Abstract and Introduction
Abstract
There has been recent interest in this Journal concerning the occurrence of profound bradycardia with impaired consciousness during insertion of intrauterine contraceptive devices or systems. Questions have been raised regarding the requirement for medication for reversal of the condition, the role of the nurse practitioner in the light of this, and the effects upon sexual and reproductive health care service delivery. We present three cases where this condition affected patients under our care and suggest that although very infrequent, it is important. Medication for treatment and staff trained to administer it should always be available.
Introduction
Bradycardia and syncope during insertion of an intrauterine contraceptive device (IUD) or system (IUS) are recognised complications and are thought to be due to stimulation of the vagus nerve. Although this is not a common occurrence, women undergoing the procedure may rapidly become profoundly unwell. The guidance on intrauterine contraception of the UK Faculty of Sexual and Reproductive Healthcare (FSRH) states that the availability of appropriate emergency medication, including atropine, during IUD/IUS insertion is essential, and this is a service standard for resuscitation in sexual health services.
In a retrospective chart review of 545 patients seen over a 3-year period, Farmer and Webb reported that bradycardia [pulse <60 beats per minute (bpm)] occurred in 1.8% of IUD insertions. They mentioned earlier ECG studies that had estimated the occurrence of bradycardia as 32%, although this was in an era of more inflexible, rigid devices, specifically the Dalkon Shield, and referred to other studies reporting syncope in 2.1% of insertions. In recent correspondence in this Journal, Gormley and Eady drew attention to the rarity of the condition and called for evidence that a doctor must be present for all insertions, yet offered only anecdotal evidence as to the lack of need for atropine. Hollingworth used personal experience and that of her colleagues to query the FSRH guidelines on resuscitation in sexual health services and specifically the availability of atropine. Mansour conducted a poll of over 70 inserters, none of whom had ever needed to use atropine – the implication being that simple first aid measures should be sufficient to reverse the condition. Mehigan believed the FSRH guidance to be "unrealistic". Gormley and Eady championed the preparedness of the woman and the universal use of local anaesthesia; however, there is little evidence to support the assumption that pain is part of the pathogenesis of this condition.
Dickson et al. responded to these communications in 2011, setting out the origin of the Faculty standards. Specifically, and pertinent to our communication, they discussed the Resuscitation Council guideline that intravenous atropine should be administered if adverse signs such as shock or syncope are present. We now report three cases of the condition in patients under our care, in whom conservative measures were ineffective but who responded successfully to the administration of atropine.