Non-Hormonal Therapy in Obstetrics and Gynaecology Flashcards
Name the 4 clear indications for antihypertensive therapy in pregnancy
1) Persistent BP over 160/100
2) Acute severe hypertension
3) Fulminating PET
4) Eclampsia
Note = Treatment over 140/90 is debatable, most obstetricians pragmatically treating over 150/100
Talk to me about labetalol, class action, is it safe, what are the side effects
Labetalol = Considered safe and used extensively in human pregnancy. Generally it is considered to be first line treatment
Class = non specific alpha and beta blockers
Indications = Can be used for HTN, but also can be used for acute hypertension as IV.
Side effects
1) May cause IUGR with prolonged used = even after controlling for BP control
2) Neonatal hypoglycaemia + Bradycardia = Rare occurences
Talk to me about methyldopa, its class action, is it safe, and its side effects
Methyldopa = Considered safe in pregnancy and also extensively used in human pregnancy. It is add on treatment after labetalol, but can also be used first line (asthmatics)
Action = Post synaptic a2 agonist. Im this way it actually reduces sym action
Side effects =
1) Rebound hypertension
2) depressed mood = With long term use
3) Flattened CTG variability
4) Autoimmune haemolytic anaemia = Rare
5) Raised prolactin
6) Hepatitis
Talked to me about nifedipine for hypertension in pregnancy, is it safe, when is it used, class action, side effects.
Nifedipine = Not licensed in pregnancy, but commonly used as second line treatment. Use the MR version as otherwise can cause acute hypotension.
Action = Ca blocker. has preferential effect on vessels as vasodilator rather then heart.
Indication = Can also be used for acute hypertension
Labour = It also may inhibit premature labour (unlicensed used) Has been used as a tocolytic agent.
Side effects
1) acute hypotension, if give sublinguially
2) Peripheral oedema
3) Headache + Flushin
Talk to me about the use of hydralazine for hypertension in pregnancy. When is it used, how does it act, and what are the side effects
IV hydralazine = Used for acute hypertension. Give slowly over a minimum of 5 minutes, and can be repeated IV every 15 minutes
Action = Potent vasodilator
Metabolism = By acetylisation in liver.
Side effects
1) Acute hypotension = If given to fast or too often
2) Idiosyncratic adverse event = Of a lupus like syndrome = Occurs in people who are slow acetylators in liver.
Talk to me about the use of magnesium sulphate in pregnancy. How it acts, when it is used, and the side effects
MgSO4 = Best prevent and treatment for fits in severe PET or eclampsia.
MAGPIE trial = MgSO4 halved the risk of eclampsia and reduced maternal deaths.
Action = It is membrane stabaliser.
Monitoring = Only requires monitoring if the patient is oliguric
Side effects =
1) Hyporeflexia
2) Resp depression
3) Cardio-resp arrest
Name the 2 classes of antihypertensives that cannot be used in pregnancy and the reasons why including teratogenic effects
ACE-Is = Cannot use
Congenital malformations = Esp CVS
Skull defects
Oligohydramnios + Impaired renal function = Less AF as kidneys work less
Thiazide diuretics = Try not to use
Causes neonatal thrombocytopaenia with bendrometahfluzide
Give 3 indications for the use of a tocolytic medication
1) To abolish unwanted contractions = Preterm labour
2) Acute hyperstimulation
3) External cephalic version
What are the 2 uses for a tocolytic agent when used for pre term labour
1) To achieve 24 hr steroid latency in gestations less then 34 weeks.
2) Where in utero transfer to a neonatal centre is neccesary.
What are 5 main drugs used as tocolytics for preterm labour. Which one is first line, and what are the side effects.
First line = Nifedipine as recommended by NICE. Works as well as the other drugs below with better side effect profile
Second line = Atosiban = This works as an oxytocin antagonist.
Side effects = Naseua, tachycardia, hypotension
Beta-sympathomimentics = Such as salbutamol, ritodrine, terbutaline. These used to be used a lot, but now not so much because of side effects
Side effects = Tachycardia, hypotension, pulmonary oedema, hypokalaemia, hyperglycaemia. NICE says DO NOT USE
Mg SO4 = More used in the USA. Use for neuroprotection from 24-30 weeks gestation, and some evidence for 30-34 weeks.
GTN patches = No benefit over others really. But less side effects = Headache, hypotension.
Which tocolytic agents are used for ECV?
Terbutaline S/C = Can only be used in primigravidae women prior to ECV
Evidence = Shown to increased procedural success.
Which tocolytic agent is used in emergency tocolysis. When is it used, and how does it help
Terbutaline IV = This is a beta sympathomimentic, so side effects are these.
