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Flashcards in Treatments 6 Deck (94):
1

Central precocious puberty

Continuous GnRH

2

Pseudoprecocious puberty

Remove tumor, cortisol replacement for CAH

3

Pros of HRT for menopause

Control symptoms
Reduced risk of osteoporosis
Reduced risk of colorectal cancer
May decrease coronary calcification if taken age 50-59 (unknown correlation w/ cardiac disease)

4

Cons of HRT for menopause

Increases risk of invasive breast cancer, endometrial cancer (NO estrogen w/o progesterone if woman still has uterus)
Increases risk of stroke, heart disease, hypercoagulability, biliary disease

5

Non-HRT options for hot flashes

Desvenlafaxine, venlafaxine
Clonidine
Gabapentin
Time

6

Menopause treatment

Vaginal lubricants (dyspareunia)
Calcium, vitamin D, bisphosphonates, weight bearing exercise (osteoporosis risk)
SERMs (tamoxifen, raloxifene) (osteoporosis risk)

7

Emergency contraception

High dose OCPs (lots of AE)
Levonorgestrel (Plan B, just progesterone)
Copper IUD (insertion w/i 4-5 days of intercourse)
Mifepristone (RU 486) (low dose, high dose for abortion)

8

Pros of OCPs

Reliable
Reduce risk of endometrial and ovarian cancer
Decreased incidence of ectopic pregnancy
Menses lighter, more regular, less painful

9

C/I for OCPs

Pregnancy
History of DVT/PE/hypercoagulability disorder
History of estrogen-dependent tumor
History of stroke or CAD
Poorly controlled HTN
Smokers >35 yo
Hepatic disease or neoplasm
Abnormal vaginal bleeding of unknown etiology
Migraine w/ aura, neuro sx or vascular involvement

10

Amenorrhea, behavioral

Behavior modification (eating, exercise)

11

Amenorrhea, anatomic

Surgical correction

12

Amenorrhea, HPO dysfunction

Leuprolide (GnRH agonist), pulsatile

13

Amenorrhea, prolactinoma

Dopamine agonists (bromocriptine, cabergoline)

14

Dysmenorrhea

NSAIDs, OCPs

15

PMS, PMDD

NSAIDs, OCPs
Vitamin B6, SSRI +/- alprazolam, exercise, progestins

16

Endometriosis

OCPs, progestins, GnRH, NSAIDs, (danazol)
Laparoscopy
Definitive = hysterectomy + b/l salpingo-oopherectomy

17

Abnormal uterine bleeding

Treat cause
NSAIDs, OCPs
Endometrial ablation / hysterectomy

18

When to get endometrial biopsy w/ abnormal uterine bleeding

Patient >45
Patient w/ multiple risk factors for endometrial cancer
Patient w/ persistent AUB >6 months

19

PCOS

Exercise, weight loss
OCPs (or at least progesterone by itself)
Spironolactone
Metformin
Consider statin, acne meds as needed

20

PCOS if patient wants to get pregnant

Clomiphene (antiestrogen, acts at hippocampus)

21

Pelvic prolapse

Mild - pelvic floor exercises
Moderate - pessary
Severe - surgery

22

Uterine fibroids (leiomyomas)

Asymptomatic - observation
GnRH agonists (temporary), OCP/IUD (for bleeding)
Myomectomy, hysterectomy, UAE

23

Endometrial cancer

TAH w/ bilateral salpingo-oopherectomy and LN sampling
Progestins to maintain fertility then surgery after finished
Add chemo/radiation for mets

24

Cervical cancer

Microscopic (<5 mm): TAH or conization
Visibly invasive: radical hysterectomy + lymphadenectomy
Major invasion/mets: radiation + chemo

25

SCC of the vagina

Radiation

26

Lichen sclerosis

Punch biopsy to r/o SCC
Steroids (clobetasol)

27

Benign ovarian tumors

Observation for functional cysts
Cysectomy or oopherectomy if malignant potential
TAH-BSO for postmenopausal

28

Ovarian cancer

Epithelial - TAH-BSO w/ pelvic wall sampling, abdominal omentum resection, LN resection w/ adjuvant chemo
Germ cell - oopherectomy +/- debulking w/ chemo

