Week 4 Flashcards

Question

**Postnatal depression** - Management? Tx?

Answer 1

Only social support and psychological treatments may be appropriate, depending on the severity of the depressive episode. If there is a need for medication, (in individuals who have moderate depression where there are risks or non response to other treatments, or in individuals with severe depression), consideration needs to be given to whether the patient is breastfeeding. If not, recommended management of depression will be the same as in a non-breastfeeding woman. If breastfeeding, the risk benefit ratio of different antidepressants needs to be discussed with the patient, so they can make their own choice about treatment. Again published guidelines recommend different antidepressants for use in breastfeeding women, so it may be best to seek advice from pharmacy colleagues or specialist Perinatal Psychiatry Services.

Answer 2

1. Feeling ‘high’, ‘manic’ or ‘on top of the world’. 2. Low mood and tearfulness. 3. Anxiety or irritability. 4. Rapid changes in mood. 5. Severe confusion. 6. Being restless and agitated. 7. Racing thoughts. 8. Behaviour that is out of character. 9. Being more talkative, active and sociable than usual. 10. Being very withdrawn and not talking to people. 11. Finding it hard to sleep, or not wanting to sleep. 12. Losing your inhibitions, doing things you usually would not do. 13. Feeling paranoid, suspicious, fearful. 14. Feeling as if you’re in a dream world. 15. Delusions: odd thoughts or beliefs that are unlikely to be true. For example, you might believe you have won the lottery. You may think your baby is possessed by the devil, or that people are out to get you. 16. Hallucinations: you see, hear, feel or smell things that aren’t really there.

Answer 3

Parental mental illness can have significant and lasting effects on infants and young children. The early years of a child's life are critical for their emotional, cognitive, and social development, and the presence of mental illness in a parent can influence various aspects of their well-being. Addressing parental mental illness involves a holistic approach that considers the well-being of both the parent and the child. Early identification, access to mental health services, support systems, and a nurturing environment can significantly mitigate the potential negative impact of parental mental illness on infants and young children.

Answer 4

Experiencing a stillbirth, the loss of a baby after the 20th week of pregnancy, is a devastating and emotionally complex event. The management of a woman who has had a stillbirth involves a combination of medical care, emotional support, and guidance to address the physical and emotional aspects of the situation. The issue of suppressing lactation, which can be particularly challenging, is an important consideration as well.

Answer 5

- Apply breast pads to assist in soaking up any breastmilk leakage. Encourage changing pads when they become soaked - Advise woman to lie on her back or on one side with an extra pillow to support her breasts. If she would like to lie on her front, place a pillow under her hips and stomach to ease the pressure on her breasts. A soft towel or cloth nappy can be placed across her breasts to soak up any leaking milk.

Answer 6

- In the US, more intense and longer-lasting vasomotor symptoms are reported for Black individuals than individuals of other racial or ethnic groups. - In menopausal individuals, estrogen production mainly results from the conversion of adrenal androgens by peripheral aromatase in adipose tissue. The onset of menopause may occur later in individuals with obesity, who have additional estrogen from adipose stores. - **Menopausal HAVOCS**: Hot flashes/Heat intolerance, Atrophy of Vagina, Osteoporosis, Coronary artery disease, Sleep impairment.

Answer 7

**Early menopause** - The occurrence of physiological menopause between 40 and 45 years of age with no other identified cause - Affects 5% of women. - Clinical features and diagnostics are the same as for older patients. - Systemic HRT is usually recommended to reduce risks associated with early menopause, e.g.: Increased risk of heart disease, Dementia, Increased risk of overall mortality - Smoking is associated with earlier onset of menopause.

Answer 8

**General principles** - In individuals ≥ 40 years of age, perimenopause and menopause are diagnosed clinically. - A pelvic examination is usually performed to confirm GSM or evaluate for other causes. - The effects of oral contraceptives can mask the signs and symptoms of menopause. - Diagnostic testing is reserved for: 1. Premature menopause 2. Patients with an unreliable menstrual cycle history 3. Suspected differential diagnoses of menopause and perimenopause

Answer 9

**Approach to Treating Menopause** 1. Determine the severity of symptoms and their impact on the patient's quality of life. 2. All symptomatic patients: Initiate symptom-specific nonpharmacological interventions for menopause. 3. For patients with moderate to severe symptoms, consider adding pharmacological therapy for menopause. 4. Screen for and treat associated conditions and/or complications and provide appropriate preventive care. 5. Screen for depression. 6. Educate patients on the increased risk of osteoporosis and heart disease and initiate: Primary prevention of ASCVD & Prevention of osteoporosis - Hormone replacement therapy is not indicated for all patients but should be prescribed for premature menopause, early menopause, and patients with moderate to severe symptoms of menopause. - Evidence does not support the use of alternative medical therapies for menopause, e.g., soy, black cohosh, omega-3 supplementation, and acupuncture.

