Emergency Care of Lactating Patients

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Emergency providers receive training to care for pregnant patients but little training to care for breastfeeding patients. Many myths persist, particularly urging patients to “pump and dump” (pump and discard milk instead of feeding the baby) after medications or illness that are, in fact, completely safe to continue breastfeeding through . We review popular medications used in the emergency department (ED) as well as other pearls regarding the ED care of lactating patients (references for drugs come from LactMed, other references are listed at bottom of page).

Medications During Breastfeeding

We often obsess over medications that are safe in pregnancy but may not have much of an idea of what medications are ok in patients who are breastfeeding. Rare medications are unsafe in breastfeeding (chemotherapy, radioactive isotopes) but most that we prescribe in the emergency department are fine (including anesthesia/procedural sedation meds – see this Anesthesia graphic). Please review medications prior to prescribing to ensure that they are safe for the infant and will have no deleterious effects on lactation. For example, pseudoephedrine, a seemingly benign medication, can dry up a patient’s milk supply.

LactMed is a searchable database provided by the National Institutes of Health that summarizes the safety of medications in breastfeeding and the effects of medications on lactation. There is also a free LactMed app. Providers and patients can also call InfantRisk( 806) 352-2519  regarding specific medications (Mon-Fri 9am-6pm CST)

**Note: Some sources cite different safety profiles so we have tried to synthesize this information but depending on the patient and the source, the risk profile may be a bit different.

Medical illnesses specific to the lactating patient

General support for the lactating patient

Thanks to the physicians and lactation experts of Dr. Milk (@DoctorDrMilk) for providing peer review.

Rosh Review Emergency Board Review Questions

A 36-year-old woman presents to the office for a painful right breast for the past two days. She is one month postpartum. The patient reports swelling and redness of the right breast in addition to pain. She is febrile to 101.2°F. On physical examination, the lower lateral quadrant of the right breast is erythematous, firm, warm, and markedly tender to palpation. Enlarged right axillary lymph nodes are noted on exam. In addition to warm compresses, which of the following would be the most appropriate course of treatment?

A. Cease breastfeeding from the affected breast

B. Incision and drainage

C. Initiation of dicloxacillin 500 mg four times daily

D. Initiation of trimethoprim-sulfamethoxazole 800 mg-160 mg two times daily

Answer

C. Initiation of dicloxacillin 500 mg four times daily is the treatment of choice for postpartum women with lactational mastitis who do not have a penicillin allergy. Mastitis is an infection of the breast commonly seen in breastfeeding women from milk duct blockage, prolonged breast engorgement, and nipple trauma. The most common bacterial pathogen implicated in mastitis is Staphylococcus aureus. Patients most commonly complain of a swollen, painful, red breast. Diagnosis is a clinical one, but a breast milk culture can be performed in severe infections or infections refractory to initial treatment. For worsening symptoms or infection that is not responsive to usual treatment, an ultrasound of the breast may be indicated to rule out a breast abscess. Treatment includes analgesics, warm compresses, and continued emptying of the breast. Antibiotic choice includes dicloxacillin, cephalexin, or clindamycin (if penicillin-allergic). For individuals with increased risk of methicillin-resistant S. aureus (MRSA), clindamycin or trimethoprim-sulfamethoxazole can be used. Sulfa-containing drugs should not be used in mothers who are nursing newborns due to risk of kernicterus.

References:

  1. Dobiesz VA, Robinson DW. “Drug Therapy in Pregnancy.” Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Chapter 180; p 2277-2295.e3
  2. Breastfeeding and Maternal Medication Recommendations for Drugs in the Eleventh WHO Model List of Essential Drugs
  3. Manual on Contrast Media. American College of Radiology. 2017
  4. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation: a reference guide to fetal and neonatal risk. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2008
  5. Practice Advisory on Codeine and Tramadol for Breastfeeding Women. American College of Obstetrics and Gynecology. April 27, 2017.
  6. Hang BS. “Breast Disorders.” Tintialli’s Emergency Medicine. 8th ed. Chapter 104.
  7. Haastrup MB, Pottegård A, Damkier P. Alcohol and breastfeeding. Basic Clin Pharmacol Toxicol. 2014;114(2):168-73.

Episode 70 – Nonpregnant Vaginal Bleeding

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The WOMAN trial of tranexamic acid (TXA) for post-partum hemorrhage has been covered well by several free open access medical education (FOAM) sources.  We review the trial and coverage from the following excellent sites:

The Core Content

We have previously covered vaginal bleeding after the first trimester and ectopic pregnancies and first tri, ester vaginal bleeding. In this episode we cover non-pregnant vaginal bleeding using Rosen’s Emergency Medicine (8th ed), Chapter 100 , Tintialli’s Emergency Medicine (8th ed), Chapter 96 and the ACOG guidelines as guides.

Rosh Review Emergency Board Review Questions

A 32-year-old woman presents with vaginal bleeding for 2 weeks. She states she has about 1 pad of bleeding every 2-3 hours. Vital signs are stable and physical exam only reveals blood from the cervical os. The patient’s hemoglobin is 12 g/dl and her pregnancy test is negative. What treatment is indicated for this patient?

