Womens Health PPT Flashcards
(178 cards)
1
Q
2 phases to indction:
A
• Achieving cervical dilatation to enable ARM – mechanical or pharmacological
• Then augmenting labour - oxytocin
2
Q
indications of inducing labout
A
- prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
- prelabour premature rupture of the membranes, where labour does not start
- maternal medical problems: diabetic mother > 38 weeks, pre-eclampsia, obstetric cholestasis)
- intrauterine fetal death
3
Q
Bishop scoring
A
score over 8 = induce
greater score means that the chance of successful induction is higher
4
Q
Methods of inducing labour
A
`1) membrane sweep
• can be done by midwife at antenatal clinic
• typically offered at 40-41 weeks
• vaginal prostaglandin E2 – dinoprostone
• Oral prostaglandin E1 – misoprostol
• Maternal oxytocin infusion
• Amniotomy – breaking of waters
• Cervical ripening balloon
5
Q
how do prostaglandins work
A
• Prostaglandins induce contractions (ferguson reflex) and acts directly on collagenase in the cervix
6
Q
CI of prostaglandin E2
A
- Active cardiac disease, active pulmonary disease, history of caesarean section, history of major uterine surgery.
7
Q
cautions of prostaglandin
A
• Asthma, epilepsy, RF for DIC, uterine scarring and uterine rupture
8
Q
Oxytocin - key SE
A
Oxytocin -> similar structure to ADH/ vasopressin so leads to hyponatraemia
9
Q
cautions of oxy
A
: uterine scars, CV disease, HTN, (be careful w pre-eclampsia – fluid overload)
10
Q
oxytocin can lead to ? Which means it would need to be stopped
A
Excessive uterine contractions leads to hypertonus and fetal distress -> stop the oxytocin, start terbutaline (tocolytic)
11
Q
oxytocin - water intoxication
A
Water intoxication and hyponatraemia: input/ output monitoring, monitor U&Es, fluid restriction, stop oxytocin use
12
Q
ergometrine - MAO
A
· Alpha agonist -> uterine contractions and arterial vasoconstriction
13
Q
CI of ergometrine
A
· : eclampsia, severe cardiac disease, severe HTN
14
Q
steroids in pregnancy
A
• Can affect maternal glucose tolerance for 5 days – higher risk in diabetics
• Increased risk of neonatal hypoglycaemuia
15
Q
Mg sulphate Ix
A
: in pre-eclampsia: prevents seizures, pre-term labour: reduces risk of CP
16
Q
Mg sulphate SE
A
Neonatal bone demineralisation and osteopenia with prolonged or repeated doses in pregnancy
17
Q
Mg toxicity
A
Mg toxicity: drowsiness, confusion and absent reflexes. Resp depression
Reflexes and obs must be checked every 4 hrs
18
Q
inducing labour - bishop score of under 6
A
• Vaginal prostanglandins or oral misoprostol
• Mechanical methods like balloon catheter if woman at higher risk of hyperstimulation or prev C section
19
Q
inducing labour - bishop > 6
A
Amniotomy + IV oxytocin infusion
20
Q
comps of inducing labour
A
• Uterine hyperstimulation -> repeated contractions lead to fetal hypoxaemia
• Mx of uterine hyperstimulation -> removing vaginal prostaglandins and stopping oxytocin
21
Q
PPH initial Mx
A
• Emergency – call senior immediately
• ABC approach – 2 peripheral cannulae, lie the woman flat, bloods – group and save. Warmed crystalloid infusion
22
Q
PPH - first line
A
• Mechanical – palpate uterus and rub it to stimulate contractions – rubbing up the fundus
• Catheterisation to prevent bladder distension
23
Q
medical management of PPH
A
- IV oxytocin: slow IV injection followed by an IV infusion
- Tranexamic acid
- ergometrine slow IV or IM (unless there is a history of hypertension)
- carboprost IM (unless there is a history of asthma)
- misoprostol sublingual
24
Q
when should ergometrine not be used
A
HTN history
25
caroprost CI
Asthma
26
TXA mechanism
- competitive reversible inhibitor of conversion of plasminogen to plasmin
- prevents degradation of fibrin clot by plasmin.
