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3152 - nat > ic17 women's health and contraception > Flashcards

ic17 women's health and contraception Flashcards

1
Q

When should hypertension be treated in pregnancy

A

SBP > 140 or DBP > 90

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2
Q

What is considered severe hypertension in pregnancy

A

SBP > 160 or DBP > 110 for 2 measurements

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3
Q

Between these medication, which are first, second, third line for hypertension treatment?

Methyldopa, Labetalol, Nifedipine ER, Hydrochlorothiazide, Hydralazine

And what to look out for?

A

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

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4
Q

Definition of Chronic Hypertension

A

Less than 20 weeks gestation
Proteinuria absent

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5
Q

Definition of Chronic HTN with superimposed preeclampsia

A

Less than 20 weeks gestation
Proteinuria present

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6
Q

Less than 20 weeks gestation
Proteinuria absent

A

Chronic Hypertension

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7
Q

Less than 20 weeks gestation
Proteinuria present

A

Chronic HTN with superimposed preeclampsia

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8
Q

Definition of Gestational HTN

A

At least 20 weeks gestation
Proteinuria absent

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9
Q

At least 20 weeks gestation
Proteinuria absent

A

Gestational HTN

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10
Q

Definition of Preeclampsia

A

More than 20 weeks gestation
+ Proteinuria / Signs of end organ dysfunction / Uteroplacental dysfunction

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11
Q

Hypertension
+ More than 20 weeks gestation
+ Proteinuria / Signs of end organ dysfunction / Uteroplacental dysfunction

A

Preeclampsia

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12
Q

What are 3 markers to diagnose Proteinuria

A

1) 24hr urinary protein (UTP) at least 300mg
2) Dipstick protein: at least 2+
3) Urine protein : Creatinine ratio uPCR
> 0.3mg/dL

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13
Q

Signs of end organ damage (5 points)

A

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

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14
Q

How to prevent Preeclampsia?

Who is this recommended for? (5 points)

A

Low dose aspirin

For high risk patients eg. HTN on previous pregnancy
Multifetal gestation (eg. twins, triplets)
Autoimmune disease
DM
CKD

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15
Q

When should low dose aspirin be started?

A

Start after 12 weeks (1st trimester), continued till delivery

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16
Q

What is the normal level and effect of Estrogen and Progesterone after ovulation?

What happens during Ovulation?

What happens if there is no Ovulation?

A

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

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17
Q

How do Contraceptives work?

What happens during the placebo period

A

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

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18
Q

Advantage of condoms (male and female)

Disadvantages of condoms (3 points)

A

Adv:
STI protection if used correctly

Disadv:
High user failure rate
Not widely received
Possibility of breakage

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19
Q

Advantages (2 points) and Disadvantages (5 points) of Diaphragm with spermicide and Cervical cap

A

Adv:
Low cost
Reusable

Disadv:
High failure rate
Low protection against STI
Increased risk of UTI
Cervical irritation
Cause Toxic Shock Syndrome

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20
Q

What are the 2 concepts of Contraception?

A

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)

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21
Q

What is the role of Progestin? (3 points)

A

1) Thicken cervical mucus, slow sperm movement
2) Block LH surge
3) Induce endometrial atrophy

Provide most of contraceptive effect

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22
Q

What is the role of Estrogen? (2 points)

A

1) Reduce FSH secretion
2) Thicken endometrial lining

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23
Q

What is the most common form of Estrogen

What is the standard dose?

A

Ethinyl estradiol (EE)

30-35ug

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24
Q

What is the main issue with Progestins?

A

Progestins may cause androgenic side effects eg. Acne, Oily skin, Hirsutism

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25
Q

What is the lower dose for EE?

Who should be taking lower dose of EE?

A

15-25ug

Adolescence
Underweight (<50kg)
Older than 35
Peri-menopausal
Unable to tolerate SE eg. bloating, N/V, breast tenderness, weight gain

26
Q

Population that can take higher dose of EE (3 points)

A

Obesity, > 70.5kg

For early to mid cycle breakthrough bleeding
Indicates that estrogen level not high enough to inhibit cycle

For less adherent patients

27
Q

Differences between older and newer gen Progestins

A

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

28
Q

Under what circumstances should we have higher progestational activity?

A

1) Experience late cycle bleeding
2) Painful menstrual cramps

29
Q

What is Drospirenone?