A. Admission for dilation and curettage

B. Combination oral contraceptives

C. Hysterectomy

D. Intravenous estrogen therapy

Answer
B. This patient presents with non-life threatening dysfunctional uterine bleeding (DUB), which can initially be managed with combination oral contraceptives. DUB is typically split into anovulatory (90%) and ovulatory (10%). In patients with vaginal bleeding of childbearing age, the most important first step in diagnosis is to rule out pregnancy. After this, it is important to explore other causes including medications, genital tract pathology and systemic disease. Once these are excluded, a diagnosis of DUB can be reached. Some treatments include NSAIDs that inhibit PGE1 production and can both relieve cramping and pain and also decrease bleeding. In anovulatory bleeding, combination oral contraceptive pills can aid in regulating the menstrual cycle and counteract the effects of unopposed estrogen. Typically, patients are instructed to take combination oral contraceptive pills twice a day for 5-7 days or until the bleeding stops followed by once daily dosing. Dilation and curettage (A) is typically offered to patients with heavy vaginal bleeding evidenced by hemodynamic instability. A hysterectomy (C) is rarely needed in the treatment of DUB but is indicated for patients with heavy bleeding and hemodynamic instability in which conservative management fails. Intravenous estrogen therapy (D) is effective in stopping heavy bleeding, but is not considered first line therapy.

A 55-year-old postmenopausal woman presents with a complaint of vaginal bleeding. Which of the following is the most appropriate next step in management?

A. Abdominal ultrasound

B. Endometrial biopsy

C. Hysterectomy

D. Watchful waiting

Answer

Vaginal bleeding after menopause is an abnormal finding. The most common cause of vaginal bleeding after menopause is atrophy of the vaginal mucosa or endometrium, however 5-10% of postmenopausal women with vaginal bleeding have endometrial cancer. Endometrial cancer is potentially lethal, therefore any postmenopausal woman who presents with vaginal bleeding needs to be evaluated to rule out this etiology. After a careful history and physical exam, initial diagnostic testing to rule out endometrial cancer involves either endometrial biopsy or transvaginal ultrasound. Advantages of an endometrial biopsy include its high sensitivity, low cost and low incidence of complications. Women who need evaluation of the adnexa or myometrium, or who can’t tolerate endometrial biopsy should be referred for transvaginal ultrasound. If either test is inconclusive, further testing is warranted. Cervical cancer screening should also be a part of the workup for postmenopausal vaginal bleeding.

Abdominal ultrasound (A) is not recommended for women with postmenopausal vaginal bleeding. If ultrasound needs to be used, transvaginal ultrasound is the appropriate diagnostic test to order. Postmenopausal women with an endometrial thickness < 3-4 mm on transvaginal ultrasound are unlikely to have endometrial carcinoma. Hysterectomy (C) may be indicated based on the results of the diagnostic imaging, but is not an initial step in management of postmenopausal vaginal bleeding. All women who present with postmenopausal vaginal bleeding should be evaluated with either endometrial biopsy or transvaginal ultrasound, there is no role for watchful waiting (D).

 

Episode 60 – Resuscitative Hysterotomy + First Trimester Emergencies

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We review a talk by Dr. Sara Gray from SMACC (Social Media and Critical Care) conference in June 2016, Resuscitative hysterotomy, which is the new name for perimortem c-section [1]. In this talk she challenges the “4 minute” rule: if resuscitative efforts following maternal circulatory arrest are unsuccessful, cesarean delivery should be commenced at 4 minutes and completed by 5 minutes to optimize fetal outcome. 

resuscitative hysterotomy

Core Content

We delve into core content on pregnancy emergencies using Rosen’s Emergency Medicine (8th edition) Chapter 98and Tintinalli’s Emergency Medicine (8th edition) Chapter 178 as a guide.

first trimester bleeding

septic abortion

Nausea and vomiting are very common in pregnancy, but few patients have hyperemesis gravidarum (~2%).  Hyperemesis gravidarum is characterized by severe nausea and vomiting with starvation ketosis and significant weight loss and dehydration [2,3].

first trimester vomiting

uti in pregnancy

 Rosh Review Emergency Board Review Questions

A 22-year-old woman presents complaining of vaginal bleeding and cramping for the last 4 hours. She is known to be 14-weeks pregnant. Her cervical os is dilated to 4 cm and she is actively bleeding. Pelvic ultrasound shows the gestational sac in the lower uterine segment near the cervix. Which of the following is the most likely diagnosis?

A. Complete abortion

B. Inevitable abortion

C. Missed abortion

D. Septic abortion

Answer

The patient is experiencing an inevitable abortion, which is characterized by an open cervical os and a gestational sac at the opening of the uterus on ultrasound. The case should be discussed with the patient’s obstetrician as the patient may ultimately require dilatation and curettage if all the products of conception (POC) do not pass spontaneously or the bleeding is not controlled.  A complete abortion (A) occurs when the patient has passed all POC have passed. On examination, the cervix is closed and the uterus is firm and nontender. A missed abortion (C) occurs when a pregnant patient fails to pass the products of conception greater than two months after fetal demise. The pregnancy test will be negative, however ultrasound will show retained POC. A septic abortion (D) occurs when the patient develops foul-smelling discharge, vaginal bleeding, uterine tenderness and peritoneal signs following a spontaneous or induced abortion.

What is the most common cause of bleeding in the primigravid woman?
 

Threatened abortion

References:

  1. Rose CH, Faksh A, Traynor KD, Cabrera D, Arendt KW, Brost BC. Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy. American journal of obstetrics and gynecology. 213(5):653-6, 653.e1. 2015. [pubmed]
  2. Heaton, H. “Chapter 98: Ectopic Pregnancy and Emergencies in the First 20 Weeks of Pregnancy.” Tintinalli’s Emergency Medicine: A Comprehensive Review. 8th edition
  3. “Chapter 178: Acute Complications of Pregnancy.”  Rosen’s Emergency Medicine