29

Fibrocystic changes

Observation
Caffeine and dietary fat reduction, OCPs

30

Breast abscess

I&D, antibiotics (dicloxacillin, cephalexin, amoxicillin-clavulanate, TMP-SMX for MRSA, metronidazole for anaerobes), continue breastfeeding

31

Phyllodes tumor

Excision (some malignant potential)

32

Fibroadenoma

May observe if asymptomatic
Surgical excision or US-guided cryotherapy

33

Intraductal papilloma

Surgical excision (rare malignant potential)

34

Physiologic anemia of pregnancy

Iron supplementation if Hct <10.5 (second trimester)

35

Increased nutritional demands of pregnancy

Folic acid, calcium, iron
Protein, fluids
Vitamin D, B12 for strict vegetarians

36

Vaccines indicated during pregnancy

Tetanus q10 years (esp P of TdaP) in 2nd/3rd trimester
Influenza (shot) annually
Only if indicated: pneumococcal, meningococcal, Hep A/B

37

Vaccines C/I during pregnancy

Live
MMR, varicella
Oral polio, intranasal influenaza

38

Postpartum or post-abortion vaccines

Rubella before discharge if non-immune
TDaP if none in last 10 years
Varicella before discharge if non-immune (2nd dose 4-8 weeks later)

39

Gestational or pregestational diabetes

Diet and exercise
Insulin = DOC

40

Preeclampsia

Delivery is only definitive cure
Monitor patient closely (out or inpatient)
Blood pressure control
MgSO4 until 24 hrs post delivery

41

Eclampsia

Delivery is only definitive cure
Stabilize w/ O2 and blood pressure control
MgSO4 until 48 hrs post delivery
Try diazepam to control acute seizure

42

BP medications in pregnancy

HTN moms love nifedipine
Hydralazine
Methyldopa
Labetalol (BB)
Nifedipine

43

Epilepsy in pregnancy

Keep on anticonvulsants w/ folate supplementation
Diazepam to break active seizures (Mg is useless)

44

Asthma in pregnancy

Same as non-pregnant
Mild intermittent: short-acting B agonists (albuterol) PRN
Mild persistent: add low dose inhaled steroid
Moderate persistent: medium dose steroid or low dose steroid + long-acting B agonist (salmeterol)
Severe persistent: high dose inhaled steroid + long-acting B agonist

45

Hyperemesis gravidarum

Hydration, avoid large meals
Vitamin B6 + ginger
OTC doxylamine
Prescription ondansetron or promethazine

46

DVT in pregnancy

Heparin / LMWH until 6 weeks postpartum (stop during L&D)
Can switch to warfarin PP (safe during breastfeeding)

47

UTI in pregnancy

Amoxicillin, nitrofurantoin, cephalexin x7 days
NO fluoros

48

Toxoplasmosis in pregnancy

Pyrimethamine, sulfadiazine, folinic acid
(avoid cat litter boxes, raw meat, unpasteurized milk, gardening)

49

Rubella in pregnancy

No treatment while pregnant

50

Rubeola in pregnancy

Immune serum globulin during pregnancy

51

Syphilis in pregnancy

Maternal or neonatal penicillin

52

CMV in pregnancy

No treatment while pregnant
Ganciclovir may decrease effects in newborns

53

HSV in pregnancy

Acyclovir starting wk 34-36
Deliver by c-section if active lesions
Acyclovir may be beneficial in newborns

54

Hep B in pregnancy

Maternal vaccination (can be during pregnancy)
Vaccination and Ig for neonate

55

HIV in pregnancy

HAART during pregnancy (avoid certain drugs)
AZT during labor
Usually c-section
No breastfeeding

56

Gonorrhea/chlamydia in pregnancy

Erythromycin for mom or baby (can be eye drops for neonate)

57

VZV in pregnancy

Varicela Ig to nonimmune mother and neonate born during active infection

58

GBS in pregnancy

IV B-lactams (penicillin/ampicillin) or clindamycin if:
+GBS screening at week 36
+GBS bacteruria during pregnancy
Previous infant with GBS infection
If no screening, intrapartum fever, preterm labor or prolonged rupture of membranes

