OB Flashcards
(196 cards)
1
Q
Viable pregnancy can be seen on US when?
A
5wks
1500-2000mIU/ml
Heart motion at 6wks trans vag - 5000-6000
2
Q
Embryo
A
fertilization - 8 wks, 10wks GA
3
Q
fetus
A
8 wks - birth
4
Q
infant
A
delivery - 1 yr
5
Q
Developmental age vs gestational
A
Developmental age is 2wks more than GA due to fertilization, but neglects the beginning of the cycle
6
Q
Nagele rule
A
-3 months, add 7 days to LMP
7
Q
Signs(7) and symptoms of pregnancy (4)
A
chadwicks sign ( bluish tinge), Goodell’s sign (softening/cyanosis of cervix at 4wks), Ladin (soft uterus at 6 wks), Breast swelling and tender, linea nigra from umbilicus to pubis, telangiectasia, palmar erythema
Amenorrhea, N/V, breast pain, quickening
8
Q
US dating in 1st trimester for dates
A
should be in 1 wk
measure crown to rump, 3-5 day variance
9
Q
Doppler HR of fetus at
A
10 wks
20 wks by none electronic
10
Q
Quickening at ?
A
16- 20 wks
11
Q
Cardiac changes in pregancy (2)
A
CO increases 30-50%, increase in SV and maintained by increase in HR 3rd trip
Systemic vascular resistance drios - fall of arterial pressure, elv progesterone-> smooth muscle relacation
12
Q
Changes in pulm in pregnancy
A
increase tidal volume - 30-40%-> increase in alveolar and arterial PO2 levels and decrease in PACO2 and PaCO2(30mmHg)
Gradient facilitates unloadingof oxygen and CO removal from fetus
13
Q
Morning sickness reslomves
A
14-16wks gestation, 2/2 hormine changes
14
Q
Hyperemesis gravidarum
A
severe form of morning sickness w/ weight loss >5% and ketosis
15
Q
Renal Changes in pregnancy
A
kidneys increase and ureters dilate increasing GFR 50% and drops BUN- Cr 25%
16
Q
Hematology changes in pregnancy
A
plasma volume increase 50%, RBC only 20-30 leading to dilutinal anemia
Stress can lead to WBC
slight drop in platelets but considered hypercoaguable 2/2 elv fibrinogen and factors VII and X, clot and bleed times do NOT change
17
Q
Hormones of pregnancy (4)
A
Estrogen from the placenta - little from the ovaries -< fetal well being
hCG - dissimilar alpha and beta subunits, alpha similar to LH , FSH and TSH, beta differs; doubles every 48hours, peaks at 10-12wks, made by placenta to maintain Corpus Luteum
Progesterone - initally Corp Lut, then placenta-> relaxed smooth muscles
Human placental lactogen, - placenta, indues lipolysis and insulin antagoist -> nutrients in blood stream
Prolactin
18
Q
Thyroid in pregnancy
A
estrogen stimulates binding globulin TBG - > increase of total T3 and T4, free levels constant
hCG weak stimulator on thyroid-> increase of T3 and T4 and slight decrease of TSH
19
Q
melasma
A
mask of pregnancy w/ increase of melanocyte stimulating hormones and steropds
20
Q
Wrist pain in pregnance
A
2/2 carpel tunnel and swelling
21
Q
Nutrition in pregnancy
A
increase to 300kcal/day extra when pregnant and 500 when breast feeding
gain 20-30 lbs, overwight 15-25lbs, underweight 28-40lbs
22
Q
3 vitamin/nuturion supplementation
A
protein 60-75g/day
Calcium - 1.5/day
folate 0.4-0.8mg/day
23
Q
Bloodworm on initial pregnant eval
A
CBC Blood type Antibody screen RPR/VDRL; G/C Rubella antibody Hepatits B UA Urine cultutre chickenpox titre PPD if high risk HIV offered
24
Q
Maternal serum alpha fetoprotein(MSAP)
A
2nd trimetster - 15-18 wks, elevation shows increases risk for neural tube defects
triple screen - beta hCG and estriol,
Quad sceen - inhibin A
25
Screening US at?
18-20 wks,
usually quickening at 16-20
26
Rhogram offered
to Rh moms at 28wks
prenatal visits 2-3 weeks from 28-36wks, weekly after
27
Glucose loading test
27-29 weeks
given a 50g oral glucose load and check serum 1 hr later >140 (+)
f/u w/ Glucose tolerance test of 100g- measured at 1, 2 and 3 hr, elv of 2+ is positive (180-hr, 155-2hr, 140-3hr)
28
Screen for group B strep at
36 wks
| + treated with IV penicillin when present for labor
29
Biophysical profiles (5)
3rd trimester US of high risk pregnancy, score 0-2
-> amniotic fluid, fetal tone, fetal activity, fetal breathing, nonstress test (NST)
8/10 reassuting
30
Reactive NST if ?
