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Pharm III > Lecture 11 (OB)-Exam 5 > Flashcards

Lecture 11 (OB)-Exam 5 Flashcards

1
Q

Infertility
* What is the def?*
* Specific treatment depends on what?

A
  • Inability to conceive after 12 months with regular, unprotected intercourse
  • Specific treatment depends on underlying etiology
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2
Q

Infertility
* What are the general lifestyle factors? (3)

A
  • Abstain from tobacco
  • Limit alcohol intake
  • Maintain BMI > 17 and < 30 kg/m2
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3
Q
A
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4
Q

Infertility
* How do you men and women start the work up?

A
  • Men – start with semen analysis
  • Women – determine if ovulating
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5
Q

Infertility
* What is the first test for infertility in women? What are the levels?

A

Day 21 progesterone level
* ≥ 5ng/mL = ovulating, evaluate for other causes
* < 5ng/mL = not ovulating, evaluate underlying cause
* Consider ovulation induction

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6
Q
A
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7
Q

Ovulation induction
* What is the MOA of Clomiphene (SERMs)

A

Inhibits estrogen receptors in the hypothalamus
* Inhibits the estrogen negative feedback
* Hypothalamus increases GnRH release in response to decreased estrogen negative FB
* Increased LH/FSH
* Ovary stimulation
* Ovulation

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8
Q

Ovulation induction
* When do you take Clomiphene

A

50 to 100 mg PO daily on days 5 to 10 of ovarian cycle

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9
Q

Ovulation induction:Letrozole
* What is the MOA?
* Not what?
* Stimulates what?
* Replaces what?
* Highest what?

A

Letrozole – aromatase inhibitor
* Not FDA approved indication
* Stimulates ovulation
* Replaces historic clomiphene
* Highest cumulative pregnancy and live birth rate (80% and 30 to 40%, respectively)

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10
Q

Ovulation induction
* When do you take letrozole?

A

Regimen: 2.5 to 7.5 mg PO daily on days 3 to 7 of the ovarian cycle

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11
Q

Immunizations
* When should they be given ideally?

A

Ideally should be administered prior to pregnancy

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12
Q

TEST

Immunizations
* What is safe during pregnancy?(6)

A
  • Pneumococcal
  • Meningococcal
  • Hepatitis A, B
  • Inactivated polio
  • Inactivated influenza–should be given, ok any trimester
  • Tdap
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13
Q

Tdap:
* Should be given when?

A

should be given at 27-36 weeks REGARDLESS of prior immunization hx (there is some passive antibody transfer to infant). All persons with close contact to infant should also be immunized

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14
Q

Immunizations
* What is not safe?
* What is uncertain/not recommended?

A

Not safe:
* Measles/mumps/rubella
* Polio
* Varicella

Uncertain/Not recommended
* HPV Vaccine. No adverse outcomes have been described but not recommended. If found to be pregnant during series, remaining doses given after pregnancy

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15
Q

RH incompatibility
* What is it?

A

Discordant pairing of maternal and fetal Rh factor
* Rh negative mothers – Rh positive infants

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16
Q

RH incompatibility
* What is the process?
* What is the goal?

A
  • Exposure to Rh positive blood cells from fetus results in development of maternal anti-D IgG antibodies against Rh positive antigens on the fetus RBCs
  • Antibodies can cross placenta of subsequent pregnancies and destroy fetal RBCs
  • Hemolytic disease of the newborn
  • Goal is to prevent formation of anti-D IgG antibodies
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17
Q

RH incompatibility
* All women need to be screen ?
* Rh neg women->

A
  • All women should be screened for Rh status at first prenatal visit
  • Rh neg women -> check anti-D antibodies
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18
Q

RH incompatibility
* If anti-Rh D antibody positive->
* If anti-Rh D antibody negative->

A

If anti-Rh D antibody positive -> NOT a candidate for Rh0 (D) immune globulin
* May require no additional testing if dad is known to be Rh negative

If anti-Rh D antibody negative -> further testing and Rh0 (D) immune globulin indicated

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19
Q

Rh0 (D) immune globulin - prophylaxis
* What is the standard regimens? (28 week gestation and postpartum)

A
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20
Q

Rh0 (D) immune globulin - prophylaxis
* What are the sensitizing event regimens?

