UMEM Educational Pearls - Obstetrics & Gynecology

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.

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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.

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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.

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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.

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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.

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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.

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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.

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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. 

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Treatment:

• Vitamin B6 has been shown in a number of randomized placebo-controlled trials to be very effective in treatment of the 1st trimester nausea and vomiting and is a supported recommendation by the American College of Obstetrics and Gynecology (ACOG).
  • For refractory symptoms, efficacy is increased with supplementation of the sleep aide Doxylamine (found in Unisom pills over the counter)
  • Dosing of Vitamin B6 is 10 to 25mg every 8 hours daily
  • Dosing for Doxylamine is 12.5mg as needed in the morning, 12.5mg as needed in the afternoon, and 25mg as needed at bedtime.

• Ginger (ginger ale and ginger supplements) taken at 250mg daily doses has been recommended as 1st line treatment by ACOG.

Consider these therapies the next time you see a pregnant with persistent nausea and vomiting in her 1st

 

--Yemi

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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.

Postpartum Headaches:

• Occurs in up to 40% of woman during the first week after delivery.
• Though thoughts of Sheehan's syndrome (pituitary infarction), and SAH might come to mind the most common causes are due to migranes and tension headcaches.
• About 5% are spinal  (postdural) headaches due to a persistant CSF leak from spinal anesthesia or a complication of their epidural catheters.
• Rare causes include embolic stroke, carotid and vertebral artery dissections, SAH, Central Venous Sinus Thrombosis and Sheehan syndrome.

• Most headaches can be treated the same as any other person.
• Make sure you inquire about breast feeding and ensure the medications you are giving will not be excreted into the breast milk. 
• If your patient has signs of hypopituitarism an MRI scan will be needed to make the diagnosis of Sheehan syndrome.

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

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Third Trimester Bleeding:

• Estimated to occur in 4% of Pregnancy
• 50% will have a benign cause, the other 50% will have a life threatening cause
• Life Threatening Causes:
  • Placenta Abruption
  • Placenta Previa
  • Uterine Rupture
  • Vasa Previa (fetal vessels crossing or running in close proximity to the inner cervical os.
    
• Benign or Non-OB Causes
  • Contact Bleeding (local trauma)
  • Cervical Inflammation (i.e. infection)
  • Cervical effacement and dilation
  • Cervical cancer
  • Other sites:
    • rectal bleeding
    • urinary bleeding
• Evaluation:
  • ABC's: Stablilize mother, consider 2 large bore IVs
  • Consult OB/GYN early (most centers with OB/Gyn will have these patients evaluate and treated in Labor and Delivery), if not readily available complete evaluation as listed below:
  • Initially avoid bimanual exam
  • Obtain baseline labs (CBC, Coags, Chemistries, Consider LFTs if suspecting eclampsia or HELLP syndromes). If not known obtain Rh status
  • Fetal Monitioring ideally with continous fetal heart rate and tocometry
  • Sterile Speculum exam for culture and check for active bleeding.
  • Obtain ultrasound.

 

 

Bacterial Vaginosis

1. The most common vaginal infection in childbearing women. 
2. Associated with burning, itching, and malodorous discharge.
3. Cause is not fully understood but associated with
   
   1. douching
   2. multiple sexual partners.
4. Complications caused by BV
   
   1. Increased susceptibility to HIV, HSV, chlamydia and gonnorrhea
   2. Increased risk for preterm labor.
   3. Increases the chance of an HIV woman passing HIV to her sex partner.
5. Woman at high risk for preterm delivery should be tested for and treated for BV, however, the US Preventive Services Task Force just released a statement discouraging testing in woman at low risk for preterm delivery. 
6. Treatment options include metronidazole and clindamycin.

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Ultrasound in Pregnancy

1.  A full bladder is needed for Transabdominal Ultrasound and an empty bladder for transvaginal ultrasound.
2. A gestational sac should be visible on transabdominal ultrasound with a quantative HcG of 5000-6000 mIU/ml, and a quant of 1500-2000 mIU/ml on transvaginal.
3. When taking photos, ensure that you show all of the applicable landmarks.  [i.e.: bladder, and uterus]  If you just zoom in on the pregnancy anybody else (i.e.: your expert witness) reading the scan will not be able to confirm that the pregnancy is in the uterus.
4. To confirm an IUP, you must see the yolk sac within the gestational sac.  A double decidual sign is an early sign of pregnancy but it is not always seen and should not be relied upon.
5. If you have a confirmed IUP an additional ectopic pregnancy is extremely unlikely unless the patient was taking medication to stimulate their ovaries (i.e. Infertility treatment).  If on stimulation therapy a very thorough exam needs to be done to look for additional pregnancies.
6. If Quant >2000 mIU/ml and there is no evidence of an IUP, patient needs to be treated as an ectopic pregnancy.