Answer 10

**Systemic hormone replacement therapy (HRT) - General principles** - Reevaluate patients on HRT yearly. - Short-term use (< 5 years) may be preferred to reduce the risk of adverse effects (e.g., breast cancer). - There is no consensus on how to taper or when to discontinue HRT. - Approx. 50% of individuals using HRT experience a recurrence of symptoms upon discontinuation. -

Answer 11

**Menopause - Vaginal hormone therapy** - **Indication**: Vaginal hormone therapy is indicated for moderate to severe genitourinary symptoms of menopause. - Some low doses of vaginal estrogen preparations (e.g., creams, rings) slightly increase serum estrogen levels; there is currently no research on whether this increase has any clinical significance (e.g., increased risk of cardiovascular disease or endometrial cancer).

Answer 12

**Complications of Menopause** **1 - Coronary artery disease** - Estrogen exerts protective effects on the cardiovascular system. - Menopause is associated with increased triglycerides, LDL, weight gain, and hypertension. **2 - Osteoporosis** - Decreased circulating estrogen impairs bone formation.

Answer 13

The peri-menopause and menopause are transitional phases in a woman's life marked by hormonal changes and the cessation of menstruation. These phases can have significant psychological effects due to the fluctuations and decline in hormones, primarily estrogen and progesterone.

Answer 14

**Examinations at postpartum visit** 1. Signs of anaemia 2. Blood pressure 3. Breasts and nipples 4. Breastfeeding position 5. Perineum – check wounds 6. LUCS wound 7. Thyroid 8. Uterine fundus 9. Urine – exclude UTI, protein, glucose

Answer 15

**Perineal lacerations**: tear of the perineal area due to significant or rapid stretching forces during labor and delivery **Epidemiology**: most common obstetric injury of the pelvic floor **Risk factors** 1. Macrosomia 2. Forceps delivery 3. No previous delivery 4. Prolonged second stage of labor 5. Occiput posterior delivery 6. Rapid delivery of head in breech presentation 7. Head extension before crowning 8. Lack of perineal elasticity (e.g., perineal edema)

Answer 16

- **First degree:** cutaneous to subcutaneous tissue tear (skin, fourchette, posterior vaginal wall) with no involvement of the perineal muscles - **Second degree**: first-degree lacerations plus laceration of the perineal muscles without involvement of the anal sphincter - **Third degree**: second-degree lacerations plus involvement of the external anal sphincter (may lead to fecal incontinence due to sphincter involvement) **A:** < 50% of the external anal sphincter is torn. **B: **> 50% of the external anal sphincter is torn. **C:** external and internal anal sphincters are torn. - **Fourth degree**: third-degree lacerations plus lacerations of the anterior wall of the anal canal or rectum

Answer 17

**Complications of Perineal tears** - Primarily associated with third- and fourth-degree lacerations. - Complications include: 1. Pain and dyspareunia 2. Rectovaginal fistulae 3. Hemorrhage 4. Infection 5. Wound dehiscence

Answer 18

Prevention: application of warm compress to perineum during delivery

Answer 19

**Episiotomy** - Consists of an incision of the perineum (usually in the midline) to enlarge the vaginal opening during delivery - No longer routinely recommended. - Can be considered if vaginal delivery needs to be expedited and maternal perineal tissue is thought to pose a signficant obstacle, e.g.: 1. Shoulder dystocia 2. Inability to insert instruments required for assisted vaginal delivery 3. Vaginal breech delivery

Answer 20

OASIS = Obstetric anal sphincter injury or injuries

Answer 21

**Resumption of sexual activity** There is currently no evidenced-based research demonstrating the ideal time to resume sexual intercourse following a perineal injury. Thus, the abstinence period is typically determined by the woman during her recovery period. The median time of return to intercourse is six to eight weeks postpartum.

