Podcast appearances and mentions of jeff since

Jeff talks about going to the reading and Q&A for Frederick Smith and Chaz Lamar's In Case You Forgot. The guys also talk about their recent trip to see the musical The Drowsy Chaperone starring Bruce Vilanch. It's a Heidi Cullinan double feature this week as Will reviews Nowhere Ranch and Jeff reviews The Doctor's Secret. Jeff talks with Jacqui Greig, the creator and editor of Blush magazine. Jacqui talks about why she created the magazine and what sparked her love of all things romance. We also find out about the books that she writes and how she encourages anyone who is interested to start an online magazine. Complete shownotes for episode 197 along with a transcript of the interview are at BigGayFictionPodcast.com. Interview Transcript – Jacqui Greig This transcript was made possible by our community on Patreon. You can get information on how to join them at patreon.com/biggayfictionpodcast. Jeff: Thanks for coming to the podcast Jacqui it is so great to have you here. Jacqui: My absolute pleasure. Jeff: So Will and I have loved “Blush” since the first issue came out and. Jacqui: Thank you. Jeff: I love what one of the things on the website that talks about you where it says “I may or may not have started this publication and in order to fangirl my favorite authors without getting slapped with a restraining order.” Jacqui: Pretty much. Jeff: Which sounds so awesome. It’s like a mission statement. Jacqui: But it’s so true. I used to finish reading a book and then I just I loved it so much that I wanted to be best friends with the author. I wanted to know everything about them. I just you know wanted to delve into their heads I guess. And that’s kind of what “Blush” lets me do. Yeah without getting hit with a restraining order. Jeff: We feel the same way about the podcast it’s so great to just dive in with these folks. Jacqui: Yeah absolutely. Jeff: Tell us a little bit for our listeners who may not have discovered blush yet. What is the magazine kind of all about besides obviously of course romance books? Jacqui: So essentially, it’s an online magazine for romance readers. So I just wanted something that was specific for people who read romance and there’s already so many amazing blogs and podcasts that I just thought a magazine would be a fun way of getting that information across. And yeah. So it’s kind of interviewing authors, looking at the different books that are coming out at the moment, the different trends in the industry. I’m calling it an online digital platform. There’s even things like I imagine what a particular heroine in a book would wear. And I based a fashion page on that. So it’s just kind of interpreting the romance genre in different ways. Jeff: It really is because you go so much further than a Book Review blog or like what we do on the podcast because you do have, as you mentioned, the fashion thing or I believe in June it was the ‘book crush’ with Jamie Frazier which everybody can have that crush, right? Jacqui: Right? Jeff: There are elements of reviews that work their way in, but then you do some dives on the industry too, or talking about tropes and such. Jacqui: Yeah. I think that’s probably my background in journalism as well. I used to work on magazine in Sydney. I worked in a travel magazine and on a hair magazine of all things. And then I started my own magazine, a women’s lifestyle magazine, which was print – that was more than 10 years ago now. So the industry has evolved so much since then and it’s so much easier to do a digital magazine than it is a print magazine. Yes. So I just thought I’d give it a go. Jeff: How do you decide what goes in to each issue. Because there’s so many things to pick from. Jacqui: I know there’s so many things to pick from and it’s actually been a little – it’s getting easier every month because the magazine is getting more widely known and people are actually messaging me, emailing me, then giving me content ideas, which is fantastic, but it’s just whatever I like. Yeah. I don’t know. Whatever I’ve been reading or what I’ve seen or I am quite big on Instagram I get a lot of inspiration there. Jeff: Yeah. And I enjoy watching your Instagram just because it’s so creative. Jacqui: I’m a graphic designer as well so I see lots of cheeky quotes and things like that and I just redesigned them for my own purposes which is fun. Jeff: Your July issue will have been out a short time by the time this episode airs. What can readers find in July? Jacqui: So I’m super excited. In July I have three authors that I definitely fangirl over. So I’ve got Eve Dangerfield. I’ve got an interview with her. I have an interview with Sarah MacLean and an interview with Abbi Glines. Jeff: Wow. Three of them are all in the same issue. Jacqui: Yeah, well in my very first issue I had Beverly Jenkins and Kylie Scott and I thought, “Right, I’m happy to finish this right now. I’ve reached my peak.” That was epic for me. I think romance authors are so generous with their time and knowledge and it’s just such a beautiful, interesting industry to be in. Jeff: Yeah, it really is because there’s so many warm people who are just happy to tell their story and tell everybody about their books. What are the regular sections that readers look for each month? Jacqui: So I generally start with a ‘Lust-Haves’, which is just kind of products/bookish things that basically I would like to be spending my money on. I think in one issue I had a pair of cashmere socks that were like one hundred and ten dollars and I had a girlfriend calling me, she said, “You didn’t buy those, did you?” I didn’t. I’d like to. So yeah, we did ‘Lust-Haves’, we do an IG profile. I pick an Instagram account that’s really inspiring and has gorgeous images and profile them. We’ve got our author interviews. I generally have a couple of features. So for example, in the current issue we did one on the rise of rural romance. So it’s basically Australian authors writing romance set in rural settings… on farms which is really lovely. I live in a small country town myself, so I can really identify with that. We do a ‘Book Crush’ every issue. So that’s just a hero that we’ve got a bit of a crush on at the time and it’s really fun to contact the author and find out what they had in mind when they were writing that character. I get them to share their Pinterest pages with inspiration that they drew when writing, which I love. And there’s a bookshelf at the back, which features a lot of books, and it’s a really great showcase for indie authors I think. So yeah, that’s kind of it. Jeff: You say that’s kind of it, but that’s a lot. I mean, there’s a lot of stuff that goes into these issues. What kind of overall timing and process goes into creating a single issue? Jacqui: Well, having done in my previous life the print lifestyle magazine that was a whole circus. So I had staff and we had an office and because that I was spending forty thousand dollars an issue just to print it. So it was big. Right. So because [Blush] is digital – it’s online – my overheads are tiny, it’s literally me sitting at my kitchen table and, I have I don’t have it here, but I literally designed up on an A3 bit of paper for weeks and split it into the days and split the jobs across it and I laminated it so that I can write over the top of it – every issue. And it’s actually not too involved I think because I know what I’m doing. And I love what I’m doing. And I think as a working mother you become… I just have to get shit done. Like I just, I’ve got no windows in between kids being at school or ballet lessons or you know all of that kind of jazz. I just have to really, really be productive with my time and bang it out. Jeff: And I think the online magazine in a lot of ways gives you a much broader design to work with than if you were locked in to any kind of website format. Jacqui: Yeah, I think it’s fun because you can flip through the pages. It kind of it feels interactive and you can, you know, I can put gifs onto the pages so there’s movement, there’s different animations that you can use. And it’s just readers really like the tactile experience of a physical magazine. And because I can’t do that, I think a digital magazine – it is still something different from a blog post and not to say that, you know, there’s some fantastic blogs out there, but this is just a different format. Jeff: Yeah, it’s a different medium, but it’s going to be interesting, I think to see if other people move in that direction. I think we’re all so used to seeing blogs that this is another similar but different way to go. Jacqui: Yeah, it’s just a bit fun, little bit different. Jeff: July is also kind of a milestone for you because it’s six months old for the magazine – issue number six. What’s your favorite thing to write about so far in those six months? Jacqui: I think the interview with Beverly Jenkins, that was kind of amazing. She’s an icon in the industry and she’s so generous and I couldn’t believe that she’s giving me the time of the day, especially because I hadn’t published a magazine by that stage. I literally had nothing to show her. She just kind of said, “Yeah sure.” So that was really incredible. I do freelance digital marketing, which I’ve just stopped, and I’m focusing all my energy on ‘Blush’ because I really want to give it a go. I felt like I was building other people’s dreams, helping them build their dreams and I wasn’t really putting any time into my own. So yeah, I’m kind of all in with this. I got skin in the game now. Jeff: That’s awesome. It’s a good feeling. Jacqui: Yeah, it really is. And I do need to say my husband is super supportive and I’m very lucky. But yeah, like this is my gig now. Jeff: What’s surprised you over the six months. Jacqui: I don’t know if it was surprise. It was probably just reinforced how wide and how deep this romance genre is and how amazing it is. I mean, if Alexa Riley can beat Michelle Obama in the rankings on Amazon, that’s huge. Jeff: And you’re right about the romance genre being so big. I have found, so far, that you try to cover seemingly all of it. You’ve featured all kinds of romance including LGBTQ romance. Jacqui: Well, that’s a that’s a big sector and it’s valid and I know that, especially in the states, you’ve been having a lot of diversity talk at the moment – and so you should. ‘Blush’ is a vehicle for the romance industry and I want it to encompass all aspects of that. Jeff: And we talked a little bit before we started recording that it was ‘Blush’ that first put ‘Red, White & Royal Blue’ on our radar as the thing we needed to watch out for in the spring. Jacqui: Well, I’m sure you hadn’t seen it with me, you would have seen it very soon because it has been so well received and validly So like she’s amazing, Casey’s [McQuiston] she’s going places. Jeff: Yeah, absolutely. What got you into romance? Jacqui: So my parents owned a newsagent when I was younger. And romance novels were distributed by magazine companies, which meant that if they didn’t sell, it was cheaper to rip the cover off and throw it out than it was to send it back to the company. So I used to scavenge through the back bin and I just fell into it. I read to my heart’s content. The only problem was, that because it didn’t have a cover, I knew the title, but without that image on the top on the cover and the title, I can’t remember any of them. And probably I was reading so many of them, I was just kind of consuming them. But yes, so that’s how I got into it – scavenging. Jeff: That is awesome. What a great way to get books. Jacqui: I know