2 accelerations of FHR n 20 min > 15 beats above baseline
31
fetal lung maturity
tested w/ lecithin to sphingomyelin ration from amniocentesis (should increase normal)
Type II pneumocytes secrete surfactant using phospholipids
32
Braxtin Hicks
Contractions w/out changes in cervix - several times/hr -day
33
woman with vaginal bleeding and/or abdominal pain think of?
ectopic pregnancy
34
Risk factors for ectopic pregnancy
```
prior ectopic,
assistive reproductive technology
IUD
PID
Pelvic, ab surgery
Smoking
```
35
Findings of ectopic
unilateral lower abdominal pain, vaginal bleeding, uterus SGA,
hypotensive, tachy, unresponives if ruptures, peritoneal irritation
US Adnexal mass,
36
IUP b hCG rise level
66% every 48hrsm ectopic is not as predictable and not as high go a level
37
heterotropic pregnancy
small risk of intrauteral pregancy and ectopic, concern w/ IVF preganacies
38
b HCG in ectopic
follow it serially q 48 hrs for doubling, lack of -> ectopic
39
Tx of ectopic
fluids , blood and pressers if needed
-exploratory laparotomy, stable -> lapararoscopy and salpingostomy vs salpingectomy
Unruptured - surgical or methotrexate, <5000, single IM dose vs multidose
40
Spontaneous abortion (SAB)
miscarriage, ends <20 wks
| 15-25% of all pregnancies
41
Abortus
fetus lost before 20wks or <500g
42
complete abortion
complete expulsion of POC before 20 wks
43
Incomplete abortion
partial expulsion of POC before 20 wks
44
Inevitable abortion
no expulsion of POC but vaginal bleeding and dilation
45
threatened abotion
any vaginal bleeding before 20 wks w/o dilation of cervix or expulsion
46
missed abortion
death of embryo or fetus before 20 wks w/ complete retention
47
Ddx of 1st trip bleeding
```
SAB
Postcoital bleeding
ectopic
vaginal/cervical lesions/lac
extrusion of molar reg
nonpregnancy causes
```
48
Hemodynamically unstable incomplete abortions need
OR and D &C
49
Medical management of incomplete abortion
prostglandins-misoprostol
| +/- mifepristone
50
threatened abortion mgmt
pelvic rest, nothing per vagina
51
1st tri vs 2nd tri abortions
chromosomal abnormalities vs infection, maternal uteringe/cervical anomalies, maternal sustemic disease, fetotocixic agents
more often a D and E vs D and C depending of GA (16-24wks)
52
incompetent cervix
oainless dilation and effacement, 2nd tri
infection risk, cramps,
Risk w/ cervical trauma - LEEP, D and C, Cervical conization, DES exposure
53
Tx of cervical incompetence
elective termination if <24 wks is an option
Viable pregnancies - betamethasone; tocolysis if there is PTL
cerclage - suture around cervix or in the os- offered for subsequent pregnancies
54
Recurrent pregnancy loss
W/u
3+ consecuative SABs, less than 1%
2/2: chromosomal ab, systemic disease, anatomic defects, infection, antiphospholipid antibody (APA), luteal phase defect-lack of progesterone
karyotype, HSG, hypohyroidism, DM, APA, hypercoag, SLE, serum progesterone, cultures
55
Vaginal bleeding giva all women?
Rhogram if Rh -
56
Most common ectopic sites
70% ampulla -> isthmus -> fimbriae, Rarely overly, pelvic
57
increase in Hgb A2 think of
Beta thalassemia - seen couple months after birth with dealing Hgb F and more need of beta in production of Hgb
MCV <80 as well
58
Cis and trans mutations in alpha thalessemia
cis - SE asians
Trans - africanns
deletions of 2-4 genes varying in genotype
59
Hb bart
is Hbalpha4, no HbF or HbA without alpha subunits
all 4 deleted
60
Hemoglobin H disease
deletion of 3 alpha global genes -> excess beta chains
61
Alpha thalassemia trait
2 deletions - milder -. Microcytic anemia, normal Hgb electrophoresis.
1 gene silent carriers.
