Each month several of our residents prepare and present a topic based on a clinical question generated during a shift. These presentations invariably generate healthy discussion among the group present at didactics. They start with a question rather than a known body of evidence.  Therefore, the question may remain without a definite answer supported by high-level evidence. The exercise is meant to prioritize the practice of seeking evidence-based answers to everyday clinical questions. Summaries of these presentations are posted here monthly.


Rhogam for Rh- Women with repeat ED visits for vaginal bleeding.

By Dr. Kevin Dougherty

Brief patient presentation
23 y/o F G2P1 who presents with vaginal bleeding. She was seen in the same ED 3 days prior for the same complaint and was found to have RH- Negative blood type. She was administered 300 mcg Rho(D) immune globulin (Rhogam).

Clinical question – PICO
Do pregnant patients with multiple episodes of spontaneous vaginal bleeding need Rho(D) immune globulin (Rhogam) administration with each visit to the emergency department?

Available research – list references and assign level of evidence
Visscher RD, Visscher HC. Do Rh-negative women with an early spontaneous abortion need Rh immune prophylaxis? American Journal of Obstetrics and Gynecology Volume 113, Issue 2, 15 May 1972, Pages 158-165 – Level III evidence

Howard HL1, Martlew VJ, McFadyen IR, Clarke CA. Preventing Rhesus D haemolytic disease of the newborn by giving anti-D immunoglobulin: are the guidelines being adequately followed? Br J Obstet Gynaecol. 1997 Jan;104(1):37-41. – Level V evidence

Von Stein GA1, Munsick RA, Stiver K, Ryder K. Fetomaternal hemorrhage in threatened abortion. Obstet Gynecol. 1992 Mar;79(3):383-6. – Level III evidence

Hannafin, Blaine; Lovecchio, Frank; Blackburn, Paul Do Rh-negative women with first trimester spontaneous abortions need Rh immune globulin? The American Journal of Emergency Medicine (2006): 487-9. – Level IV evidence

ACOG practice bulletin. Prevention of Rh D Alloimmunization. Int J Gynaecol Obstet. 1999;66(1):63. – Level V evidence

Does the literature in your search answer the question?
The literature does not provide conclusive evidence as to a definite management strategy for these patients.

Does your search reveal a POEM?
The evidence suggests Rh isoimmunization is very rare with first trimester non-traumatic vaginal bleeding in pregnancy. However most experts recommend immunization with Rho(D) immune globulin (Rhogam) as the relative risks of the medication are low and there does exist a theoretical risk to mother and fetus if Rh isoimmunization occurs.

How will you proceed the next time this problem is encountered?
Per ACOG recommendations: 300 mcg of Rho(D) immune globulin (Rhogam) should be administered. Ensure close follow up with OB with follow up Coombs/ Kleihauer–Betke testing to ensure adequate dosing continues.



tPA for stroke patients found to have vertebral artery dissection

By Dr. Tim Scheel

Brief patient presentation
29 y/o F arrived to the ED with left sided weakness, numbness, nausea, vomiting, left-sided neck pain, and vertigo. She was found to have a vertebral artery dissection.

Clinical Question – PICO
In patients with vertebral artery dissection and neurological deficits does treatment with tPA improve patient outcomes (morbidity, mortality, neurological deficits) when compared to treatment with heparin alone?

Available research – list references and assign level of evidence
Safety and outcome of thrombolysis in patients with vertebral artery-related stroke appear similar to those for stroke from all causes. Thrombolysis should not be withheld in patients with neurological deficits with vertebral artery dissection.

Life in the Fast Lane: http://lifeinthefastlane.com/ccc/cervical-artery-dissection/
tPA may be considered in patient’s with stroke due to spontaneous extra cranial dissection. Less improvement is expected when compared to non-dissection stroke patients. Should not be used in intracranial dissections (increased risk of SAH) or those with aortic involvement.

Does the literature in your search answer the question?
No, Not much research has been done, mostly case reports.

Does your search reveal a POEM?

How will you proceed the next time this problem is encountered?
I am more confident in giving tPA in stroke patients with vertebral artery dissections.




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