right. I mean it’s so demoralizing and awful for an author to think about – that’s how some of your books may end up. I don’t know if that’s still the practice – I would hope not. But yeah, that’s back when I was 12 or 13. That’s how we did it. Jeff: On the other hand, I mean how terrific that it must be – Yes, they didn’t get paid for – but they inspired somebody to go out and create something like this later in life. Jacqui: Well that’s true. That’s a really nice way of looking at it. Oh, thank you. Jeff: You can’t remember some of the titles and authors obviously, but do you remember what tropes and what sort of elements of the story fueled your interest in the genre? Jacqui: I read a lot of the historicals, which I loved. But I kind of stopped reading for a while – going through high school and then university – and got back into it with Kylie Scott, who’s an Australian author who wrote a romance in a zombie apocalypse, which is very far removed from historical romance, but freaking awesome. She wrote two books and a novella and then found mainstream success with her Rockstar romances. But she kind of got me back into reading romance, her and Amy Andrews who is another Australian author. She’s got a ‘Sydney Smoke’ rugby series, which is a series of books set around a rugby team in Sydney and she just has the dialogue down pat, like she is so dynamic with her writing. Yeah, she is really, really incredible. I think those two got the ball rolling to get me back into it and now I don’t really have a favorite trope or a favorite genre. I will literally read anything you put in front of me. I will read it. Jeff: That’s awesome. I’m kind of the same way. Will has is his thing where he likes contemporary/low angst – may take a few diversions off that path… But if I like the blurb, I’m at least game to see where it goes. Jacqui: Exactly. Yep. I’m with you. Jeff: Now, since we are an LGBTQ romance podcast, what are some of your recent reads, kind of in that genre. Jacqui: So what I’ve really loved is that some of my favorite authors are diversifying. I guess they’re going into that queer space. So Kate Canterbury, she wrote The Walsh series – which I devoured I loved – and then it’s an offshoot. There’s a lobster fisherman who marries Aaron and Nick in book 6. And So the lobster fisherman he gets his own book and he falls in love with a tech tycoon. And honestly it was one of the hottest romances I’ve ever read. Like it was. She nailed it. And that was her first male/male book. And I just went, “Oh wow, you’ve done such a good job.” Also Tessa Bailey she wrote a male/male. What’s it called… I wrote it down. ‘Heat Stroke’. She wrote ‘Heat Stroke’ which is just really sweet. And the relationship between the two men, it was so believable and she’s really good at characterization. She’s fantastic, but my absolute favorite of mine is Sierra Simone, who wrote the ‘Camelot’ series. So it starts with ‘American Queen’ goes to ‘American Prince’ and I actually haven’t read the third one because I got a spoiler and I don’t have the emotional fortitude at the moment. Jeff: I understand how that it goes. Jacqui: But she just writes… So it’s a male/female/male, but the two guys, they’ve been in love for so long before Greer, the woman, actually comes into it and just the depth of their love for each other. And she’s, I mean, it’s kind of filthy – the writing, but awesome. It’s emotional and it’s just, yes, she’s fantastic. Jeff: Since you look at romance really from around the world for ‘Blush’, because you’re in Australia and have read so many Australian authors, do you see a difference of what romance is around the world – what gets written into the books from the native authors? Jacqui: I think that a lot of Australian authors are actually setting their books in the US. I don’t know if that’s a marketing thing or if that’s just what they read and that’s what they want to write, but then there’s a whole crop of Australian authors who are writing rural romance, which is set on an Australian farm as opposed to an American ranch. So you know there are differences in words I guess. I don’t know. Apart from that though, I kind of think everyone’s just writing their own happily ever after. And it’s and in different ways, using different tropes, different locations. I do wish that there were more Indigenous Australians writing romance novels. I think that would be amazing. There are some amazing Indigenous authors, just not so many writing romance, so that that would be really incredible to see. I actually am writing as well. I’m sure everyone who reads is trying to write as well. So I’ve just published my second book, but I would like to co-author a book with… I grew up in a small country town with a high indigenous Aboriginal population. So I went to school with all of these Aboriginal girls and I need to make contact with them and see if one of them will sit down with me and co-write a book, a romance from their point of view. I think that would be amazing. I don’t think that I would have the guts, I guess, to write from that point of view, even if I had a sensitivity reader come in and read it afterwards. I really do think that their issues and their worldviews and, you know, they have their differences and you’ve got to do justice to that. Jeff: So what do you write? Tell us a little bit about your books. Jacqui: Well my full name is Jacqueline, and my maiden name is Hayley, so they’ve written under Jacqueline Hayley. And second, which literally I published yesterday, it’s ‘Getting Under Her Skin’, and it’s set in Sydney. So they’re contemporary romances that are a little bit sexy, I don’t think I really want my mum reading them. Jeff: Yeah that’s awesome. Any chance of a male/male book in your future? Jacqui: Yeah, I think So but I think that, again, I would want to team up with a gay male author to help me do that. Like, I just I don’t want to presume that I would know their life experiences. So I think that would be super fun. Jeff: I hope you get to do that. We’d have to have you back on the show to talk about that when it comes out. Jacqui: Absolutely. Jeff: What can you tell us about upcoming issues [of ‘Blush’] for the rest of this year? Jacqui: Oh, the rest of this year. So I’m actually heading to the Australian Romance Writers Association, their annual conference is in Melbourne, and I have lined up some authors that I’m going to do video interviews with as bonus content for my readers. So we’re just finalizing the details of that, but I do think that video, which can be embedded into the magazine – in the magazine we also find YouTube clips and things as well, the digital magazine format allows for that, which I think is really fun. The video will start to become a little bit more of a thing with the magazine, as much as I don’t really want to see myself on video, I think that it would be really fun for authors, who are normally behind the pen – behind the computer – and you don’t see their faces or hear them. I think that that would be a really fun thing to do. Jeff: Very much looking forward to that. It’s great seeing how the video gets in there to really make this interactive magazine. What’s the best way for people to keep up with ‘Blush’ online and how do they get the subscription? Tell us all about that. Jacqui: So at the moment, to be able to read the magazine, you have to head to the website which is blushmagazine.com and sign up with your email address. So it’s free. And then the magazine gets emailed to you, well a link to the magazine gets sent to you, so that you can view the magazine. Previous issues are available on the website, so you can you can click through there, but probably I’ most prolific on Instagram. That’s kind of where that’s my jam. That’s what I like doing. So you know, for cheeky quotes and books that are coming up, all the behind the scenes of what I’m doing here, that’s Instagram, is where it’s at. Jeff: Very cool, and can readers of the magazine get in touch and suggest ideas? Jacqui: Absolutely. I love it. The interaction is one of the best things that I love about what I’m doing, so I get DMs on Facebook, Instagram, and my email is hello.BlushMagazine@gmail.com. Jeff: And what would you say to anybody who is like, “Gosh, I really like that. Maybe I should start my own.” Jacqui: Yeah. So I guess have a look at the different platforms that are out there to do a magazine on. I use readymag which I really love. But there’s also issu, which I’m kind of looking at as I get bigger. That might be where I go just because you can get more stats on what particular pages people are staying on longer. That kind of thing. So I guess just have a really clear view of what you want to put in your magazine, you’ve got to structure it like a real magazine. So go and get a physical magazine, you need a contents page and an editor’s letter and kind of build it from there, but just know that readers like continuity, so if you’re going to start a section, you’ve got to kind of continue it. So have a really clear idea of what kind of content you want to do. I haven’t done this and I probably should have build up content so that you’re an issue ahead of yourself so that, you know, just to for timing I guess, that would make life easier. I like making things hard for myself. Give it a go, like why not? Compared to the money that I used to put into print publishing, digital publishing… there’s barely any any cost. So yeah, give it a go. Jeff: Cool. Hopefully somebody will take up the inspiration because – at least the way we feel concerning podcasts, the more podcasts the better, the more magazines the better, the more blogs the better. Jacqui: Built this industry! Jeff: Yes absolutely. Well Jacqui, thank you so much for telling us about ‘Blush’, we’re going to link up to everything we talked about- the authors and the magazine – in the show notes, and we look forward to see what comes out in future issues. Jacqui: Thank you so much for having me. It was just the highlight of my week. Thank you so much. Book Reviews Here’s the text of this week’s book reviews: Nowhere Ranch by Heidi Cullinan. Reviewed by Will. Admittedly, I’m a little late to the party when It comes to this book. When I posted online that I’d finished reading Nowhere Ranch, I got a slew of responses, “Isn’t it the best?”, “That’s my favorite Heidi book.” So, for the few that haven’t yet experienced the sexy wonder of this cowboy romance, Nowhere Ranch is about a young guy named Monroe, Roe for short. He’s the prototypical lone cowboy who’s just landed a job at Nowhere Ranch. On one of his free nights, Roe travels several hours away to the nearest gay bar. To his surprise he runs into his boss, Travis Loving. After some flirty banter and surmising that they are both definitely into each other, they spend one wild night together in Travis’s hotel room. Roe tries to keep things professional with his boss, but Travis is just too damn irresistible. After a trip to the rodeo, he gives into his desire yet again. His hook-ups with Travis are so amazing that he begins to reconsider his ‘no relationships’ policy. When it comes to the bedroom, Roe likes things a little kinky. Travis is more than willing to give him everything he wants. After a rough and raunchy tumble in a horse stall on his birthday, Roe is so turned on and turned around, that he just doesn’t know what to do. Guys, this book is incendiary. I’m no expert when it comes to Heidi Cullinan’s books, but the few that I have read, have ridden that delicious line between sweetly romantic and utterly filthy. The kink explored in Nowhere Ranch isn’t