27
CI of TXA
• CI: DIC, thromboembolism, history of seizures
28
Surgical options for PPH
- if medical options fail to control bleeding
- first line: intrauterine balloon tamponade when uterine atony is the cause
- other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
29
First line surgical option for PPH
intrauterine balloon tamponade
30
severe uncontrolled PPH ->
hysterectomy
31
Mx of premature pre-term rupture of membranes
• admit
• regular obs -> chorioamniocentesis
• oral erythromycin for 10 days
32
what should be given to protect fetus in premature preterm ROM
antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
33
When should delivery be considered for Preterm premature ROM
delivery should be considered at 34
34
Mx of preterm labour with intact membranes
>• Fetal monitoring (CTG or intermittent auscultation)
• Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
• Maternal corticosteroids: can be offered before 35 weeks gestation
> IV Mg sulphate
> delayed cord clamping or cord milking - increasing the blood volume in the baby at birth
35
Tocolysis
- Nifedipine/ Atosiban – oxytocin receptor antagonist when nifedipine CI
- Used to delay labour and buy time for the fetus to develop
- Used as a short term measure – 48 hrs or less
36
Antenatal steroids
• Giving the mother steroids helps to develop the lungs and reduce resp disress syndrome
• Used in women under 36 weeks
37
Management of anovulation
• Clomifene: stimulates ovulation
• Gonadotropins may be used to stimulate ovulation in women resistant to clomifene.
• Ovarian drilling may be used in polycystic ovarian syndrome
• Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
38
Clomifene mechanism
> Clomifene: SERM (anti-oestrogen) -> stops negative feedback effect of oestrogen -> more LH and FSH
> first line in PCOS induction
39
Gonadotrophins
• Gonadotropins – contains FSH/LH to directly stimulate
• Risks: OHSS and ovarian hyperstimulation syndrome
40
what happens in IVF
• Superovulation
• Controlled ovarian hyperstimulation is achieved using gonadotrophins (FSH) with or without GnRH analogs.
41
Levonestrogel - mechanism
• Must be taken within 72 hours of unprotected sex
• Acts to stop ovulation & inhibit implantation
• Single dose
42
When should levonestrogel be doubled
BMI > 26 or weight over 70kg, dose should also be doubled if taking enzyme-inducing drugs (although a copper IUD as emergency contraception is preferable in this situation)
43
when should dose be repeated - levonestrogel
if vomiting occurs within 3 hrs
44
how many times can levonestrogel be used
can be used more than once in a menstrual cycle
45
how soon after levonestrogel be hormonal contraception be started
· hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
46
mechanism of ulprilstat
• Selective progesterone receptor modulator – inhibits ovulation
• Within 120 hours of intercourse
47
time between ulprilstat and hormonal conraception
Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Use barrier methods in this time
48
ulprilstat CI
extreme caution with asthma
49
BF after taking ulprilstat
delayed by 1 week
50
how many times can ulprilstat be taken
more than once in the same cycle
51
most effective emergency contraception
copper IUD
52
Copper IUD timing as emerg contraception
within 5 days of UPSI
53
when can the IUD be fitted as emerg contrcaeption
- if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
- can be used at any time during the cycle
54
COCP mechanism
inhibits ovulation
55
POP mechanism
thickens cervical mucus
56
Destrogel only pill Mx
Primary: Inhibits ovulation
Also: thickens cervical mucus
57
Depo injection Mx
Primary: Inhibits ovulation
Also: thickens cervical mucus
58
implant Mx
Primary: Inhibits ovulation
Also: thickens cervical mucus
59
IUD MX
Decreases sperm motility and survival
60
IUS Mx
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
61
IUD mechanism as emerg contraception
Primary: Toxic to sperm and ovum
Also: Inhibits implantation
62
Nonoxinol
: spermicidal used in conjunction with barrier methods such as diaphragms and caps
63
when should anti d be given with abortion
• Anti D prophylaxis should be given to rhesus negative women who are past 10 weeks gestation
64
Medical termination of pregnancy
• Mifepristone (anti progesterone) followed by misoprostol 48 hrs later
• May be done at home
65
what must be done after medical termination of pregnancy
• Multi level pregnancy test (measures HCG level) must be done 2 weeks after to confirm that the pregnancy ended
66
surgical method of abortion
• E.g. manual vacuum aspiration, electric vacuum aspiration, dilatation and evacuation
• cervical priming with misoprostol +/- mifepristone is used before procedures
67
what can be done immediately after surgical abortion
IUD can be inserted immediately after evacuation
68
Pregnancy - changes to drug concentration
• plasma volume expansion -> diluted drug concentration
• GFR increased -> increased elimination of renally excreted drugs
• Increased volume of distribution for water soluble drugs due to expanded plasma volume
• Enhanced metabolism of heparin reduces its half-life, while slowed clearance of theophylline leads to higher drug levels.
