Modern Contraception

[LucidResq]

If you don't think this topic is important, you don't think the nearly 40 million women using contraception in the US are important either.

I'm curious as to how "up-to-date" our EMS providers are as to current topics in contraception. Please respond honestly to the poll, I don't blame you if you don't know anything about contraception since it's oft ignored in our education.

Note: knowing a few things about "the pill" should not warrant a "yes." If you can hold an intelligent conversation about the indications, contraindications, pharmokinetics and potential EMS concerns about a Mirena IUD, Nuvaring, Essure procedure, Paragard, etc... then you can answer yes. Having heard of it or having a girlfriend/cousin/sister etc who's had it does not mean you are in the know.

Some scenarios to throw at you... first one:

You are seeing a 24 yo female with a chief complaint of disperse, dull lower abdominal pain. Appears to be in mild distress and is alone - lives alone too. It started three days ago and has gotten progressively worse. It is worsened by sexual intercourse. She also complains of spotting.

Vitals are all within normal limits.

No allergies.

She uses a Mirena IUD for birth control - it was inserted about 7 months ago after a therapeutic abortion, she hasn't had regular check-ups with a doc but hasn't had any problems with it so far and has been able to feel the strings as recently as this AM. No other medications.

G1 P0 - 1 TAB 7 months ago. No other medical or surgical history.

Had a normal breakfast and lunch.

Nothing of remark over the past few days - has been attending work as a bank teller as usual.

What other questions do you have? What could possibly be going on? What are some possible emergent complications associated with IUDs?

 

[LucidResq]

Grrr.... it didn't allow me to add a poll.... just post here I suppose.

 

[TransportJockey]

I'd assume PID from what you've posted... But when it comes to most forms of contraceptives I know very little, just enough to keep me out of trouble

 

[NepoZnati]

Even that I am not sure how would I design questions about it, my first thought would be some kind of infection or damn thing moved and she has some pain and spotting... But something more in detail I would not know. It was ignored at my class also.

 

[LucidResq]

But when it comes to most forms of contraceptives I know very little, just enough to keep me out of trouble

Hahaha as far as business or your personal life goes?

Good call on the PID... it's definitely a possibility.

Our big concerns with IUDs are PID and perforation.

PID is really only a larger concern in the first few weeks after insertion, and in women at risk of STDs. Essentially, if one develops an STI/STD while using a Mirena IUD, the infection progressing to full-blown PID is a more likely probability. If one has an IUD and avoids STIs, the risk of PID is almost the same as a woman without an IUD. For this reason, doctors used to avoid placing IUDs in younger, unmarried or non-monogamous women. Now most are opening their eyes and allowing patients to take responsibility for themselves with plenty of information on the risk of PID and how to avoid it with safe sex and condom usage.

Here's another one for you.....

You are seeing a young mother of a 2 year old who is experiencing shortness of breath. She has a Paragard IUD in place. Does this increase her risk of developing emboli?

 

[LucidResq]

Some tips as far as assessing patients with Mirena/Paragard/Implanon/IUD/IUS:

What type of device do they have?

In the US we have 3 forms of what we call Long-Acting Reversible Contraception (LARC): Mirena, Implanon and Paragard

Mirena
A levonorgestrel-releasing intrauterine device. In lay-terms, it is a small, flexible T-shaped device inserted into the uterus by a health care professional. It releases an extremely low level of a synthetic progestogen and may be used for up to 5 years.
More information here.

Paragard
The Paragard is similar to the Mirena in that it is inserted in to the uterus by a HCP, however it contains NO hormones - instead it is wrapped in a thin copper coil. It can be used for up to 10 years.
More information.

Implanon
An Implanon is a match-stick sized flexible rod inserted subdermally in the arm between the biceps and triceps. Like the Mirena, it releases a low level of a progestogen, etonogestrel in this case. It can be used for up to 3 years.
More information.

Risks
It is important to note that none of these contain estrogen, therefore, they do not increase clotting risk. These devices therefore are often used by women who are otherwise contraindicated from using Combined Oral Contraceptive Pills or other methods that use estrogen.

With the Paragard and Mirena we are mostly worried about perforation, PID and expulsion. Perforation is when the device moves out of the uterus. This may occur during insertion or later. With this you may see abnormal bleeding and abdominal pain. I've briefly discussed PID above. Expulsion is when the device comes out of the uterus through the cervix. Often the woman will discover the device itself. Sometimes she will just notice that she can't feel the strings that normally hang a few centimeters out of the cervical os anymore.

Doctors advise women with IUDs to "check their strings" regularly. They instruct women to insert a finger or two into the vagina, go deep, and feel for their cervix (it feels like the tip of your nose, kinda), and make sure they can feel at least one fishing-line like string, preferably two. They should remain at a consistent length as well. They are advised to use back-up methods of contraception and immediately see their doctor if they can't feel them, as it may mean that the device has either expelled or perforated.

Like many other methods of birth control, when pregnancy does occur with an IUD in place it may be more likely to be an ectopic pregnancy.

Serious risks associated with the Implanon are few and far between... there may be problems with the site of insertion such as infection or fibrosis.



I'll post some tips on assessment and questions to ask in a bit... before this becomes a beast of a post...

 

[atropine]

easy one, have the bls crew take her to the hospital since this is not emergent.

 

[LucidResq]

Excuse me, PID is serious. This patient may not be in imminent danger of death, but few of our patients in EMS, even the "ALS" ones (which is the most irritating distinction ever), are.

Please keep in mind PID can lead to sepsis which is life-threatening, and infertility which I would consider somewhere between the seriousness of loss of life and limb.

 

[LucidResq]

I really hope you're kidding, because "it's not emergent" is not an excuse for ineptness, not understanding commonly utilized pharmaceuticals and being a piss poor medic.

Remember that you're talking to someone who works primarily in women's health care and I do not take ignorance lightly. I've had paramedics and EMTs come to our clinic and do an awful job taking sick patients from us because they are incompetent in this area of medicine, and I'm tired of it. There's no excuse.

 

[mycrofft]

Not addressable in the field. Need to know to gather that data.

You know me, Nurse Cut To The Chase. Prehospital EMS needs to know what questions to ask and info for the pt to bring, and know/show sensitivity, but not much to be done pre-clinic or ER other than support VS and get billing info.

I share your degree feelings, but also in regard to post bariatric surgery people. Sometimes we are the zebras, and the zebras are multiplying.

 

[LucidResq]

I agree that there isn't much to be done prehospital, but standing there with your mouth wide open forming a puddle of drool on the floor with no idea how to continue when your patient tells you they're using one of these devices in unacceptable, in my book.

 

[mycrofft]

My point zackly.

......

 

[Veneficus]

I really hope you're kidding, because "it's not emergent" is not an excuse for ineptness, not understanding commonly utilized pharmaceuticals and being a piss poor medic.

Remember that you're talking to someone who works primarily in women's health care and I do not take ignorance lightly. I've had paramedics and EMTs come to our clinic and do an awful job taking sick patients from us because they are incompetent in this area of medicine, and I'm tired of it. There's no excuse.

Welcome to my world.

But on the side note, I am guessing the EMTs and medics taking your patients are IFT? I can't think of how an emergency room would be of greater benefit to a female experiencing OB/GYN complications than anything done outpatient for minor problems or better served by a direct admit to another service in the hospital.

It was also a really good point about the seriousness of this type of medicine. The negative consequences of gynecological pathology can be life long and more life altering than loss of a limb.