Side effects of Drospirenone

A

It’s a 4th gen progestin, Mineralcorticoid antagonist, similar to Spironolactone

Can cause hyperkalemia, thromboembolism and bone loss

30
Q

What are the 3 ways of starting contraceptives?

Which need back up contraceptive and for how long?

A

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

31
Q

What is the reason for back up contraceptive for
“Sunday Start” and “Quick start”?

A

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.

32
Q

What is associated with VTE

A

1) Estrogen (increase hepatic production of clotting factors)

2) New generation Progestins (when combined with Estrogen)
Progestins alone do not cause VTE

33
Q

Which contraceptives to recommend with lowest VTE risk

A

Progestin-only contraceptives, and use Old gen (1st, 2nd) Progestins

Barrier methods

34
Q

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

A

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

35
Q

What is absolutely contraindicated with Estrogen containing contraceptives? (3 points)

A

Migraine with aura
Breast cancer
VTE (and other risk factors causing VTE eg. smoking, post partum, diabetes > 20 years w complications etc)

36
Q

What if patient has acne?

A

Use an antiandrogenic progestin eg. Drospirenone
OR
Increase estrogen, change Progestin-only to COC
(how to rmb: acnE)

37
Q

Why would headache occur?

Recommendation

A

Usually occurs during pill free week due to fluctuation of hormones

Change to a continuous dose or one with shorter pill free interval

38
Q

What if patient has nausea, vomiting, bloating?

A

Reduce estrogen
+
(N/V) Change to POP or take pills at night
(Bloating) Change to progestin with mild diuretic effect eg. Drospirenone

39
Q

What if patient has menstrual cramps?

A

Increase progestin
Switch to extended cycle or continuous cycle

40
Q

What if patient has breast tenderness / weight gain?

A

Keep both estrogen and progestin as low as possible

41
Q

3 drugs that can cause DDI with COC

A

1) Rifampicin
2) Anticonvulsants
3) HIV antiretrovirals

42
Q

What to do if missed one dose (less than 48 hours)

A

Take missed dose immediately
May need to take 2 pills on the same day
No need additional contraceptive

43
Q

What to do if missed 2 doses (more than 48 hours)

A

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

44
Q

What to do if missed during last week of hormonal tablets

A

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

45
Q

Indication for Progestin only Pills (POP) (3 points)

A

Good for breastfeeding

Conditions that preclude estrogen
Migraine with aura
Have VTE or High risk of VTE

Cannot tolerate Estrogen NV side effects

46
Q

Absolute contraindication for Progestin-only Pill

A

Breast cancer

47
Q

MOA of Progestin only pill (POP)

A

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

48
Q

What are the 3 types of POP?

A

1st, 2nd, 4th

1st: Norethindrone / Norethisterone
2nd: Levonorgestrel
4th: Drospirenone

49
Q

How to start POP?

A

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

50
Q

What if miss POP dose?

A

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

51
Q

Which population is transdermal contraceptives not useful?

A

Obese patients

52
Q

Other non pill hormonal contraceptives (4 points)

A

Transdermal patch
Vaginal rings
Progestin injections
Long acting reversible contraception (IUD or Implants)

53
Q

What is the advantage of vaginal rings over diaphragms / cervical cups?

A

Precise placement not needed, hormones are absorbed

54
Q

Adverse effects of Progestin injections (3 points)

A

Cannot be fertile immediately once stopped
Weight gain
Short term bone loss

54
Q

What are examples of Long Acting Reversible contraception (LARC)?

Benefits of LARC? (2 points)

A

Intrauterine Devices (IUD)
Implants

Highly effective (<1% failure)
Can become fertile soon after stopping
but invasive

55
Q

MOA of Intrauterine devices (IUD)

A

1) Inhibit sperm migration
2) Damage ovum
3) Disrupt transport of fertilised ovum

56
Q

Contraindications of IUD (6 points)

A

Pregnancy
Current STI
Undiagnosed vaginal bleeding
Malignancy of genital tract
Uterine abnormalities
Uterine fibroids

57
Q

2 types of IUD, how long do they last?

A

Levonorgestrel IUD - 5 years
Copper IUD - 10 years

58
Q

Which IUD is ideal for which conditions?

A

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

59
Q

How long can a Subdermal Progestin Implant last?

A

3 years

60
Q

Need to take emergency contraceptives by when?

A

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

61
Q

What is in Ella tablet?

A

Ulipristal, a Progestin receptor modulator

Will not be effective if patient is taking Progestin at the same time!

3152 - nat (16 decks)

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