62
diagnosis of aneuploidy
only through karyotype definitely, US not specific. Can screen for 18 and 21
1st trimester - 11-18wks - nuchal translucency, PAPP-A, beta hCG;
2nd tri - sequential screen - MSAFP, estriol, b hCG, inhibin
63
Screen test of choice for Trisomy 18
US, tri and quad screen from tri21 overlap as well
64
Turner syndrome changes?
limites - cystic hygroma on US if anything
low set ears, broad chest. primary amenorrhea, webbed neck
no screeing test
65
Klinefelter syndrome
XXY
small firm testesm infertility, gynectomatia, mental retardation, elv gonadotopin levels
66
Early embryosis
zygote -> 16cell morula -> blastocyst w/ separation of embryo and trophoblast -> trophoblast becomes inner cytotrophoblast and outer syncytiotrophoblas ultimately the placenta, inner cell mads becomes bilaminar germ disc (edibles and hypoblast) -> epiblast forms 3 germ layers
organogenesis 3-8 weeks
67
Majority go neural tube defects occur
during defective closure by week 4 DA (6wkGA)
68
spina bifida US signs
lemon sign - concave frontal bones
Banana sign - cerebellum pulled caudally and flattened
ventriculomegaly and club feet
aslo have elv amniotic fluid of alpha fetoprotein (AFP)
69
Cardiac development in what week
begins in 3rd, 4 chambers at 4 weeks
70
tetrology of ballot see
overiding aorta
pulm stenosis
VSD
and RVH
71
Potter syndrome
renal failure leading to anhydeaminos -> pulm hypoplsaia and contractors/deformed limbs
bilateral renal ageneisis, can be 2/2 bladder outlet
Kidneys form wk4
72
metanephros vs mesonephric duct
mesonephric -> vas deferins, epidydymis, ejaculatory duct, seminal vesicles
Metanephric duct - function fidney and forms nephrons w/
73
Nuchal translucency
screens for aneuploidy and down - (70%)
done 1st tri
add on PAPP-A and beta hCG get 80% sensitivity (Serum is 60% alone)
74
```
Quad screen for Trisomy 21, 18, 13
MSAFP
Estriol
beta hCG
inhibin
```
75%-80% sens w/ 5% false positive
21- MSAFP:low; Estriol: low; hCG: Elv; Inhibin:elv
18-MAFSP:low; estriol: low; hCG:low; inhibin:low
13- depends on defects
75
Risk of downs >35
1:190 of aneuploidy, quad screen more sensitive to 80% vs 60% in younger
76
MSAFP elvation w/o elv amniotic AFP
greater risk of placental abruption, preeclampsia, IUGR, IUFD
77
echogenic intracardiac focus
soft US finding in down syndrome, calcification of papillary muscle w/o particular pathophys
78
Amniocentisis
15wks or greater for fetal karyotype, FISH
| higher loss rates 1:200 -1:350
79
Chroionic villus sampling -
get karyotype sooner at 9-12 wks, sample the chronionic villi of placenta
higher risk of complications
80
Percutaneous umbilical blood sampling - PUBS
needle transabdominally into uterus and phebotemize umbilcal cord -> fetal hematocrit or platelet count, Rh alloimmunicatidn
rapid karyotype
can transfuse the fetus as well
81
18-20wk US can ID what defets
cleft lip, polydactyl, clubfoot, fetal sex, NTD, abdominal wall defects, renal anomalies, cardiac and brain anomalies
82
MSAFP elevation concerning for
neural tube defect (spina bifida, meningomyelocele and anaencephaly)
ab wall defects - omphalocelle or gastroschisisis
folate deficiency possiblity
83
Neuro Tube defects increased in
DM and seizure disorders (carbamazepine, Valproic acid)
treat w/ 0.4 w/ no disorder, 4g if known risk
84
Ebstein anomaly 2/2 what drug
lithium - displaced tricuspid valve
85
SSRI effects on pregnancy
some affect on increase of fetal cardiac anomialis
86
prednisone affect on pregnancy
does not cross the placenta but leads to hyperglycemia
87
Leopold manuvers
fundus
Maternal left and right
pubic symphysis
determine fetal lie: longitudinal v transverse
presentation: breech vs vertex
88
PROM prolonged when
>18hrs before labor
| increase risk ofinfection
89
Diagnosis of rupture of membranes w/ 3 tests
pool- + if collection of fluid in vagina
nitrazine -amniotic fluid is basic -> blue
fern tests - estrogen -> crystallization
90
Bishop score (5)
>8 -> favors spontaneous labor, inducible, score 0-3
```
dilation: Closed, 1-2, 3-4, >5
Effacement: 0-30%, 40-50%, 60-70%, >80%
station: -3, -2, -1-0, >1
consistency: firm, med, soft
position: posterior, mid, anterior
```
91
Effacement
normal 3-5cm cervix,
if feels 2cm from ext to internal about 50%
100% when cervic is joining lower uterine segment
92
station in relation to
ischial spin = 0
93
fetal position in vrtex
Occiput transverse and occiput posterior can lead to prolonged delivery
Anterior fontanelle - diamond- 2 frontal and parietal
posterior fontanelle - triangle - 2 parietal and occipatal bone
94
labor =
contractions causing cervical changed
95
prodromal labor
irregular contractions w/ little to no cervical change
96
induce labor when?
