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PPT Phase II > Obs and Gynae > Flashcards

Obs and Gynae Flashcards

1
Q

name 7 important prescribing considerations during pregnancy/breastfeeding

A
  1. Changes to the mother’s physiology
  2. drugs passing through placenta to foetus
  3. drugs passing through breast milk to baby
  4. less available licensed medications
  5. minimal evidence base
  6. patient/healthcare professional anxiety surrounding prescibing in pregnancy
  7. dose alterations required in pregnancy.
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2
Q

How does the CVS change in pregnancy?

A

increases in plasma volume, CO, stroke volume, HR.
Decreases in serum albumin conc, and serum colloid osmotic pressure.
increases in coagulation factors and fibrinogen
compression of the IVC by the uterus.
Results in hyperdynamic circulation.

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3
Q

What might you find on CVS examination in a pregnant woman?

A

bounding pulse, 3rd heart sound, systolic flow murmurs

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4
Q

What normal physiological ECG changes might you see in a pregnant woman?

A

Left axis deviation, ectopic beats, ST depression and flattening/inverted T waves in inferior and lateral leads.

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5
Q

what normal physiological blood test findings might you find in a pregnant woman?

A

dilutional anaemia, leukocytosis, low albumin

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6
Q

what happens to the GFR in pregnancy?

A

Increases due to increases in renal blood flow

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7
Q

what physiological changes do you get in the lungs in pregnant women?

A

increase in tidal volume and minute ventilation.

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8
Q

what physiological changes do you get to the GI system during pregnancy?

A

N&V, delayed gastric emptying (allows increased nutrient absorption but can result in constipation), prlonged small bowel transit time, Gastrointestinal reflux

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9
Q

How might GI changes in pregnancy affect drug absorption?

A

delayed gastric emptying nad prolonged transit time alters drug bioavailability, with prolonged time to reach peak levels after oral administration and an overall decrease in maximum conc achieved. N&V can also affect absorption

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10
Q

how might changes to the CVS during pregnancy affect drug distribution?

A

increased total body water/extraellular fluid increases volume of distribution of water-soluble drugs. this could necessitate a higher inital and maintenance dose of drugs to obtain therapeutic plasma concentrations. lipid-soluble drugs are also affected due to increased fat compartment stores.

with increasing plasma volume, there is an associated reduction in maternal plasma protein conc. decreased plasma albumin conc. leads to decreased protein binding and increases free fraction of the drug. this is impoartnat for drugs such as midazolam, digoxin, phenytoin, valproic acid. However, these effects may be off-set by changes in metabolism and elimination.

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11
Q

What effects do maternal changes have on distribution?

A

increased plasma volume - increased volume of distribution of water-soluble drugs, requires higher drug doses.

Reduction in plasma protein levels - decreased protein binding, increased free fraction of the drug

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12
Q

what physiological effects on the liver occur in pregnancy?

A

changes in oxidative liver enzymes, such as cytochrome P450

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13
Q

how might metabolism of drugs be affected in pregnancy?

A

altered cytochrome P450 activity in pregnancy (unchanged/increased/decreased), alters oral bioavailability and hepatic elimination.

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14
Q

how is elimination of drugs affected during pregnancy?

A

incraesed renal blood flow and GFR means increased clearance, shorter half-lives of renal cleared drugs.

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15
Q

If clearance of lithium is doubled in the third trimester, how might the dose need to be adjusted?

A

higher dose will be required

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16
Q

what is the background risk of congenital malformationsi in pregnancy

A

2-3%

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17
Q

what is the background risk of congenital malformations in women with epilepsy who take AEDs during pregnancy?

A

4-10%

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18
Q

name 5 risks of using medications during pregnancy

A
  1. teratogenesis
  2. effects on growth and development
  3. effects on the neonate during delivery
  4. passage of drug through breast milk
  5. long term effects on IQ or behavioural problems
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19
Q

name 7 prescribing principles in pregnancy

A
  1. pre-pregnancy counselling
  2. risk vs benefit decision
  3. minimise drug use in first trimester
  4. small effective dose
  5. opt for ‘well-known’ meds
  6. monotherapy where possible
  7. consider non-drug options
  8. carefully monitor meds and their effects.
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20
Q

what is the daily recomended pre-conception dose of folic acid and for how long should it be prescribed?

A

400 micrograms daily up to 12wks gestation

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21
Q

what dose of foic acid is recommended for higher risk women during pregnancy?

A

5mg

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22
Q

name 3 AEDs with lower risks of malformations (2-5%)

A

lamotrigine, levetiracetam (Keppra), carbamazepine

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23
Q

name the AED with the higher risk of malformations (7-10%)

A

sodium valproate (Epilim)

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24
Q

What properties of a drug allow it to cross the placenta?

A

lipid-soluble drugs, or lipid soluble metabolites of some drugs

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25
Q

what is meant by complete transfer of a drug acorss teh placenta?

A

where drugs rapidly cross the placenta, equilibrating in maternal and fetal blood

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26
Q

what is meant by exceeding transfer of a drug across the placenta?

A

where drugs cross the placenta to reach greater concentrations in fetal compared to maternal blood

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27
Q

what is meant by incomplete transfer of a drug acorss the placenta?

A

where drugs incompletely cross the placenta resulting in higher conc in maternal compared with fetal blood

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28
Q

almost all drugs can pass freely through the placenta with the exception of what?