your mommas 50 Shades style slap ‘n tickle. This is hardcore stuff in the best possible way. Back to the story. Hailey, the daughter of the ranch foreman, becomes fast friends with Roe and it becomes her personal mission to tutor Roe so he can get his GED. After learning some English composition basics, Roe writes an essay especially for his boss entitled, “Why Travis Loving Should Fuck Me”. What’s wonderful is that the entire text of the essay is included as part of the story. It’s sweet, it’s funny, and it leads to some more smoking hot sex for our two heroes. Unfortunately, the course of true love never did run smooth. A letter from the family that rejected Roe years earlier, forces him to examine what “home” really means. Home is definitely Nowhere Ranch. Some drama eventually forces Roe to make an unwanted trip to deal with the backwards, judgmental people he once called his family. With Travis and Hailey by his side, he sets things to rights and accepts that he is, in fact, worthy of his very own happily-ever-after. There’s a brief time jump at the end of the story to show us just how happy the happily-ever-after is for Roe and Travis. It’s wonderfully schmoopy and surprisingly sweet for a story that is so dang filthy. It just goes to show, that in the hands of a skilled author, kink doesn’t have to equal dark or angsty. The story of two hot and horny cowboys can be just as swoon-worthy as the lightest of rom-coms. The Doctor’s Secret by Heidi Cullinan. Reviewed by Jeff. This book had me at its cover with its clean design, heartbeat along the top and the handsome doctor. And I snatched the audiobook out from under Will because Iggy Toma was doing the narration. As with my other experiences with Heidi and Iggy, this one was above and beyond. The Doctor’s Secret brings Dr Hong-Wei Wu, or Jack as he tells the staff to call him, to Copper Point, Wisconsin. Hong-Wei’s left a high powered residency and his family in Texas to re-locate to this tiny town that needs a surgeon. He also hopes to lead a quiet life here. That’s derailed almost as soon as he steps off the plane because he meets Simon Lane, the hospital’s surgical nurse and the person who was dispatched to pick him up. Simon wasn’t quite ready for the attraction either. He’s in Copper Point working alongside his two best friends who all wanted to stay and give back to their home town–a place so small Simon’s sure he’ll never find a man for him. Hong-Wei is torn from the beginning because he came to Copper Point to get away from complications, but he can’t deny the immediate attraction to Simon. He tends to put himself under a tremendous amount of pressure to always do the right thing, even if that means saying yes to things he doesn’t want. As Simon learns more about Hong-Wei–from his love of classical music as well as his dislike for most pop music, his love of Taiwanese food and even the meticulous way he wants his operating room set up–only made him fall for the man more. Simon’s incredible from the get go. Instead of using “Jack,” Simon wants to use Hong-Wei’s given name and takes the time to learn how to pronounce it. It’s super adorable too how Simon can’t believe Hong-Wei might be flirting with him–their interactions at the hospital are super cute as they both easily get flustered. Their potential relationship comes with great risk. Copper Point is a small town with small town drama and shenanigans. St. Ann’s Hospital has a stranglehold on its employees with a hospital board that attempts to rule with an iron fist. This includes a no-dating policy. As they grow closer though, Hong-Wei’s having none of it, insisting he’ll protect Simon. Simon’s friends Owen and Nick, also doctors at the hospital, help the two get together in secret. As you can imagine neither men want to live in secret, and the more they fall for each other it becomes more difficult to keep it. Beyond Simon catching Hong-Wei’s attention, he starts to fall for the entire town of Copper Point. From the owners of his favorite restaurant to his co-workers to the local orchestra. It’s far more than he ever planned for and he’s not quite sure how to manage all the feelings of peace and happiness he has here. When a medical emergency forces Hong-Wei to reveal more of himself than he planned, the major power struggle begins around the dating policy and the future of St. Ann’s. Heidi does a tremendous job about making us care not only for Hong-Wei and Simon, but for everything that’s at stake for the town. There’s so much to love in this book between Simon and Hong-Wei, their friends, the citizens of Copper Point. The book also has one of the best grand gestures ever. It gave me all the feels. Kudos to Iggy Toma for a brilliant performance, infusing everyone with strong emotions and rich personalities. The tender moments between Simon and Hong-Wei are perfection. I’m looking forward to Owen and Nick’s books in the series. Owen’s is already out but I’m hanging tight for the audio and Nick’s book releases in August.

Welcome to Golf Talk Live! Tune in Thursday at 6:00 PM Central This week on the Coaches Corner Panel: Chuck Evans & Clint Wright. Later in the show I'm joined by special guest: Jeff Harrison – Senior Vice-President of Education for Western Golf Association. More on Jeff: Since 2013, Jeff Harrison has served as Senior Vice President of Education for the Western Golf Association/Evans Scholars Foundation. In this role, he directs all of the organization’s caddie and scholarship programs, including scholarship selection and overseeing the nearly 1,000 current Evans Scholars in school. Prior to his current role, he was Vice President of Education, serving in that role since January 2008, after 18 years as associate educational director. Harrison caddied at Birmingham Country Club in Birmingham, Michigan, and graduated as an Evans Scholar from Michigan State University in 1986. He was the first Evans Scholars Alum in the storied history of the WGA to serve as educational director. He lives in Elmhurst, Illinois, with his wife and two sons. Join us LIVE Thursdays 6:00 - 8:00PM Central http://www.blogtalkradio.com/golftalklive Or listen on any of these social media platforms:  iTunes , Stitcher, Tunein, Castbox, TalkStreamLive & Spotify.

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving from the trauma bay back to a more private setting, to discuss Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases. Nachi: And for those of you who follow along with the print issue and might be reading in a public place, this issue has a few images that might not be ideal for wandering eyes. Jeff: I’d say we need a “not safe for work” label on this episode, though I think we are one of the unique workplaces where this is actually quite safe. Nachi: And we’re obviously pushing for “safe” practices this month. The article was authored by Dr. Pfenning-Bass and Dr. Bridges from the University of South Carolina School of medicine. It was edited by Dr. Borhart of Georgetown University and Dr. Castellone of Eastern Connecticut Health Network. Jeff: Thanks, team for this deep dive. Nachi: STDs or STIs are incredibly common and often under recognized by both the public and health care providers. Jeff: In addition, the rates of STDs in the US continue to rise, partly due to the fact that many patients have minimal to no symptoms, leading to unknowing rapid spread and an estimated 20 million new STDs diagnosed each year. Treating these 20 million cases amounts to a whopping $16 billion dollars worth of care annually. Nachi: 20 million! Kinda scary if you step back and think about it. Jeff: Definitely, perhaps even more scary, undiagnosed and untreated STDs can lead to infertility, ectopic pregnancies, spontaneous abortions, chronic pelvic pain and chronic infections. On top of this, there is also growing antibiotic resistance, making treatment more difficult. Nachi: All the more reason we need evidence based guidelines, which our team from South Carolina has nicely laid out after reviewing 107 references dating back to 1990, as well as guidelines from the CDC and the national guideline clearinghouse. Jeff: Alright, so let’s start with some basics: pathophysiology, prehospital care, and the H&P. STDs are caused by bacteria, viruses, or parasites that are transmitted vaginally, anally, or orally during sexual contact, or passed from a mother to her baby during delivery and breastfeeding. Nachi: In terms of prehospital care, first, make sure you are practicing proper precautions and don appropriate personal protective equipment to eliminate or reduce the chance of bloodborne and infectious disease exposure. In those with concern for possible sexual assault, consider transport to facilities capable of performing these sensitive exams. Jeff: As in many of the prehospital sections we have covered -- a destination consult could be very appropriate here if you’re unsure of the assault capabilities at your closest ER. Nachi: And in such circumstances, though patient care comes first, make sure to balance medical stabilization with the need to protect evidence. Jeff: Exactly. Moving on to the ED… The history and physical should be conducted in a private setting. For the exam, have a chaperone present, whose name you can document. The “5 Ps” are a helpful starting point for your history: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. Nachi: 5 p’s, I actually haven’t heard this mnemonic before, but I like it and will certainly incorporate it into my practice. Again, the 5 p’s stand for: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. After you have gathered all of your information, make sure to end with an open ended question like “Is there anything else about your sexual practices that I need to know?” Jeff: Though some of the information and even the history gathering may make you or the patient somewhat uncomfortable, it’s essential. Multiple partners, anonymous partners, and no condom use all increase the risk of multiple infections. Try to create a rapport that is comfortable and open for your patient to provide as much detail as they can. Nachi: And as with any infectious work up, tachycardia, hypotension, and fever should all raise the concern for possible sepsis. In your sepsis source differential, definitely consider PID in addition to the usual sources. As a mini plug for a prior issue, PID was actually covered in the December 2016 issue of Emergency Medicine Practice, in detail. Jeff: Getting back to the physical exam: though some question the utility of the pelvic exam as our diagnostics get better, the literature suggests the pelvic definitely still has a big role both in diagnosing and differentiating STDs and other pathology. Don’t skip this step when indicated. Nachi: Now that we have a broad overview, let’s talk about specific STDs, covering diagnosis, testing, and treatment. Jeff: If following along in the article, appendices 1, 2 and 3, list detailed physical exam findings for the STDs were going to discuss, while table 3 lists treatment options. A great resource to use while following along or as a reference during a clinical shift! Nachi: First up, let’s talk chlamydia, the most common bacterial cause of STDs, with 1.7 million reported infections in 2017. Most are asymptomatic, which increases spread, especially in young women. Jeff: Chlamydia trachomatis has a 2-3 day life cycle in which elementary bodies enter endocervical and urethral cells and replicate, eventually causing host cell wall rupture and further spread. Nachi: Though patients with chlamydia are often asymptomatic, cervicitis in women and urethritis in men are