post term, preeclampsia, DM, non reassuring fetal test, IUGR,
41 wks generally accepted
97
maternal and obstetric contraindications for prostoglandins
asthma and glaucoma
prior c section and non reassuring fetal testing
98
amniotomy
amnio hook used to puncture amniotic sac -> induction
99
FHR normal
110-160 bpm
>160 concern for distress w. infection, hypoxia or anemia
decl >2 min and HR action
100
```
FHR variability def
absent
minimal
oderate
marked
```
absent - <3BPM cariation
minmal 3-5; moderate 6-25; marked 26+
tracing should be jagged, flat lines are worrisome
formally reactive is 2 accelerations of 15bpm over baseline for 15s w/in 20 min
101
Early decelerations
begin and end at approximately same time as contraction, 2/2 increased vagal tone w/ head compression
102
variable decelerations
any time, drop fast, 2/2 umbilical cord compression
103
Late decelerations
begin peak of contraction and slowly return after contraction is finished, worry of uteroplacental insufficiency , worrisome
104
fetal scalp monitor
indication - repetitive decelerations or difficult doppler traces
electrode placed on fetal scalp
105
category 1 FHR
normal FHR w/ normal baseline, moderate variability, no variable or late decelerations
106
category 2 FHR
indeterminate FHR, variable and late decels, bradycardia, tachy, minimal or marked variability,
107
category 3 FHR
adnormal FHR, absent variablity, recurrent late or variable decellerations, bradycardia. sinusoidal pattern (anemia)
108
Montevideo unit
measurement of intrauterine pressure, 1015 normal, 20 30 early labor, 40-60 labor progression
109
Cardinal movements of labor(6)
Engagement; descent; flexion; internal rotation(OT->OA); extension, external rotation
110
3 stages of labor
Stage 1 - onset of labor -> dilation and effacement complete
Stage 2 - time of full dilation until delivery
Stage 3 - infarct till delivery of placenta
111
Stage 1 of labor lasts
2 phases
10-12 hrs in nulliparous, 6-8 in multiparous.
latent phase - onset -> 3-4cm dialtion
active phase 4-> 9cm; 1cm/hr dialation (null) vs 1.2cm/hr (multi)
112
3 Ps of labor
powers - 200montevideounits desired
passenger - concern for cephalopelvic disproportion (too large)
pelvis
113
Stage 2 too long if?
prolonged by?
>4hrs (2-3 in null; 1-2 in multi)
epidural use and null parity
114
hypertonus and tachysystole def
hypertonus - single contraction >2 min
tachysystole >5 contraction in 5 min
give terbutaline to help relax uterus
- nonreassuring w/ intervetnion (prolonged decelerations and bradycardia) -> c section
115
episiotomy indications
hasten delivery
ongoing shoulder dystocia
median and mediolateral options
116
Placental seperation is allowed how long?
Signs
30 minutes
cord lengthening, gush of blood and uterine fundal rebound
117
degree of lacerations
1st degree - mucosal of skin - interupted
2nd degree - extend to perineal body but not sphincter, repair layers
3rd - extend into or through anal sprinter,
4th degree - anal mucosal itself is torn
118
Indications for c section
no change in cervix for 4 hours
breech presentation, teansverse lie, shoulder presents, placenta previa, placental abruption, fetal intolerance of labor, non reassuring fetal status, cord propse, active herpes lesion, untreated HIV, uterine surgeryprevious c section
119
TOLAC
trial of labor after c-section - greatest risk in VBAC
risk of uterine rupture, higher risk with induction ( ab pain, FHR decl, drop of IUPC, maternal sensation of "pop"
120
Analgesia in labor
-narcotics: fentanyl, nubain, stadol, IM morphine early on, no narcs late in labor 2/2 resp depression in kids
-Pudendal block - bilaterally
-local for episiotomy
-epidural catheter in L3-L4, not given till active pass, vaginal labor
-spinal - region similar to epidural but 1 time dose into spinal canal vs continuous, c section
(concern of maternal hypotension)
121
postpartum timeline
6 wks after delivery
122
Hormone that stimulates milk let down
oxytocin, released from pituitary gland
also stimulates uterine contractions
123
Benefits of breast feeding
lose weight
| decrease childhood infection, lowe risk of T2DM,
124
Trap given when?
