ic17 women's health and contraception Flashcards
When should hypertension be treated in pregnancy
SBP > 140 or DBP > 90
What is considered severe hypertension in pregnancy
SBP > 160 or DBP > 110 for 2 measurements
Between these medication, which are first, second, third line for hypertension treatment?
Methyldopa, Labetalol, Nifedipine ER, Hydrochlorothiazide, Hydralazine
And what to look out for?
First line
Labetalol
Monitor for bronchoconstrictive effects, bradycardia
Nifedipine ER
Monitor for pedal edema, flushing, headaches
Second line
Hydrochlorothiazide
Potential interference with normal blood volume expansion with pregnancy
Third line
Methyldopa
Low potency, Increased adverse effects eg. sedation, dizziness
Hydralazine
Adverse effects mimic symptoms associated with severe preeclampsia
Definition of Chronic Hypertension
Less than 20 weeks gestation
Proteinuria absent
Definition of Chronic HTN with superimposed preeclampsia
Less than 20 weeks gestation
Proteinuria present
Less than 20 weeks gestation
Proteinuria absent
Chronic Hypertension
Less than 20 weeks gestation
Proteinuria present
Chronic HTN with superimposed preeclampsia
Definition of Gestational HTN
At least 20 weeks gestation
Proteinuria absent
At least 20 weeks gestation
Proteinuria absent
Gestational HTN
Definition of Preeclampsia
More than 20 weeks gestation
+ Proteinuria / Signs of end organ dysfunction / Uteroplacental dysfunction
Hypertension
+ More than 20 weeks gestation
+ Proteinuria / Signs of end organ dysfunction / Uteroplacental dysfunction
Preeclampsia
What are 3 markers to diagnose Proteinuria
1) 24hr urinary protein (UTP) at least 300mg
2) Dipstick protein: at least 2+
3) Urine protein : Creatinine ratio uPCR
> 0.3mg/dL
Signs of end organ damage (5 points)
Platelet count < 100
LFTs > 2x ULN
Doubling SCr in the absence of other renal disease
Pulmonary edema
Neurological complications eg. altered mental status, severe headache with visual disturbances
How to prevent Preeclampsia?
Who is this recommended for? (5 points)
Low dose aspirin
For high risk patients eg. HTN on previous pregnancy
Multifetal gestation (eg. twins, triplets)
Autoimmune disease
DM
CKD
When should low dose aspirin be started?
Start after 12 weeks (1st trimester), continued till delivery
What is the normal level and effect of Estrogen and Progesterone after ovulation?
What happens during Ovulation?
What happens if there is no Ovulation?
E and P are high to suppress ovulation, suppress FSH and LH to prevent ovaries from releasing eggs
If Ovulation occurs, E and P remain high throughout pregnancy
If no ovulation occurs, E and P falls, causing menstruation, bleeding
How do Contraceptives work?
What happens during the placebo period
Maintain high level of E and P → FSH and LH are suppressed, no egg is released. Mimics the period after ovulation aka tricking the body into thinking that ovulation has occurred
During placebo, E and P falls, withdrawal bleeding occurs
Advantage of condoms (male and female)
Disadvantages of condoms (3 points)
Adv:
STI protection if used correctly
Disadv:
High user failure rate
Not widely received
Possibility of breakage
Advantages (2 points) and Disadvantages (5 points) of Diaphragm with spermicide and Cervical cap
Adv:
Low cost
Reusable
Disadv:
High failure rate
Low protection against STI
Increased risk of UTI
Cervical irritation
Cause Toxic Shock Syndrome
What are the 2 concepts of Contraception?
1) Methods that act as barriers or prevent ovulation
eg. COC, Progestin injection, Transdermal patch, Anything with hormones
2) Prevent fertilised ovum from successfully implanting in the endometrium, creating an unfavourable uterine environment (eg. COC)
What is the role of Progestin? (3 points)
1) Thicken cervical mucus, slow sperm movement
2) Block LH surge
3) Induce endometrial atrophy
Provide most of contraceptive effect
What is the role of Estrogen? (2 points)
1) Reduce FSH secretion
2) Thicken endometrial lining
What is the most common form of Estrogen
What is the standard dose?
Ethinyl estradiol (EE)
30-35ug
What is the main issue with Progestins?
Progestins may cause androgenic side effects eg. Acne, Oily skin, Hirsutism
What is the lower dose for EE?
Who should be taking lower dose of EE?
15-25ug
Adolescence
Underweight (<50kg)
Older than 35
Peri-menopausal
Unable to tolerate SE eg. bloating, N/V, breast tenderness, weight gain
Population that can take higher dose of EE (3 points)
Obesity, > 70.5kg
For early to mid cycle breakthrough bleeding
Indicates that estrogen level not high enough to inhibit cycle
For less adherent patients
Differences between older and newer gen Progestins
Older gen (1st, 2nd)
Better for VTE
Have more androgenic side effects
Newer gen (3rd, 4th)
NO androgenic side effects (esp for Drospirenone 4th gen)
Higher risk of VTE
Under what circumstances should we have higher progestational activity?
1) Experience late cycle bleeding
2) Painful menstrual cramps
What is Drospirenone?
Side effects of Drospirenone
It’s a 4th gen progestin, Mineralcorticoid antagonist, similar to Spironolactone
Can cause hyperkalemia, thromboembolism and bone loss
What are the 3 ways of starting contraceptives?
Which need back up contraceptive and for how long?