the most common presenting symptoms. Vaginal discharge is the most common exam finding followed by cervical ectropion, endocervical mucus, and easily induced bleeding. Other presenting symptoms include urinary frequency, dysuria, PID, or even Fitz-Hugh-Curtis syndrome, which is a PID induced perihepatitis. In men, epididymitis, prostatitis, and proctitis are all possible presenting symptoms also. Jeff: And of note, chlamydia can also cause both conjunctivitis and pharyngitis. Nachi: This article has a ton of helpful images. Check out figures 1 and 2 for some classic findings with chlamydial infections. Jeff: When testing for chlamydia, nucleic acid amplification is the test of choice as it has the highest sensitivity, 92% when tested from a first-catch urine sample vs. 97% from a vaginal sample. While these numbers are similar, and you’re gut may be to forego the pelvic exam, consider the pelvic exam to aid in the diagnosis of PID and to evaluate for cervicovaginal lesions or other concomitant stds. Nachi: Similarly, in men, the test of choice is also a nucleic acid amplification test, with a first catch urine preferred over a urethral swab. Jeff: And lastly, nucleic acid amplification is also the test of choice from rectal and oropharyngeal samples, though you need to check with your lab first as nucleic acid amplification is not technically cleared by the FDA for this indication. Nachi: Treatment for chlamydia is simple, 1g of azithromycin, or doxycycline 100 mg BID x 7 days. Fluoroquinolones are a second line treatment modality. Jeff: In pregnant women, chlamydia can lead to ectopic pregnancy, premature rupture of membranes, and premature delivery. The single 1g azithromycin dose is also safe and effective with amox 500 mg TID x 7 days as a second line. Pregnant women undergoing treatment should have a documented test-of cure 3-4 weeks after treatment. Nachi: Next up, we have gonorrhoeae, the gram-negative diplococci. Gonorrhea is the second most commonly reported STD, affecting 0.8% of women and 0.6% of men, with over 500,000 reported cases in 2017. Jeff: Gonorrhea attaches to epithelial cells, altering the surface structures leading to penetration, proliferation and eventual systemic dissemination. Nachi: Though some may be asymptomatic, women often present with cervicitis, vaginal pruritis, mucopurulent discharge, and a friable cervical mucosa, along with dysuria, frequency, pelvic pain and abnormal vaginal bleeding. Jeff: Men often present with epididymitis, urethritis, along with dysuria and mucopurulent discharge. Proctitis, pharyngitis, and conjunctivitis are all possible complications. Nachi: In it’s disseminated form, gonorrhea can lead to purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: In both men and women the test of choice for gonorrhea again is NAAT, with endocervical samples being preferred to urine samples due to higher sensitivity. In men, urethral and first catch urine samples have a sensitivity and specificity of greater than 97%. Nachi: And as with chlamydial samples, the FDA has not approved gonorrhea NAAT for rectal and oropharyngeal samples, but most labs are able to process these samples. Jeff: Yeah, definitely check before you go swabbing samples that cannot be run. Lastly, in regards to testing, though it won’t likely change your management in the moment, the CDC does recommend a gonococcal culture in cases of confirmed or suspected treatment failure Nachi: It’s also worth noting that although NAAT can be used in children, but culture is additionally preferred in all settings due to legal ramifications of sexual abuse. Jeff: It pains me just to think about how awful that is. Ugh. Moving on to treatment: when treating gonorrhea, the current recommendation is to treat both with cefitriaxone and azithro. 250 mg IM is the preferred dose, up from just 125 mg IM which was preferred dose two decades ago along with 1g of azithro. Nachi: And if ceftriaxone IM cannot be administered easily, 400 mg PO cefixime is the second line treatment of choice. If there is a documented cephalosporin allergy, PO gemifloxacin or gentamycin may be used. And for those with an azithomycin intolerance, a 7 day course of doxycycline may be substituted instead. Jeff: In pregnant women, gonococcal infections are associated with chorioamnionitis, premature rupture of membranes, preterm birth, low birth weight, and spontaneous abortions. Pregnant woman therefore should be treated with both ceftriaxone and azithro in the same manner as their non pregnant counterparts. Nachi: There is also one quick controversy to discuss here. Jeff: oh yeah, go on… Nachi: The CDC currently recommends the IM dose of ceftriaxone, not IV. And this is because of the depot effect. However, it’s unclear if this effect is in fact true, as IM and IV ceftriaxone levels measured in blood 24 hours later are similar. So if the patient has an IV already, should we just give the ceftriaxone IV instead of IM? Jeff: I think it is probably okay, but I’ll wait for a bit more research. For now, I would continue to stick with the CDC recommendation of IM as the correct route. Nachi: And with the continuing rise of STD’s and the public health and economic burden we are describing here, I think the IM route, which is known to be effective, should still be used -- until the CDC changes their recommendations. Next up we have the great imitator/masquerader, syphilis, caused by the spirochete Treponema pallidum. LIke the other STDs we’ve discussed so far, cases of syphilis are also on the rise with over 30k cases in 2017, a 10% increase from 2016. Jeff: Syphilis is spread via direct contact between open lesions and microscopic abrasions in the mucous membranes of vagina, anus, or oropharynx. The organism then disseminates via the lymphatics and blood stream. Nachi: Infection with syphilis comes in three stages. Primary syphilis is characterized by a single, painless lesion, or chancre, which occurs about 3 weeks after inoculation. 6-8 weeks later, secondary syphilis develops. This often presents with a rash, typically on the palms and soles of the feet, or with condyloma lata, or lymphadenopathy. Jeff: Tertiary syphilis doesn’t appear until about 20 years post infection and it includes gummatous lesions and cardiac involvement including aortic disease. Nachi: Patients at any stage may go long periods without any symptoms, which is known as latent syphilis. In addition, at any stage a patient may develop neurosyphilis, which can present with strokes, altered mental status, cranial nerve dysfunction, and tabes dorsalis. Jeff: In early syphilis, dark-field examination is the definitive method of detection, though this is impractical in the ED setting. There are, instead, 2 different algorithms to follow. The CDC traditional algorithm recommends a nontreponemal test like rapid plasma reagin or RPR or the venereal disease research lab test also called VDRL, followed by confirmational treponemal test (fluoresent treponemal antibody absorption or FTA-ABS or T pallidum passive agglutination also called TP-PA). More recently there has been a shift to the reverse sequence, with screening with a treponemal assay followed by a confirmatory nontreponemal assay. Nachi: The reason for the change is that there is an increased availability of rapid treponemal assays. And where available, the reverse sequence offers increased throughput and the ability to detect early primary syphilis better. The CDC, however, still recommends the traditional testing pathway -- that is nontreponemal tests first like RPR or VDRL, followed by treponemal tests like FTA-ABS or TP-PA. The article also notes that emergency clinicians should rely on clinical manifestations in addition to serologic testing, when determining whether to treat for syphilis. Jeff: For neurosyphilis, the CSF-VDRL test is highly specific but poorly sensitive. In cases of a negative CSF-VDRL but still with high clinical suspicion, consider a CSF FTA-ABS test, which has lower sensitivity, but is also highly specific and may catch the diagnosis. Nachi: Treatment for primary, secondary, and early latent syphilis is with 2.4 million units of Penicillin G IM. For ocular and neurosyphilis, treatment is with 18-24 million units of pen G IV every 4 hours or continuously for 10-14 days. In patients who have a penicillin allergy, skin testing and desensitization should be attempted rather than azithromycin due to concerns for resistance. Jeff: For pregnant women, PCN is the only proven therapy. Interestingly, there is some evidence to suggest that a second IM dose may be beneficial in treating primary and secondary syphilis in pregnancy though data are limited. Nachi: We also have to mention the Jarisch-Herxheimer reaction before moving on. This is a syndrome of fevers, chills, headache, myalgias, tachycardia, flushing and hypotension following high dose PCN treatment due to a massive release of endotoxins when the bacteria die. This typically occurs in the first 12 hours but can occur up to 24 hours after treatment. Treatment is supportive. Concern of this reaction should never delay PCN treatment!! Jeff: The next condition to discuss is Bacterial vaginosis, or BV, which, interestingly, is not always an STD. It is therefore critically important to choose your words wisely when speaking with a patient who has BV. Nachi: That is an important point that is worth repeating. BV is not always an STD. So what is BV? BV occurs when there is a decrease or absence of lactobacilli that help maintain the acidic pH of the vagina leading to an overgrowth of Gardnerella, bacteroides, ureaplasma and mycoplasma. BV does not occur in those who have never had intercourse and it may increase the risk of other STDs and HIV. Jeff: 50% of women with BV are asymptomatic, while the others will have a thin, grayish-white, homogeneous vaginal discharge with a fishy smell, along with pruritis. Nachi: To diagnose BV, most use the amsel criteria, which requires 3 of following 4: 1) a thin, milky, homogeneous vaginal discharge, 2) the release of a fishy odor before or after the addition of potassium hydroxide, 3) a vaginal pH > 4.5, and 4) the presence of clue cells in the vaginal fluid. These criteria are 90% sensitive and 77% specific, with clue cells being the most reliable predictor. Jeff: And for those of us without immediately available microscopy, you can make the diagnosis based on characteristic vaginal discharge alone. Treat with metronidazole, 500 mg BID for 7 days, metronidazole gel, or an intravaginal applicator for 5 days, with the intravagainal applicator being better tolerated than the oral equivalent Nachi: BV in pregnancy increases risk of preterm birth, chorioamnionitis, postpartum endometriitis and postcesarean wound infections. Pregnant patients are treated the same as nonpregnant or with 400 mg of clindamycin BID x 7 days. Jeff: Always nice when there is really only one treatment regimen across the board. And that will be a general theme for treatment options in pregnancy with a few exceptions. Nachi: Next up we have Granuloma inguinale, or donovanosis, which is caused by Klebsiella granulomatis. Jeff: Granuloma inguinale is endemic to India, the Caribbean, central australia, and southern africa. It is rarely diagnosed in the US. Nachi: Granuloma inguinale presents with highly vascular, ulcerative lesions on the genitals or perineum. They are typically painless and bleed easily. If disseminated, Granuloma inguinale can lead to intra-abdominal organ and bone lesions and elephantiasis-like swelling of the external genitalia. Jeff: Granuloma inguinale can can be diagnosed by microscopy