if not received vaccine in 10yrs prior to pregnancy to protect from pertussis
125
Rhogram postpartum given
w/in 72hrs if Rh negative
antibodies to Rh D that remove any fetal + cells from mom's circulation
126
contraceptum postpartum
30days needed for postpartum tubal
Progesterone only if breastfeeding(depo, implanon, mirena), combo pills decrease milk production, also should wait 6 wks if venous thromboembolic risk
Usually wait 6 wks for IUD
127
Complications post vaginal delivery
postpartum hemorrhage, vaginal hematoma, cervical laceration, retained POC, mastitis, postpartum depression
Rare: endomyometritis, episiotomy infection, episiotimy breakdown
128
Complications of C seciton
postpartum hemorrhage, surgical blood loss, wound infection, endomyometritis, mastitis, postpartum depression
Rare: Wound seperation, wound dehiscence
129
Post partum hemorrhage
blood loss > 500mL vaginal >1000 c section. early or late depending on 24hrs
2/2 uterine atony, retained POCs, placenta accreta, cervical lacerations
loss of 2-3L concern of consumptive coagulopathy
130
Sheehan syndorme
absence of lactation2/2 lack of prolactin or failure to restart menstruation due to lack of gonadotropins
hypovolemic pituitaty
131
uterine atony
leading cause of postpartum hemorrhage
higher risk if: chorioamnionitis, ma sulfate, mtpl gestation, macrocosmic fetus, polyhydraminos, prolonged labor, Uterine abnormalities or fibroids interfering w/ contraction
132
uterine atony tx
Tx w/ IV oxytocin w/ strong uterine massage, methylergonovine if continues(not in HTN), hemabate (PGF2) is next step (not asthma)
D and C to r/o POC is continued
133
Retained POC
uerus to be explored manually if cervix is not contracted or US (uterine strip)
D and C if suspicion is high as diagnostic and therapeutic
134
Tx of uterine inversion
uterine relaxant - nitro or general anesthesia - then manual replacement
135
Etiology of postpartum hemorrage
Vaginal: vaginal lac, cervical lac, uterine atony, placental accreta, vaginal hematoma, retained POC, uterine inversion, uterine rupture
C section: uterine atony, surgical blood loss, placental accrete, uterine rupture
136
Endomyometritis
polymicrobial infection of uterine lining often invading the underlying muscle wall
more common in c sections but also seen in vaginal delivery
DxL fever, WBC, uterine tendeness 5-10 days after delivery. Get US to r/o retained POC
Tx w/ IV abx until afebrile for 48hrs and no pain no WBC
137
Cellulitis post c section
1-5%
local erythema and tenderness, warm
-expansion around erythema in over 12-24hrs also makes Dx
TX broadly
Access if not better and need surgical I and D
138
mastitis
regional infection of breast -> erosion or cracked nipple, focal tenderness, erythema, difference in temp local
fever and WBC
Tx: dicloxacillin and still breastfeed or pump
139
Postpartum depression
2-3 days after delivery, resolving in 2 weeks.
Sad, disinterested,
low energy level, anhedonia, anorexia, apathy, sleep disturbance, extreme sadness, - feel incapable of caring for their kid, Suicidal
Hx of bipolar
140
Surgical mgmtof post partum hemorrhage
D and C-> exploratory laparotomy -> uterine artery ligation ->hypogastric artery ligation -> hysterectomy
141
lactational amenorrhea
Prolactin suppresses pulsitile GnRH from hypothalamus suppressing ovulation
ovulation occurs before menstration-> pregnancy 15-55%
Max 6 months
142
MOA of IUD
most widely used reversible contraception worldwide
elicit sterile inflammatory responsein sperm being engulfed, immobilized and destroyed, also reduce tubal mobility to inhibit sperm and blastocyst transport.
NOT ovulation affect's nor abortifacints
Progesterone in mirena thickens cervical mucus and atrophies endometrium
143
SFx of IUDs
safe but can have pain, bleeding, pregnancy, expulsion perforationn. Placement w. cervical infections can lead to PID, Screen for gonorrhea and chlamydia prior to insertion of IUD, no need for PPX abx
Mirenas may lead to decrease PID w/ cervical mucus
SAB increases 40-50% if pregnant on IUD. can remove IUD to prevent
144
absolute contraindication to IUD
Absolute: known/suspected preg, diagnosed ab vaginal bleeding, acute cervical/uterine/salpingeal infection, copper allergy, current breast CA
relative prior ectopic, Hx of STI (3months), uterine anomaly or fibroid distorting cavity, current menorrhagia or dysmennorhea, STI
145
absolute contraindication to IUD
Absolute: known/suspected preg, diagnosed ab vaginal bleeding, acute cervical/uterine/salpingeal infection, copper allergy, current breast CA
relative prior ectopic, Hx of STI (3months), uterine anomaly or fibroid distorting cavity, current menorrhagia or dysmennorhea, STI
146
Advantages of IUD
approved for 5y (mirena) and 10y (paragaurd)
IUD can be inserted after induced or spontaneous 1st tri abortion w/o risk of infection or perforation; paragaurd emergency contraception when placed w/n 72 hrs
place generally 6 wks after can be postpartum
Mirena-> decreases menorrhagia and dysmenorrhea, tx endometriosis, endometrial hyperplasia, Protects to PID, 20% amenorrhea in 1yr w/ 60 % after 5 yrs
147
OCP MOA
induces pseudopregnancy w/ interference of pulsatile FSH and LH-> suppressed ovulation, no surge so no follicle growth, recruitment.
