Lecture 11 (OB)-Exam 5 Flashcards
(103 cards)
1
Q
Infertility
* What is the def?*
* Specific treatment depends on what?
A
- Inability to conceive after 12 months with regular, unprotected intercourse
- Specific treatment depends on underlying etiology
2
Q
Infertility
* What are the general lifestyle factors? (3)
A
- Abstain from tobacco
- Limit alcohol intake
- Maintain BMI > 17 and < 30 kg/m2
3
Q
A
4
Q
Infertility
* How do you men and women start the work up?
A
- Men – start with semen analysis
- Women – determine if ovulating
5
Q
Infertility
* What is the first test for infertility in women? What are the levels?
A
Day 21 progesterone level
* ≥ 5ng/mL = ovulating, evaluate for other causes
* < 5ng/mL = not ovulating, evaluate underlying cause
* Consider ovulation induction
6
Q
A
7
Q
Ovulation induction
* What is the MOA of Clomiphene (SERMs)
A
Inhibits estrogen receptors in the hypothalamus
* Inhibits the estrogen negative feedback
* Hypothalamus increases GnRH release in response to decreased estrogen negative FB
* Increased LH/FSH
* Ovary stimulation
* Ovulation
8
Q
Ovulation induction
* When do you take Clomiphene
A
50 to 100 mg PO daily on days 5 to 10 of ovarian cycle
9
Q
Ovulation induction:Letrozole
* What is the MOA?
* Not what?
* Stimulates what?
* Replaces what?
* Highest what?
A
Letrozole – aromatase inhibitor
* Not FDA approved indication
* Stimulates ovulation
* Replaces historic clomiphene
* Highest cumulative pregnancy and live birth rate (80% and 30 to 40%, respectively)
10
Q
Ovulation induction
* When do you take letrozole?
A
Regimen: 2.5 to 7.5 mg PO daily on days 3 to 7 of the ovarian cycle
11
Q
Immunizations
* When should they be given ideally?
A
Ideally should be administered prior to pregnancy
12
Q
TEST
Immunizations
* What is safe during pregnancy?(6)
A
- Pneumococcal
- Meningococcal
- Hepatitis A, B
- Inactivated polio
- Inactivated influenza–should be given, ok any trimester
- Tdap
13
Q
Tdap:
* Should be given when?
A
should be given at 27-36 weeks REGARDLESS of prior immunization hx (there is some passive antibody transfer to infant). All persons with close contact to infant should also be immunized
14
Q
Immunizations
* What is not safe?
* What is uncertain/not recommended?
A
Not safe:
* Measles/mumps/rubella
* Polio
* Varicella
Uncertain/Not recommended
* HPV Vaccine. No adverse outcomes have been described but not recommended. If found to be pregnant during series, remaining doses given after pregnancy
15
Q
RH incompatibility
* What is it?
A
Discordant pairing of maternal and fetal Rh factor
* Rh negative mothers – Rh positive infants
16
Q
RH incompatibility
* What is the process?
* What is the goal?
A
- Exposure to Rh positive blood cells from fetus results in development of maternal anti-D IgG antibodies against Rh positive antigens on the fetus RBCs
- Antibodies can cross placenta of subsequent pregnancies and destroy fetal RBCs
- Hemolytic disease of the newborn
- Goal is to prevent formation of anti-D IgG antibodies
17
Q
RH incompatibility
* All women need to be screen ?
* Rh neg women->
A
- All women should be screened for Rh status at first prenatal visit
- Rh neg women -> check anti-D antibodies
18
Q
RH incompatibility
* If anti-Rh D antibody positive->
* If anti-Rh D antibody negative->
A
If anti-Rh D antibody positive -> NOT a candidate for Rh0 (D) immune globulin
* May require no additional testing if dad is known to be Rh negative
If anti-Rh D antibody negative -> further testing and Rh0 (D) immune globulin indicated
19
Q
Rh0 (D) immune globulin - prophylaxis
* What is the standard regimens? (28 week gestation and postpartum)
A
20
Q
Rh0 (D) immune globulin - prophylaxis
* What are the sensitizing event regimens?
A
21
Q
Rh0 (D) immune globulin
* What is the MOA?
* What are the SEs?
A
MOA: thought to destroy Rh positive blood cells before maternal antibodies can be formed
Adverse reactions:
* Headache, drowsiness, dizziness, blood pressure changes, injection site reactions, allergic reaction
22
Q
Rh0 (D) immune globulin
* What is the dosing?
