Updates with Respiratory Syncytial Virus (RSV)

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Since the recording of this episode, the RSV vaccine has officially been approved by the CDC and should be available starting this month!

What is RSV? 

  • RSV = respiratory syncytial virus 

    • Negative sense, single-stranded RNA virus 

    • Name is derived from the large cells known as syncytia that form when infected cells fuse 

  • Why do we care? 

    • Usually causes mild, cold-like symptoms in healthy individuals, and most people will recover in 1-2 weeks 

    • Most of the time, symptoms are localized to upper respiratory tract, but can also cause lower respiratory tract infections 

    • However, infants and older adults are more likely to develop severe disease that require hospitalization 

    • Most children under the age of 2 will contract RSV due to contact with others 

      • Most common cause of bronchiolitis and pneumonia in children <1 year 

      • Leads to 2.1 million outpatient visits as well as 58,000 - 80,000 hospitalizations per year 

      • Also leads to 100-300 deaths among children <5 annually 

    • Those at risk for severe disease 

      • Premature infants and infants <6 months 

      • Individuals with chronic heart or lung disease 

      • Those with immunocompromise 

      • Older adults (65+) 

Why are we discussing RSV now? 

  • Because patients are going to start asking you about it due to two recent developments! 

  • RSV Vaccine 

    • Recently, FDA approved the Abrysvo vaccine for RSV use in infants up to 6 months of age and older adults (July 2023) 

    • Even more recently (8/21/2023), the FDA approved the RSV vaccine for pregnant individuals to prevent RSV in infants 

      • Approved for use between 32-36 weeks gestation 

      • Antibodies can cross the placenta and protect the infant for up to 6 months of age 

      • However, the CDC has not yet set recommendations about Abrysvo, and will not do so until October 2023 

    • This is a bivalent vaccine composed of two recombinant RSV fusion surface glycoproteins to protect against RSV A and B strains 

    • The Data - two randomized controlled trials  

      • Pregnant patients - 3682 patients weeks 24-36 weeks were given the vaccine and 3697 received placebo 

        • There were significantly fewer medically attended severe lower respiratory tract illnesses in infants within 90 days after birth in those that received the vaccine (efficacy 81.8%, 99.5% CI 40.6- 96.3) 

        • There were also fewer medically attended severe lower respiratory tract illnesses within 180 days after birth (efficacy 69.4%, 97.58% CI 44.3-84.1%) 

        • Similar adverse events in both groups 

          • However, in safety studies, low birth weight and jaundice in infants occurred in higher rate in the vaccine group 

          • There is also an imbalance of preterm births in abrysvo recipients (5.7%) vs. placebo (4.7%), but data is currently insufficient to establish a causal relationship with the vaccine 

          • This is why current recommendation is to give after 32 weeks of gestation 

      • Older adults - >18,000 adults 60 years or older were given vaccine, and another >18,000 similar cohort were given placebo 

        • Significantly fewer RSV-associated lower respiratory tract illnesses with two signs or symptoms in the vaccine group compared to placebo group (efficacy 66.7%, 96.7% CI 28-85.8)

        • Significantly fewer RSV-associated lower respiratory tract illness with 3 signs or symptoms in vaccine group (efficacy 85.7%, 96.7% CI 32-98.7) 

        • Higher rates of local reaction with vaccine (12% vs. 7%), and similar rates of adverse events through 1 month after injection 

      • Currently, FDA is requiring the company to conduct postmarketing studies to assess risk of preterm birth and pre-eclampsia 

  • RSV Monoclonal Antibody 

    • FDA has approved the use of nirsevimab (trade name Beyfortus, a long-acting monoclonal antibody) for use to prevent lower respiratory tract disease due to RSV in infants and young children on 7/17/2023 

    • Recommendation 

      • All neonates and infants born during or entering their first RSV season at <8 months of age may receive this antibody for prevention 

      • Also children up to 24 months of age who remain vulnerable to severe RSV disease through their second RSV season 

        • Includes children who are at immunocompromised 

    • Administered as single IM injection 

    • The Data - 3 clinical trials 

      • In one trial of preterm infants born at 29-35 weeks gestation, 969 received single dose of nirsevimab, and 484 received placebo 

        • Those who received nirsevimab, 2.6% experienced medically attended RSV LRTI, compared to 9.5% of infants who received placebo (reduces risk by 70%) 

      • Another trial of infants born at >35 weeks gestation, 994 received nirsevimab, and 496 received placebo 