from the surface debris of purulent ulcers. Nachi: Once you have the diagnosis, the CDC recommends treatment with azithromycin for at least 3 weeks and until all lesions have resolved. Jeff: Next we have lymphogramuloma venereum or LGV. Nachi: LGV is a C. Trachomatis infection of the lymphatics and lymph nodes. This is predominantly a disease of the tropics and subtropical areas of the world. Jeff: On exam, in the primary stage, you would expect a small, painless papule, pustule, nodule or ulcer on the coronal sulcus of the penis or on the posterior forchette, vulva, or cervix of women. The primary stage eventually progresses to the secondary stage, which is characterized by unilateral lymphadenopathy with fluctuant, painful lymph nodes known as buboes. Nachi: Check out figure 11 for a great classic image of the “groove sign” which is involvement of both the inguinal and femoral lymph nodes, and is seen in 15-20% of cases. And actually even more common than the groove sign is a presentation with proctitis. Jeff: Testing for LGV should be based on high clinical suspicion, and NAAT should be performed on a sample from the primary ulcer base or from aspirate from a bubo. Nachi: Treatment for LGV is with doxycycline 100 mg BID x 21 days. Jeff: So, to summarize, for LGV, remember painful lymphadenopathy, especially in those with proctitis. Treat with doxy. Nachi: Next we have Mycoplasma genitalium, which causes nongonococcal urethritis in men and mucopurulent cervicitis and PID in women. Jeff: Unfortunately, there is no diagnostic test for M. genitalium, and it should be considered clinically, especially in the setting of recurrent urethritis. Nachi: Treat with azithro, but not 1g x 1. Instead, M. Genitalium should be treated with a course of azithro, with 500 mg on day 1 followed by 250 mg daily for 4 days. Moxifloxacin is an alternative. Jeff: Simple enough. Moving on to everybody’s favorite, genital herpes. Nachi: umm, I’m not sure sure anybody would call herpes their favorite. Why would you even say that? Jeff: i don’t know, seemed natural at the time… Regardless, primary genital herpes is caused by either HSV1 or HSV2. Though only an estimate, and likely an underestimate at that, it is estimated that at least 1 in 6 people in the US between 14 and 49 have genital herpes. Nachi: That’s much higher than I would have thought. Jeff: Patients usually contract oral herpes from HSV-1 due to nonsexual contact with saliva and genital herpes due to sexual contact with an infected person. Nachi: Keep in mind, however, that HSV1 can and will also cause genital infections if spread via oral sex. Jeff: Localized symptoms include pain, itching, dysuria, and lymphadenopathy and systemic symptoms include fever, headache, and malaise. In women, look for herpetic vesicles on the external genitalia along with tender ulcers in areas of rupture, see figure 12 for a characteristic image. Nachi: Though symptoms tend to be more severe in woman, men may present with vesicles on the glans penis, penile shaft, scrotum, perianal area, and rectum or even with dysuria and penile discharge. Jeff: HSV1 and 2 infections also have the ability to recur, though recurrences tend to become less frequent and severe over time. Nachi: It’s noteworthy that there is also a direct correlation between stress levels and the severity of an HSV outbreak. Jeff: Herpes can be diagnosed by viral culture of an unroofed vesicle or by NAAT. PCR based assays can also differentiate between HSV1 and HSV2 Nachi: While there is no cure, antivirals may help prevent and shorten outbreaks. Ideally you should begin treatment within 72 hours of lesion appearance. Treat with acyclovir, valacyclovir, or famciclovir. In addition, don't forget about adjuncts like analgesia, sitz bathes, and urinary catheter placement for severe dysuria. Jeff: HSV can also be vertically transmitted from mother to child so in pregnancy, treat with acyclovir 400 mg 3x/day for 7 days or valacyclovir Nachi: And because transmission is so easy, babies born to mothers with active lesions should be delivered by cesarean section. Jeff: Let’s move on to human papillomavirus, or HPV. There are over 100 types of HPV with 40 being transmitted through skin to skin contact, typically via vaginal and anal intercourse. Nachi: Most infections are asymptomatic and clear within 2 years. Jeff: Right, but one of the main reasons this is such a big deal is that HPV types 16 and 18 are oncogenic strains and can lead to cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers. Amazingly, HPV is responsible for more than 95% of the cervical cancers in women. Nachi: Hence the importance of the new vaccine series that most young adults and children are now opting for. Vaccination should occur in women through age 26 or men through age 21 if not previously vaccinated. Jeff: Critically important to take advantage of a vaccine that can prevent cancer! Nachi: And though not as important in terms of health consequences, just be aware that HPV 6 and 11 may lead to anogenital warts, known as condyloma acuminata. Jeff: In terms of exam findings, as you just mentioned, most infections are asymptomatic and self-limited. If symptoms do develop, HPV typically causes those cauliflower like or white plaque like growths lesions on the external genitalia, perineum, and perianal skin. Nachi: For testing, there is a limited role in the ED. Diagnosis should be made by visual inspection, followed eventually by a biopsy. Jeff: And just like the biopsy, which is unlikely to be done in the emergency department, most treatment is also not ED based. Treatment options include cryotherapy, immune-based therapy, and surgical excision, which has both the highest success rates and lowest recurrence. Nachi: Next up, we have trichomoniasis. Jeff:Trichomoniasis is a single-celled, flagellated, anaerobic protozoa, that directly damages the epithelium, causing microulcerations in the vagina, urethra, and paraurethral glands. Nachi: With an estimated 3.7 million infected people in the US, this is something you’re also bound to see. Jeff: Risk factors include recent or current incarceration, IV drug use, and co-infection with BV. Nachi: Note the common theme here - co infection. It’s very common for patients to have more than one STD, so make sure not to anchor when you think you’ve nailed the diagnosis. Jeff: On exam the majority of both women and men are asymptomatic. In women, you may find a purulent, frothy vaginal discharge, vaginal odor, vulvovaginal irritation, itching, dyspareunia, and dysuria Nachi: And don’t forget about the classic colpitis macularis, or the strawberry cervix. Though this is frequently taught and stressed, it’s actually only seen in 2-5% of infected women. Jeff: But to be fair, a strawberry cervix and frothy vagianl discharge together have a specificity of 99% for trich, which is really not bad. Nachi: While many EDs sadly aren’t blessed with a wet mount, the wet mount has the advantage of being simple, convenient, and generally low cost. Jeff: While all of that is true regarding the wet mount, it’s no longer first line, again with NAAT being preferred, as it’s highly sensitive, approaching 100%. Nachi: And for those of us who don’t have access to NAAT, there are also antigen-detecting tests which don’t perform quite as well, but they are much more sensitive than the traditional wet mount. Jeff: Treatment for trichomoniasis is with oral metronidazole, 2g in a single oral dose a or 500 mg twice a day for 7 days. Alternatively, the more expensive tinidazole, 2g for 1 dose, is actually superior according to the most recent evidence. Nachi: For pregnant patients, trichomoniasis is unfortunately associated with premature delivery and premature rupture of membranes, with no improvement following treatment. Still, patients should be tested and treated, preferentially with metronidazole, to relieve symptoms and prevent partner spread. Jeff: We have two more special populations to discuss in this month’s issue - those in correctional facilities and sexual partner treatment. If you are lucky enough to be involved in treating those in correctional facilities, keep in mind that rates of gonorrhea, chlamydia, syphilis, and trichomoniasis are higher in persons in both juvenile and adult detention facilities than the general public. Nachi: In general for patients in correctional facilities, maintain a lower threshold for just about everything. This is just an at-risk population. Jeff: Let’s move on to sexual partners, and expedited partner therapy or EPT. Nachi: Once you’ve diagnosed a patient with an STD, you can also provide a prescription or medication to the patient to give to their partner or partners. Jeff: This practice is critically important to stop partners from unknowingly spreading the STD further which is a real problem. Unless prohibited by law, emergency clinicians should routinely offer EPT to patients with chlamydia, gonorrhea, or trichomoniasis. To see your states’ current status, the CDC maintains a list of the status in all 50 states. Nachi: In terms of specific partner therapies, for chlamydia, EPT can be accomplished with a single 1g dose of azithromycin or doxycyclin 100 mg bid for 7 days. Consider concurrent treatment for gonococcal infection also. Jeff: For Gonorrhea, EPT includes a single oral dose of 400 mg of cefixime and a 1g oral dose of azithromycin. Nachi: For EPT for syphilis, unfortunately the partner has to present to the ED for a single IM injection of penicillin G. While this does place a burden on the partner, it opens up an opportunity for additional serologic testing and possibly treatment of his or her partners as well. Jeff: Routine EPT for those with BV is not recommend as the data shows that partner treatment does not affect rates of relapse or recurrence. Nachi: For genital herpes, you should counsel patients and their partners that they should abstain from sexual activities when there are lesions or prodromal symptoms. Make sure to refer partners for evaluation as well. Jeff: Since there isn’t much data on HPV partner notification, for now, encourage patients to be open with their partners so they may seek treatment as well. Nachi: And lastly, for Trichomoniasis, EPT includes 2 g of metronidazole or 500 mg BID for 7 days or that single 2g dose of tinidazole. Jeff: In general, it is always better to have the partner present to a physician for diagnosis and treatment, but EPT is an option when that seems unlikely or impossible. Nachi: Also, when possible be sure to inquire about drug allergies and provide some guidelines on ER presentation for allergic reactions. Jeff: So that wraps up EPT. Let’s discuss disposition. Though most will end up going home, a few may require IV medications, such as those with severe HSV, disseminated gonococcus, and neurosyphilis. Nachi: Admission should also be strongly considered in those who are pregnant or with concern for complications. Those with severe nausea, vomiting, high fever, the inability to tolerate oral antibiotics, and those failing oral antibiotics should also be considered for admission. Jeff: But if your patient doesn’t meet those criteria, as most will not, and they are headed home, stress the importance of follow up. Especially for those with gonorrhea and chlamydia, for whom a test of cure after completion of their medication is recommended. This is even more important for pregnant women. Nachi: Chlamydia, gonorrhea, HIV, and syphilis are among the many infectious diseases that require mandatory reporting. Definitely familiarize yourself with your states’ reporting laws, as most of these patients