A
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21
Q

Rh0 (D) immune globulin
* What is the MOA?
* What are the SEs?

A

MOA: thought to destroy Rh positive blood cells before maternal antibodies can be formed

Adverse reactions:
* Headache, drowsiness, dizziness, blood pressure changes, injection site reactions, allergic reaction

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22
Q

Rh0 (D) immune globulin
* What is the dosing?

A

Most indications
* 300 mcg IM x 1 dose
* 300 mcg provides sufficient antibody if volume of exposed Rh pos RBC exposure is ≤ 30 mL

Spontaneous / threatened / induced abortion < 13 weeks
* 50 mcg IM x 1 dose

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23
Q

* TEST

What are the Drugs contraindicated in pregnancy?(7)

A
  • Statins
  • Spironolactone
  • Warfarin – fetal syndrome
  • Anticonvulsants – topiramate
  • Guaifenesin – neural tube defects
  • Isotretinoin, tretinoin
  • Antibiotics
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24
Q

Drugs in lactation
* Need for what?
* Potential SE on what?
* What are the characteristics for amount excreted in breast milk?

A

Need for drug by mom

Potential side effects on milk production

Amount excreted in the breast milk
* Unionized, small molecule, high lipid solubility, low Vd, low protein binding

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25
Q

Drugs in lactation
* Drug what?
* Potential what?
* Age of who?
* What status?
* What agents?

A
  • Drug half-life
  • Potential adverse effects
  • Age of infant
  • Maternal HIV status
  • Chemotherapy agents
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26
Q

lactation
* What are the contraindicated medications?(6)

A
  • Acebutolol, atenolol– hypotension, bradycardia
  • Amiodarone - hypothyroidism
  • Antidepressants - some
  • Aspirin – metabolic acidosis
  • Benzodiazepines
  • Cytotoxic agents – methotrexate
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27
Q

lactation
* What are the rest of the contraindicated medications?

A
  • Ergotamine – N/V/seizures
  • Estradiol
  • Lamotrigine
  • Lithium
  • Nitrofurantoin – hemolysis if G6PD deficient
  • Phenobarbital
  • Sulfasalazine – blood diarrhea
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28
Q

Ectopic pregnancy treatment
* What are the three primary options? (general)

A
  • Surgical – salpingostomy or salpingectomy
  • Methotrexate
  • Expectant management
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29
Q

Ectopic pregnancy treatment: Methotrexarte
* For who?
* What bhCG levels?
* What is not on US?
* Reliable/close access to what?

A
  • Hemodynamically stable
  • Beta-hCG ≤ 5000 milli-IU/mL
  • No fetal cardiac activity on transvaginal ultrasound (TVUS)
  • Reliable / close access to emergency services
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30
Q

Ectopic pregnancy treatment: Expectant management
* Common or uncommon?
* What is the bhCG levels?
* No identifiable what?
* Reliable / close access to what?

A
  • Uncommon
  • Beta hCG < 200 and falling
  • No identifiable pregnancy on TVUS
  • Reliable / close access to emergency services
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31
Q

methotrexate
* What is the MOA?
* Pharmacokinetics?

A

MOA:
* Folic acid antagonist
* Inhibits DNA synthesis and cell reproduction of rapidly proliferating cells
* Trophoblasts and fetal cells

Pharmacokinetics:
* Rapid clearance by the kidney
* 90% cleared in 24 hours

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32
Q

methotrexate
* What are the SE?
* When do you need to follow up?