A
Most indications
* 300 mcg IM x 1 dose
* 300 mcg provides sufficient antibody if volume of exposed Rh pos RBC exposure is ≤ 30 mL
Spontaneous / threatened / induced abortion < 13 weeks
* 50 mcg IM x 1 dose
23
Q
* TEST
What are the Drugs contraindicated in pregnancy?(7)
A
- Statins
- Spironolactone
- Warfarin – fetal syndrome
- Anticonvulsants – topiramate
- Guaifenesin – neural tube defects
- Isotretinoin, tretinoin
- Antibiotics
24
Q
Drugs in lactation
* Need for what?
* Potential SE on what?
* What are the characteristics for amount excreted in breast milk?
A
Need for drug by mom
Potential side effects on milk production
Amount excreted in the breast milk
* Unionized, small molecule, high lipid solubility, low Vd, low protein binding
25
Drugs in lactation
* Drug what?
* Potential what?
* Age of who?
* What status?
* What agents?
* Drug half-life
* Potential adverse effects
* Age of infant
* Maternal HIV status
* Chemotherapy agents
26
lactation
* What are the contraindicated medications?(6)
* **Acebutolol, atenolol– hypotension, bradycardia**
* **Amiodarone - hypothyroidism**
* Antidepressants - some
* Aspirin – metabolic acidosis
* Benzodiazepines
* **Cytotoxic agents – methotrexate**
27
lactation
* What are the rest of the contraindicated medications?
* **Ergotamine – N/V/seizures**
* **Estradiol**
* Lamotrigine
* Lithium
* Nitrofurantoin – hemolysis if G6PD deficient
* Phenobarbital
* Sulfasalazine – blood diarrhea
28
Ectopic pregnancy treatment
* What are the three primary options? (general)
* Surgical – salpingostomy or salpingectomy
* Methotrexate
* Expectant management
29
Ectopic pregnancy treatment: Methotrexarte
* For who?
* What bhCG levels?
* What is not on US?
* Reliable/close access to what?
* Hemodynamically stable
* Beta-hCG ≤ 5000 milli-IU/mL
* No fetal cardiac activity on transvaginal ultrasound (TVUS)
* Reliable / close access to emergency services
30
Ectopic pregnancy treatment: Expectant management
* Common or uncommon?
* What is the bhCG levels?
* No identifiable what?
* Reliable / close access to what?
* Uncommon
* Beta hCG < 200 and falling
* No identifiable pregnancy on TVUS
* Reliable / close access to emergency services
31
methotrexate
* What is the MOA?
* Pharmacokinetics?
MOA:
* Folic acid antagonist
* Inhibits DNA synthesis and cell reproduction of rapidly proliferating cells
* Trophoblasts and fetal cells
Pharmacokinetics:
* Rapid clearance by the kidney
* 90% cleared in 24 hours
32
methotrexate
* What are the SE?
* When do you need to follow up?
Adverse reactions:
* MC stomatitis / conjunctivitis
* Nausea / vomiting
Follow up:
* hCG level on days 4 and 7
* If ≥ 15% decrease no additional doses
* Monitor hcg weekly until undetectable
* If < 15% decrease, additional doses indicated
33
Caring for the Pregnant Diabetic Patient
* tight glycemic control to what?
* Poor control in early pregnancy =
* Poor control in late pregnancy =
* Tight glycemic control to normal HbA1c [< 6 (ideal) to < 7] – while preventing hypoglycemia
* Poor control in early pregnancy = increased risk of spontaneous abortion and congenital malformations
* Poor control in late pregnancy = increased risk of pre-term labor, preeclampsia, shoulder dystocia, and stillbirth
## Footnote
Frequent monitoring of blood sugar recommended
34
# * TEST
Gestational diabetes screening - 24 to 28 weeks gestation
KNOW NUMBERS
35
# *
Gestational diabetes
* What is the txt?
* What is the pharmacotherapy?
*
36
Gestational diabetes
* What are the goals? (3)
* Fasting and preprandial blood glucose concentration: <95 mg/dL (5.3 mmol/L)
* One-hour postprandial blood glucose concentration: <140 mg/dL (7.8 mmol/L)
* Two-hour postprandial glucose concentration: <120 mg/dL (6.7 mmol/L)
37
Gestational diabetes
* Women with gestational diabetes are at increased risk of what?
* 2-hour oral glucose tolerance test recommended when?
* **Screen patients when?**
* Women with gestational diabetes are at increased risk of developing diabetes
* 2-hour oral glucose tolerance test recommended at 6-weeks postpartum
* **Screen patients at least every 3 years for diabetes**
38
Gestational diabetes
* What are the lifestyle interventions?
