Vasovagal with Cervical Dilation/Pressure

[Incandescent]

Saw a pt today who came in for Mirena placement. She was nulli-p and they had to dilate her cervix a little more than usual to get the IUD inserted properly. She was in quite a bit of discomfort and pain, and then when it was all over, we noticed she was diaphoretic and a set of vitals revealed hypotension (80's/40's) and bradycardia (42 bpm). No syncope.

She got some ibuprofen (800 mg) for the pain, drank some water, took some rest and within 2 hours she was feeling 100% again.

She had mentioned to me that she had 2 prior episodes of flushing/hypotension/bradycardia during the first day of an usually heavy period (after a missed period). She was wondering whether since she appears to go vasovagal with cervical pressure/dilation, would this be a problem in pregnancy?

The NP suggested that pregnancy was different somehow and she doubted it, but I wasn't sure why and can't seem to find any good literature about this. Is the NP right, or does the patient pose any increased risk to go vasovagal during pregnancy or labor?

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[starayamoskva]

Saw a pt today who came in for Mirena placement. She was nulli-p and they had to dilate her cervix a little more than usual to get the IUD inserted properly. She was in quite a bit of discomfort and pain, and then when it was all over, we noticed she was diaphoretic and a set of vitals revealed hypotension (80's/40's) and bradycardia (42 bpm). No syncope.

She got some ibuprofen (800 mg) for the pain, drank some water, took some rest and within 2 hours she was feeling 100% again.

She had mentioned to me that she had 2 prior episodes of flushing/hypotension/bradycardia during the first day of an usually heavy period (after a missed period). She was wondering whether since she appears to go vasovagal with cervical pressure/dilation, would this be a problem in pregnancy?

The NP suggested that pregnancy was different somehow and she doubted it, but I wasn't sure why and can't seem to find any good literature about this. Is the NP right, or does the patient pose any increased risk to go vasovagal during pregnancy or labor?

At least not for the next 5 years since you placed the Mirena. I haven't heard of anyone having a vasovagal response to the cervical dilation associated with labor. If you think about the different circumstances of the two, rapid physical dilatation with metal dilator versus very slow initial dilation in labor. She is probably a patient I would be reluctant to use a foley in the cervix for induction for though.

Did they do a paracervical block before dilating? I usually premedicate with valium and ibuprofen especially on nulliparous patients and if dilation is required do a paracervical block.

 

[Incandescent]

At least not for the next 5 years since you placed the Mirena. I haven't heard of anyone having a vasovagal response to the cervical dilation associated with labor. If you think about the different circumstances of the two, rapid physical dilatation with metal dilator versus very slow initial dilation in labor. She is probably a patient I would be reluctant to use a foley in the cervix for induction for though.

Did they do a paracervical block before dilating? I usually premedicate with valium and ibuprofen especially on nulliparous patients and if dilation is required do a paracervical block.

No, no paracervical block or anything. She had not taken any ibuprofen prior to coming and she was not offered anything for premedication. They went in there without any medication whatsoever - I think they might have given the patient the impression that she would only experience some "mild cramping." She said during the procedure that she had no idea it would hurt "this bad" and was obviously in a lot of pain. But damn, she soldiered through it. I felt really bad for her! (I'm a med student).

Anyway, thanks for your input.

 

[chrisisinnocent]

No, no paracervical block or anything. She had not taken any ibuprofen prior to coming and she was not offered anything for premedication. They went in there without any medication whatsoever - I think they might have given the patient the impression that she would only experience some "mild cramping." She said during the procedure that she had no idea it would hurt "this bad" and was obviously in a lot of pain. But damn, she soldiered through it. I felt really bad for her! (I'm a med student).

Anyway, thanks for your input.