Answer 22

**RANZCOG Guidelines** - Although the prediction of macrosomia is imprecise, elective caesarean birth may be beneficial for newborns with suspected macrosomia who have an estimated fetal weight of 5000g or more in women without diabetes and an estimated fetal weight of 4500g or more in women with diabetes.

Answer 23

Severe vomiting during pregnancy, known as hyperemesis gravidarum, can lead to dehydration, electrolyte imbalances, and weight loss, and it requires prompt medical attention and management.

Answer 24

**Hyperemesis gravidarum** refers to persistent and severe vomiting during pregnancy, which leads to weight loss, dehydration and electrolyte imbalances. - It affects 0.3 – 3.6% of pregnant women, and is one of the more common reasons for hospital admission during pregnancy. - Nausea and vomiting of pregnancy (NVP) normally starts between 4 and 7 weeks’ gestation. It reaches a peak in the 9th week, and settles by week 20 in 90% of women. - Hyperemesis gravidarum (HG) is diagnosed when there is prolonged and severe NVP with: 1. More than 5% pre-pregnancy weight loss 2. Dehydration, and 3. Electrolyte imbalances.

Answer 25

An objective scoring system can be used to classify the severity, for example the Pregnancy-Unique Quantification of Emesis (PUQE) score; a score of 6 correlates to mild NVP, 7-12 moderate and 13-15 severe. 1. Nausea, vomiting 2. Physical signs of dehydration 3. Hypersalivation, 4. Orthostatic hypotension 5. Malnourishment

Answer 26

**Diagnostics** 1. Clinical diagnosis 2. Laboratory analysis - Electrolyte disturbances: hypokalemia and hypochloremic metabolic alkalosis or metabolic acidosis - Signs of dehydration (e.g., ↑ hematocrit) - Ketonuria

Answer 27

**Treatment** 1. Antiemetic therapy 2. May require glucocorticoid therapy (see stepwise approach above) 3. IV fluid resuscitation/replacement (see IV fluid therapy) 4. Electrolyte and thiamine repletion 5. Enteral feeding or TPN is recommended in patients with persistent symptoms and weight loss despite antiemetic therapy.

Answer 28

1. Heavy menstrual bleeding 2. Pelvic pain 3. Uterine prolapse (vaginal hysterectomy) 4. Gynaecological malignancy (usually ovarian, uterine or cervical) 5. Risk reducing surgery, usually in cases of BRCA 1 or 2 mutations, or Lynch syndrome. 6. Hysterectomy may also be performed as a life saving procedure in the management of major postpartum haemorrhage.

Answer 29

A hysterectomy can be classified by the amount of tissue resected: 1. **Total hysterectomy** – removal of the uterus and cervix. 2. **Sub-total hysterectomy** – removal of the body of the uterus only, leaving the cervix behind. 3. **Total hysterectomy and bilateral salpingo-oophorectomy** – removal of the uterus, cervix, fallopian tubes and ovaries. 4. **Radical hysterectomy** – removal of the uterus and cervix, the parametrium, a vaginal cuff and part of or the whole of the fallopian tubes. This procedure is carried out in selected cases of cervical cancer. The ovaries may be removed or may be left behind, depending on the patient’s age.

Answer 30

Salpingo-oophorectomy is the removal of the fallopian tube (salpingectomy) and ovary (oophorectomy). A unilateral salpingo-oophorectomy is appropriate for patients in whom an ovary is unable to be preserved, including cases of ruptured ectopic pregnancy with an inability to achieve hemostasis without removal of the tube and ovary, adnexal torsion in which the ovary and tube are necrotic, a tuboovarian abscess not responsive to antibiotics, or a benign ovarian mass in which there is no remaining normal ovarian tissue able to be conserved. A bilateral salpingo-oophorectomy is generally one of three types: elective at time of hysterectomy for benign conditions, prophylactic in women with increased risk of ovarian cancer, or because of malignancy.