Lifestyle interventions (eg, achieving a healthy weight, appropriate level of physical activity/exercise) are clearly beneficial for reducing the incidence of diabetes, and related comorbidities such as cardiovascular disease.
39
# * TEST
Hypertension - pregnancy
* What is the definition?
≥ 140 or ≥ 90 mmHg on two separate occasions at least 4 hours apart or ≥ 160/110 mmHg on one occasion
| *
40
Hypertension - pregnancy
* What is pre-eclampsia?
* What is eclampsia?
* Pre-eclampsia – new onset hypertension after 20 weeks gestation associated with proteinuria ± edema, elevated liver enzymes, thrombocytopenia, cerebral edema/vision changes
* Eclampsia – pre-eclampsia plus seizures
41
Hypertension - pregnancy
* What is chronic hypertension?
* What is gestational hypertension?
* Chronic hypertension – preexisting hypertension prior to pregnancy
* Gestational hypertension – hypertension after 20 weeks gestation NOT associated with proteinuria or other systemic symptoms
42
Chronic hypertension - pregnancy
* Txt recommended for who?
Treatment recommended for SBP ≥ 140 mmHg or DBP ≥ 90 mmHg on two separate occasions at least 4 hours apart
43
Chronic hypertension - pregnancy
* What is the 2022 CHAP trial?
2408 patients randomized to
* Standard therapy – no treatment until SBP ≥ 160 mmHg or DBP ≥ 110 mmHg
* Blood pressure control – goal < 140 /90 mmHg
Blood pressure control group had significant reductions in pre-eclampsia, preterm birth, severe hypertension, fetal death
44
Gestational HTN/Pre-eclampsia
* What is the def?
* Treatment is recommended for who?
* New pregnancy-related hypertension after 20 weeks gestation
* Treatment is recommended for SBP 150 to 159 mmHg and/or DBP 100 to 109 mmHg that persists over multiple measurements and delivery is expected to be delayed for several days or weeks
45
Gestational HTN/Pre-eclampsia
* Txt is suggested for who?
Treatment suggested for SBP 140 to 149 mmHg and/or DBP 90 to 99 mmHg that persists over multiple measurements and delivery is expected to be delayed for several days or weeks
46
# * TEST
Preeclampsia
* What is essential of dx?
Maternal blood pressure elevation of ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on 2 occasions 4 hours apart
47
Preeclampsia
* Need an one of the following:(6)
* Proteinuria (either ≥ 300 mg in a 24-hour urine specimen or a spot urine protein/creatinine ratio ≥ 0.3)
* Thrombocytopenia (a platelet count < 100,000/µL)
* Renal insufficiency (serum creatinine concentration > 1.1 mg/dL or a doubling of the serum creatinine in the absence of other renal disease)
* Impaired liver function (elevated blood concentrations of liver transaminases to twice normal concentration)
* Pulmonary edema
* Cerebral or visual symptoms
48
Preeclampsia expectant therapy
* Initiation of what? Who gets it?
Initiation of low dose aspirin (81mg) at 12 to 16 weeks gestation indicated for women with at least
* One high-risk factor OR
* Two moderate-risk factors
49
Preeclampsia expectant therapy
* Reduces what? (3)
* Reduces the incidence of severe preeclampsia
* Reduce the risk of intrauterine growth retardation
* Reduce the risk of preterm delivery (14%)
50
# * TEST
Preeclampsia expectant therapy
51
Preeclampsia – clinical features
* without severe features?
Fewer complaints, DBP <110, platelet count over 100,000/mcL, fetal testing reassuring
52
Preeclampsia – clinical features
* With severe features?
53
Preeclampsia – clinical features
54
Preeclampsia treatment
* Delivery: over 37 weeks?
≥ 37 weeks gestation
* Improves maternal morbidity and mortality
* Safest for fetus
55
Preeclampsia treatment
* Delivery: ≥ 34 weeks gestation with severe symptoms?
* In labor or ruptured membranes
* Abnormal maternal / fetal test results
* Suspected abruptio placentae
* Fetal size < 5th percentile
## Footnote
Viable to 33 6/7 = more controversial
56
Preeclampsia treatment
* What is the expectant management of < 37 weeks gestation without severe symptoms?(3)
* Close maternal and fetus monitoring
* BID blood pressures
* Twice weekly labs
* Platelets, serum creatinine, liver enzymes
57
Preeclampsia treatment
* Delivery required if symptoms progress?
* Severe HTN
* End organ damage
* Non-reassuring fetal well being
58
# * TEST
Magnesium sulfate
* Indicated for who? What does it cause?