69
pregnancy - gastric changes
• Delayed gastric emptying: slower drug absorption
70
pregnancy - drug binding
• Decreased serum albumin levels: reduces binding of protein bound drugs and increases free drug availability
71
Ab in pregnancy
• Penicillins, cephlasprons. Aminoglycosides: safe but increased renal clearance
• Tetracyclines: CI in pregnancy -> inhibit bone growth in fetus & risks of dental discoloration
72
AC in pregnancy
· Warfarin CI -> use LMWH instead
73
anti hypertensives in pregnancy
- ACE/ ARB – CI due to risks of fetal renal failure, oligohydramnios, craniofacial abn
- Labetolol and nifedipine: safe
74
sodium valproate
associated with neural tube defects – sig risk of neurodevelopmental delay so CI in pregnant women and in women of childbearing age
75
# & what should PW be given
phenytoin in pregnancy
: associated with cleft palate. All pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the baby
76
all AED are safe to BF on except for…
barbituates
77
SSRis in pregnancy
· – generally safe but risk of pulmonary HTN
78
antidiabetic drugs which are safe
insulin and metformin. All others must be stopped
79
Thyroid - thyroxine in preg
· Levothyroxine: increased dose in pregnancy
80
preferred antithyroud drug in T1
PTU
81
Vaccines given in pregnancy
• Inactivated influenza vaccines – any stage of pregnancy
• DPT vaccine between 16-32 weeks
82
High risk women are also given the ? Vaccine
hep B if mother is high risk - healthcare worker, IVDU
83
Live vaccines & pregnancy
• CI in pregnancy e.g. MMR or chickenpox
• Women should have these before pregnancy especially MMR
84
distrubion changes in pregnancy
• Increased volume of distribution of water-soluble drugs
• May require higher drug doses
• Reduction in plasma protein levels
85
risk of birth defects
• 2-3% of the general population
• 3% of epilepsy in those who don’t take AEDs, 4-10% in those who take AEDs
86
folic acid dose
• 400microg recommended pre-conception to 12 weeks gestation -> reduced risk of neural tube defects
87
5mg folic acid when:
- Antiepileptic meds
- Family history of NTD
- Diabetes
- Sickle cell
- obesity
88
antiepileptics with lower risk of malformations
Lamotrigene, levetiracetam, carbamazepine
89
Teratogens - ACEi
• renal abn, patent DA, oligohydramnios
• 2nd and 3rd T
90
Teratogens - carbimazole (anti-thyroid)
• Neonatal hypothyroidism
• After week 10 of gestation
91
teratogens - BB
• IUGR, neonatal hypogly, bradycardia
• Throughout pregnancy
92
Teratogens - LITHIUM
• First trimester
• Ebsteins anomaly (Cardiac)
93
methotrexate as a teratogen
• Medical termination, craniofacial defects, cardiac anomalies
94
NSAIDs as a teratogen
- Prem closure of DA, oligohydramnios
- After week 30 – T3
95
Phenytoin as a teratogen
· Fetal hydantoin syndrome, craniofacial abn, mental retardation
96
retinoids as a teratogen
• CNS abnormalities, renal/ear/eye/parathyroid abnormalities
• Weeks 4-10
97
sodium valproate as a teratogen
• Neural tube defects - main, craniofacial abn, organ malformations
• T1
98
tetracyclines as a teratogen
• Tooth discoloration, impaired long bone growth
• 2nd & 3rd trimester
99
warfarin as a teratogen
• Fetal warfarin syndrome: weeks 6-12
• CNS/ eye abn, fetal/ placental haemorrhage: 2nd/ 3rd T
100
safe pregnancy drugs
• Beta lactams
• Erythromycin
• Bronchodilators
101
paternal methotrexate must be stopped ? B4 conception
6 months
102
azathioprine must be stopped ? Before conception
3 months
103
Avoid amiodarone in BF due to
: Iodine content may cause neonatal hypothyroidism
104
Avoid aspirin in BF ->
Reyes syndrome
105
Avoid barbituates in BF ->
drowsiness
106
Avoid benzodiazepines in BF ->
drowsiness
107
Avoid carbimazole in BF ->
Hypothyroud
108
avoid codeine in BF ->
: risk of opiate overdose
109
cocp AND bf
can diminish milk supply and quantity
110
dopamine agonists and BF
suppresses lactation in mother
111
tetracyclines and BF
Tooth discoloration
112
parathyroid abn ->
retinoids
113
where to find relevant information about choosing and adjusting drug dosage in pregnant women and women of child-bearing potential