        • Antibody group had 1.2% MA RSV LRTI compared to 5.0% of infants who received placebo (reduces risk by 75%) 

      • Final trial was a randomized, double-blind, active-controlled multicenter trial to prove safety 

        • Beyfortus vs. palivizumab (monoclonal antibody used previously to decrease severe disease caused by RSV; only used in those children at high risk for RSV, including premature infants <35 weeks gestation who are also <6 months of age, children <2 who require treatment for bronchopulmonary dysplasia, and children <2 who have hemodynamically significant congenital heart disease) 

        • 925 preterm infants and infants with chronic lung disease of prematurity or congenital heart disease → Beyfortus was non-inferior in terms of safety 


Some lingering questions 

  • When will the vaccine and monoclonal antibody be available? 

    • The monoclonal antibody should be available this fall, per FDA 

    • Vaccines should be available at doctor’s offices and at pharmacies if CDC approves in October 

    • Monoclonal antibody should be available at pediatrician’s offices and in hospitals after delivery 

  • What is the cost? 

    • Per the American Academy of Pediatrics, one dose of Beyfortus is $495 for both the 50 mg and 100 mg doses 

    • Per Pfizer, the RSV vaccine Abrysvo will cost somewhere between $180-$270 

    • For reference, the pediatric influenza vaccines cost somewhere between $14 - $30 

Third Stage of Labor, feat. Dr. Alyssa Hersh

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Today we are joined by Dr. Alyssa Hersh, a resident at Oregon Health and Sciences University (OHSU) who is the lead author on a new Gray Journal (AJOG) review on the third stage of labor.

Check out the paper for all the good stuff, but here are the highlights of the podcast:

  • The third stage of labor occurs between fetal and placental delivery. It typically lasts 4-10 minutes, with complications starting to increase after 30 minutes.

  • WThe ACOG definition of postpartum hemorrhage is blood loss ≥1,000 milliliters regardless of mode of delivery, or blood loss along with signs of excessive blood loss.

    • Remember the 4 T’s of etiologies of postpartum hemorrhage, including tone, tissue, trauma and thrombin.

  • The original components of active management of the third stage of labor include:

    • Uterotonic, namely oxytocin;

    • Early cord clamping;

    • Controlled cord traction;

    • External uterine massage.

      • However, not all of these components are still evidence-based.

  • There may be more effective uterotonic regimens than oxytocin alone for preventing postpartum hemorrhage.

  • While TXA may be an effective adjunct to a uterotonic for prevention of postpartum hemorrhage, current evidence is conflicting and there is insufficient evidence to support its broad use at this time after all births.

  • There is evidence supporting the use of controlled cord traction, particularly for reducing the need for manual extraction of the placenta.

    • External uterine massage is not effective for preventing postpartum hemorrhage.

  • Early cord clamping has largely been replaced with delayed cord clamping due to the known benefits for both preterm and term infants.

  • Cord milking may be harmful for very preterm neonates without sufficient data to support using it for neonates at higher gestational ages.

Pre-Exposure Prophylaxis (PrEP) for HIV

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Reading: 

What is PrEP?

  • Pre-exposure prophylaxis specifically for prevention of HIV 

  • Use of antiretroviral medication to individuals who do not have HIV, but are at risk for it.

    • Has been recommended by the CDC since 2012.

Why is PrEP needed?

  • HIV remains a significant public health problem in the USA and around the world.

    • 1.2 million persons have HIV as of 2021, with 87% aware of their diagnosis.

    • About 36,000 people receive HIV diagnosis per year.

      • Heterosexual contact accounts for ~22% of all HIV diagnoses.

      • Injection drug use accounts for ~7% of diagnoses.

    • The majority of new infections occur during reproductive years – about 20k of the 36k diagnoses per year are under the age of 35.

    • Persons of color and trans persons are disproportionately affected – and PrEP can be part of solution to fight inequity.

  • PrEP is effective, but underutilized:

    • 23% of persons who can benefit from PrEP are prescribed it – lots of room for improvement!

    • Discuss more on efficacy later.

    • As part of CDC’s End the HIV Epidemic initiative, they hope to increase PrEP coverage to 50% by 2025.

How effective is PrEP?

  • Very! Let’s quickly review some major trial data in heterosexual couples:

  • 2012: TDF2 Study Group, NEJM

    • RCT in Botswana randomizing to daily tenofovir-emtricitabine or placebo.

      • Two reverse transcriptase inhibitors

      • Brand names: Truvada, Descovy

    • 1219 men and women underwent randomization (45.7% women) and followed for a median of 1.1 years, but max 3.7 years.