Indicated for preeclampsia with severe features
* Decreases the risk of eclamptic seizures
* Decreases risk of placenta abruption
* Initiated at the onset of symptoms, labor, or labor induction
* Continued for 12 to 24 hours post delivery
59
Magnesium sulfate
* First line txt for who?
First-line treatment for eclampsia
60
Magnesium sulfate
* What is the dosing?
* Dose reduction required for?
* Loading dose: 4 to 6 grams IV over 15 minutes
* Continuous infusion: 1 to 2 grams / hr IV
* Dose reduction required for renal impairment
61
Magnesium sulfate
* Infusion should be held for what? (3)
* Loss of deep tendon reflexes
* RR < 12 BPM
* UOP < 100mL over 4 hours
62
# * TEST
Magnesium sulfate
* What is the antidote?
* What is the monitoring?
* Antidote: calcium gluconate
* Periodic magnesium level monitoring recommended
63
Magnesium sulfate
* What are the SE?(5)
* N/V
* Headache
* Muscle weakness
* Visual disturbances
* Palpitations
64
Acute therapies – severe hypertension
* What is first line? What are the other options?
IV labetalol
OR
IV hydralazine
Alternatives:
* PO nifedipine (ER vs IR formulations)
* IV nicardipine
* IV nitroprusside
65
Chronic maintenance therapy
* What is first line and alternatives?
First-line:
* Labetalol
* Nifedipine
Alternatives:
* Hydralazine
* Methyldopa
66
Chronic maintenance therapy
67
Inhibition of preterm labor
* What are the goals? (3)
* Delay preterm labor for 48 hours until after administration of antenatal corticosteroids
* Allow for safe neonatal transport to appropriate facility
* Prolong pregnancy during self-limited condition that triggered contractions (UTI/surgery)
68
Inhibition of preterm labor
* What are the contraindications? (5)
* Advanced labor – not going to stop it
* Mature fetus
* Intrauterine infection
* Significant vaginal bleeding
* Severe preeclampsia
69
Inhibition of preterm labor - tocolytics
70
# * TEST
Inhibition of preterm labor - tocolytics
71
# * TEST
Management of PPROM (preterm premature rupture of membranes)
72
# * TEST
Management of PPROM (preterm premature rupture of membranes)
73
Antenatal corticosteroids
* Indicated when?
* Accelerates what?
* What are the options?
* Indicated between 24 and 34 0/7 weeks gestation if risk of delivery in the next 7 days
* Accelerates lung maturation
* Betamethasone and Dexamethasone
74
Antenatal corticosteroids
* What is the MOA of corticosteroids?
75
Group b Streptococcus Prophylaxis (s. agalactiae)
* What is the goal?
* What is the screening?
Goal:
* Minimize risk of neonatal GBS infection for infants born to mothers colonized with organism
Screening:
* All pregnant women 36 to 37 weeks gestation
* Vaginal and rectal swabs
76
Group b Streptococcus Prophylaxis (s. agalactiae)
* Treatment if GBS positive or what?
77
Group b Streptococcus Prophylaxis (s. agalactiae)
* No treatment when?
No treatment if screening negative
* C-section with intact membranes
78
# * TEST
Group b Streptococcus Prophylaxis (s. agalactiae)
* What is the txt?
* IV penicillin G or ampicillin
* Loading dose plus q4h dosing until delivery
* Multiple second-line options for patients with penicillin allergy
79
Labor Induction Methods
* What are the different methods?(4)
* Membrane stripping – pulling away sac
* Cervical ripening to enhance induction success
* Oxytocin
* Amniotomy
* Others (anecdotal evidence): nipple stimulation, intercourse, spicy food
80
Labor Induction Methods: amniotomy
* Artificial what?
* Note what?
* Monitor what?
* Risk of what?
* Artificial rupture of membranes
* Note clarity of fluid and presence of meconium
* Monitor FHR before and immediately after
* Risk of umbilical cord prolapse
81
Labor induction: Goal
* Maximizes what?
* Not recommened when?
* Pregnancies > 42 weeks have increased risk of what? Why?
Maximize health and safety of mom and baby
Not recommended prior to 39 weeks for otherwise healthy pregnancies
Pregnancies > 42 weeks have increased risk of neonate morbidity
* Meconium aspiration
* Hypoxic ischemic encephalopathy
* NICU admissions
82
# *
Labor induction: Cervical ripening – softening, dilation, effacement
* Indicated for who?
* Increases what? What can it cause?
Indicated for unfavorable cervix based on Bishop’s score
Increases uterine contractions
* Can cause tachysystole = ≥ 5 contractions in 10 min
83
Labor induction
* What are the options for cervical ripening?