A

Adverse reactions:
* MC stomatitis / conjunctivitis
* Nausea / vomiting

Follow up:
* hCG level on days 4 and 7
* If ≥ 15% decrease no additional doses
* Monitor hcg weekly until undetectable
* If < 15% decrease, additional doses indicated

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33
Q

Caring for the Pregnant Diabetic Patient
* tight glycemic control to what?
* Poor control in early pregnancy =
* Poor control in late pregnancy =

A
  • Tight glycemic control to normal HbA1c [< 6 (ideal) to < 7] – while preventing hypoglycemia
  • Poor control in early pregnancy = increased risk of spontaneous abortion and congenital malformations
  • Poor control in late pregnancy = increased risk of pre-term labor, preeclampsia, shoulder dystocia, and stillbirth

Frequent monitoring of blood sugar recommended

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34
Q

* TEST

Gestational diabetes screening - 24 to 28 weeks gestation

A

KNOW NUMBERS

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35
Q

*

Gestational diabetes
* What is the txt?
* What is the pharmacotherapy?

A

*

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36
Q

Gestational diabetes
* What are the goals? (3)

A
  • Fasting and preprandial blood glucose concentration: <95 mg/dL (5.3 mmol/L)
  • One-hour postprandial blood glucose concentration: <140 mg/dL (7.8 mmol/L)
  • Two-hour postprandial glucose concentration: <120 mg/dL (6.7 mmol/L)
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37
Q

Gestational diabetes
* Women with gestational diabetes are at increased risk of what?
* 2-hour oral glucose tolerance test recommended when?
* Screen patients when?

A
  • Women with gestational diabetes are at increased risk of developing diabetes
  • 2-hour oral glucose tolerance test recommended at 6-weeks postpartum
  • Screen patients at least every 3 years for diabetes
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38
Q

Gestational diabetes
* What are the lifestyle interventions?

A

Lifestyle interventions (eg, achieving a healthy weight, appropriate level of physical activity/exercise) are clearly beneficial for reducing the incidence of diabetes, and related comorbidities such as cardiovascular disease.

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39
Q

* TEST

Hypertension - pregnancy
* What is the definition?

A

≥ 140 or ≥ 90 mmHg on two separate occasions at least 4 hours apart or ≥ 160/110 mmHg on one occasion

*

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40
Q

Hypertension - pregnancy
* What is pre-eclampsia?
* What is eclampsia?

A
  • Pre-eclampsia – new onset hypertension after 20 weeks gestation associated with proteinuria ± edema, elevated liver enzymes, thrombocytopenia, cerebral edema/vision changes
  • Eclampsia – pre-eclampsia plus seizures
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41
Q

Hypertension - pregnancy
* What is chronic hypertension?
* What is gestational hypertension?

A
  • Chronic hypertension – preexisting hypertension prior to pregnancy
  • Gestational hypertension – hypertension after 20 weeks gestation NOT associated with proteinuria or other systemic symptoms
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42
Q

Chronic hypertension - pregnancy
* Txt recommended for who?

A

Treatment recommended for SBP ≥ 140 mmHg or DBP ≥ 90 mmHg on two separate occasions at least 4 hours apart

43
Q

Chronic hypertension - pregnancy
* What is the 2022 CHAP trial?

A

2408 patients randomized to
* Standard therapy – no treatment until SBP ≥ 160 mmHg or DBP ≥ 110 mmHg
* Blood pressure control – goal < 140 /90 mmHg

Blood pressure control group had significant reductions in pre-eclampsia, preterm birth, severe hypertension, fetal death

44
Q

Gestational HTN/Pre-eclampsia
* What is the def?
* Treatment is recommended for who?

A
  • New pregnancy-related hypertension after 20 weeks gestation
  • Treatment is recommended for SBP 150 to 159 mmHg and/or DBP 100 to 109 mmHg that persists over multiple measurements and delivery is expected to be delayed for several days or weeks
45
Q

Gestational HTN/Pre-eclampsia
* Txt is suggested for who?

A

Treatment suggested for SBP 140 to 149 mmHg and/or DBP 90 to 99 mmHg that persists over multiple measurements and delivery is expected to be delayed for several days or weeks

46
Q

* TEST

Preeclampsia
* What is essential of dx?