A

those with a molceular weight of >1kDa

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29
Q

give an example of a drug with molecular weight of >1kDa meaning it doesn’t cross the placenta

A

insulin, heparin

30
Q

name 5 NICE recommendations for the management of pregnancy-induced nausea

A

reassurance and rest, avoidance of triggers, eating plain crackers in teh morning, eating bland, small, frequent meals, cold meals if nausea is smell-related, drink little and often, ginger, acupressure

31
Q

what gestation does pregnancy induced N&V usually resolve by

A

16-20wks

32
Q

name 4 antiemetic therapies that can be used first line for pregnancy-induced N&V

A

cyclizine, prochlorperazine, promethazine, chlorpromazine

33
Q

name 3 second-line antiemetic therapies that can be used for pregnancy-induced N&V

A

metoclopramide, domperidone, ondansetron

34
Q

if neither first or second line antiemetics have worked for pregnancy-induced N&V, what can be tried third line?

A

hydrocortisone

35
Q

other than antiemetics, what additional treatmetn should be given in hyperemesis gravidarum

A

IV fluid rehydration with potassium supplementation, pabrinex/thiamine (if prolonged vomiting).
in severe cases may need enteral/parenteral feeding.
TOP is last resort.

36
Q

What did thalidomide used to be used for?

A

immunomodulator initially used to treat pregnancy-related nausea

37
Q

what effect did thalidomide have on babies?

A

phocomelia (where limb buds don’t form correctly). also deformities of ears, heart, kidneys.
high mortality rate (40%)

38
Q

name 6 common teratogenic drugs or drug classes

A 
ACEi
Anti-thyroid drugs
beta-blockers
lithium
methotrexate
NSAIDs
39
Q

what effects can ACEi have on the fetus

A

renal abnormalities, PDA, oligohydramnios

40
Q

what effects does carbimazole have on a neonate?

A

neonatal hypothyroidism

41
Q

what effects can beta blockers have on the fetus and newborn?

A

IUGR, neonatal hypoglycaemia, bradycardia

42
Q

what teratogenic effect does lithium have?

A

cardiac defects (Ebstein’s anomaly - a congenital heart defect where the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart.

43
Q

what teratogenic effects does methotrexate have

A

medical termination, craniofacial defects, ear/kidney/lung defects, cardiac abnormalities

44
Q

what effect can NSAIDs have after 30wks gestation?

A

premature closure of the ductus arteriosus, oligohydramnios, PPHN (persistent pulmonary HTN of the newborn)

45
Q

what teratogenic effect does phenytoin have?

A

craniofacial abnormalities, growth/mental deficiency

46
Q

what teratogenic effect do retinoids have?

A

CNS abnormalities, renal/ear/eye/parathyrdoi abnormalities between wks 4-10

47
Q

what teratogenic effects does sodium valproate have?

A

neural tube defects

48
Q

which trimester does sodium valproate cause teratogenic effects

A

1st trimester

49
Q

what teratogenic effect do tetracyclines have?

A

tooth discolouration

50
Q

what teratogenic effects do thiazide diuretics have?

A

electrolyte abnormalities, growth retardation

51
Q

what teratogenic effects does warfarin have?

A

fetal warfarin syndrome, CNS defects/eye abnormalities, fetal/neonatal/placental hamorhage

52
Q

what does fetal warfarin syndroem casue

A

results in abnormalities including low birth weight, slower growth, mental retardation, malformed bones, cartilage, joints, deafness, small head size.

53
Q

which two antihypertensives tend to be used in pregnancy as they are considered safer?

A

labetalol or nifedipine

54
Q

name 3 drugs that can cause genetic abnormalities in the sperm

A

methotrexate
azathioprine
mercaptopurine

55
Q

how long does the manufacturer of antimetabolite drugs such as methotrexate advise delaying conception for due to genetic abnormalities it could cause in teh sperm?

A

6 months

56
Q

why should amiodarone be avoided in breastfeeding mothers?

A

iodine content may cause neonatal hypothyroidism

57
Q

why should aspirin be avoided in breastfeeding mothers?

A

theoretical risk of Reye’s syndrome

58
Q

why should barbiturates be avoided in breastfeeding mothers?

A

drowsiness

59
Q

why shoudl benzodiazepines be avoided in breastfeeding mothers?

A

lethargy

60
Q

why should carbimazole be avoided in breastfeeding mothers?

A

hypothyroidism

61
Q

why shoudl codeine be avoided in breastfeeding mothers?

A

risk of opiate overdose

62
Q

why should COC pill be avoided in breastfeeding mothers?

A

may diminish milk supply and quantity

63
Q

why should cytotoxic drugs be avoided in breastfeeding mothers?

A

immunosuppression and neutropaenia

64
Q

why should dopamine agonists be avoided in breastfeeding mothers?

A

may suppress lactation

65
Q

why shoudl ephedrine be avoided in breastfeeding mothers?

A

irritability

66
Q

hwhy should tetracyclines be avoided in breastfeeding mothers?

A

risk of tooth discolouration

67
Q

renal abnormalities in the newborn are named with which two drugs or drug classes?

A

ACEi and methotrexate

68
Q

parathyroid abnormalities in the newborn are associated with which drug class?

A

retinoids

69
Q

what antibiotics are first line for PID

A 
Ceftriazone IM
\+
Metronidazole BD 14/7
\+
Doxycycline BD 14/7
70
Q

what is the definition of primary infertility?

A

not being able to conceive after 1yr of regular, unprotected intercourse

71
Q

what is the definition of secondary infertility?

A

those who have conceived in teh past (irrespective of the outcome of the pregnancy be it miscarriage, termination, ectopic or normal delivery), but fail to do so again after regular unprotected intercourse for one yr

PPT Phase II (37 decks)

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