59

Parvovirus B19 in pregnancy

Monitor fetal hemoglobin
Possible transfusion by PUBS

60

Ectopic pregnancy

MTX (<5,000 B-hCG, etc) or surgical excision

61

Threatened abortion

Bed rest, limited activity

62

Missed abortion

Expectant management (most pass w/i 2 weeks)
Misoprostol (PGE1)
D&C

63

Inevitable abortion

Expectant management
Misoprostol (PGE1)
D&C

64

Incomplete abortion

Misoprostol (PGE1)
D&C

65

Complete abortion

None

66

Intrauterine fetal demise

<24 weeks can undergo D&E
Induce labor and delivery (oxytocin, PGE1, 2)

67

IUGR

Monitor
Nutrition/O2/bed rest for mom
Delivery if fetal growth slows further or maternal or fetal distress

68

Oligohydramnios

Expectant management if no fetal distress
Delivery if fetal distress
Hydration +/- bed rest

69

Polyhydramnios

Percutaneous drainage if mom very uncomfortable or threat of pre-term labor
32 weeks: amnioreduction alone

70

PROM / PPROM

34 weeks: abx + delivery

71

Preterm labor, tocolysis

MgSO4, terbutaline, indomethacin or nifedipine (48 hrs)

72

Preterm labor, overall

Tocolysis + glucocorticoids <34 weeks
Ampicillin if delivery imminent

73

Placenta previa

Bed rest, RhoGam, tocolysis + steroids
C-section usually (can try vaginal in low-lying)

74

Placenta abruptio

Bed rest inpatient
Usu have quick delivery, if not perform c-section for hemodynamic instability

75

Molar pregnancy

D&C
Follow B-hCG to zero and then 1 year after

76

Choriocarcinoma

Hysterectomy
Chemo (MTX, etc) if metastatic
Follow B-hCG to zero and then 1 year after

77

Early decels during labor

None (head compression)

78

Variable decels during labor

Change mother position

79

Late decels during labor

Possibly need prompt delivery

80

Labor dystocia - assessment

3Ps
Power - contraction strength (>200 MVU/10 min), duration and frequency (every 2-3 min)
Passenger - baby size, lie (anterior occiput/looking down > posterior occiput/looking up)
Pelvis - shape and diameter

81

Non-reassuring fetal heart tones during labor

Maternal O2, movement to LLD
Turn off oxytocin/cervidil (maybe terbutaline to stop)
Manage maternal hypotension
Vaginal exam for cord prolapse

82

Breech presentation

Offer ECV at 37 weeks
C-section if unchanged

83

Indications for c-section

Maternal: eclampsia, prior uterine surgery (inc c-section), cardiac disease, birth canal obstruction, maternal death, cervical cancer, active genital herpes
Fetal: acute fetal distress, malpresentation, cord prolapse, macrosomia
Both: failure to progress in labor, placenta previa or abruptio, cephalopelvic disproportion

84

Postpartum bleeding

Uterine massage + oxytocin/pitocin

85

Mastitis

Continue nursing
Rest, ibuprofen, antibiotics (dicloxacillin cephalexin, TMP-SMX for MRSA, metronidazole for anaerobes)
I&D for abscess

86

Oral contraceptives for lactating women

Progesterone only

87

Postpartum bleeding w/ HTN

Hemabate (if no asthma)

88

Postpartum bleeding w/ asthma

Methergine (methylergonovine) (if no HTN)

89

Postpartum bleeding, non medical options

Uterine or iliac artery ligation, arterial embolization, hysterectomy
D&C for retained placenta
Tamponade

90

Postpartum endometritis

Gentamicin + clindamycin +/- ampicillin

91

Infantile thrush

Nystatin oral suspension

92

SIDS prevention

Sleep on back
Sleep on firm surface
Avoid soft objects in bed
Avoid overheating
Use pacifier while sleeping
No smoking

93

Work-up on newborn w/ single umbilical artery

Renal sonogram for abnormalities

94

Car seat guidelines

<13 in back seat