A

Maternal blood pressure elevation of ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on 2 occasions 4 hours apart

47
Q

Preeclampsia
* Need an one of the following:(6)

A
  • Proteinuria (either ≥ 300 mg in a 24-hour urine specimen or a spot urine protein/creatinine ratio ≥ 0.3)
  • Thrombocytopenia (a platelet count < 100,000/µL)
  • Renal insufficiency (serum creatinine concentration > 1.1 mg/dL or a doubling of the serum creatinine in the absence of other renal disease)
  • Impaired liver function (elevated blood concentrations of liver transaminases to twice normal concentration)
  • Pulmonary edema
  • Cerebral or visual symptoms
48
Q

Preeclampsia expectant therapy
* Initiation of what? Who gets it?

A

Initiation of low dose aspirin (81mg) at 12 to 16 weeks gestation indicated for women with at least
* One high-risk factor OR
* Two moderate-risk factors

49
Q

Preeclampsia expectant therapy
* Reduces what? (3)

A
  • Reduces the incidence of severe preeclampsia
  • Reduce the risk of intrauterine growth retardation
  • Reduce the risk of preterm delivery (14%)
50
Q

* TEST

Preeclampsia expectant therapy

51
Q

Preeclampsia – clinical features
* without severe features?

A

Fewer complaints, DBP <110, platelet count over 100,000/mcL, fetal testing reassuring

52
Q

Preeclampsia – clinical features
* With severe features?

53
Q

Preeclampsia – clinical features

54
Q

Preeclampsia treatment
* Delivery: over 37 weeks?

A

≥ 37 weeks gestation
* Improves maternal morbidity and mortality
* Safest for fetus

55
Q

Preeclampsia treatment
* Delivery: ≥ 34 weeks gestation with severe symptoms?

A
  • In labor or ruptured membranes
  • Abnormal maternal / fetal test results
  • Suspected abruptio placentae
  • Fetal size < 5th percentile

Viable to 33 6/7 = more controversial

56
Q

Preeclampsia treatment
* What is the expectant management of < 37 weeks gestation without severe symptoms?(3)

A
  • Close maternal and fetus monitoring
  • BID blood pressures
  • Twice weekly labs
    * Platelets, serum creatinine, liver enzymes
57
Q

Preeclampsia treatment
* Delivery required if symptoms progress?

A
  • Severe HTN
  • End organ damage
  • Non-reassuring fetal well being
58
Q

* TEST

Magnesium sulfate
* Indicated for who? What does it cause?

A

Indicated for preeclampsia with severe features
* Decreases the risk of eclamptic seizures
* Decreases risk of placenta abruption
* Initiated at the onset of symptoms, labor, or labor induction
* Continued for 12 to 24 hours post delivery

59
Q

Magnesium sulfate
* First line txt for who?

A

First-line treatment for eclampsia

60
Q

Magnesium sulfate
* What is the dosing?
* Dose reduction required for?

A
  • Loading dose: 4 to 6 grams IV over 15 minutes
  • Continuous infusion: 1 to 2 grams / hr IV
  • Dose reduction required for renal impairment
61
Q

Magnesium sulfate
* Infusion should be held for what? (3)

A
  • Loss of deep tendon reflexes
  • RR < 12 BPM
  • UOP < 100mL over 4 hours
62
Q

* TEST

Magnesium sulfate
* What is the antidote?
* What is the monitoring?

A
  • Antidote: calcium gluconate
  • Periodic magnesium level monitoring recommended
63
Q

Magnesium sulfate
* What are the SE?(5)

A
  • N/V
  • Headache
  • Muscle weakness
  • Visual disturbances
  • Palpitations
64
Q

Acute therapies – severe hypertension
* What is first line? What are the other options?

A

IV labetalol
OR
IV hydralazine

Alternatives:
* PO nifedipine (ER vs IR formulations)
* IV nicardipine
* IV nitroprusside

65
Q

Chronic maintenance therapy
* What is first line and alternatives?

