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3152 - nat > ic17 women's health and contraception > Flashcards

ic17 women's health and contraception Flashcards

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1
Q

When should hypertension be treated in pregnancy

A

SBP > 140 or DBP > 90

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2
Q

What is considered severe hypertension in pregnancy

A

SBP > 160 or DBP > 110 for 2 measurements

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3
Q

Between these medication, which are first, second, third line for hypertension treatment?

Methyldopa, Labetalol, Nifedipine ER, Hydrochlorothiazide, Hydralazine

And what to look out for?

A

First line
Labetalol
Monitor for bronchoconstrictive effects, bradycardia

Nifedipine ER
Monitor for pedal edema, flushing, headaches

Second line
Hydrochlorothiazide
Potential interference with normal blood volume expansion with pregnancy

Third line
Methyldopa
Low potency, Increased adverse effects eg. sedation, dizziness

Hydralazine
Adverse effects mimic symptoms associated with severe preeclampsia

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4
Q

Definition of Chronic Hypertension

A

Less than 20 weeks gestation
Proteinuria absent

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5
Q

Definition of Chronic HTN with superimposed preeclampsia

A

Less than 20 weeks gestation
Proteinuria present

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6
Q

Less than 20 weeks gestation
Proteinuria absent

A

Chronic Hypertension

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7
Q

Less than 20 weeks gestation
Proteinuria present

A

Chronic HTN with superimposed preeclampsia

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8
Q

Definition of Gestational HTN

A

At least 20 weeks gestation
Proteinuria absent

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9
Q

At least 20 weeks gestation
Proteinuria absent

A

Gestational HTN

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10
Q

Definition of Preeclampsia

A

More than 20 weeks gestation
+ Proteinuria / Signs of end organ dysfunction / Uteroplacental dysfunction

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11
Q

Hypertension
+ More than 20 weeks gestation
+ Proteinuria / Signs of end organ dysfunction / Uteroplacental dysfunction

A

Preeclampsia

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12
Q

What are 3 markers to diagnose Proteinuria

A

1) 24hr urinary protein (UTP) at least 300mg
2) Dipstick protein: at least 2+
3) Urine protein : Creatinine ratio uPCR
> 0.3mg/dL

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13
Q

Signs of end organ damage (5 points)

A

Platelet count < 100

LFTs > 2x ULN

Doubling SCr in the absence of other renal disease

Pulmonary edema

Neurological complications eg. altered mental status, severe headache with visual disturbances

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14
Q

How to prevent Preeclampsia?

Who is this recommended for? (5 points)

A

Low dose aspirin

For high risk patients eg. HTN on previous pregnancy
Multifetal gestation (eg. twins, triplets)
Autoimmune disease
DM
CKD

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15
Q

When should low dose aspirin be started?

A

Start after 12 weeks (1st trimester), continued till delivery

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16
Q

What is the normal level and effect of Estrogen and Progesterone after ovulation?

What happens during Ovulation?

What happens if there is no Ovulation?

A

E and P are high to suppress ovulation, suppress FSH and LH to prevent ovaries from releasing eggs

If Ovulation occurs, E and P remain high throughout pregnancy

If no ovulation occurs, E and P falls, causing menstruation, bleeding

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17
Q

How do Contraceptives work?

What happens during the placebo period

A

Maintain high level of E and P → FSH and LH are suppressed, no egg is released. Mimics the period after ovulation aka tricking the body into thinking that ovulation has occurred

During placebo, E and P falls, withdrawal bleeding occurs

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18
Q

Advantage of condoms (male and female)

Disadvantages of condoms (3 points)

A

Adv:
STI protection if used correctly

Disadv:
High user failure rate
Not widely received
Possibility of breakage

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19
Q

Advantages (2 points) and Disadvantages (5 points) of Diaphragm with spermicide and Cervical cap

A

Adv:
Low cost
Reusable

Disadv:
High failure rate
Low protection against STI
Increased risk of UTI
Cervical irritation
Cause Toxic Shock Syndrome

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20
Q

What are the 2 concepts of Contraception?