Bleed is during withdrawal of hormone rather than a menstrual period
secondary have thickened cervical mucus and changing endometrium
148
Only drug that decreases OCP efficacy
Rifampin
can also barbs, carbamazepine, griseofulvin, phenytoin, st johns wart, topiramate
Medications whose efficacies are changed: chlordiazepoxide, diazapam, hypoglycemics,methyldopa, phenothiazides, tricyclics
149
OCP SFx
Cardio: DVT, PE, CVA, MI, HTN(estrogen >50mg)
-higher w/ 35y, and smoke
Other:
cholelithiases,
cholecystitis,
benign liver adenoma (rare), cervical adenocarcinoma(rare), retinal thrombosis (rare)
N/V HA, weight gain, breakthrough bleeding
150
OCP contraindicated is
>35 years old and smoke 15> cigarettes a day
-Progestin also raise LDL while lowering HDL;
PE, thromboembolism, CVA, breast/endometrial CA, unexplained vaginal bleeding, abnormal liver function, hypercholesterolemia, hypertrigleridemia
Relative: fibroids, lactation, DM, sickle cell, hepatic disease, HTN, SLE, age 40, migraine HA, seizure disorders, elective surgery
151
Ortho evra FYIs
progestin and estrogen containing
| Have INCREASED risk of DVT and PE compared to OCPs
152
Ortho evra FYIs
progestin and estrogen containing
Have INCREASED risk of DVT and PE compared to OCPs
1/wk patch for 3 wks
Decreased effectiveness in markedly overweight women (>198lbs/90kg)
153
Nuva ring FYIs
estradiol and etonogestrel
vagina for 3 wks and removed for 1 wk for w/drawal. can be dosed continuously for up to 3 months
removed rings should be replaced w/in 3 hours
154
progesterone only pills
taken everyday of the cycle w/ no hormone free periods
thought to thicken the cervical mucus but decreases in 22hrs. MUST be taken SAME time everyday; also endometrial atrophy and ovulation suppression
NOT as effective as combo's w/ 8% failure
SFx: irregular cycles, breakthrough bleeding, increased follicular cysts, acne, breast tender
155
Use or progesterone only pills
nursing moms and where estrogen is contraindicated: >35 and smoke, HTN, CAD, collagen vascular disorder,,
abnormal uterine bleeding in high risk medical populations
Disadvantage: irregular menses and strict timeline (w/in 3 hrs)
156
Depo-provera
DMPA - medroxyprogesterone acetate
lasts 3 months and acts to suppress ovulation, thicken cervical mucus, make endometrium unsuitable. No ovulation for 14 wks (2wks grace)
SFx: irregular menstural bleeding(70% and main reason for d/c- 50% amnenorrhea after 1 yr), depression, weight gain, hair loss, HA
Amenorrhea -> choice option for: bleeding disorders, women on anticoag, military, mentally ill and disabled
>2yrs experience reversible decrease in bone mineralization due to decrease estradiol. Vit D, Ca, weight bearing activities
157
Good and bad of Depo
good: highly effective - shots every 3 months, reduces risk of endometrial CA and PID, Tx menorrhagia, dysmenorrhea, endometriosis, menstrual related anemia, endometrial hyperplasia
Bad: irregular bleeding, mood changes and weight gain, delay to ovulation ranges from 6-18 months, avg 10
158
Depo-provera
DMPA - medroxyprogesterone acetate
lasts 3 months and acts to suppress ovulation, thicken cervical mucus, make endometrium unsuitable. No ovulation for 14 wks (2wks grace)
SFx: irregular menstural bleeding(70% and main reason for d/c- 50% amnenorrhea after 1 yr), depression, weight gain, hair loss, HA
Amenorrhea -> choice option for: bleeding disorders, women on anticoag, military, mentally ill and disabled
>2yrs experience reversible decrease in bone mineralization due to decrease estradiol. Vit D, Ca, weight bearing activities- no role of DEXA, bisphosphonates, SERMS
159
Good and bad of Depo
good: highly effective - shots every 3 months, reduces risk of endometrial CA and PID, Tx menorrhagia, dysmenorrhea, endometriosis, menstrual related anemia, endometrial hyperplasia
Bad: irregular bleeding, mood changes and weight gain, delay to ovulation ranges from 6-18 months, avg 10
160
Nexplanon
subdenraml progestin(etonogestrel) implant - 3 yrs;
effective after 24hrs and quick return to fertility, suppresses ovulation, alters endometrium and increases cervical mucus
most highly effective reversible contraceptive method
SFx: irregular and inpredictable light bleeding -> 15 of discontinuation, some have HA
161
Emergency contraception
NOT for known or suspected pregnancy, only for failure of other methods, No known adverse effecs to mom, fetus if unintentionally taken
can be used if Hx of DVT, PE, MI, stroke etc
