Lecture 18, 19 & 20: Medicines In Pregnancy, Infertility & Menopause Flashcards
1
Q
What is the pregnancy prevention programme when a patient is prescribed valproate?
A
- Use 1 highly effective contraception (IUD/ implant) OR 2 contraception w/ barrier method
- Dispense in original packs, copy of packet leaflet, patient card and valproate warning sticker
- Annual risk form/ 2 independent specialist, continue if no effective treatment
2
Q
What are the problems with teratogenic meds?
A
- Causes developmental abnormality in embryo/foetus
3
Q
What can sodium valproate do to men in regards to fertility?
A
- Impair fertility and cause testicular toxicity and cause spermatogenesis abnormalities
4
Q
When would sodium valproate be fine to use in women?
A
- Post menopause w/ hysterectomy (uterus removed)
5
Q
What should be done if pregnancy is suspected and patient is on sodium valproate?
A
- Don’t stop valproate and urgent refer to specialist
- Switch/dose reduction/ withdrawal if seizures are well controlled
6
Q
A
7
Q
Name some drugs with teratogenic effect?
A
- ACE inhibitors
- Warfarin: congenital malformations
- Lithium: avoid in first trimester
- Antibiotics: Clarithromycin (Avoid 1st trimester), Metronidazole (avoid high dose), Chloramphenicol (risk of grey-baby syndrome in 3rd trimester), tetracyclines (discolouration of teeth in 2nd/3rd trimester), aminoglycosides (auditory/vestib damage in 2nd/3rd)
- Oral retinoids: PPP
- Statins: discontinue 3mnths before
- Trimethoprim: folate antagonist important in foetal neural development in 1st trimester
- Pregabalin
- Methotrexate
- Phenytoin
- Benzodiazepines: Floppy infant syndrome
8
Q
What are the weeks for the 3 trimesters and when do congenital malformations most likely happen?
A
- 1st trimester: wk1-12 (starts first day of last menstrual cycle)
- 2nd trimester: wk13-26 (limbs/facial features)
- 3rd trimester: wk27-40
- Between 3rd and 11th week
9
Q
What are some immunisations needed when planning preg?
A
- Rubella
- Varicella: usually women without definite Hx of chicken pox or shingles
- Hep B: IV drug users, change partners frequently = more likely to contract
10
Q
What is 1st line treatment for morning sickness and what meds can be given?
A
- Sleep hygiene, regular meals, avoid fatty food, plenty fluids
- Antihistamines: promethazine/ cyclizine or ondansetron (2nd line as evidence for cleft lip in 1st trimester)
11
Q
What are 2 supplements that are recommended to be taken in pregnancy?
A
- Folic acid: reduces neural tube defects (spins bifida). 400ug OD before preg and 1-12wk, 5mf OD if fhx of NTD, diabetes, sickle cell anaemia, on antiepileptic med, obese (BMI over 30)
- Vitamin D: 10ug OD
12
Q
What is the advice for pregnant women on obesity/smoking/alcohol?
A
- Obesity: lose weight before preg (25-29 = overweight), increases risk of NTD, heart defects, cleft palate
- Smoking: stop, increases risk for miscarriage, pre term delivery, reduced birth weight, perinatal death (better to avoid NRT)
- Alcohol: can cause foetal alcohol spectrum (small head, facial defects, thin upper lip, miscarriage)
13
Q
What is the advice for pregnant women on OTC, Herbal rem, Vit a (retinol) and iron supplements?
A
- oTC: ask pharmacist
- Herbal rem: avoid
- Vit A: congenital defects (don’t exceed 700ug)
- Iron supp: don’t offer, no benefit and mother has side effects
14
Q
What should be done when diagnosed with DVT in pregnancy?
A
- Give low molecular weight heparin, warfarin contraindicated
- Give tinzaparin and monitor anti Xa lvls and discontinue 24hrs before delivery as increased bleeding risk
15
Q
How should asthma be controlled in pregnancy and what should happen with someone with RA who wishes to be pregnant?
A
- Needs to be controlled, take meds, needs little modification, steroid tabs given as normal
- Refer to rheumatologist, most DMARDs should be discontinued months before preg
16
Q
How should diabetes be managed in pregnancy?