• NICE, BNF
• UK teratology information service – Data on teratogenic drugs
• MHRA – risks and usage restrictions in pregnancy
114
Toxic when BF drugs mneumonic
B - (anti)Biotics
R - Rheumatoid - methotrexate
E - Extremes of mood - Lithium
A - Amiodarone & Aspirin
S - Sulfonylureas
T - (cyto)toxic drugs
115
where to find information about choosing and adjusting drug doses in BF women
NICE, BNF, UK drugs in Lactation Advisory service, breastfeeding network
116
simple meaures to treat hyperemesis
rest and avoid triggers, bland plain food, ginger, P6 (Wrist) acupressure
117
First line meds - hyperemesis
• antihistamines: oral cyclizine or promethazine
• phenothiazines: oral prochlorperazine or chlorpromazine
• combination drug doxylamine/pyridoxine
118
second lines in hyperemesis
> ondansteron
> metoclopramide
> domperidone
119
ondansteron is assoc w
cleft lip/palate
120
metoclopride causes
· – causes EPS so should not be used for more than 5 days
121
if admission required for hyperemesis
• IV hydration – normal saline with added potassium
• Pabrinex/ thiamine if prolonged vomiting
122
Mx of eczema - first
• Emollients – hydrate skin & reduce transdermal water loss and restoring skim barrier
• Use at least twice daily
123
steroids in eczema Mx
· Topical steroids: used for acute flares and moderate to severe excema
124
lower vs high potency steroids
• Lower potency such as hydrocortisone on more delicate areas such as face and genitals
• High potency steroids: betamethasone – more severe cases or thicker skin like palms
125
what can be used in eczema when long term steroid use is CI
· Topical calcineurin e.g. tacrolimus – alt to steroids. Useful when long term steroid use CI such as on the face
• Used for svr eczema when other Tx failed
126
eczema + bacterial infection
add ab e.g. impetigo
127
what else can be added for severe eczema
• Systemic IS therapies such as ciclosporin, azathioprine, methotrexate – severe refractory eczema
• Biologics – dupilmab – mab targeting IL-4 and IL-13
128
managing itch w eczema
antihistamines
129
Mx eczema in child
• Avoid irritants
• Simple emollients
• Topical steroids
• Wet wrapping
130
mx of contact derm
• Avoid triggers
• Emollient use and soap substitutes
• Topical steroids if required
131
work related contact derm
• Employer has legal responsibility ro assess health risks at work and prevent
• Legal duty to report case of the disease to health and safety executive
132
mx of chronic plaque psoriasis
- emollients
- 1st: corticosteroid + vitamin D
- 2nd: : if no improvement after 8 weeks - a vitamin D analogue twice daily
- 3rd: : if no improvement after 8-12 weeks then offer a potent steroid or a coal tar preparation
133
secondary care options for psoriasis
> phototherapy
> systemic therapy - oral methotrexate first line especially if associated joint disease
• ciclosporin
• systemic retinoids
• biological agents: infliximab, etanercept and adalimumab
134
phototherapy increases risk of
increases risk of squamous cell cancer – not melanoma
135
Management of scalp psoriasis
• topical steroids for 4 weeks
• if no improvement use a different formulation of the steroid e.g. shampoo and/or topical agents like salicylic acid to remove scale
136
Face, flexural and genital psoriasis Mx
Mild/ moderate steroid for a max of 2 weeks
137
steroids SE
• -> skin atrophy, striae, rebound symptoms
• Systemic side effects when potent steroids used on large body areas
138
? Break between steroid courses
4 week break btwn steroid courses
139
potent steroids should not be used for greater than…
• potent corticosteroids for no longer than 8 weeks at a time and very potent corticosteroids for no longer than 4 weeks at a time`
140
Vitamin D analogues
• examples of vitamin D analogues include calcipotriol (Dovonex), calcitriol and tacalcitol
• they work by ↓ cell division and differentiation → ↓ epidermal proliferation
• can be used long term
141
vitamin D analogues should be avoided in
pregnancy
142
vitamin D analogues improve ? In psoriasis
· improves scale but not erythema
143
dithranol