"Mild cramping" haha my favorite euphemism is "You are going to feel a little pressure"

 

[Global Disrobal]

Let me see if I can address your original post in an organized way:

1. IUD insertions, and at times dilation and curettage procedures, are in fact associated with syncopal or "vasovagal" episodes. If you look at the family planning literature, often time, a symptom or outcome controlled for in IUD studies is syncope. Whether this is due to rapid dilation of the cervix is unclear, however it is interesting to note that some smaller studies with laminaria and Misoprostol as a ripening tool prior to insertion have shown decreased episodes of syncope. The overall rate of these events in IUD insertions is somewhere around 0.08-0.1% based on some of the retrospective studies from the 80's and 90's.

2. As for your questions regarding pregnancy, I do believe that the NP is correct. There are a myriad of other factors associated with cervical dilation in labor that protect the patient against the syncope. Some of these are: pain anticipation, dilation rate (slower), higher PG release, higher endorphin concentrations, difference in blood flow and nerve conduction.

3. Lastly, her reports of vaso-vagal symptoms the first few days of her period can possibly be attributed to the passing of some larger clots through the os. They may cause a mild/rapid dilation of the cervix with the pain receptors leading to the symptoms.

Anyhow, this is my 2 cents worth from personal experience. You may want to look up the literature and let us all know what you find.

Good luck the rest of your rotation!

 

[LadyGrey]

I usually premedicate with valium and ibuprofen especially on nulliparous patients and if dilation is required do a paracervical block.

Maybe TMI, but Starayamoskva, I wish you were there to put in mine. I had the medical knowledge to premedicate myself with ibuprofen (and damn did I aftermedicate with it) but something else would've been nice.

It didn't help that the NP had never put one in a nullip before and let me know repeatedly that she was worried that that she wouldn't be able to get it in. Maybe dilation with a block would've been more fun than the brute force shoving involved. "Okay, that's through the outer os now..." 😱

Despite the less-than-fun insertion (and some horrible cramping for about 2 weeks afterward), it's a pretty awesome option in the long run. And isn't being a med student all about enduring short term pain for future benefit? 🙄

 

[brightness]

I just could not deal with the pain and ultimatley, she was unable to get the Mirena in. I don't feel like I'm a big wuss about pain, either; I've got tattoos, piercings, and was somewhat stoic when I had my kidney infection (somewhat...it hurt like a 😱) I think there is something about pain in that particular region that is specifically hard to deal with, and having someone that "up in my stuff" made me a little uncomfortable...

How do you find out if a provider will give more pain meds than just ibuprophen? I mean, you can't really call the office and ask, 😕 and the last OB-GYN I had wouldn't give me anything. I am on medications that interfere with birth control, and that is a major reason why an IUC would be perfect for me.

 

[starayamoskva]

I just could not deal with the pain and ultimatley, she was unable to get the Mirena in. I don't feel like I'm a big wuss about pain, either; I've got tattoos, piercings, and was somewhat stoic when I had my kidney infection (somewhat...it hurt like a 😱) I think there is something about pain in that particular region that is specifically hard to deal with, and having someone that "up in my stuff" made me a little uncomfortable...

How do you find out if a provider will give more pain meds than just ibuprophen? I mean, you can't really call the office and ask, 😕 and the last OB-GYN I had wouldn't give me anything. I am on medications that interfere with birth control, and that is a major reason why an IUC would be perfect for me.

You absolutely can call ahead and ask... People do it with dentists all the time... "does Dr Payne use gas for cleanings and fillings?". No different to say you are looking for a physician to place a Mirena and would like to know what they use for sedation and pain control in a nullip as you have a previous failed attempt.

PERFECTLY REASONABLE.

I have one patient that is so anxious about pap smears that I give her valium anytime a speculem is involved in her care.

 

[brightness]

Thanks a bunch for the info. Maybe I can finally get a solution for my bc conundrum!!

 

[OBGYN07]

Another thing that I have found helpful in nulliparous patients is Cytotec 200mcg buccally about 30-60 min prior to insertion. It works like a charm! (in addition to ibuprofen before and after). I have found that it actually can save the patient from the initial discomfort of a paracervical block.