A

First-line:
* Labetalol
* Nifedipine

Alternatives:
* Hydralazine
* Methyldopa

66
Q

Chronic maintenance therapy

67
Q

Inhibition of preterm labor
* What are the goals? (3)

A
  • Delay preterm labor for 48 hours until after administration of antenatal corticosteroids
  • Allow for safe neonatal transport to appropriate facility
  • Prolong pregnancy during self-limited condition that triggered contractions (UTI/surgery)
68
Q

Inhibition of preterm labor
* What are the contraindications? (5)

A
  • Advanced labor – not going to stop it
  • Mature fetus
  • Intrauterine infection
  • Significant vaginal bleeding
  • Severe preeclampsia
69
Q

Inhibition of preterm labor - tocolytics

70
Q

* TEST

Inhibition of preterm labor - tocolytics

71
Q

* TEST

Management of PPROM (preterm premature rupture of membranes)

72
Q

* TEST

Management of PPROM (preterm premature rupture of membranes)

73
Q

Antenatal corticosteroids
* Indicated when?
* Accelerates what?
* What are the options?

A
  • Indicated between 24 and 34 0/7 weeks gestation if risk of delivery in the next 7 days
  • Accelerates lung maturation
  • Betamethasone and Dexamethasone
74
Q

Antenatal corticosteroids
* What is the MOA of corticosteroids?

75
Q

Group b Streptococcus Prophylaxis (s. agalactiae)
* What is the goal?
* What is the screening?

A

Goal:
* Minimize risk of neonatal GBS infection for infants born to mothers colonized with organism

Screening:
* All pregnant women 36 to 37 weeks gestation
* Vaginal and rectal swabs

76
Q

Group b Streptococcus Prophylaxis (s. agalactiae)
* Treatment if GBS positive or what?

77
Q

Group b Streptococcus Prophylaxis (s. agalactiae)
* No treatment when?

A

No treatment if screening negative
* C-section with intact membranes

78
Q

* TEST

Group b Streptococcus Prophylaxis (s. agalactiae)
* What is the txt?

A
  • IV penicillin G or ampicillin
  • Loading dose plus q4h dosing until delivery
  • Multiple second-line options for patients with penicillin allergy
79
Q

Labor Induction Methods
* What are the different methods?(4)

A
  • Membrane stripping – pulling away sac
  • Cervical ripening to enhance induction success
  • Oxytocin
  • Amniotomy
  • Others (anecdotal evidence): nipple stimulation, intercourse, spicy food
80
Q

Labor Induction Methods: amniotomy
* Artificial what?
* Note what?
* Monitor what?
* Risk of what?

A
  • Artificial rupture of membranes
  • Note clarity of fluid and presence of meconium
  • Monitor FHR before and immediately after
  • Risk of umbilical cord prolapse
81
Q

Labor induction: Goal
* Maximizes what?
* Not recommened when?
* Pregnancies > 42 weeks have increased risk of what? Why?

A

Maximize health and safety of mom and baby

Not recommended prior to 39 weeks for otherwise healthy pregnancies

Pregnancies > 42 weeks have increased risk of neonate morbidity
* Meconium aspiration
* Hypoxic ischemic encephalopathy
* NICU admissions

82
Q

*

Labor induction: Cervical ripening – softening, dilation, effacement
* Indicated for who?
* Increases what? What can it cause?

A

Indicated for unfavorable cervix based on Bishop’s score

Increases uterine contractions
* Can cause tachysystole = ≥ 5 contractions in 10 min

83
Q

Labor induction
* What are the options for cervical ripening?

A

Mechanical – catheter dilation

Misoprostol – prostaglandin E1
* Multiple routes – MC intravaginal tablet
* May repeat every 4 hours

Dinoprostone – prostaglandin E2
* Vaginal gel or 10mg time-release vaginal insert

84
Q

Labor induction:
* Monitor what?
* What can be used alone with favorable cervix?

A
  • Monitor fetal activity and heart rate
  • Amniotomy – can be used alone with favorable cervix
85
Q

FYI

Labor induction

86
Q

Oxytocin
* What are the indication? (4)
* What is the MOA?

A

Indications
* Augment labor
* Induction of abortion
* Decreases postpartum hemorrhage
* Induces milk let down

MOA:
* Synthetic form of endogenous peptide hormone
* Released by posterior pituitary
* Induces uterine contractions
* Constriction the spiral arteries and decreasing uterine blood flow

87
Q

FYI

Oxytocin
* How do you initiate it?