3 forms: morning after pill, paraguard, elective progesterone receptor modulator (Ella)
162
Emergency contraceptive pills
HIGH dose estrogen and progestins or progesterone alone
-levonorgestrel methods preferred over estrogen-progesterone regimens
plan B - progestin only- must be taken w/in 72 hrs
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Emergency contraceptive pills
HIGH dose estrogen and progestins or progesterone alone
-levonorgestrel methods preferred over estrogen-progesterone regimens
plan B - progestin only- must be taken w/in 72 hrs, sooner the better (fail 0.2-3%)
SFx: N/v - 50%/20%; HA, dizzy, breast tenderness; no real contraindications
164
Most effective form of emergency contraception
copper IUD
creates a sterile inflammatory response(making env unsuitable for fertilization), Can be inserted in cavity w/in 120d(5 days)
165
Most effective form of emergency contraception
copper IUD
creates a sterile inflammatory response(making env unsuitable for fertilization), Can be inserted in cavity w/in 120d(5 days)
166
Emergency progesterone receptor modulator - ELLA, ulipristal
newest form, acts as a selective progesterone receptor modulator w/ agonist and antagonist effects -> delay of ovulation and inhibiting implantation
5d after effectiveness (2%)
SFx- HA, bleeding, N and ab pain
Contraindicated if pregnant/breastfeeding, need a pregnancy test prior and is prescription only
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Emergency progesterone receptor modulator - ELLA, ulipristal
newest form, acts as a selective progesterone receptor modulator w/ agonist and antagonist effects -> delay of ovulation and inhibiting implantation
5d after effectiveness (2%)
SFx- HA, bleeding, N and ab pain
Contraindicated if pregnant/breastfeeding, need a pregnancy test prior and is prescription only
168
Surgical sterilization options
postpartum sterilization- peri-delivery (modifed Pomeroy tubal ligation)
laparoscopic tubal ligation -post (bipolar cautery, silastic banding w/ Falope rings, haulka or fishie clips)
hysteroscopic tubal occlusion - essure (12 wks to sterilization- HSG can confirm)
low risk of pregnancy but when occurs-> ectopic; reduced risk of ovarian CA due to less carcinogens?
Regret is highest when
169
Surgical sterilization options
postpartum sterilization- peri-delivery (modifed Pomeroy tubal ligation)
laparoscopic tubal ligation -post (bipolar cautery, silastic banding w/ Falope rings, haulka or fishie clips)
hysteroscopic tubal occlusion - essure (12 wks to sterilization- HSG can confirm)
low risk of pregnancy but when occurs-> ectopic; reduced risk of ovarian CA due to less carcinogens?
Regret is highest when
170
Rx in abortions
```
mifepristone RU486(synthetic progesterone receptor antagonist-> blocking stim on endometrial growth) and misoprostol - only through 1st trimester, Use up to 63 from LMP
-> methotrexate off-label available up to 49d LMP
```
SFx: abnormal pain, cramps, N/V, urerine bleeding (2hrs after prostaglandin, time completion is typically 24-48hrs), vaginal bleeding 10-17d
Failed -> D and C
D and C; MVAC in 1st tri; D and E in 2nd tri (14wks)
171
Rx in abortions
```
mifepristone RU486(synthetic progesterone receptor antagonist-> blocking stim on endometrial growth) and misoprostol - only through 1st trimester, Use up to 63 from LMP
-> methotrexate off-label available up to 49d LMP
```
SFx: abnormal pain, cramps, N/V, urerine bleeding (2hrs after prostaglandin, time completion is typically 24-48hrs), vaginal bleeding 10-17d
Failed -> D and C
D and C; MVAC in 1st tri; D and E in 2nd tri (14wks)
172
infertility defined
failure of a couple to not concieve after 12 months of unprotected sex
>35yr/o female start eval after 6 months
fecundity rate = 20-25% in 3 months
most common: ovulatory, fallopian tube abnormalities (pelvic adhesions) and endometriosis
173
Ovulatory Disorders for infertility
most common are PCOS and advanced maternal age
Oocyte aging is important(rate of loss of viable follicles accelerates after mid 30s)
premature factors: tobacco, viruses, radiation and chemo and autoimmune and genetic disorders
decline in quantity and quality
174
Tubal disorders for infertility
PID primarily; also can have severe endometriosis, Hx of ectopic, pelvic adhesions, non gyn Hx of appendicitis and diverticulitis
175
Endometriosis in infertility
15% of infertile woman
Unknown MOA - tubal obstruction, trapping of oocyte?