Rhogam 

• Remember to administer Rhogam to any Rh negative mother that has the following conditions:
• Pregnancy/delivery of an Rh-positive baby
• Abortion/threatened abortion at any stage of gestation
• Ectopic pregnancy
• Antepartum fetal-maternal hemorrhage (suspected or proven) resulting from antepartum hemorrhage (e.g., placenta previa), amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling, other obstetrical manipulative procedure (e.g., version) or abdominal trauma
• Transfusion of Rh incompatible blood or blood products (i.e.: platelets)

Dosing:

• 300 mcg IM
• Can give 50 mcg IM within 72 h of exposure of a therapeutic or spontaneous abortion if gestation age is 12 weeks or less. (Order as MICRhogam)
• Additional doses of Rhogam may be necessary when the patient has been exposed to > 15 mL of Rh-positive red blood cells. This may be determined by use of qualitative or quantitative tests for fetal maternal hemnorrhage but generally will only occur during a full term delivery or if incompatible blood products are given.

 

Trivial Fact: Rhogam is Pregnancy Class C

Migraines and Pregnancy

• Typically headache frequency will increase during the first 2 to 3 months of pregnancy
• 70% of women report significant improvement in headaches during their second and third trimester.
• Most migraine medication should NOT be given to pregnant woman.  Verify prior to prescribing.
  • Class X/D drugs include
    • Cafergot (ergotamine)
    • Depakote
    • Dihydroergotamine (DHE)
  • Class C drugs include
    • Imitrex
    • Zomig
    • Midrin
    • Relapex
• Some headache centers will prophalax pregnant woman with Vitamin B2 and Magnesium.

 

Placental Abruption

• Leading cause of fetal death (1-80 pregnancy)
• Evaluation
  • Ultrasound has very poor sensitivity
• Can check D-Dimer, Coags, Fibrinogen and Fibrin Split Products
• For a stable patient MRI can make diagnosis.
• Fetal monitoring (minimum four hours) where fetal distress and uterine contractions are seen.
• Risk factors for Placental Abruption
  • Hypertension
  • Pre-eclampsia
  • Diabetes
  • Trauma
  • Smoking
  • Cocaine
  • Advanced maternal age
• Treatment
  • C-Section

If you are facing the imminent delivery of a newborn with shoulder dystocia remember the mnemonic HELPERR. * Help. Call for it. * Episiotomy. o Necessary only to make more room if rotation maneuvers are required. * Legs (the McRoberts maneuver) o This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. * Pressure, Suprapubic o The hand of an assistant should be placed suprapubically over the fetal anterior shoulder, applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the fetal shoulder. This maneuver should be attempted while continuing downward traction. * Enter maneuvers (internal rotation) o Attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis. * Remove o Remove the posterior arm. * Roll the patient. o Rolling the patient on all-fours will often dislodge the shoulder, and the position change allows gravity to aid in the disimpaction of shoulder. Baxley EG, Gobbo RW. Shoulder Dystocia, Am FamPhysician. 2004;69(7):1709-1714.

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.

• Should an Erb's Palsy result as a consequence of a shoulder dystocia, a medical malpractice suit is inevitable.
• The medical record documentation is particularly critical in defending the medical care rendered.
• The medical record should reflect timely recognition of the shoulder dystocia.
• It is important that appropriate implementation of the maneuvers described last week are done in a timely fashion.
• Vital documentation should describe the amount of traction placed if any.
• Terms such as minimal or mild or light traction should be used.
• Terms such as strong, forceful, significant traction should be avoided.
• Never state in the record that uterine pressure was used as opposed to suprapubic pressure.
• Uterine pressure is contraindicated.

Erb's Palsy cases are difficult to defend. They are impossible to defend with improper documentation.