    • 9 persons in treatment group and 24 persons in the placebo group became infected.

      • Estimated efficacy: 62.2%.

      • Higher rates of nausea/vomiting and dizziness in treatment group, but not long enough following to determine long-term safety data.

  • 2012: Partners PrEP Study Team, NEJM.

    • RCT in Kenya and Uganda for HIV-1 serodiscordant heterosexual couples, with three arms: daily tenofovir; daily combination tenofovir-emtricitabine; or placebo.

    • 4747 couples were followed.

      • In 38% of couples, the seronegative partner was female.

    • 17 infections in the tenofovir group; 13 infections in the combo drug group; and 52 infections in the placebo group.

      • Risk reduction of 67% with tenofovir alone, and 75% with the combo drug.

      • Rates of serious adverse events similar across groups.

  • 2012: FEM-PrEP Study Group, NEJM

    • RCT in multiple countries in Africa 

    • 2120 HIV-negative women to tenofovir-emtricitabine or placebo daily over two years.

    • 33 infections in combo drug group, 35 infections in placebo group.

      • No difference. Why?

        • Hypothesized that adherence was poor – while pill-count data suggested 88% of meds were taken, drug level testing suggested target plasma level was only identified in about 25% of participants tested.

        • Remember that a daily pill regimen can be challenging!

  • The CDC currently says that PrEP is:

    • 99% effective in reducing risk of HIV acquisition from sexual activity

    • 74% effective in reducing risk of HIV acquisition from IV drug use, when taken as prescribed.

CDC - PREP GUIDANCE

CDC - PREP GUIDANCE

Who should receive PrEP?

  • Patients at the highest risk are those who do not have HIV, but are known to have a male sexual partner that is infected with HIV (a “sero-discordant couple”). 

  • Other high-risk candidates where PrEP should be prescribed:

    • Engage in sexual activity within high HIV-prevalence area or social network, with:

      • Limited or no condom use

      • Diagnosis of other STIs

      • Use of IV drugs or alcohol dependence, or both

      • Incarceration

      • Exchange of sex for commodities, such as drugs, shelter, food, or money

  • Otherwise – if your patient is sexually active, with a partner with unknown HIV status or if they’ve had a bacterial STI in the last six months – it’s a good idea to at least discuss PrEP!

    • Currently, the CDC has a very simple flowsheet for determining if PrEP prescriptions are immediately appropriate. But discuss with your sexually active patients!

      • Including adolescents – ACOG Practice Advisory was a limited update to encourage PrEP discussion in this population.

      • PrEP is OK for anyone > 35 kg / 77 lbs.

How should I prescribe PrEP?

  • Preparation:

    • Determine baseline HIV status with testing – if positive, need treatment, not PrEP

      • Remember – if they’ve had a potential HIV exposure or acute HIV infection symptoms in prior 4 weeks, may need re-testing before determining if they are positive.

    • Determine STI status for other infections such as gonorrhea, chlamydia, and syphilis.

    • Assess hepatitis B status

      • Because emtricitabine and tenofovir can be used to treat hepatitis B, it’s important to test for this – stopping the medicine suddenly in an infected person can lead to rebound hepatitis.

        • If HBV is found or a patient is known to be HBV positive → counsel about this risk and monitor LFTs / HBV viral loads if they discontinue PrEP.

    • Assess kidney function:

      • Oral tenofovir can cause some minor renal damage, and rarely acute renal failure.

        • If CrCl > 60 mL/min, OK to proceed with oral PrEP.

        • If CrCl > 30 mL/min, OK to proceed with injectable PrEP (more on that later!)

    • Assess lipid profile:

      • Oral PrEP may cause changes in lipid profile – baseline assessment should be performed with triglycerides.

    • Same day prescribing of PrEP is OK for most patients as these labs are drawn – but do not prescribe in patients where testing can’t be obtained, patients with concerning history for acute HIV infection or renal disease/associated conditions, or without confirmed means of contact for discussing lab results.

  • Medications and Monitoring:

    • Daily Oral PrEP:

      • Truvada or Descovy (both are combinations of emtricitabine and tenofovir)

        • Truvada has been approved for heterosexual women, as well as MSM and trans women.

        • Descovy has been approved only for MSM and trans women (not for heterosexual women).