A

1) Methods that act as barriers or prevent ovulation
eg. COC, Progestin injection, Transdermal patch, Anything with hormones

2) Prevent fertilised ovum from successfully implanting in the endometrium, creating an unfavourable uterine environment (eg. COC)

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21
Q

What is the role of Progestin? (3 points)

A

1) Thicken cervical mucus, slow sperm movement
2) Block LH surge
3) Induce endometrial atrophy

Provide most of contraceptive effect

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22
Q

What is the role of Estrogen? (2 points)

A

1) Reduce FSH secretion
2) Thicken endometrial lining

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23
Q

What is the most common form of Estrogen

What is the standard dose?

A

Ethinyl estradiol (EE)

30-35ug

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24
Q

What is the main issue with Progestins?

A

Progestins may cause androgenic side effects eg. Acne, Oily skin, Hirsutism

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25
What is the lower dose for EE? Who should be taking lower dose of EE?
15-25ug Adolescence Underweight (<50kg) Older than 35 Peri-menopausal Unable to tolerate SE eg. bloating, N/V, breast tenderness, weight gain
26
Population that can take higher dose of EE (3 points)
Obesity, > 70.5kg For early to mid cycle breakthrough bleeding Indicates that estrogen level not high enough to inhibit cycle For less adherent patients
27
Differences between older and newer gen Progestins
Older gen (1st, 2nd) Better for VTE Have more androgenic side effects Newer gen (3rd, 4th) NO androgenic side effects (esp for Drospirenone 4th gen) Higher risk of VTE
28
Under what circumstances should we have higher progestational activity?
1) Experience late cycle bleeding 2) Painful menstrual cramps
29
What is Drospirenone? Side effects of Drospirenone
It's a 4th gen progestin, Mineralcorticoid antagonist, similar to Spironolactone Can cause hyperkalemia, thromboembolism and bone loss
30
What are the 3 ways of starting contraceptives? Which need back up contraceptive and for how long?
1) First day method Start on first day of menstrual cycle No back up contraceptive needed 2) Sunday start Start on first Sunday after menstrual cycle Require backup contraceptive for 7 days after starting contraceptive 3) Quick start Start now Require backup contraceptive for at least 7 days and until next menstrual cycle begins
31
What is the reason for back up contraceptive for "Sunday Start" and "Quick start"?
Sunday start: Start on first Sunday after menstrual cycle begins Ovulation might have already occurred, or the COC might have been too late and not been able to prevent ovulation.
32
What is associated with VTE
1) Estrogen (increase hepatic production of clotting factors) 2) New generation Progestins (when combined with Estrogen) Progestins alone do not cause VTE
33
Which contraceptives to recommend with lowest VTE risk
Progestin-only contraceptives, and use Old gen (1st, 2nd) Progestins Barrier methods
34
Which condition is absolutely contraindicated to Combined Oral Contraceptives? (COC) What should we use instead? What about the rest of the conditions eg. VTE, post partum, migraine w aura
Breast cancer, current and recent history within 5 years DONT USE HORMONAL CONTRACEPTIVES AT ALL Use copper IUD, barrier Rest of the conditions eg. VTE, Migraine with aura Use Progestin-only contraceptives, or 1st/2nd gen Progestin (for VTE) / barrier method, copper IUD
35
What is absolutely contraindicated with Estrogen containing contraceptives? (3 points)
Migraine with aura Breast cancer VTE (and other risk factors causing VTE eg. smoking, post partum, diabetes > 20 years w complications etc)
36
What if patient has acne?
Use an antiandrogenic progestin eg. Drospirenone OR Increase estrogen, change Progestin-only to COC (how to rmb: acnE)
37
Why would headache occur? Recommendation
