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Women's Health Exam 2 and Final > Infertility, Miscarriage, and Abortion > Flashcards

Infertility, Miscarriage, and Abortion Flashcards

1
Q

Infertility definition

A

inability to conceive after 1 yr unprotected sex

if a woman is >35 yo, then 6 months of the same

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2
Q

primary vs secondary infertility

A 
primary = never conceived a child
secondary = prior conception, subsequent inability to conceive again
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3
Q

male causes of infertility

A

endocrine
anatomic
sexual dysfunction

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4
Q

female causes of infertility

A

ovulatory (PCOS)
cervical
tubal/uterine/peritoneal (PID)

PID, PCOS, endometriosis, uterine fibrosis, idiopathic

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5
Q

non pharm infertility management

A 
protein, fruits, veggies
(men can take zinc)
exercise to a normal BMI
smoking cessation
D/C meds that cause infertility
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6
Q

meds that impair infertility via hyperprolactinemia

A 
phenothiazines
haloperidol
opiates
H2 antags
SSRis
Verapamil
estrogen
metoclopramide
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7
Q

meds that impair fertility via impaired spermatogenesis

A 
alcohol, caffeine, marijuana, nicotine
allopurinol
anabolic steroids
codeine
spironolactone
sulfasalazine
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8
Q

assisted reproductive technologies

A 
in vitro fertilization (IVF)
intrauterine insemination (IUI)
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9
Q

what increase in basal body temp indicates ovulation

when do you take basal body temp?

A

0.4-0.6 deg F increase means ovulation has occurred

day 1 of cycle, qd

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10
Q

what do ovulation predictor kits detect

when do you start

A

LH surge

start 3-4d prior to expected ovulation, have intercourse 24-48 h after color change detected

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11
Q

which infertility medication is a SERM

A

Clomiphene citrate

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12
Q 
Clomiphene
MOA
dosing
AE
OHSS common?
CI
A

Selective estrogen receptor modulator; –| (-)fb on HPO axis so body thinks estrogen is low, GnRH inc, LH + FSH inc. resulting in ovulation

50-100mg po qd x5d (start on day 3,4 or 5 of cycle)

OHSS uncommon
AE: ovary enlargement, hot flashes/flushes (bc estrogen “decreased”)
CI: thyroid and adrenal dysfunction

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13
Q

which infertility med is an aromatase inhibitor

A

Letrozole

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14
Q

what does a patient need in order to respond to clomiphene

A

sufficient FSH and estradiol to respond

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15
Q 
Letrozole
MOA
dosing
AE
OHSS common?
CI
A

inhibits aromatase which converts androgens to estrogens, decreases estrogen, GnRH increases, LH and FSH increase

2.5-7.5mg po qd x5d (start on day 3,4 or 5 of cycle)
up to 5 tx cycles

AE: flushing, edema, HA, dizziness, fatigue, night sweats, Nausea, weight gain

OHSS rare

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16
Q

Gonadotropin (FSH)/Follitropin alpha (Gonal-f), Follitropin beta (Follistim AQ)
dosing and admin
AE
OHSS?

A

individualize dose based on response to therapy, use lowest effective
dose can range from 37-450IU SQ or IM qd
AE: ovarian cysts!, HA, abdominal pain, nausea, inj site rxn, URI

!higher risk of OHSS and multiple births!
32% have multiple gestations

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17
Q

Gonadotropin releasing hormone antagonists meds

A

Cetrorelix, Ganirelix

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18
Q

GnRH antags (Cetrorelix, Ganirelix)
dose
AE
OHSS?

A

0.25mg SQ in abdomen
AE: HA, OHSS. abdominal pain, nausea, pelvic pain, vaginal hemorrhage, inj site rxn

Higher risk of OHSS and multiple births

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19
Q

(recombinant) human chorionic gonadotropin/hCG;r-hCG
when to give?
admin route?
AE (OHSS?)

A

give after GnRH ag or antag
IM or SQ dep on if recombinant or not
risk of OHSS

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20
Q

human menopausal gonadotropin meds

A

Menotropin/hMG(Menopur)

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21
Q

human menopausal gonadotropin Menotropin/hMG(Menopur)
dosing
AE
CI

A

75-450 IO sq qd
AE: multiple gestations (35%), HA, OHSS, abd pain, vomiting, diarrhea, ectopic pregnancy,

Ci in primary ovarian failure (high FSH)

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22
Q

Human growth hormone med

A

Somatropin

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23
Q

somatropin
moa
AE
monitiring

A

human growth hormone
periph edema, HA, abd pain, arthralgia, inj site rxn, nausea

monitor: fluid status, BG, HbA1c, lipid profile, BP, thyroid fxn, BMI

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24
Q

estrogen use in infertility

A

reset cycle going into IVF or IUI

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25
Q

Progesterone for infertility
dosage forms
BBW

A

intravaginal get, insert
IM injection
compounded suppositories
capsules

26
Q

example of fertilization protocol

four steps, four meds

A
  1. mid luteal (21d-28d) - GnRH ag
  2. menstruation day 2-13 - GnRH ag + gonadotropin
  3. day 14 - hCG
  4. day 15 and on - progesterone
27
Q 
GnRH ag
med?
MOA?
duration?
AE
A

Leuprolide (Lupron Depot)
stimulated GnRH and inc (-) fb, shuts it off so it becomes an antag
duration <12 mo
AE: inj site rxn

28
Q

what should GnRH ags/antags be combined with

A

gonadotropin

29
Q

Fertility treatment complications (4 major ones)

A

multiple births, Ovarian Hyperstimulation Syndrome (OHSS), psychiatric disorders, insurance complications

30
Q

what is OHSS

A

ovary enlargement, capillary permeability inc and protein rich fluid escapes into intravascular space

