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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
Progesterone for infertility dosage forms BBW
intravaginal get, insert IM injection compounded suppositories capsules
26
example of fertilization protocol | four steps, four meds
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
``` GnRH ag med? MOA? duration? AE ```
Leuprolide (Lupron Depot) stimulated GnRH and inc (-) fb, shuts it off so it becomes an antag duration <12 mo AE: inj site rxn
28
what should GnRH ags/antags be combined with
gonadotropin
29
Fertility treatment complications (4 major ones)
multiple births, Ovarian Hyperstimulation Syndrome (OHSS), psychiatric disorders, insurance complications
30
what is OHSS
ovary enlargement, capillary permeability inc and protein rich fluid escapes into intravascular space
31
Patient has abdominal distention/discomfort, mild N/V, dyspnea, diarrhea which stage of OHSS
mild
32
patient has abdominal distention/discomfort, mild N/V, dyspnea, diarrhea and ascites on ultrasound which stage of OHSS
Moderate
33
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
severe
34
Patient has low BP, pleural effusion, rapid weight gain, severe abdominal pain, venous thrombosis, acute renal failure, respiratory distress, sepsis which stage of OHSS
Critical
35
PCOS | patho
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
#1 cause of anovulatory infertility
PCOS
37
PCOS risk factors
FHx PCOS, DM, insulin resistance, irregular menses or anovulation, CV disease
38
PCOS s + sx
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
PCOS treatment | non pharm
exercise, diet hirsutism: bleaching, plucking, shaving, eflornithine (Vaniqa) 13.9% cream acne: OTC agents tx metabolic conditions with statins, insulin, sensitizing agents
40
PCOS pharm tx options
CHC antiandrogens insulin sensitizers (metformin) oral ovulation induction agents (clomiphene, letrozole) injectable ovulation induction (gonadotropins)
41
PCOS CHC tx target MOA clinical pearls
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
1st line PCOS tx
CHCs (Drosperinone preferred progestin) | **unless fertility is desired
43
PCOS antiandrogen tx target MOA clinical pearls
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
PCOS insulin sensitizer (Metformin) tx targets recommended to use in addition to what?
targets hirsutism, acne, menstrual irregularities, anovulation, insulin resistance, infertility use in addition to clomiphene (SERM)
45
PCOS oral ovulation induction agents targets agent?
targets infertility only | letrozole first line if desires infertility improvements
46
PCOS injectable ovulation induction agents when to use target
use when failed oral ovulation induction with letrozole
47
PCOS tx algorithm order
(lifestyle mod if obese), letrozole for ovulation induction, metformin, refer to infertility expert
48
endometriosis dx patho
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
endometriosis risk factors
``` obstruction of menstrual flow exposure to diethylstilbestrol in utero short menstrual cycles low birth weight exposure to endocrine disrupting chemicals ```
50
endometriosis sx
``` pelvic pain DYSMENORRHEA, often NSAIDs do not help dyspareunia infertility GI sx ```
51
endometriosis tx associated pain | diff than endometriosis fertility tx
surgical (1st line or after pharm failure) ``` pharmacologic NSAIDS +/- hormonal: CHC, progestins = 1st line GnRH ag, antag = 2nd line danazol aromatase inhibitor ```
52
what do CHCs do in endometriosis tx
cyclical or continuously used for dysmenorrhea and pelvic pain
53
what do progestins do in endometriosis tx | what are the option
dysmenorrhea and pelvic pain | norethindrone, medroxyprogesterone acetate, LNG IUD
54
tx of endometriosis assoc infertility
surgical, artificial insemination, assisted reproductive technology (IVF, IUI)
55
first, second and third line agents for endometriosis pain tx
NSAIDs + CHC or POC GnRH ag (Leuprolide) or GnRH antag (elagolix) Danazol, aromatase inhibitors
56
miscarriage risk factors
women who have experienced previous early pregnancy loss | advanced maternal age
57
miscarriage sx
vaginal bleeding | uterine cramping
58
managing a miscarriage what to give for pain? what to give for medication?
NSAIDs or APAP Misoprostol 800mcg vaginally, may repeat if needed within 7d
59
Medications for medical abortion
Mifepristone 200mg on day 1 + Misoprostol 800 mg buccally or vaginally 24-48h after mifepristone Methotrexate - use through 49d gestational age
60
Misoprostol for medical abortion counseling
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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