      • Patients should be monitored with:

        • HIV testing q3 months

        • Syphilis, gonorrhea, chlamydia testing approximatley every 6 months

        • Creatinine clearance estimate every 6 months

        • Lipid panel yearly

    • Injectable PrEP:

      • Relatively new (Dec. 2021): injectable cabotegravir (brand name: Apretude)

        • FDA approved for heterosexual women, MSM, and trans women at risk of HIV infection.

        • Injection schedule is 2 injections x 1 month apart, followed by q2 month injection.

      • Patients should be monitored with recommended surveillance STI testing:

        • HIV testing with every injection visit

        • Gonorrhea, chlamydia, syphilis on an approximately every 6 month basis.

    • 2-1-1 Oral PrEP

      • This is event-driven / “coitally-timed” PrEP.

        • This can be used by adult MSM, but is not recommended by the CDC and not FDA approved at this time. 

        • It hasn’t been studied in heterosexual women or trans patients.

What if my patient becomes pregnant on PrEP?

  • Women seeking to conceive and pregnant/breastfeeding women can use oral PrEP.

  • Important to understand in HIV is the “undetectable, untransmissible” or U/U principle:

    • Women whose sexual partner has a viral load <200 copies/mL have effectively no risk of sexual acquisition.

      • If partner remains on maximally effective antiretroviral therapy and has undetectable VL, PrEP may not provide additional protective benefit.

    • PrEP may be continued if desired, and a antiretroviral pregnancy registry is available to prospectively and anonymously submit information to obtain further data (www.apregistry.com) 


Further info

  • The CDC maintains a very extensive prescriber’s guide that is worth looking through to implement your own PrEP practice!

    • There is also a National Clinician Consultation Center at 855-448-7737 (855-HIV-PREP) that is available 9A to 8P ET on M-F to have clinician consultation for testing, prevention, treatment, and pre-exposure prophylaxis, and post-exposure prophylaxis resources.

  • The ACOG Practice Advisory also notes PrEP is widely covered with state Medicaid as preventive healthcare, and medication assistance is widely available – check out the end of the advisory for a list of resources.

Medical Ethics

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What is medical ethics, and why do we need them? 

  • What is ethics? 

    • Covers the study of the nature of morals and specific moral choices to be made 

    • It can attempt to answer the question: which general moral norms for the guidance and evaluation of conducts should we accept and why? (Beauchamp TL, Childress JF. Principles of bioethics. 7th ed. Oxford University Press; 2013.)

      • Some moral norms for correct conduct are common to everyone despite differences in culture, religion, etc. = common morality 

      • Some are norms that only exist within a certain group = particular morality 

    • Bioethics and Clinical ethics are two examples of particular morality that should govern physician professional standards 

    So why do we need them? 

    • The best example of why we need medical ethics is to look at history and when medical ethics was ignored 

    • There have been multiple times in history when there have been medical abuse of human subjects in research and medical interventions without informed consent

      • Examples: Tuskegee syphilis study, Henrietta Lacks and the use of HeLa cells, World War II etc. 

    • To avoid repeating history, we should follow the following principles of medical ethics 

    • And of course, there is always 1-2 questions on CREOGs and your written boards about medical ethics, so this is a good time to review them!

The Fundamental Principles of Medical Ethics 

  • Beneficence 

    • Obligation of the physician to act for the benefit of the patient and help protect and defend the rights of others, prevent harm, remove conditions that will cause harm, help persons with disabilities, and rescue persons in danger 

    • This is distinct from the next principle of “nonmaleficence” in that beneficence has positive requirements (actually doing something to promote benefit to others) 

    • Some examples: providing vaccines, speaking at an event to discuss STI prevention, encouraging a patient to stop smoking 

  • Nonmaleficence 

    • The obligation of a physician not to harm the patient 

    • Obvious examples - do not kill, do not cause pain and suffering, do not incapacitate, etc.

    • Practical application is more difficult – this is when the physician needs to weigh the benefits against risks/burdens of all interventions and treatments 

    • This can especially come into play in things like end of life care decisions and pain/symptom control 

  • Autonomy

    • Patients have the power to make rational decisions and moral choices for themselves, and each person should be allowed to exercise their capacity for self-determination 

    • Like other principles, autonomy does need to be weighed against other competing moral principles 

    • Sometimes, autonomy needs to be overridden in the cases where patients are not deemed to have decision-making capacity 

      • Capacity: person’s ability to use information they are given and make a choice that is congruent with their own choices and preferences 

      • This is different from competency = legal judgment that is informed by assessment of capacity 

      • See our previous episode on informed consent where we talk about how to assess capacity!