will be headed home and you’ll want to make sure you don’t miss your chance to prevent further spread. Jeff: Perfect, so that’s it for this month’s issue. Let’s close out with some high yield points and clinical pearls. Nachi: STDs are under recognized by patients and healthcare professionals. They can often present with minimal or no symptoms and are passed unknowingly to partners. Jeff: STD’s can have devastating effects during pregnancy on the fetus. Treat these patients aggressively in the ER. Nachi: The rising rate of STD’s continues to be an economic burden on the U.S. healthcare system. Jeff: Patients can present with multiple STD’s concurrently. Avoid premature diagnostic closure and consider multiple simultaneous processes. Nachi: Urinary tract infections and STD’s can present similarly. Be sure to do a pelvic exam to avoid misdiagnosis. For the exam, always have a chaperone present. Jeff: Acute unilateral epididymitis is most commonly a result of chlamydia in men under the age of 35. Nachi: Chlamydia is the most common bacterial STD. The diagnostic test of choice is nucleic acid amplification testing (NAAT). Treat with azithromycin or doxycycline. Jeff: Gonorrhea is the second most common STD. The diagnostic test of choice here is again NAAT. Treat with ceftriaxone and azithromycin. Nachi: Gonorrhea can lead to disseminated infection such as purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: Syphilis has a wide variety of presentations over three stages. For concern of early syphilis, send RPR or VDRL for nontreponemal testing as well as an FTA-ABS or TP-PA for treponemal testing. Nachi: Tertiary syphilis can present with gummatous lesions or aortic disease many years after the primary syphilis infection. Jeff: At any stage of syphilis, the central nervous system can become infected, leading to neurosyphilis. Nachi: Bacterial vaginosis presents with a white, frothy, malodorous vaginal discharge. Treat with metronidazole. Jeff: Genital herpes is caused by HSV-1 or HSV-2. Diagnosis can often be made clinically. If sending a sample for testing, be aware that viral shedding is intermittent, so you may have a falsely negative result. Antivirals can help prevent or shorten outbreaks and decrease transmission. Nachi: Lymphogranuloma Venereum presents with small, painless papules, nodules, or ulcers. Groove sign is present in only 15%-20% of cases. Jeff: Consider Fitz-Hugh-Curtis syndrome in your differential for a sexually active patient with right upper quadrant pain. Nachi: Offer expedited partner therapy to all patients with STD’s to prevent further spread Jeff: So that wraps up Episode 27 - STDs in the ED! Incredibly high yield topic with lots of pearls. Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: I’ll repeat that, since saving money is important. APPs, use the promotion code APP4 at checkout to receive 50% off on your subscription. Speaking of PAs - for those of you attending the SEMPA conference in just a few weeks, make sure to check out the EB Medicine Booth, #302 for lots of good stuff. For those of you not attending the conference, just be jealous that your colleagues are hanging out in New Orleans. Nachi: And the address for this month’s credit is ebmedicine.net/E0419, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 3. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(Rr- 03):1-137. (Expert guidelines/systematic review) 5. Torrone E, Papp J, Weinstock H. Prevalence of Chlamydia trachomatis genital infection among persons aged 14-39 years- -United States, 2007-2012. MMWR Morb Mortal Wkly Rep. 2014;63(38):834-838. (Expert guideline/systematic review) 98. Schillinger JA, Gorwitz R, Rietmeijer C, et al. The expedited partner therapy continuum: a conceptual framework to guide programmatic efforts to increase partner treatment. Sex Transm Dis. 2016;43(2 Suppl 1):S63-S75. (Systematic review; 42 articles) 103. Centers for Disease Control and Prevention. 2018 National Notifiable Conditions (Historical). National Notifiable Diseases Surveillance System (NNDSS). Accessed March 10, 2019. (CDC website) 105. Carter MW, Wu H, Cohen S, et al. Linkage and referral to HIV and other medical and social services: a focused literature review for sexually transmitted disease prevention and control programs. Sex Transm Dis. 2016;43(2 Suppl 1):S76-S82. (Systematic review; 33 studies)

  Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic… Nachi: … woah wait, slow down for a minute, before we begin this month’s episode – we should take a quick pause to wish all of our listeners a happy new year! Thanks for your regular listenership and feedback. Jeff: And we’re actually hitting the two year mark since we started this podcast. At 25 episodes now, this is sort of our silver anniversary. Nachi: We have covered a ton of topics in emergency medicine so far, and we are looking forward to reviewing a lot more evidence based medicine with you all going forward. Jeff: With that, let’s get into the first episode of 2019 – the topic this month is first trimester pregnancy emergencies: recognition and management. Nachi: This month’s issue was authored by Dr. Ryan Pedigo, you may remember him from the June 2017 episode on dental emergencies, though he is perhaps better known as the director of undergraduate medical education at Harbor-UCLA Medical center. In addition, this issue was peer reviewed by Dr. Jennifer Beck-Esmay, assistant residency director at Mount Sinai St. Luke’s, and Dr. Taku Taira, the associate director of undergraduate medical education and associate clerkship director at LA County and USC department of Emergency Medicine. Jeff: For this review, Dr. Pedigo had to review a large body of literature, including thousands of articles, guidelines from the American college of obstetricians and gynecologists or ACOG, evidence based Practice bulletins, ACOG committee opinions, guidelines from the American college of radiology, the infectious diseases society of America, clinical policies from the American college of emergency physicians, and finally a series of reviews in the Cochrane database. Nachi: There is a wealth of literature on this topic and Dr. Pedigo comments that the relevant literature is overall “very good.” This may be the first article in many months for which there is an overall very good quality of literature. Jeff: It’s great to know that there is good literature on this topic. It’s incredibly important as we are not dealing with a single life here, as we usually do... we are quite literally dealing with potentially two lives as the fetus moves towards viability. With opportunities to improve outcomes for both the fetus and the mother, I’m confident that this episode will be worth your time. Nachi: Oh, and speaking of being worth your time…. Don’t forget that if you’re listening to this episode, you can claim your CME credit. Remember, the indicates an answer to one of the CME questions so make sure to keep the issue handy. Jeff: Let’s get started with some background. First trimester emergencies are not terribly uncommon in pregnancy. One study reported 85% experience nausea and vomiting. Luckily only 3% of these progressed to hyperemesis gravidarum. In addition, somewhere between 7-27% experience vaginal bleeding or miscarriage. Only 2% of these will be afflicted with an ectopic pregnancy. Overall, the maternal death rate is about 17 per 100,000 with huge racial-ethnic disparities. Nachi: And vaginal bleeding in pregnancy occurs in nearly 25% of patients. Weeks 4-8 represent the peak time for this. The heavier the bleeding, the higher the risk of miscarriage. Jeff: Miscarriage rates vary widely based on age, with an overall rate of 7-27%. This rises to nearly 40% risk in those over 40. And nearly half of miscarriages are due to fetal chromosomal abnormalities. Nachi: For patient who have a threatened miscarriage in the first trimester, there is a 2-fold increased risk of subsequent maternal and fetal adverse outcomes. Jeff: So key points here, since I think the wording and information you choose to share with often scared and worried women is important – nearly 25% of women experience bleeding in their first trimester. Not all of these will go on to miscarriages, though the risk does increase with maternal age. And of those that miscarry, nearly 50% were due to fetal chromosomal abnormalities. Nachi: So can we prevent a miscarriage, once the patient is bleeding…? Jeff: Short answer, no, longer answer, we’ll get to treatment in a few minutes. For now, let’s continue outlining the various first trimester emergencies. Next up, ectopic pregnancy… Nachi: An ectopic pregnancy is implantation of a fertilized ovum outside of the endometrial cavity. This occurs in up to 2% of pregnancies. About 98% occur in the fallopian tube. Risk factors for an ectopic pregnancy include salpingitis, history of STDs, history of PID, a prior ectopic, and smoking. Jeff: Interestingly, with respect to smoking, there is a dose-relationship between smoking and ectopic pregnancies. Simple advice here: don’t smoke if you are pregnant or trying to get pregnant. Nachi: Pretty sound advice. In addition, though an IUD is not a risk factor for an ectopic pregnancy, if you do become pregnant while you have in IUD in place, over half of these may end up being ectopic. Jeff: It’s also worth mentioning a more obscure related disease pathology here – the heterotopic pregnancy -- one in which there is an IUP and an ectopic pregnancy simultaneously. Nachi: Nausea and vomiting, though not as scary as miscarriages or an ectopic pregnancy, represent a fairly common pathophysiologic response in the first trimester -- with the vast majority of women experiencing nausea and vomiting. And as we mentioned earlier, only 3% of these progress to hyperemesis gravidarum. Jeff: And while nausea and vomiting clearly sucks, they seem to actually be protective of pregnancy loss, with a hazard ratio of 0.2. Nachi: Although this may be protective of pregnancy loss, nausea and vomiting can really decrease the quality of life in pregnancy -- with one study showing that about 25% of women with severe nausea and vomiting had actually considered pregnancy termination. 