31
Q

Patient has abdominal distention/discomfort, mild N/V, dyspnea, diarrhea
which stage of OHSS

A

mild

32
Q

patient has abdominal distention/discomfort, mild N/V, dyspnea, diarrhea and ascites on ultrasound
which stage of OHSS

A

Moderate

33
Q

Patient has patient has abdominal distention/discomfort, mild N/V, dyspnea, diarrhea and ascites on ultrasound, oliguria/anuria, intractable N/V, hydrothorax
which stage of OHSS

A

severe

34
Q

Patient has low BP, pleural effusion, rapid weight gain, severe abdominal pain, venous thrombosis, acute renal failure, respiratory distress, sepsis
which stage of OHSS

A

Critical

35
Q

PCOS

patho

A

inappropriate GnRH stimulation, inc LH and FSH, excessive androgen production, endometrial hyperplasia and cancer, LH and FSH surge when follicle is not ready, no ovulation

Rotterdam Criteria (at least 2 of...)
 chronic anovulation (amenorrhea)
 androgen excess
 polycystic ovaries
36
Q

1 cause of anovulatory infertility

A

PCOS

37
Q

PCOS risk factors

A

FHx PCOS, DM, insulin resistance, irregular menses or anovulation, CV disease

38
Q

PCOS s + sx

A

androgen excess: irregular menses, amenorrhea, hirsutism, acne, alopecia
Metabolic: obesity, insulin resistance, dyslipidemia
Polycystic ovaries: 12+ follicles 2-9cm ea., inc ovarian volume >10mL during ovarian phase

39
Q

PCOS treatment

non pharm

A

exercise, diet

hirsutism: bleaching, plucking, shaving, eflornithine (Vaniqa) 13.9% cream
acne: OTC agents

tx metabolic conditions with statins, insulin, sensitizing agents

40
Q

PCOS pharm tx options

A

CHC
antiandrogens
insulin sensitizers (metformin)
oral ovulation induction agents (clomiphene, letrozole)
injectable ovulation induction (gonadotropins)

41
Q

PCOS CHC tx
target
MOA
clinical pearls

A

targets menstrual cycle irregularity, hirsutism and acne

estrogen suppresses LH secretion, decrease androgen excess, increase circulating sex hormone binding globulin, inc cycle regularity

1st line!
nonandrogenic progestin preferred (Norgestimate, Desogestrel, Drosperinone)

42
Q

1st line PCOS tx

A

CHCs (Drosperinone preferred progestin)

**unless fertility is desired

43
Q

PCOS antiandrogen tx
target
MOA
clinical pearls

A

targets hirsutism and acne
inhibits ovarian and adrenal steroidogenesis and competes for androgen receptors in hair follicles

can combine w CHC is fertility not desired
Spironolactone most commonly used

44
Q

PCOS insulin sensitizer (Metformin) tx
targets
recommended to use in addition to what?

A

targets hirsutism, acne, menstrual irregularities, anovulation, insulin resistance, infertility

use in addition to clomiphene (SERM)

45
Q

PCOS oral ovulation induction agents
targets
agent?

A

targets infertility only

letrozole first line if desires infertility improvements

46
Q

PCOS injectable ovulation induction agents
when to use
target

A

use when failed oral ovulation induction with letrozole

47
Q

PCOS tx algorithm order

A

(lifestyle mod if obese), letrozole for ovulation induction, metformin, refer to infertility expert

48
Q

endometriosis
dx
patho

A

dx with laparoscopic surgery (GOLD STANDARD)
patho: retrograde menstruation/lymphatic spread of hormone sensitive endometrial cells and tissues that implant, induce inflammatory response, angiogenesis and adhesions

49
Q

endometriosis risk factors

A 
obstruction of menstrual flow
exposure to diethylstilbestrol in utero
short menstrual cycles
low birth weight
exposure to endocrine disrupting chemicals
50
Q

endometriosis sx

A 
pelvic pain
DYSMENORRHEA, often NSAIDs do not help
dyspareunia
infertility
GI sx
51
Q

endometriosis tx associated pain

diff than endometriosis fertility tx

A

surgical (1st line or after pharm failure)

pharmacologic
NSAIDS +/-
hormonal: CHC, progestins = 1st line
                  GnRH ag, antag = 2nd line
danazol
aromatase inhibitor
52
Q

what do CHCs do in endometriosis tx

A

cyclical or continuously used for dysmenorrhea and pelvic pain

53
Q

what do progestins do in endometriosis tx

what are the option

A

dysmenorrhea and pelvic pain

norethindrone, medroxyprogesterone acetate, LNG IUD

54
Q

tx of endometriosis assoc infertility

A

surgical, artificial insemination, assisted reproductive technology (IVF, IUI)

55
Q

first, second and third line agents for endometriosis pain tx

A

NSAIDs +

CHC or POC
GnRH ag (Leuprolide) or GnRH antag (elagolix)
Danazol, aromatase inhibitors

56
Q

miscarriage risk factors

A

women who have experienced previous early pregnancy loss

advanced maternal age

57
Q

miscarriage sx

A

vaginal bleeding

uterine cramping

58
Q

managing a miscarriage
what to give for pain?
what to give for medication?

A

NSAIDs or APAP

Misoprostol 800mcg vaginally, may repeat if needed within 7d

59
Q

Medications for medical abortion

A

Mifepristone 200mg on day 1 +
Misoprostol 800 mg buccally or vaginally 24-48h after mifepristone
Methotrexate - use through 49d gestational age

60
Q

Misoprostol for medical abortion counseling

A

Take 24-48h post mifepristone
bleeding and cramping will start a couple hours after taking misoprostol
call if bleeding soaks 2 full-size pads per hour for two consecutive hours

Women's Health Exam 2 and Final (5 decks)

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