    • Autonomy can also at times be in conflict with certain social norms depending on culture/religion etc 

      • Example: in some cultures, full disclosure of medical status, end-of-life status, etc. is frowned upon and some cultures may prefer a family-centered approach where these statuses are hidden from the patient 

    • As the definition currently stands, respecting the principle of autonomy obliges physician to disclose medical information and treatment options that are necessary for the patient to exercise self-determination

  • Justice 

    • The fair, equitable and appropriate treatment of persons 

    • The thing that is important to take away, especially in the US for this principle is “distributive justice” 

      • Fair, equitable, and appropriate distribution of health-care resources

      • There are different principles of distributive justice, and can be based on equal share, according to need, according to effort, according to contribution, according to merit, and according to free-market exchanges 

        • Each principle is not exclusive and these principles are often combined in application

        • However, this does increase the difficulty in choosing, balancing, and refining these principles  

    • Examples of justice: rules for allotment of scarce resources, allotment of time for outpatient visits

Three Other Principles Derived from the Original Four

  • Informed Consent

    •  In order to obtain informed consent, things that are required: 

    • Patient who is able to give consent 

    • Presentation of accurate information that includes: 

      • Diagnosis (if it is known) 

      • Nature and purpose of the recommended interventions 

      • The risks, benefits, and alternatives of all options 

    • Documentation of the conversion and the ultimate decision 

    • We won’t go into this too much because we have a whole episode! 

  • Truth-Telling 

    • This is a vital component of the physician-patient relationship – full disclosure of disease process is the normal in the US 

    • However, this may be variable in other countries 

  • Confidentiality 

    • Physicians are obligated not to disclose confidential information given by a patient to another party without the patient’s authorization 

    • Primary exemption would be disclosure of necessary medical information for care of patient to other health-teams 

Some examples of conflicts between principles

  • Paternalism 

    • When beneficence and autonomy collide 

    • The physician may be trying to do what he/she thinks is best for the patient, but patient autonomy suggests that patients have the right to refuse treatment 

    • Paternalism happens when physician takes away patient autonomy by nondisclosure, manipulation, deception, or coercion 

  • Consumerism 

    • Extreme form of patient autonomy where the physician’s role becomes limited to providing all the medical information and available choices and letting the patient select; ie. a menu of choices  

    • This does not permit the physician full use of his/her knowledge and skill for beneficence

Clinical Challenges of Long Acting Reversible Contraception (LARC)

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Read along with CO 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods 

Increased LARC Use 

  • There has been an increase in LARC use over the last few decades 

    • As high as 13.1% in women 20-29 and 11.7% in women 30-39 years of age in 2018 

    • This is compared to 2.4% of all women in 2002 

    • While overall complication of IUDs and implants are low (<1%), the absolute number of these complications will increase as more patients use them.

Complications with IUDs

  • Pain with IUD insertion 

    • IUD insertion can be painful, especially for nulliparous women 

    • Unfortunately, a 2015 Cochrane Review concluded that lidocaine 2% gel, NSAIDs, and misoprostol for cervical ripening were not effective for reducing pain associated with insertion

    • A word on misoprostol use

      • Can cause nausea and abdominal cramping per some trials 

      • Does also require a delay - can be a barrier to access  

    • Paracervical block 

      • Has demonstrated effectiveness in other office transcervical procedures 

      • Studies have shown reduced pain with tenaculum placement after local injection of anesthetic at the tenaculum site 

      • However, other studies have shown no difference in pain with treatment vs. no treatment 

      • Meta-analysis of various analgesic measures did conclude that lidocaine paracervical block reduces pain scores associated with tenaculum placement and IUD insertion 

    • Recommendation: 

      • Routine misoprostol use before IUD insertion in nulliparous women is not recommended, but can be considered with difficult insertions 

      • Pain with IUD insertion needs to be addressed, and one possible way is via a parcervical block as well as injection of lidocaine at the tenaculum site  

    • One last note: patients’ pain should be believed, and discussion for pain relief should be individualized.