Usually occurs during pill free week due to fluctuation of hormones Change to a continuous dose or one with shorter pill free interval
38
What if patient has nausea, vomiting, bloating?
Reduce estrogen + (N/V) Change to POP or take pills at night (Bloating) Change to progestin with mild diuretic effect eg. Drospirenone
39
What if patient has menstrual cramps?
Increase progestin Switch to extended cycle or continuous cycle
40
What if patient has breast tenderness / weight gain?
Keep both estrogen and progestin as low as possible
41
3 drugs that can cause DDI with COC
1) Rifampicin 2) Anticonvulsants 3) HIV antiretrovirals
42
What to do if missed one dose (less than 48 hours)
Take missed dose immediately May need to take 2 pills on the same day No need additional contraceptive
43
What to do if missed 2 doses (more than 48 hours)
Take missed dose immediately Discard the rest of the missed doses Dont take more than 2 pills a day Back up contraceptive for at least 1 week
44
What to do if missed during last week of hormonal tablets
Finish remaining active pills in current pack SKIP hormone free interval + Start new pack the next day Back up contraceptive for at least 7 days
45
Indication for Progestin only Pills (POP) (3 points)
Good for breastfeeding Conditions that preclude estrogen Migraine with aura Have VTE or High risk of VTE Cannot tolerate Estrogen NV side effects
46
Absolute contraindication for Progestin-only Pill
Breast cancer
47
MOA of Progestin only pill (POP)
POP stops ovulation only, by suppressing LH release This means that FSH is still high and the follicle is ready to be released, but is held back by low LH If we stop POP, LH will increase and result in ovulation, hence missed dose is stricter and back up contraceptive
48
What are the 3 types of POP?
1st, 2nd, 4th 1st: Norethindrone / Norethisterone 2nd: Levonorgestrel 4th: Drospirenone
49
How to start POP?
If start within 5 days of menstrual cycle No need back up contraceptive Any other day Back up contraceptive for 2 days Drospirenone: 7 days
50
What if miss POP dose?
Norethindrone (1st), Levonogestrel (2nd) if miss > 3 hours, take one immediately + back up contraceptive for 2 days Drospirenone Miss 1 pill → no need back up Miss 2 or more pills → need back up for 7 days
51
Which population is transdermal contraceptives not useful?
Obese patients
52
Other non pill hormonal contraceptives (4 points)
Transdermal patch Vaginal rings Progestin injections Long acting reversible contraception (IUD or Implants)
53
What is the advantage of vaginal rings over diaphragms / cervical cups?
Precise placement not needed, hormones are absorbed
54
Adverse effects of Progestin injections (3 points)
Cannot be fertile immediately once stopped Weight gain Short term bone loss
54
What are examples of Long Acting Reversible contraception (LARC)? Benefits of LARC? (2 points)
Intrauterine Devices (IUD) Implants Highly effective (<1% failure) Can become fertile soon after stopping but invasive
55
MOA of Intrauterine devices (IUD)
1) Inhibit sperm migration 2) Damage ovum 3) Disrupt transport of fertilised ovum
56
Contraindications of IUD (6 points)
Pregnancy Current STI Undiagnosed vaginal bleeding Malignancy of genital tract Uterine abnormalities Uterine fibroids
57
2 types of IUD, how long do they last?
Levonorgestrel IUD - 5 years Copper IUD - 10 years
58
Which IUD is ideal for which conditions?
Levonorgestrel IUD Help reduce bleeding -> for concomitant menorrhagia Cannot be used for emergency contraception Copper IUD Help increase bleeding -> for concomitant amenorrhea Can be used as emergency contraceptive
59
How long can a Subdermal Progestin Implant last?
3 years
60
Need to take emergency contraceptives by when?
rmb 5 5 2+3 Copper IUD within 5 days Ella tablet 1 tab within 5 days Postinor tablet 2 tabs within 12 hours, if not 3 days
61
What is in Ella tablet?
Ulipristal, a Progestin receptor modulator Will not be effective if patient is taking Progestin at the same time!

3152 - nat (16 decks)

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