventions are offered to both pregnant individuals and their neonates.
However, a recently published case series evaluating hospitals in Maryland noted that there were 6 new cases of perinatal HIV transmission in 2022, compared with nationwide decreases and zero cases in the state of MD in 2021. Transmission was believed to be related to several issues: delayed entry to prenatal care, HIV diagnosis occurring in pregnancy (as opposed to pre-conception), adherence in the setting of hardships such as substance use, and delays in anti-retroviral therapy (ART) initiation during pregnancy.
How can we work to lower perinatal HIV transmission? Opportunities include the use of pre-exposure prophylaxis (PrEP), routine HIV testing in individuals of child-bearing age (especially if at high-risk of HIV acquisition), and rapid initiation of ART in pregnant individuals. As emergency physicians and providers, we are at the front line of assessing for these barriers and getting patients the resources they need to minimize perinatal transmission.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Treatment:
Consider these therapies the next time you see a pregnant with persistent nausea and vomiting in her 1st
--Yemi
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.
Postpartum Headaches:
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
Third Trimester Bleeding:
Bacterial Vaginosis