1) First day method
Start on first day of menstrual cycle
No back up contraceptive needed
2) Sunday start
Start on first Sunday after menstrual cycle
Require backup contraceptive for 7 days after starting contraceptive
3) Quick start
Start now
Require backup contraceptive for at least 7 days and until next menstrual cycle begins
What is the reason for back up contraceptive for
“Sunday Start” and “Quick start”?
Sunday start: Start on first Sunday after menstrual cycle begins
Ovulation might have already occurred, or the COC might have been too late and not been able to prevent ovulation.
What is associated with VTE
1) Estrogen (increase hepatic production of clotting factors)
2) New generation Progestins (when combined with Estrogen)
Progestins alone do not cause VTE
Which contraceptives to recommend with lowest VTE risk
Progestin-only contraceptives, and use Old gen (1st, 2nd) Progestins
Barrier methods
Which condition is absolutely contraindicated to Combined Oral Contraceptives? (COC) What should we use instead?
What about the rest of the conditions eg. VTE, post partum, migraine w aura
Breast cancer, current and recent history within 5 years
DONT USE HORMONAL CONTRACEPTIVES AT ALL
Use copper IUD, barrier
Rest of the conditions eg. VTE, Migraine with aura
Use Progestin-only contraceptives, or 1st/2nd gen Progestin (for VTE) / barrier method, copper IUD
What is absolutely contraindicated with Estrogen containing contraceptives? (3 points)
Migraine with aura
Breast cancer
VTE (and other risk factors causing VTE eg. smoking, post partum, diabetes > 20 years w complications etc)
What if patient has acne?
Use an antiandrogenic progestin eg. Drospirenone
OR
Increase estrogen, change Progestin-only to COC
(how to rmb: acnE)
Why would headache occur?
Recommendation
Usually occurs during pill free week due to fluctuation of hormones
Change to a continuous dose or one with shorter pill free interval
What if patient has nausea, vomiting, bloating?
Reduce estrogen
+
(N/V) Change to POP or take pills at night
(Bloating) Change to progestin with mild diuretic effect eg. Drospirenone
What if patient has menstrual cramps?
Increase progestin
Switch to extended cycle or continuous cycle
What if patient has breast tenderness / weight gain?
Keep both estrogen and progestin as low as possible
3 drugs that can cause DDI with COC
1) Rifampicin
2) Anticonvulsants
3) HIV antiretrovirals
What to do if missed one dose (less than 48 hours)
Take missed dose immediately
May need to take 2 pills on the same day
No need additional contraceptive
What to do if missed 2 doses (more than 48 hours)
Take missed dose immediately
Discard the rest of the missed doses
Dont take more than 2 pills a day
Back up contraceptive for at least 1 week
What to do if missed during last week of hormonal tablets
Finish remaining active pills in current pack
SKIP hormone free interval + Start new pack the next day
Back up contraceptive for at least 7 days
Indication for Progestin only Pills (POP) (3 points)
Good for breastfeeding
Conditions that preclude estrogen
Migraine with aura
Have VTE or High risk of VTE
Cannot tolerate Estrogen NV side effects
Absolute contraindication for Progestin-only Pill
Breast cancer
MOA of Progestin only pill (POP)
POP stops ovulation only, by suppressing LH release
This means that FSH is still high and the follicle is ready to be released, but is held back by low LH
If we stop POP, LH will increase and result in ovulation, hence missed dose is stricter and back up contraceptive
What are the 3 types of POP?
1st, 2nd, 4th
1st: Norethindrone / Norethisterone
2nd: Levonorgestrel
4th: Drospirenone
How to start POP?
If start within 5 days of menstrual cycle
No need back up contraceptive
Any other day
Back up contraceptive for 2 days
Drospirenone: 7 days
What if miss POP dose?
Norethindrone (1st), Levonogestrel (2nd)
if miss > 3 hours, take one immediately + back up contraceptive for 2 days
Drospirenone
Miss 1 pill → no need back up
Miss 2 or more pills → need back up for 7 days
Which population is transdermal contraceptives not useful?
Obese patients
Other non pill hormonal contraceptives (4 points)
Transdermal patch
Vaginal rings
Progestin injections
Long acting reversible contraception (IUD or Implants)
What is the advantage of vaginal rings over diaphragms / cervical cups?
Precise placement not needed, hormones are absorbed
Adverse effects of Progestin injections (3 points)
Cannot be fertile immediately once stopped
Weight gain
Short term bone loss
What are examples of Long Acting Reversible contraception (LARC)?
Benefits of LARC? (2 points)
Intrauterine Devices (IUD)
Implants
Highly effective (<1% failure)
Can become fertile soon after stopping
but invasive
MOA of Intrauterine devices (IUD)
1) Inhibit sperm migration
2) Damage ovum
3) Disrupt transport of fertilised ovum
Contraindications of IUD (6 points)
Pregnancy
Current STI
Undiagnosed vaginal bleeding
Malignancy of genital tract
Uterine abnormalities
Uterine fibroids
2 types of IUD, how long do they last?
Levonorgestrel IUD - 5 years
Copper IUD - 10 years
Which IUD is ideal for which conditions?
Levonorgestrel IUD
Help reduce bleeding -> for concomitant menorrhagia
Cannot be used for emergency contraception
Copper IUD
Help increase bleeding -> for concomitant amenorrhea
Can be used as emergency contraceptive
How long can a Subdermal Progestin Implant last?
3 years
Need to take emergency contraceptives by when?
rmb 5 5 2+3
Copper IUD
within 5 days
Ella tablet
1 tab within 5 days
Postinor tablet
2 tabs within 12 hours, if not 3 days
What is in Ella tablet?
Ulipristal, a Progestin receptor modulator
Will not be effective if patient is taking Progestin at the same time!