      • Some patients may require nothing other than oral medications, but if appropriate and after discussion, some patients may require anesthesia and an OR procedure 

  • Nonvisualized strings 

    • The most common reason for nonvisualized IUD strings is string retraction into the cervical canal or uterine cavity 

      • First step: use a cytobrush to sweep the canal and see if strings are retrievable 

    • However, nonvisualized strings can also indicate other complications such as pregnancy, expulsion, or uterine perforation 

    • If strings cannot be visualized after cytobrush, then rule out pregnancy

      • Can also offer emergency contraception if indicated 

      • Next step is to obtain a pelvic ultrasound 

      • If IUD is not visualized with the pelvic ultrasound, then obtain Xray of the abdomen and pelvis - if not visualized, then IUD is likely expelled 

      • If the IUD is visualized, then this may require laparoscopic removal if there is true perforation and migration 

ACOG CO 672

  • Difficult removal of IUD 

    • If IUD removal is requested, and strings cannot be visualized, alligator forceps can be used to remove the IUD 

    • However, before instrumenting, should confirm that IUD is truly in the uterus 

    • IF strings cannot be visualized, follow above procedure 

  • Malposition/nonfundal position of IUD 

    • If an IUD is in the cervix, this is considered a partial expulsion 

      • Recommendation is to remove the IUD and replace it if it is desired 

    • If an IUD is in the lower uterine segment or low-lying, the ideal management is less clear 

      • Shared decision making - if patient is asymptomatic and IUD is above the internal os, it can be retained and will be effective

        1. However, more studies need to be done to see if failure rates of IUDs are higher when the IUD is located in the lower uterine segment 

        2. Also, many IUDs that are non fundal shortly after insertion move to a fundal position after 3 months 

  • Expulsion/Uterine Perforation 

    • Expulsion can happen in 2-10% of users and varies by IUD type and when the IUD is placed 

      • Risk factors include age <20, heavy bleeding, dysmenorrhea, placement immediately postpartum, and anatomic distortion of the uterine cavity 

      • Recommendation: if IUD is found to be expelled, rule out pregnancy and then counsel regarding contraceptive choices 

    • Perforation into the peritoneal cavity is rare and occurs <1/1000 insertions 

      • Recommendation: rule out pregnancy and then surgical removal 

      • Laparoscopy is preferred 

      • However, depending on location of IUD, it may be possible that it should be left in place if surgical risks associated with removal and considered too great 

      • Replacement of another IUD under laparoscopic guidance can be done if patient desires 

  • Infection 

    • IUDs should not placed if there is active infection 

    • Infection after IUD insertion is rare, and while the risk of PID developing is increased in the first 20 days after IUD insertion, the risk drops to baseline population risk after 

    • In patients with PID who have an IUD, the IUD can be left in-situ unless there is no clinical improvement 

      • IUD removal can be considered after this 

  • Pregnancy with IUD in place 

    • The risk of pregnancy with IUD in place is 2% after 10 years, similar to tubal sterilization procedures 

    • Ectopic pregnancy must be ruled out - first obtain pelvic ultrasound 

      • If ectopic pregnancy is present, then this needs to be managed medically or surgically. The IUD can be retained if desired  

    • If there is an intrauterine pregnancy

      • If undesired, then IUD can be removed at time of surgical abortion or before medical abortion 

      • If desired, then IUD can be removed if strings are visible 

        1. If strings are not visualized, then ultrasound should be done 

          1. If the IUD is in the cervix, then removal can be attempted 

          2. If IUD is above the cervix, then IUD should not be removed; instead, discussion should be had with patient about increased risk of obstetric complication in setting of pregnancy with IUD

            1. These include increased risk of SAB, infection, and preterm delivery 

          3. If no IUD is seen, then Xray should be done of the abdomen/pelvis after pregnancy  

Complications with Implants 

  • Nonpalpable Implant and Deep Insertion 

    • If an implant is not palpable, first thing is to rule out pregnancy 

    • Do not attempt removal unless implant location is determined

    • Obtain imaging to locate the implant 

      • As there is barium in the implant, X-ray, CT, and fluoroscopy can all be used 

      • Ultrasound and MRI can also be used if needed 

    • If there is a deep insertion that cannot be removed in office: 

      • Consult with family planning specialist or general surgery for removal 

      • If implant is not deeply located within muscle or near neurovascular bundle, then outpatient removal can be attempted with local anesthesia and ultrasound 

      • If the implant is deeply embedded into muscle or nearby neurovascular bundle, then attempt should only be made in the operating room with specialist or surgeon 

    • If imaging is not able to locate the implant, then an etonogestrel serum assay can be done – if itis negative, then there is no implant in the person’s body 

  • Pregnancy with Implants 

    • Risk overall is <1%, but if pregnancy is confirmed, there is a higher risk of ectopic pregnancy 

    • An ectopic pregnancy should be managed medically or surgically per guidelines 

    • If patient desires termination of pregnancy, the implant can be retained 

    • If the pregnancy is desired, then the implant should be removed 

      • Etonogestrel is not teratogenic