I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.
You can find more things on the FRCEM on this site here.
This one is a bit of a hodge podge of various issues surrounding pregnancy in the ED.
When should you use Anti-D in early pregnancy?
(from the detailed and nuanced British Society Haemtaology Guidance 2013 and the blunt and straightforward NICE 2012)
- administer anti D in “potentially sensitising events” as soon as possible and within 72 hrs
- in <12/40 pregnancy anti D only indicated in
- ectopic (though NICE state that it probably isn’t needed if managed medically)
- miscarriage with significant bleeding
- molar
- D and C
- (in other words most Rh D -ve folk with a threatened miscarriage in the ED do not need Anti D)
- In contrast NICE state that even fewer should get Anti D
- “Offer anti-D rhesus prophylaxis at a dose of 250 IU (50 micrograms) to all
rhesus negative women who have a surgical procedure to manage an ectopic
pregnancy or a miscarriage”
- Tests for FetoMaternal Haemorrhage are generally only indicated in >20 weeks
- Dosing
- <20/40 = 250 units
- >20/40 = 500 units
- of note Anti-D is given routinely for normal,healthy pregnancies in Rh -ve mums at around 28/40
[collapse]
How should we deal with requests for emergency contraception?
This 2017 FSRH Guideline is the NICE accredited one
- options are
- copper IUD insertion (the most effective, must be within 120 hrs)
- ‘morning after pill’
- ulipristal acetate 30mg (effective up to 120 hrs)
- levonorgestrel 1.5mg (effective up to 72 hrs)
- there’s an insanely detailed and complicated algorithm to choose which but most arrows lead to the ulipristal acetate it seems…
- they note that in general oral emergency contraception taken after ovulation is unlikely to be effective
- neither should be repeated within 5 days
- high BMI and enzyme inducers (phenytoin, carbamazepine, rifampicin sulfonyureas) can reduce effectiveness
[collapse]
What is the RCEM position with relation to early pregnancy assessment?
from this recently published statement
- “have a clinical examination space with a door which affords the appropriate level of privacy to allow necessary examinations to take place with a chaperone. This would include a room that has a securable door and is visually separated from the remainder of the clinical space.”
- seven days a week access to an early pregnancy unit and primary care should be able to refer directly there
[collapse]
What are the guidelines for VTE in pregnancy?
(From the RCOG 2015 Guideline)
- if you suspect a DVT do an ultrasound (do not use dimer or even pre test probability)
- For PE (again do not use dimer or even pre test probability)
- everyone should get ECG and CXR
- if signs of DVT scan there first and if you find DVT you’re done
- if no leg signs then do a V/Q or CTPA (thanks for the fence sitting…)
- advice pts that slightly increased fetal risk with VQ and slightly increased breast Ca risk with CPTA
- Treatment
- LMWH given at weight based dose of early pregnancy weight
- note the 2015 guidance says can be given either in one does or a divided dose as there’s not enough evidence (I think old recs might have been a divided dose…)
- Should be continued until at least 6 weeks post partum and a total of 3 months overall
- Both warfarin and LMWH are safe post partum for breast feeding
[collapse]