Answer 31

**Who is a risk-reducing BSO suitable for?** Your doctor, gynaecologist or genetic counsellor may have discussed having a risk-reducing BSO with you. This will usually be considered if you are at increased risk of ovarian cancer, for example, if you are known to have a cancer-causing BRCA1 or BRCA2 gene variant or if you have a significant family history of ovarian cancer. There is currently no effective screening for ovarian cancer, so risk-reducing surgery is an option that all at risk women are currently asked to consider. **At what age should I consider a risk-reducing BSO?** A BSO is not usually recommended in women under age 40, as ovarian cancer risk is still low up to this age, and having a BSO will immediately bring on menopause. You will be able to discuss the best timing of having a BSO with your doctor

Answer 32

1. Gonadotrophin releasing hormone from the hypothalamus 2. FSH from the pituitary stimulates follicular growth 3. LH releases egg and lutienises the follicle 4. Estradiol from the follicle causes endometrial growth 5. Progesterone from the corpus luteum, stabilises endometrium, and when it falls the endometrium sheds

Answer 33

**Postmenopausal Bleeding** * Principle is to exclude endometrial Ca * Limitations of U/S false +ve and false -ve * Histopathlogy * Endometrial hyperplasia and atypia * Atrophic vaginitis Dx of exclusion

Answer 34

**Amenorrhoea** * Primary or secondary Pregnancy & breastfeeding * Levels of failure * Hypothalamus * Pituituary * Ovarian **Investigation of Amenorrhoea** 1. LH/FSH 2. Prolactin 3. TFT 4. Pregnancy 5. E2 withdrawal bleed

Answer 35

**Gonadotropin Releasing Hormone (GnRH)** - Hypothalamus to Pituitary to release FSH and LH - 10 amino acid poly peptide - In pulses each 90 mins - Pulses modified by endorphins: Exercise reduces – so amenorrhoea & Opiate antagonists can reverse (naloxone) - Can be used in therapy (pulsatile pump and injection line) but needs 2+ weeks of treatment. - Hypothalamic Amenorrhoea / Kallmans syndrome

Answer 36

**FSH Follicle Stimulating Hormone** * 2 chain polypeptide with sugars - glycosalation changes biologic activity (hence not all assays give true indication of biologic potency) * Alpha chain same as LH, TSH, HCG * Drives follicular growth and granulosa cell activity (especially aromatase and so estrogen) * Drives sertoli cell activity in the male * FSH Is high if there is ovarian (or testicular) failure * Most fertility treatments aim to elevate FSH

Answer 37

**Estrogen - types** 1. Ethinyl estradiol – common – used in the “Pill” 2. Natural estrogen made in nature – from horses – Premarin – but has equilin and other non human estrogens (may be useful as longer life) 3. Natural estrogen made in vats – estradiol Can be given orally (nb first pass effect and liver proteins hence clotting), transcutaneously, vaginally, by subcutaneous implant.

Answer 38

**Estrogen - Uses** 1. "The Pill” - combined Estrogen & Progesterone 2. Estrogen: used to replace it in its absence 3. Generally for low estrogen - symptoms (flushes) or risks (bone loss) 4. So mainly menopause but some hypoestrogenic states (ie using the Pill in athletes) Note tachyphyllaxis and need to measure Estrogen if symptoms after implant

Answer 39

**Anti -estrogens** - ‘Traditional’ anti-estrogens are Tamoxifen and Clomiphene – they are both agonists and antagonists - Occupy the receptor – have some effect, then continue to bind and so stop replenishment of receptor thus having an antagonist effect - Used in infertility treatment to elevate FSH to stimulate follicular growth - Twins 1/12, triplets 1/200, eye symptoms rare but real - Used in estrogen dependant cancers - Can cause endometrial polyp growth - Newer – true antagonists or aromatase inhibitors

Answer 40

**Progesterone ** - Steroid hormone derived from cholesterol. - Produced in small amount by the adrenal. - Produced by the corpus luteum after ovulation and by the placenta during pregnancy. - **Actions**: 1. Changes endometrium to secretory 2. Withdrawal causes endometrium to shed. 3. Inhibits uterine contraction. 4. Increases temperature about 0.5C 5. Makes cervical mucous thicker (hence contraception) 6. Tends to give symptoms of bloating, fluid retention and breast sensations.