A
- Metformin and insulin (maternal insulin requirements increase in preg) should continue, other diabetes meds have lack of evidence
- Need to maintain good blood sugar before and during preg
- Gestational: use Metformin alone or adjunct and type 2 should be treated with insulin
17
Q
Why would a pregnant women have GI reflux and how should it be treated?
A
- Due to progesterone causing muscle relaxation, puts pressure on stomach from foetus
- Meds: gaviscon, rennie
- Lifestyle: don’t eat late, extra pillows, avoid choc, coffee, healthy, exercise, small meals
18
Q
How to treat constipation & haemorrhoids, coughs and colds in pregnancy?
A
- Constipation & haemorrhoids: common in later stages, iron exacerbates
- 1st line: increase fluid/fibre, 2nd: bulk forming laxatives, lactulose, Ice pack/anusol rectal cream for haemorrhoids
- Coughs/cold: non-med pastilles, simple linctus, avoid sympatjomimetic decongestants = incr BP
19
Q
What is the advice for vaginal discharge and what is gestational HTN in pregnancy?
A
- Vaginal discharge: normal physiological change, refer if itch, sore, smell, Dysuria, thrush = 1wk imidazole not oral
- Gestational HTN: over 140/90 after 20wks of gestation with normal BP before without proteinuria (protein in urine)
- Symptoms: oedema, blurred vision, N and V
20
Q
What is pre-eclampsia and how is it treated in pregnancy?
A
- BP over 140/90 after 20wks with proteinuria or kidney/liver dysfunction, thrombocytopenia, pulmonary oedema, cerebral/visual disturbances
- If increased risk 75mg Aspirin OD until birth
- If not treated: eclampsia (seizures can occur)
21
Q
Why is gestational HTN bad and what should/shouldn’t be used to treat it?
A
- HTN can reduce blood flow to the placenta, and foetus
receives less nutrients and oxygen - 1st choice for gestational HTN: beta blocker labetalol or Methyldopa
– Other beta blockers including propranolol and metoprolol, CCB including long acting nifedipine - Avoid Diuretics, atenolol (foetal bradycardia/ hypoglycaemia), ACE inhibitors/ ARBs (intrauterine growth retardation
22
Q
What is gestational diabetes, what can poor glucose control lead to and how is it managed (1st line)?
A
• If the woman has either:
• A fasting plasma glucose level of 5.6 mmol
above or
• A 2-hour plasma glucose level of 7.8 mmol/
above
- large baby (macrosomia)
- 1st line in management:Changes in diet, regular exercise (walking for 30 minutes after
meal
23
Q
What are meds to avoid in breastfeeding?
A
- Tetracyclines: bone growth/ teeth stains
- Chloramphenicol: bone marrow suppression
- Aspirin: Reye’s syndrome
- Codeine: resp depression
- Atorvastatin
- Apixiban
24
Q
What is the difference between primary and secondary subfertility?
A
- Primary: Couple has never concieved
- Secondary: Couple who have managed to conceive in the past, but are having difficulty conceiving again
25
Name 5 risk factors for female infertility?
- Smoking
- Obesity
- Occupational risks
- Excessive alcohol consumption
- Drug use
26
What are the main causes of infertility in the UK?
- Ovarian/ovulatory - 25%
- Tubal - 2%
- Pelvic/uterine - 10%
- Male infertility - 30%
- Unexplained - 25%
27
Describe WHO group 1,2,3 ovarian infertility?
- Group 1: hypogonadotropic hypogonadism (low FSH/LH, low estradiol) (not enough hormones being released)
- Group 2: hypothalmic-pituitary-ovarian dysfunction, normal FSH/estradiol, PCOS is most common (Good levels but ratio is impaired which effects ovary)
- Group 3: Hypergonadotropic hypogonadism (high FSH/LH) - impaired response of ovary to gonadotrophins (Good levels but ovary isnt responding - negative feedback)
28
What are the Rotterdam criteria for PCOS diagnosis?
- Must have 2 of the following 3:
- Annovulation: no ovulation
- Hyperandrogenism: excess levels of androgens (like testosterone) in the body, particularly in females
- Polycystic ovaries on ultrasound
29
What are common symptoms of PCOS?
