Tasty Morsels of EM 082 – FRCEM Early Pregnancy Specific Issues

26 Jul

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

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

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

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



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