Bradycardia Associated With Intrauterine Contraception
Bradycardia Associated With Intrauterine Contraception
Atropine is an alkaloid from the plant Atropa belladonna and is a competitive antagonist to acetylcholine. It blocks muscarinic receptors in the autonomic nervous system, thus counteracting the effects of vagal stimulation. In healthy individuals this results in a modest tachycardia, since it is the parasympathetic nervous system that is blocked, rather than the sympathetic stimulated. In therapeutics it is a relatively safe and straightforward drug, which is why several doses may be administered.
The Resuscitation Council (UK) lists shock and syncope as "adverse features" of bradycardia, for which atropine should be administered. It may be given in repeated doses to a maximum of 3 mg. Oxygen should also be administered.
A GCS of 3, as exhibited by Case 2, indicates severe unconsciousness and is the lowest possible score: even a score of 10 (Case 1) is classified as moderate impairment. It could be argued that given time, Case 1 might have responded to simple first aid measures, yet all three patients, by definition, showed clinical features indicating cerebral hypoperfusion and hypoxia. This was particularly severe in Case 3, who developed anoxic seizures.
It could also be argued that insertion might have been deferred in Case 1 due her not having eaten that morning, but there is no convincing evidence that there are any definite 'red flag' features in a woman that would alert one to an increased possibility of a vasovagal episode. There is no evidence that hunger contributes to this, nor is there evidence that pain relief is preventive. Being welcoming, calm and friendly and providing adequate analgesia are all appropriate measures for women and are good professional practice, but do not solve the problem of vagal stimulation.
Vasovagal episodes associated with cervical instrumentation or dilatation, sometimes referred to as 'cervical shock', may be rare, but the collapse may be profound, as we saw in two of our patients. In the other (Case 1) the degree of bradycardia was remarkable. The second patient had only a modest dose of atropine initially and this case illustrates that conservative first aid measures, or an inadequate dose of atropine, may be ineffective. We would be unhappy to undertake IUD insertion without the availability of suitable resuscitation equipment. In particular we advocate the availability of atropine for intravenous use and the appropriate training of staff to be able to administer it.
Discussion
Atropine is an alkaloid from the plant Atropa belladonna and is a competitive antagonist to acetylcholine. It blocks muscarinic receptors in the autonomic nervous system, thus counteracting the effects of vagal stimulation. In healthy individuals this results in a modest tachycardia, since it is the parasympathetic nervous system that is blocked, rather than the sympathetic stimulated. In therapeutics it is a relatively safe and straightforward drug, which is why several doses may be administered.
The Resuscitation Council (UK) lists shock and syncope as "adverse features" of bradycardia, for which atropine should be administered. It may be given in repeated doses to a maximum of 3 mg. Oxygen should also be administered.
A GCS of 3, as exhibited by Case 2, indicates severe unconsciousness and is the lowest possible score: even a score of 10 (Case 1) is classified as moderate impairment. It could be argued that given time, Case 1 might have responded to simple first aid measures, yet all three patients, by definition, showed clinical features indicating cerebral hypoperfusion and hypoxia. This was particularly severe in Case 3, who developed anoxic seizures.
It could also be argued that insertion might have been deferred in Case 1 due her not having eaten that morning, but there is no convincing evidence that there are any definite 'red flag' features in a woman that would alert one to an increased possibility of a vasovagal episode. There is no evidence that hunger contributes to this, nor is there evidence that pain relief is preventive. Being welcoming, calm and friendly and providing adequate analgesia are all appropriate measures for women and are good professional practice, but do not solve the problem of vagal stimulation.
Vasovagal episodes associated with cervical instrumentation or dilatation, sometimes referred to as 'cervical shock', may be rare, but the collapse may be profound, as we saw in two of our patients. In the other (Case 1) the degree of bradycardia was remarkable. The second patient had only a modest dose of atropine initially and this case illustrates that conservative first aid measures, or an inadequate dose of atropine, may be ineffective. We would be unhappy to undertake IUD insertion without the availability of suitable resuscitation equipment. In particular we advocate the availability of atropine for intravenous use and the appropriate training of staff to be able to administer it.
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