Mechanical – catheter dilation
Misoprostol – prostaglandin E1
* Multiple routes – MC intravaginal tablet
* May repeat every 4 hours
Dinoprostone – prostaglandin E2
* Vaginal gel or 10mg time-release vaginal insert
84
Labor induction:
* Monitor what?
* What can be used alone with favorable cervix?
* Monitor fetal activity and heart rate
* Amniotomy – can be used alone with favorable cervix
85
# FYI
Labor induction
86
Oxytocin
* What are the indication? (4)
* What is the MOA?
Indications
* Augment labor
* Induction of abortion
* Decreases postpartum hemorrhage
* Induces milk let down
MOA:
* Synthetic form of endogenous peptide hormone
* Released by posterior pituitary
* Induces uterine contractions
* Constriction the spiral arteries and decreasing uterine blood flow
87
# FYI
Oxytocin
* How do you initiate it?
Specific timing after cervical ripening agents
* 6-12 hr after dinoprostone gel
* 30 min after removal of dinoprostone insert
* 4 hours after misoprostol
88
Oxytocin
* What is the dosing?
* Hold when?
Dosing:
* IV as a continuous infusion titrated to desired effects
* Contractions with consistent strength/rate
* Every 2 to 3 min lasting 60 to 90 sec
Hold for contractions > q2min, abnormal fetal heart rate or variable late decels
89
Oxytocin Contraindications
* When should vaginal delivery avoided?(5)
* Breech presentation
* Placenta previa
* Active genital herpes
* Cephalopelvic disproportion
* Mom cannot tolerate labor
90
Oxytocin contraindications
* When risk is to mom and fetus?
Risks to fetus
* Distress
* Brain damage
* Death
Risks to mom
* Hyperstimulation uterus
* Uterine rupture
* Water intoxication, seizures
* Hypertension, arrythmias
91
Postpartum hemorrhage
* What is the best treatment?
* Starts with what?
* Controlled what?
* _ massage?
* Best treatment – prevention
* Starts with active management of third stage of labor (AMTSL)
* Oxytocin – immediately at the end of delivery (Reduces the risk of PPH by 50%)
* Controlled cord traction
* Uterine massage
92
Postpartum hemorrhage: Recognition
* MC when?
* Measuring what?
* Most healthy pregnant women can lose how mcuh?
* ACOG definition is what?
* Who should be closely monitored and resuscitation started?
* MC in the first 24 hours after delivery
* Measuring postpartum blood and clots
* Most healthy pregnant women can lose 500 to 1000mL before becoming symptomatic
* ACOG definition is ≥ 1000mL
* Patients with blood loss between 500 to 999ml should be closely monitored and resuscitation started
93
Postpartum hemorrhage
* Readiness?
* Response?
* Readiness – emergency hemorrhage kits
* Response – use written protocols and check lists
94
Postpartum hemorrhage
* Resuscitation should start when?
Patients with blood loss ≥ 500 mL with symptoms
95
Postpartum hemorrhage
96
# * TEST
PPH
* MCC?
* What is first line?
* MCC – Uterine atony (70%)
* First-line: Oxytocin
97
PPH
* What is the MoA of oxytocin?
* Synthetic form of endogenous peptide hormone
* Released by posterior pituitary
* Induces uterine contractions
* Constricting the spiral arteries and decreasing uterine blood flow
98
PPH: Oxytocin
* What are the SE?(3)
* Painful contractions
* N/V
* Hypertension
99
Metritis
* What is it?
* AKA?
* Ascening what?
* Most common what?
* Infection of the uterine cavity and adjacent tissue
* AKA: endomyometritis, endometritis, metritis with cellulitis
* Ascending infection from the lower genital tract - polymicrobial
* Most common infection after cesarean section
100
Metritis
* How do you dx it?
* What is the tx? What is first line?
* Dx: Fever for ≥ 2 days with in 10 days post partum
* Tx: IV ABX until patient is asymptomatic and afebrile for 24 hours
* First-line: piperacillin-tazobactam, clindamycin or metronidazole + ceftriaxone
* Clindamycin + gentamicin “textbook” but falling out of favor
101
Postpartum Depression
* Consider if what?
* Sxs start when?
* Same dx criteria as what?
102
103
Treatment of Postpartum Depression
* What is the psychotherapy?
* What is the pharmacotherapy?
Psychotherapy
* Interpersonal Therapy
* Cognitive Behavioral Therapy
Pharmacotherapy
* Selective Serotonin Reuptake Inhibitors (SSRI): Paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), etc
* Very small concentrations found in breastmilk