Answer 41

**Progesterone use 3: Physiologic** **3) Replacing Luteal Progesterone** - Used in PMS – but very variable effects and progesterone symptoms are PMS symptoms – so can make worse. - Molimina – bloating, fluid retention, breast symptoms - short half-life of progesterones – 12 hours or so oral (but can have slow release -- over years depending on method)) - Not useful for low luteal progesterone and infertility – the low progesterone is a result of poor follicular development - not the cause!

Answer 42

**Combined estrogen and progesterone** - If cyclic (prog 2 weeks on 2 weeks off) then gives a cycle and is not (very) contraceptive - In the Pill - Progesterone is prolonged – 3 weeks of 4 – results in ovulation suppression and often thin endometrium - If combined continuous – 90% get no period/bleed but irregular bleeding can happen - Why was ‘the Pill’ set at a 4 week cycle? = historical & so that people would have a bleed and prove they werent pregnant.

Answer 43

**Androgens** - Androgens are used to suppress endometrial growth – mainly ectopic endometrium in endometriosis - Danocrine is the most common - Side effects are – weight gain, oily skin and hair, hair growth, deeper voice (and masculinisation of a female fetus if pregnant so contraception is necessary) - Has been prescribed with exercise to make the most of the anabolic effect and to limit weight - They are banned substances in sport (remember to check occupation/ interests) - Occasionally androgens are used for loss of libido especially after menopause – especially surgical early menopause - Most problems with libido relate to the biggest sexual organ – the brain – be careful to avoid harm

Answer 44

**Methotrexate** - Killing trophoblast 1. Molar pregnancy 2. Ectopic pregnancy 3. In WA at some clinics for termination of pregnancy

Answer 45

**Pharmacotherapy during pregnancy - Antibiotics** 1. Penicillin group : ampicillin, amoxicillin, flucloxacillin, penicillin V, propicillin 2. Cephalosporins 3. Macrolides: erythromycin, azithromycin 4. Metronidazole 5. Fosfomycin (see also: “UTI in pregnancy”)

Answer 46

**Pharmacotherapy during pregnancy - Antifungals** 1. Topical: imidazoles 2. Vaginal: nystatin 3. Systemic: amphotericin B

Answer 47

**Pharmacotherapy during pregnancy - Antivirals** 1. Acyclovir and valacyclovir for herpes 2. Oral oseltamivir and zanamivir for influenza 3. Zidovudine PLUS lamivudine PLUS nevirapine PLUS atazanavir for HIV infection

Answer 48

**Pharmacotherapy during pregnancy - Anticoagulants** **Drugs of choice** 1. Heparin: anticoagulant of choice (does not cross the placental barrier) 2. Aspirin (ASA) - Low doses may be prescribed for high-risk preeclampsia. High doses should be especially avoided in the third trimester.

Answer 49

**Pharmacotherapy during pregnancy - Analgesics** **Drugs of choice** 1 - Non-opioid analgesics - Acetaminophen, especially in the third trimester - NSAIDs in the first trimester only 2 - Opioid analgesics (e.g., fentanyl, codeine) for moderate to severe pain

Answer 50

**Pharmacotherapy during pregnancy - Thyroid agents** **Drugs of choice** - Antithyroid drugs 1. First trimester: propylthiouracil 2. Second and third trimester: methimazole - L-thyroxine

Answer 51

- First-generation antihistamines (e.g., chlorpheniramine) may be used as antiallergenics during pregnancy. - Second-generation antihistamines (e.g., loratadine, fexofenadine, cetirizine) may be considered if chlorpheniramine is not tolerated. - Loratadine is the best-studied second-generation antihistamine.

Answer 52

1. CST 2. Culture for GC and chlamydia 3. FBC & TFTs - anaemia and thrombocytopenia 4. Blood group - ABO and rhesus status, and detect any abnormal Ab 5. Serology - hepatitis, HIV, syphilis, rubella, varicella immune status 6. Urine MSU - protein & bacteria (asymptomatic bacteruria in 5% of pregnant women, if untreated, 25-30% will get a UTI in pregnancy, increases risk of preterm labour)

Answer 53

Disseminated Intravascular Coagulation (DIC) is a complex and potentially life-threatening disorder characterized by widespread activation of the clotting cascade, which leads to both excessive clot formation (thrombosis) and simultaneous depletion of clotting factors and platelets, resulting in bleeding tendencies. Obstetric causes are among the many triggers that can lead to DIC. These causes are related to pregnancy, childbirth, and complications thereof.