A

Specific timing after cervical ripening agents
* 6-12 hr after dinoprostone gel
* 30 min after removal of dinoprostone insert
* 4 hours after misoprostol

88
Q

Oxytocin
* What is the dosing?
* Hold when?

A

Dosing:
* IV as a continuous infusion titrated to desired effects
* Contractions with consistent strength/rate
* Every 2 to 3 min lasting 60 to 90 sec

Hold for contractions > q2min, abnormal fetal heart rate or variable late decels

89
Q

Oxytocin Contraindications
* When should vaginal delivery avoided?(5)

A
  • Breech presentation
  • Placenta previa
  • Active genital herpes
  • Cephalopelvic disproportion
  • Mom cannot tolerate labor
90
Q

Oxytocin contraindications
* When risk is to mom and fetus?

A

Risks to fetus
* Distress
* Brain damage
* Death

Risks to mom
* Hyperstimulation uterus
* Uterine rupture
* Water intoxication, seizures
* Hypertension, arrythmias

91
Q

Postpartum hemorrhage
* What is the best treatment?
* Starts with what?
* Controlled what?
* _ massage?

A
  • Best treatment – prevention
  • Starts with active management of third stage of labor (AMTSL)
    * Oxytocin – immediately at the end of delivery (Reduces the risk of PPH by 50%)
  • Controlled cord traction
  • Uterine massage
92
Q

Postpartum hemorrhage: Recognition
* MC when?
* Measuring what?
* Most healthy pregnant women can lose how mcuh?
* ACOG definition is what?
* Who should be closely monitored and resuscitation started?

A
  • MC in the first 24 hours after delivery
  • Measuring postpartum blood and clots
  • Most healthy pregnant women can lose 500 to 1000mL before becoming symptomatic
  • ACOG definition is ≥ 1000mL
  • Patients with blood loss between 500 to 999ml should be closely monitored and resuscitation started
93
Q

Postpartum hemorrhage
* Readiness?
* Response?

A
  • Readiness – emergency hemorrhage kits
  • Response – use written protocols and check lists
94
Q

Postpartum hemorrhage
* Resuscitation should start when?

A

Patients with blood loss ≥ 500 mL with symptoms

95
Q

Postpartum hemorrhage

96
Q

* TEST

PPH
* MCC?
* What is first line?

A
  • MCC – Uterine atony (70%)
  • First-line: Oxytocin
97
Q

PPH
* What is the MoA of oxytocin?

A
  • Synthetic form of endogenous peptide hormone
  • Released by posterior pituitary
  • Induces uterine contractions
  • Constricting the spiral arteries and decreasing uterine blood flow
98
Q

PPH: Oxytocin
* What are the SE?(3)

A
  • Painful contractions
  • N/V
  • Hypertension
99
Q

Metritis
* What is it?
* AKA?
* Ascening what?
* Most common what?

A
  • Infection of the uterine cavity and adjacent tissue
  • AKA: endomyometritis, endometritis, metritis with cellulitis
  • Ascending infection from the lower genital tract - polymicrobial
  • Most common infection after cesarean section
100
Q

Metritis
* How do you dx it?
* What is the tx? What is first line?

A
  • Dx: Fever for ≥ 2 days with in 10 days post partum
  • Tx: IV ABX until patient is asymptomatic and afebrile for 24 hours
  • First-line: piperacillin-tazobactam, clindamycin or metronidazole + ceftriaxone
  • Clindamycin + gentamicin “textbook” but falling out of favor
101
Q

Postpartum Depression
* Consider if what?
* Sxs start when?
* Same dx criteria as what?

103
Q

Treatment of Postpartum Depression
* What is the psychotherapy?
* What is the pharmacotherapy?

A

Psychotherapy
* Interpersonal Therapy
* Cognitive Behavioral Therapy

Pharmacotherapy
* Selective Serotonin Reuptake Inhibitors (SSRI): Paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), etc
* Very small concentrations found in breastmilk

Pharm III (14 decks)

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