- Oligomenorrhea or amenorrhea (few/no periods)
- Hirsutism: excessive, male-pattern hair growth in areas where women typically have minimal or no hair.
- Obesity
- Acne
30
What are 2 conditions that cause Group 1 ovarian failure?
- Hypothalmic amenorrhea: menstrual cycle stops/irregular -> reduced GnRh, then low FSH and LH
- Hyperprolactinaemia: Prolactin increases which stimulates breast development -> menstrual irregularities -> suppresses GnRH, LH and FSH
31
What are causes of hyperprolactinaemia?
- Prolactinomas (pituitary tumours)
- Hypothyroidism
- Drugs include: antipsychotics, antidepressants, opioids and anti-hypertensives
32
What are congenital and acquired causes of type 3 ovarian infertility?
- Congenital: Chromosomal abnormalities, (Turner syndrome, Klinefelter), defects in hormone synthesis and gonadotrophin resistance
- Acquired: Damage/dysfunction to ovary, Premature ovarian failure, surgery/trauma, Chemotherapy
33
What is the most common cause of tubal infertility?
- Pelvic inflammatory disease often due to STIs like chlamydia
- Damage/blockage to fallopian tubes: prevent sperm reaching ovum
34
Name some other causes of tubal infertility?
- Previous surgery
- Pelvic tuberculosis
- Endometriosis
- Congenital defects
35
What are 2 pelvic and 2 uterine causes of infertility?
- Pelvic: Endometriosis, pelvic adhesions (from previous surgery)
- Uterine: Uterine abnormalities such as fibroids, polyps, adhesions and anomalies that affect sperm migration and embryo implantation, Ashermans syndrome (intrauterine adhesions)
36
What are possible problems that occur with unexplained infertility?
- Ovum is not released at the optimum time for fertilisation
- Implantation of blastocyst fails
37
What are drugs used for WHO group 1 infertility?
- Gonadotropins (FSH,LH),
- GnRH analogues (buserelin, goserelin and nafarelin) - activating GnRH receptor on pituitary gland, more FSH and LH
- Dopamine agonists (bromocriptine and cabergoline) for hyperprolacinemia (inhibits prolactin release)
38
What medicines contraindicate bromocriptine and cabergoline activity when treating group 1 ovarian infertility?
- Hypoprolactinaemic effect antagonised by antipsychotics, metoclopramide and possibly domperidone
39
What are the treatment options for group 2 ovarian infertility?
- Clomifene citrate (first line) or metformin (off label) or combo of both
- People with PCOS experience insulin resistance
40
What are the important points about clomifene citrate?
- Used to induce ovulation
- Given for 5 days starting cycle day 2-5
- Shouldnt be used for more than 6 cycles = risk of ovarian cancer
- Induces gonadotrophin release by occupying oestrogen receptors in hypothalamus
41
List 3 main assisted reproductive technologies?
- Intrauterine insemination (IUI)
- In vitro fertilisation (IVF)
- Intracytoplasmic sperm injection
42
What are the indications for IVF?
- Unexplained infertility
- Blocked tubes
- Failed IUI/pharmacological treatment
- Male factor infertility
43
What is Intrauterine Insemination and what is it not used for?
- Fast moving sperm placed into womans womb close to time of ovulation (day 14)
- Not for unexplained infertility, mild endometriosis (tissue similar to the lining of the uterus (endometrium) grows outside the uterus), women in late 30s, low ovary reserve
44
What is Intrauterine Insemination used for?
- Difficulty having vaginal intercourse due to disability
- Pain in intercourse
- Male impotence
- One partner with HIV
45
How many cycles of IUI are done before IVF is considered?
- 6 cycles of no success, further 6 cycles are done before IVF as its expensive
46
What is IVF?
- Womens eggs are collected and fertilised manually with sperm in the lab
- If fertilisation is successful, the embryo is allowed to develop for 2-6 days then transferred to woman's womb
47
What are 3 risks of IVF?
- Ovarian hyperstimulation syndrome: ovaries swell and enlarge due to an exaggerated response to fertility drugs, produce too many follicles and release high lvls of (VEGF), causes fluid to leak from blood vessels into surrounding tissues, especially the abdomen.
- Ectopic pregnancy
- Multiple gestation complications
48
What are symptoms of Ovarian hyperstimulation syndrome?