176
Uterine/cervical factors leading to infertility
account for
177
Uterine/cervical factors leading to infertility
account for
178
Luteal phase defect
disruption of HPGA -> inadequate production of progesterone by corpus luteum and delay of endometrial maturation
179
Luteal phase defect
disruption of HPGA -> inadequate production of progesterone by corpus luteum and delay of endometrial maturation
180
clomiphene citrate challenge test
used to asses for decreased ovarian reserve,
admin 100mg of clomiphene on days 5-9 of the menstration. FSH measured on days 3 and 10
->small elv in FSH correlate w/ decreased fecundity; good ovarian hormone reserve will make enough early to provide inhibition of FSH and keep it low (>20mIU/mL bad)
181
Alternatives to Clomiphene citrate challenge test
replaced by FSH/estradiol testing, the antral follicle count (AFC), and anti-mullerian hormone (AMH)
estradiol day3 0.5ng/mL) is adequate 0.15 is not
182
Tx of PCOS infertility
```
weight loss(5-10%),
metformin- increases peripheral glucoseintake w/ insulin sensitization 2/2 inhibition of gluconeogenesis
```
ovulation induction w/ clomid or letrozole(aromatase inhibitor)-> if failed can be done again w/ IUI or IVF
183
Hypothalamic pituitary failure Tx of infertility
pulsatile gonadotropin-releasing hormone therapy or human gonadotropins
184
Tx for primary ovarian insufficiency
none 2/2 lack of viable oocytes
offered egg donation, gestational surrogacy or adoption
185
Tx of endometriosis infertility
symptomatic relief medically or surgically but NO role for medical mgmt in Tx
Danazole, lupron, provera or continuous OCP only help w. symptoms
surgery improves fertility rate w/ ligation ofperiadnexal adhesions during laparscopy or laparotomy or fulguration of endometrial implants
186
Txx for tubal occlusion w/ infertility
tubal renastomosi is an option but most choose IVF
187
Tx of uterine factors for infertility
operative hysterpscopy - fibroids, uterine synechiae, septae, polyps
estogen therapy and intrauterine devices to prevent recurrence of adhesions
188
Male factors with infertility
35%; risk w/ occupational /env exposure to chem, heat, radiation, Hx of varicocele, mumps, hernia repair; Meds: cimetidine, sulfasalazine, spironolactone, metclopramide, chemo, beta blockers, nitrofurans, anabolic steriods, marijuana, alcholol, cocaine
semen analysis- count, volume, pH, WBC
postcoital test - rare, interaction w/ sperm and mucus
Tx: avoid, tight underwar/saunas/env exposures
washed out sperm for IUI-> low count or volume
Intracytoplasmic sperm injection: single sperm into single egg and IVF
189
Tx for tubal occlusion w/ infertility
tubal renastomosi is an option but most choose IVF
190
Male factors with infertility
35%; risk w/ occupational /env exposure to chem, heat, radiation, Hx of varicocele, mumps, hernia repair; Meds: cimetidine, sulfasalazine, spironolactone, metclopramide, chemo, beta blockers, nitrofurans, anabolic steriods, marijuana, alcholol, cocaine
semen analysis- count, volume, pH, WBC
postcoital test - rare, interaction w/ sperm and mucus
Tx: avoid, tight underwar/saunas/env exposures
washed out sperm for IUI-> low count or volume
Intracytoplasmic sperm injection: single sperm into single egg and IVF
191
Clomiphene citrate - Clomid
Selective estrogen receptor modulator (SERM). competitively binds to estrogen receptors in the hypothalamus - blocking negative feedback leading to GnRH pulsitile increase w. subsequent FSH and LH increased -> increase endogenous estrogen
given day 3 or 5 of follicular phase for 5 days, ovulation generally occurs 5-12 days after clomid
1st line unexplained infertility- 80% ovulate in correctly selected Patients and 36% pregnant, try 3-6 times
NOT premature ovarian failure
192
Letrozole
aromatase inhibitor that decreases conversion of androgens into estogen
lower estrogen reduces negative feedback, off label use in US
193
human menopausal gonadotropins - novarel, pregnyl profasi
best for infertility and ovulation induction when pituitary gland fails to secrete FSH and LH and clomid is incapable of stimulation ovulation - 80-90% success rate of ovulation and 10-40% pregnancy; higher risk of ovarian hyperstimulation
admin IM, monitor close through serial estrogen levels and pelvic US to measue # follicles, size and total estrogen
194
human menopausal gonadotropins - novarel, pregnyl profasi
best for infertility and ovulation induction when pituitary gland fails to secrete FSH and LH and clomid is incapable of stimulation ovulation - 80-90% success rate of ovulation and 10-40% pregnancy; higher risk of ovarian hyperstimulation
admin IM, monitor close through serial estrogen levels and pelvic US to measue # follicles, size and total estrogen
195
Clomide SFx
antiestrogenic - hot flashes, abdominal distension, bloating, emotional liability, depression, visual changes
mtpl gestation- major side effect 8%
196
Clomide SFx
antiestrogenic - hot flashes, abdominal distension, bloating, emotional liability, depression, visual changes
mtpl gestation- major side effect 8%