• inhibits DNA synthesis
• wash off after 30 mins
144
SE of dithranol
burning, staining
145
Mild/ moderate acne Mx
• a 12-week course of topical combination therapy should be tried first-line: topical adapalene with topical benzyl peroxide,
• topical tretinoin with topical clindamycin,
• topical benzoyl peroxide with topical clindamycin
• BP can be used as monotherapy if CI/ pt wishes
146
moderate/ severe acne Mx
• 12 week course: topical adapalene with topical benzoyl peroxide,
• topical tretinoin with topical clindamycin,
• topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline, t
• opical azelaic acid + either oral lymecycline or oral doxycycline
147
Acne - ab & pregnancy
• Tetracyclines: avoid in preg/ BF women, children < 12
• Erythromycin safe in pregnancy
148
Minocycline SE
Irreversible pigmentation
149
ab should be used for less than ? In acne
• only continue a treatment option that includes an antibiotic (topical or oral) for more than 6 months in exceptional circumstances
150
Topical retinoid or BP should always be co-prescribed with
• a topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-prescribed with oral antibiotics to reduce the risk of antibiotic resistance developing
151
gram negative folliculitis
• Gram-negative folliculitis may occur as a complication of long-term antibiotic use - high-dose oral trimethoprim is effective if this occurs
152
which ab should not be used together
topical and oral
153
Alt to oral ab in women
• COCP are an alt to oral ab in women – should be used in comb w topical agent the same as oral ab
154
Dianette should not be used for more than
• Dianette (co-cyprindiol) should not be used for more than 3 months – risk of VTE
155
starting isotrentoin
• Isotretinoin – only used under specialist supervision, pregnancy is an absolute CI to both topical and oral retinoid tx
156
To reduce the risk of antibiotic resistance developing the following should not be used to treat acne:
• monotherapy with a topical antibiotic
• monotherapy with an oral antibiotic
• a combination of a topical antibiotic and an oral antibiotic
157
classification of cellulitis
ERON
158
Eron class 1
There are no signs of systemic toxicity and the person has no uncontrolled co-morbidities
159
eron class 2
systemically unwell/ systemically well with a comorb
160
Eron class 3
significant system upset such as tachycardia or hypotension or a limb threateninf infection
161
eron class 4
sepsis or life threatening infection such as necrotising fasciitis
162
Mx of eron class 1`
• oral flucloxacillin as first-line treatment for mild/moderate cellulitis
• oral clarithromycin, erythromycin (in pregnancy) or doxycycline is recommended in patients allergic to penicillin
163
first line for mild - moderate cellulitis
flucloxacillin
164
eron class 2 Mx
• IV ab
165
eron class 3/4 Mx
: oral/IV co-amoxiclav, oral/IV clindamycin, IV cefuroxime or IV ceftriaxone
166
HIV management prinipal
- ART involves a combination of at least 3 drugs – normally 2 NRTI and either a PI or a NNRTI
- Started as soon as the patient is diagnosed
167
entry inhibitors
• maraviroc (binds to CCR5, preventing an interaction with gp41),
• enfuvirtide (binds to gp41, also known as a 'fusion inhibitor')
• prevent HIV-1 from entering and infecting immune cells
168
Nucleoside analogue reverse transcriptase inhibitor
• examples: zidovudine (AZT), abacavir, emtricitabine, didanosine, lamivudine, stavudine, zalcitabine, tenofovir
169
NRTI side effects
peripheral neuropathy
170
NNRTI
examples: nevirapine, efavirenz
171
SE of NNRTI
effects: P450 enzyme interaction (nevirapine induces), rashes
172
Protease inhib ex
• examples: indinavir, nelfinavir, ritonavir, saquinavir
173
SE of protease inhib
: diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inhibition
174
intergrase inhib
• block the action of integrase, a viral enzyme that inserts the viral genome into the DNA of the host cell
• examples: raltegravir, elvitegravir, dolutegravir
175
NRTIs end in
ine
176
PI end in
navir
177
NNRTiIs
nevirapine, efavirenz
178
intergrase inhibitirs end in
tegravir