- Abdominal bloating
- Rapid weight gain
- 3rd space fluid shift
- Dehydration
49
What are some lifestyle give to women trying to conceive?
- Achieve healthy BMI: 19-30. Under = irregular menstrual cycles, over = take longer to conceive
- Folic acid 400mcg daily
- Stop smoking/alcohol
- Screen for STIs
- Manage stress
50
Definition for menopause and perimenopause?
- Menopause: No period for 12 consecutive months, can be natural (insufficiency of hormone) or induced (oophorectomy: removal of ovaries, hysterectomy: removal of womb)
- Perimenopause: Transition phase with irregular cycles and menopausal symptoms
51
What is the average age in the UK of menopause?
- 51 years
52
When is a blood test for FSH useful in menopause diagnosis?
- Age 40-45 with atypical symptoms (not normal menopause)
- Under 40 (suspected premature ovarian insufficiency)
- Not taking oral contraception
- A single elevated FSH level more than 30 indicates ovarian insufficiency
53
Name 6 typical symptoms of menopause?
- Hot flushes
- Night sweats
- Vaginal dryness
- Mood swings
- Sleep disturbances
- Loss of libido
54
What can symptoms of menopause/perimenopause be also caused by? (weight gain, irregular bleeding, hot flushes, mood changes and sleep problems)
- Weight gain: hypothyroidism, drugs (steroids/NSAIDs)
- Irregular bleeding: PCOS, ovarian/ cervical cancer, early pregnancy
- Hot flushes: Stress, hyperthyroidism, SSRIS, TCA
- Mood changes: Steroids, bipolar/mental health
- Sleep problems: Caffeine, anxiety, drugs (Steroids/SSRIs)
55
What should a clinical assessment of menopause include?
- Symptoms
- Lifestyle
- Pregnancy risk
- Family history
- Cancer screening
- Bone health (FRAX/Q Fracture)
- BP/BMI
- Co morbidities
- Need for ongoing contraception
56
Whats the difference between sequential and continuous HRT?
- Sequential: Progesterone for 12-14 days/month (still having periods) with a withdrawal bleed. Oestrogen taken every day
- Continuous: Daily oestrogen + progesterone (no break) (used 12+ months after last period or after 6-12 months of sequential)
57
What are 4 key risks of HRT?
- VTE: higher with oral oestrogen
- Breast cancer: increased with combined HRT
- Stroke and CHD: risk increases with age especially after 60
- Endometrial cancer: risk reduced with continuous combined HRT
58
What are 4 benefits of HRT?
- Fracture and increases muscle mass: Reduced risk of fragility fracture
- In premature ovarian insufficiency: reduces risk of chronic conditions: CV disease and osteoporosis
- Reduced risk of colorectal cancer, type 2 diabetes
59
What is vaginal atrophy and how is it treated?
- Thinning, drying and inflammation of the vagina due to low oestrogen and can lead to bleeding, painful intercourse, urinary symptoms, vag infections and UTI
- Vaginal oestrogens (local cream/pessary) estriol
- Moisturisers
- Lubricants: before sex, dont use vaseline with condoms (damages latex)
60
How long should systemic HRT be used?
- For as long as it is felt that benefits symptoms and improves QOL and it outweighs risks
- Over 60: risk increases
61
What is the difference between body identical and bioidentical hormones?
- Body identical: Regulated, and same molecular structure to natural hormones by human body (e.g. 17-beta oestradiol)
- Bioidentical: custom made allowing hormones to be prescribed in combinations. Not recommended by NICE
62
Does HRT prevent pregnancy whilst in perimenopause?
- No.
- Contraception is needed as you are fertile 2 years after last period if younger than 50 and 1 year if over 50
- In general contraception can be stopped after age 55.
63
What are non-hormonal treatments for vasomotor symptoms (hot flushes, mood disorders and urogenital?
- Vasomotor: SSRI/SNRI (off label), clonidine, CBT
- Mood disorders: CBT, antidepressant
- Urogenital: Vaginal moisurisers, lubricants
64
What are some lifestyle advices for dealing with hot flushes and night sweats?
- Window open
- Cotton and thin bed sheets
- Thin clothing
- Reduce alcohol and caffeine
- Sleep hygiene: bath at night, switch off