75% of those women also stated they would not want to get pregnant again because of these symptoms. Jeff: So certainly a big issue.. Two other common first trimester emergency are asymptomatic bacteriuria and UTIs. In pregnant patients, due to anatomical and physiologic changes in the GU tract – such as hydroureteronephrosis that occurs by the 7th week and urinary stasis due to bladder displacement – asymptomatic bacteriuria is a risk factor for developing pyelonephritis. Nachi: And pregnant women are, of course, still susceptible to the normal ailments of young adult women like acute appendicitis, which is the most common surgical problem in pregnancy. Jeff: Interestingly, based on epidemiologic data, pregnant women are less likely to have appendicitis than age-matched non-pregnant woman. I’d like to think that there is a good pathophysiologic explanation there, but I don’t have a clue as to why that might be. Nachi: Additionally, the RLQ is the the most common location of pain from appendicitis in pregnancies of all gestational ages. Peritonitis is actually slightly more common in pregnant patients, with an odds ratio of 1.3. Jeff: Alright, so I think we can put that intro behind us and move on to the differential. Nachi: When considering the differential for abdominal pain or vaginal bleeding in the first trimester, you have to think broadly. Among gynecologic causes, you should consider miscarriage, septic abortion, ectopic pregnancy, corpus luteum cyst, ovarian torsion, vaginal or cervical lacerations, and PID. For non-gynecologic causes, you should also consider appendicitis, cholecystitis, hepatitis, and pyelonephritis. Jeff: In the middle of that laundry list you mentioned there is one pathology which I think merits special attention - ovarian torsion. Don’t forget that patients undergoing ovarian stimulation as part of assisted reproductive technology are at a particularly increased risk due to the larger size of the ovaries. Nachi: Great point. Up next we have prehospital care... Jeff: Always a great section. First, prehospital providers should attempt to elicit an ob history. Including the number of weeks’ gestation, LMP, whether an IUP has already been confirmed, prior hx of ectopic, and amount of vaginal bleeding. In addition, providers should consider an early destination consult both to select the correct destination and to begin the process of mobilizing resources early in those patients who really need them, such as those with hemodynamic instability. Nachi: As with most pathologies, the more time you give the receiving facility to prepare, the better the care will be, especially the early care, which is critical. Jeff: Now that the patient has arrived in the ED we can begin our H&P. Nachi: When eliciting the patient’s obstetrical history, it’s common to use the G’s and Ps. This can be further annotated using the 4-digit TPAL method, that’s term-preterm-abortus-living. Jeff: With respect to vaginal bleeding, make sure to ask about the number of pads and how this relates to the woman’s normal number of pads. In addition, make sure to ask about vaginal discharge or even about the passage of tissue. Nachi: You will also need to elicit whether or not the patient has a history of a prior ectopic pregnancies as this is a major risk for future ectopics. And ask about previous sexually transmitted infections also. Jeff: And, of course, make sure to elicit a history of assisted reproductive technology, as this increases the risk of a heterotopic pregnancy. Nachi: Let’s move on to the physical. While you are certainly going to perform your standard focused physical exam, just as you would for any non-pregnant woman - what does the evidence say about the pelvic exam? I know this is a HOTLY debated topic among EM Docs. Jeff: Oh it certainly is. Dr. Pedigo takes a safe, but fair approach, noting, “A pelvic exam should always be performed if the emergency clinician suspects that it would change management, such as identifying the source of bleeding, or identifying an STD or PID.” However, it is noteworthy that the only real study he cites on this topic, an RCT of pelvic vs no pelvic in those with a confirmed IUP and first trimester bleeding, found no difference between the two groups. Obviously, the pelvic group reported more discomfort. Nachi: You did leave out one important fact about the study enrollment - they only enrolled about 200 of 700 intended patients. Jeff: Oh true, so a possibly underpowered study, but it’s all we’ve got on the topic. I think I’m still going to do pelvic exams, but it’s something to think about. Nachi: Moving on, all unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic until proven otherwise. Ruptured ectopics can manifest with a number of physical exam findings including abdominal tenderness, with peritoneal signs, or even with bradycardia due to vagal stimulation in the peritoneum. Jeff: Perhaps most importantly, no history or physical alone can rule in or out an ectopic pregnancy, for that you’ll need testing and imaging or operative findings. Nachi: And that’s a perfect segue into our next section - diagnostic studies. Jeff: Up first is the urine pregnancy test. A UPT should be obtained in all women of reproductive age with abdominal pain or vaginal bleeding, and likely other complaints too, though we’re not focusing on them now. Nachi: The UPT is a great test, with nearly 100% sensitivity, even in the setting of very dilute urine. False positives are certainly plausible, with likely culprits being recent pregnancy loss, exogenous HCG, or malignancy. Jeff: And not only is the sensitivity great, but it’s usually positive just 6-8 days after fertilization. Nachi: While the UPT is fairly straight forward, let’s talk about the next few tests in the context of specific disease entities, as I think that may make things a bit simpler -- starting with bHCG in the context of miscarriage and ectopic pregnancy. Jeff: Great starting point since there is certainly a lot of debate about the discriminatory zone. So to get us all on the same page, the discriminatory zone is the b-HCG at which an IUP is expected to be seen on ultrasound. Generally 1500 is used as the cutoff. This corresponds nicely to a 2013 retrospective study demonstrating a bHCG threshold for the fetal pole to be just below 1400. Nachi: However, to actually catch 99% of gestational sacs, yolk sacs, and fetal poles, one would need cutoffs of around 3500, 18000, and 48,000 respectively -- much higher. Jeff: For this reason, if you want to use a discriminatory zone, ACOG recommends a conservatively high 3,500, as a cutoff. Nachi: I think that’s an understated point in this article, the classic teaching of a 1500 discriminatory zone cutoff is likely too low. Jeff: Right, which is why I think many ED physicians practice under the mantra that it’s an ectopic until proven otherwise. Nachi: Certainly a safe approach. Jeff: Along those lines, lack of an IUP with a bHCG above whatever discriminatory zone you are using does not diagnose an ectopic, it merely suggests a non-viable pregnancy of undetermined location. Nachi: And if you don’t identify an IUP, serial bHCGs can be really helpful. As a rule of thumb -- in cases of a viable IUP -- b-HCG typically doubles within 48 hours and at a minimum should rise 53%. Jeff: In perhaps one of the most concerning things I’ve read in awhile, one study showed that ⅓ of patients with an ectopic had a bCHG rise of 53% in 48h and 20% of patients with ectopics had a rate of decline typical to that of a miscarriage. Nachi: Definitely concerning, but this is all the more reason you need to employ our favorite imaging modality… the ultrasound. Jeff: All patients with a positive pregnancy test and vaginal bleeding should receive an ultrasound performed by either an emergency physician or by radiology. Combined with a pelvic exam, this can give you almost all the data necessary to make the diagnosis, even if you don’t find an IUP. Nachi: And yes, there is good data to support ED ultrasound for this indication, both transabdominal and transvaginal, assuming the emergency physician is credentialed to do so. A 2010 Meta-Analysis found a NPV of 99.96% when an er doc identified an IUP on bedside ultrasound. So keep doing your bedside scans with confidence. Jeff: Before we move on to other diagnostic tests, let’s discuss table 2 on page 7 to refresh on key findings of each of the different types of miscarriage. For a threatened abortion, the os would be closed with an IUP seen on ultrasound. For a completed abortion, you would expect a closed OS with no IUP on ultrasound with a previously documented IUP. Patients may or may not note the passage of products of conception. Nachi: A missed abortion presents with a closed os and a nonviable fetus on ultrasound. Findings such as a crown-rump length of 7 mm or greater without cardiac motion is one of several criteria to support this diagnosis. Jeff: An inevitable abortion presents with an open OS and an IUP on ultrasound. Along similar lines, an incomplete abortion presents with an open OS and partially expelled products on ultrasound. Nachi: And lastly, we have the septic abortion, which is sort of in a category of its own. A septic abortion presents with either an open or closed OS with essentially any finding on ultrasound in the setting of an intrauterine infection and a fever. Jeff: I’ve only seen this two times, and both women were incredibly sick upon presentation. Such a sad situation. Nachi: For sure. Before we move on to other tests, one quick note on the topic of heterotopic pregnancies: because the risk in the general population is so incredibly low, the finding of an IUP essentially rules out an ectopic pregnancy assuming the patient hasn’t been using assisted reproductive technology. In those that are using assisted reproductive technology, the risk rises to 1 in 100, so finding an IUP, in this case, doesn’t necessarily rule out a heterotopic pregnancy. Jeff: Let’s move on to diagnostic studies for patients with nausea and vomiting. Typically, no studies are indicated beyond whatever you would order to rule out other serious pathology. Checking electrolytes and repleting them should be considered in those with severe symptoms. Nachi: For those with symptoms suggestive of a UTI, a urinalysis and culture should be sent. Even if the urinalysis is negative, the culture may still have growth. Treat asymptomatic bacteriuria and allow the culture growth to guide changes in antibiotic selection. Jeff: It’s worth noting, however, that a 2016 systematic review found no reliable evidence supporting routine screening for asymptomatic bacteriuria, so send a urinalysis and culture only if there is suspicion for a UTI. Nachi: For those with concern for appendicitis, while ultrasound is a viable imaging modality, MRI is gaining favor. Both are specific tests, however one study found US to visualize the appendix only 7% of the time in pregnant patients. Jeff: Even more convincingly, one 2016 meta analysis found MRI to have a sensitivity and specificity of 94 and 97% respectively suggesting that a noncontrast MRI should be the first line imaging modality for potential appendicitis. Nachi: You kind of snuck it in there, but this is specifically a non-contrast MRI. Whereas a review of over a million pregnancies found no associated fetal risk with routine non-contrast MRI, gadolinium-enhanced MRI has been associated with increased rates of stillbirth, neonatal death, and rheumatologic and inflammatory skin conditions. Jeff: CT is also worth mentioning since MRI and even ultrasound may not be available to all of our listeners. If you do find yourself in such a predicament, or you have an inconclusive US without MRI available, a CT scan may be warranted as the delay in diagnosis and subsequent peritonitis has been found to increase the risk of preterm birth 4-fold. Nachi: Right, and a single dose of ionizing radiation actually does not exceed the threshold dose for fetal harm. Jeff: Let’s talk about the Rh status and prevention of alloimmunization. While there are no well-designed studies demonstrating benefit to administering anti-D immune globulin to Rh negative patients, ACOG guidelines state “ whether to administer anti-D immune globulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made.” Nachi: Unfortunately, that’s not particularly helpful for us. But if you are going to treat an unsensitized Rh negative female with vaginal bleeding while pregnant with Rh-immune globulin, they should receive 50 mcg IM of Rh-immune globulin within 72 hours, or the 300 mcg dose if that is all that is available. It’s also reasonable to administer Rh(d)-immune globulin to any pregnant female with significant abdominal trauma. Jeff: Moving on to the treatment for miscarriages - sadly there isn’t much to offer here. For those with threatened abortions, the vast majority will go on to a normal pregnancy. Bedrest had been recommended in the past, but there is little data to support this practice. Nachi: For incomplete miscarriages, if visible, products should be removed and you should consider sending those products to pathology for analysis, especially if the patient has had recurrent miscarriages. Jeff: For those with a missed abortion or incomplete miscarriages, options include expectant management, medical management or surgical management, all in consultation with an obstetrician. It’s noteworthy that a 2012 Cochrane review failed to find clear superiority for one strategy over another. This result was for the most part re-confirmed in a 2017 cochrane review. The latter study did find, however, that surgical management in the stable patient resulted in lower rates of incomplete miscarriage, bleeding, and need for transfusion. Nachi: For expectant management, 50-80% will complete their miscarriage within 7-10 days. Jeff: For those choosing medical management, typically with 800 mcg of intravaginal misoprostol, one study found this to be 91% effective in 7 days. This approach is preferred in low-resource settings. Nachi: And lastly, remember that all of these options are only options for stable patients. Surgical management is mandatory for patients with significant hemorrhage or hemodynamic instability. Jeff: Since the best evidence we have doesn’t suggest a crystal clear answer, you should rely on the patient’s own preferences and a discussion with their obstetrician. For this reason and due to the inherent difficulty of losing a pregnancy, having good communication is paramount. Nachi: Expert consensus recommends 6 key aspects of appropriate communication in such a setting: 1 assess the meaning of the pregnancy loss, give the news in a culturally competent and supportive manner, inform the family that grief is to be expected and give them permission to grieve in their own way, learn to be comfortable sharing the products of conception should the woman wish to see them, 5. provide support for whatever path she chooses, 6. and provide resources for grief counselors and support groups. Jeff: All great advice. The next treatment to discuss is that for pregnancy of an unknown location and ectopic pregnancies. Nachi: All unstable patients or those with suspected or proven ectopic or heterotopic pregnancies should be immediately resuscitated and taken for surgical intervention. Jeff: For those that are stable, with normal vitals, and no ultrasound evidence of a ruptured ectopic, with no IUP on ultrasound, -- that is, those with a pregnancy of unknown location, they should be discharged with follow up in 48 hours for repeat betaHCG and ultrasound. Nachi: And while many patients only need a single additional beta check, some may need repeat 48 hour exams until a diagnosis is established. Jeff: For those that are stable with a confirmed tubal ectopic, you again have a variety of treatment options, none being clearly superior. Nachi: Treatment options here include IM methotrexate, or a salpingostomy or salpingectomy. Jeff: Do note, however, that a bHCG over 5000, cardiac activity on US, and inability to follow up are all relative contraindications to methotrexate treatment. Absolute contraindications to methotrexate include cytopenia, active pulmonary disease, active peptic ulcer disease, hepatic or renal dysfunction, and breastfeeding. Nachi: Such decisions, should, of course, be made in conjunction with the obstetrician. Jeff: Always good to make a plan with the ob. Moving on to the treatment of nausea and vomiting in pregnancy, ACOG recommends pyridoxine, 10-25 mg orally q8-q6 with or without doxylamine 12.5 mg PO BID or TID. This is a level A recommendation as first-line treatment! Nachi: In addition, ACOG also recommends nonpharmacologic options such as acupressure at the P6 point on the wrist with a wrist band. Ginger is another nonpharmacologic intervention that has been shown to be efficacious - 250 mg by mouth 4 times a day. Jeff: So building an algorithm, step one would be to consider ginger and pressure at the P6 point. Step two would be pyridoxine and doxylamine. If all of these measures fail, step three would be IV medication - with 10 mg IV of metoclopramide being the agent of choice. Nachi: By the way, ondansetron carries a very small risk of fetal cardiac abnormalities, so the other options are of course preferred. Jeff: In terms of fluid choice for the actively vomiting first trimester woman, both D5NS and NS are appropriate choices, with slightly decreased nausea in the group receiving D5NS in one randomized trial of pregnant patients admitted for vomiting to an overnight observation unit. Nachi: Up next for treatment we have asymptomatic bacteriuria. As we stated previously, asymptomatic bacteriuria should be treated. This is due to anatomical and physiologic changes which put these women at higher risk than non-pregnant women. Jeff: And this recommendation comes from the 2005 IDSA guidelines. In one trial, treatment of those with asymptomatic bacteriuria with nitrofurantoin reduced the incidence of developing pyelonephritis from 2.4% to 0.6%. Nachi: And this trial specifically examined the utility of nitrofurantoin. Per a 2010 and 2011 Cochrane review, there is not evidence to recommend one antibiotic over another, so let your local antibiograms guide your treatment. Jeff: In general, amoxicillin or cephalexin for a full 7 day course could also be perfectly appropriate. Nachi: A 2017 ACOG Committee Opinion analyzed nitrofurantoin and sulfonamide antibiotics for association with birth defects. Although safe in the second and third trimester, they recommend use in the first trimester -- only when no other suitable alternatives are available. Jeff: For those, who unfortunately do go on to develop pyelo, 1g IV ceftriaxone should be your drug of choice. Interestingly, groups have examined outpatient care with 2 days of daily IM ceftriaxone vs inpatient IV antibiotic therapy and they found that there may be a higher than acceptable risk in the outpatient setting as several required eventual admission and one developed septic shock in their relatively small trial. Nachi: And the last treatment to discuss is for pregnant patient with acute appendicitis. Despite a potential shift in the standard of care for non pregnant patients towards antibiotics-only as the initial treatment, due to the increased risk of serious complications for pregnant women with an acute appy, the best current evidence supports a surgical pathway. Jeff: Perfect, so that wraps up treatment. We have a few special considerations this month, the first of which revolves around ionizing radiation. Ideally, one should limit the amount of ionizing radiation exposure during pregnancy, however avoiding it all together may lead to missed or delayed diagnoses and subsequently worse outcomes. Nachi: It’s worth noting that the American College of Radiology actually lists several radiographs that are such low exposure that checking a urine pregnancy test isn’t even necessary. These include any imaging of the head and neck, extremity CT, and chest x-ray. Jeff: Of course, an abdomen and pelvis CT carries the greatest potential risk. However, if necessary, it’s certainly appropriate as long as there is a documented discussion of the risk and benefits with the patient. Nachi: And regarding iodinated contrast for CT -- it appears to present no known harm to the fetus, but this is based on limited data. ACOG recommends using contrast only if “absolutely required”. Jeff: Right and that’s for iodinated contrasts. Gadolinium should always be avoided. Let me repeat that Gadolinium should always be avoided Nachi: Let’s also briefly touch on a controversial topic -- that of using qualitative urine point of care tests with blood instead of urine. In short, some devices are fda-approved for serum, but not whole blood. Clinicians really just need to know the equipment and characteristics at their own site. It is worth noting that there have been studies on determining whether time can be saved by using point of care blood testing instead of urine for the patient who is unable to provide a prompt sample. Initial study conclusions are promising. But again, you need to know the characteristics of the test at your ER. Jeff: One more controversy in this issue is that of expectant management for ectopic pregnancy. A 2015 randomized trial found similar outcomes for IM methotrexate compared to placebo for tubal ectopics. Inclusion criteria included hemodynamic stability, initial b hcg < 2000, declining b hcg titers 48 hours prior to treatment, and visible tubal pregnancy on trans vaginal ultrasound. Another 2017 multicenter randomized trial found similar results. Nachi: But of course all of these decisions should be made in conjunction with your obstetrician colleagues. Jeff: Let’s move on to disposition. HDS patients who are well-appearing with a pregnancy of undetermined location should be discharged with a 48h beta hcg recheck and ultrasound. All hemodynamically unstable patients, should of course be admitted and likely taken directly to the OR. Nachi: Also, all pregnant patients with acute pyelonephritis require admission. Outpatient tx could be considered in consultation with ob. Jeff: Patient with hyperemesis gravidarum who do not improve despite treatment in the ED should also be admitted. Nachi: Before we close out the episode, let’s go over some key points and clinical pearls... J Overall, roughly 25% of pregnant women will experience vaginal bleeding and 7-27% of pregnant women will experience a miscarriage 2. Becoming pregnant with an IUD significantly raises the risk of ectopic pregnancy. 3. Ovarian stimulation as part of assisted reproductive technology places pregnant women at increased risk of ovarian torsion. 4. Due to anatomical and physiologic changes in the genitourinary tract, asymptomatic bacteriuria places pregnant women at higher risk for pyelonephritis. As such, treat asymptomatic bacteriuria according to local antibiograms. 5. A pelvic exam in the setting of first trimester bleeding is only warranted if you suspect it might change management. 6. Unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic pregnancy until proven otherwise. 7. If you are to use a discriminatory zone, ACOG recommends a beta-hCG cutoff of 3500. 8. The beta-hCG typically doubles within 48 hours during the first trimester. It should definitely rise by a minimum of 53%. 9. For patients using assisted reproductive technology, the risk of heterotopic pregnancy becomes much higher. Finding an IUP does not necessarily rule out a heterotopic pregnancy. N. Send a urine culture for patients complaining of UTI symptoms even if the urinalysis is negative. J. The most common surgical problem in pregnancy is appendicitis. N, If MRI is not available and ultrasound was inconclusive, CT may be warranted for assessing appendicitis. The risk of missing or delaying the diagnosis may outweigh the risk of radiation. J. ACOG recommends using iodinated contrast only if absolutely required. N. For stable patients with a pregnancy of unknown location, plan for discharge with follow up in 48 hours for a repeat beta-hCG and ultrasound. J For nausea and vomiting in pregnancy, try nonpharmacologic treatments like acupressure at the P6 point on the wrist or ginger supplementation. First line pharmacologic treatment is pyridoxine. Doxylamine can be added. Ondansetron may increase risk of fetal cardiac abnormalities N So that wraps up episode 24 - First Trimester Pregnancy Emergencies: Recognition and Management. J: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. N: And the address for this month’s credit is ebmedicine.net/E0119, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!