Indication = Used in uterine hyperstimultion which is normally brought on by oxytocin. Shown to improve foetal heart rate patterns and foetal pH
Talk to me about paracetamol in pregnancy
Absolutely fine for both pyrexia + analgesia
Use it first line
What are the indications for taking aspirin in pregnancy. When is it taken. When should it be stopped
Low dose aspirin 75mg = Used to prevent pre-eclampsia and IUGR. Should not be used liberally in low risk women, only high risk.
Indication = For high risk women to take from 12-36 weeks gestation
High risk:
1) Hypertensive disease in prev pregnancy
2) CKD
3) Autoimmune diseases like SLE or antiphospholipid syndrome
4) Type 1 or 2 DM
5) Chronic hypertension = BIG ONE
Stop taking = 2-3 weeks prior to pregnancy as theoretical risk of neonatal haemorrhage.
Can NSAIDs be used in pregnancy, what are there main side effects.
They should NEVER be used as analgesic. They have been used (like aspirin) to prevent preterm labour.
Side effects
1) Possible increase risk in miscarraige
2) Foetal renal impairment and oligohydrmanios (makes sense)
3) Increased risk of premature closure of ductus arteriosis.
4) Potential small increase risk of NEC
5) Cause maternal UGI symptoms and renal impairment.
Which opiods are commonly and safely used in pregnancy.
Codeine phosphate + Dihydrocodeine are both fine for moderate pain
Can also be given in mixed paracetamol preperations
Dextropropophene = more potent oral opiod that is used in more severe pain.
Describe the common analgesics used during labour, their indications, and their side effects. Including what meds are used in epidural
ENTONOX = 50/50 mix of nitrous oxide and O2 = Safe, stable, very rapid onset and offset.
Side effects = nausea, you feel drunk
Pethidine IM = Rapid onset and short half life.
Side effects = N+V, narcosis, resp depression in neonate if given within 2 hrs of delivery
Morphine = Used less, but also safe and effective.
In epidurals = Commonly use a mixture of Bupivicaine (LA) and fentanyl for effective pain relief
Side effects = Hypotension, loss of mobility, higher chance of assissted delivery and there are epidural insertion complications (dural tap, haematoma, high block)
Describe the use of syntometrine in the third stage of labour, including indication, action and side effects
Syntometrine IM = Ergometrine + Syntocinon.
Ergometrine = causes prolonged vasoconstriction
Syntocinon = Causes uterine contraction
Side effects = N+V and hypertension
Contraindication = Hypertensive pregnancies, as it can cause more hypertension as it is vasoconstricting…
Describe the use of Misprostol in the third stage of labour, including indication, action and side effects
Misoprostol 800mcg PO/PV/PR = This is a PGE1 analogue.
Indication = Also to treat and prevent PPH.
Side effects = Common diarrhoea and N+V
Describe the use of Carboprost in the third stage of labour, including indication, action and side effects
Carboprost IM or intra-myometrially = This is a PGF2a analogue.
indication = Secondline treatment of PPH
Caution = Required in hypertension, and DO NOT used in asthmatics.
What is the first line anti-emetic in pregnancy, how does it act, and what are the side effecs
First line = Promethazine (from Phenothiazine family). It has long history of use in human pregnancy.
Action = H1 (histamine) antagnoist. Also mild anti-muscarinic effect.
Side effects = Sedation, and rarely some extra-pyramidal side effects like tardive dyskinesia
What are the second line agents for anti-emesis in pregnancy (there are 2), what are their mechanisms of action and side effects
1) Metoclopramide = No foetal harm and used second line.
Action = D2 antagonist so central effect. But it also delays gastric emptying
Side effects = Akathisia (restlessness) and tardive dyskinesia
2) Prochlorperazine (also from phenothiazine family like promethazine). Also extensive use in human pregnancy
Side effects = Same as promethazine with sedation and some extra-pyramidal
What is the third line agent for anti-emesis in pregnancy, what is effect, and side effects
Ondansetron and related drugs
Action = Potent 5-HT3 (serotonin) antagonists.
Pregnancy = not actually licensed but are used third line and appear safe
Side effects = Headache, diarrhoea, sedation
What is the fourth line anti-emetic in pregnancy, what is its efficacy
Corticosteroids = Either methylprednisolone or hydrocortisone are really only used in resistance cases once everything else has been tried.
Evidence = Some evidence of efficacy, but no large trials.
Not teratogenic, but should not stay on steroids for a long time.
Give 2 anti-acids that are safe in pregnancy
1) Gaviscon = Contains sodium alginate, calcium carbonate, and sodium bicarbonate
2) Maalox = Aluminium and magnesium hydroxide containing alternative.
Describe the 2 medications used for menorrhagia. How they differ, how they act, efficacy, and side effects
1) Mefanamic acid = NSAID used for both dysmenorrhoea and menorrhagia.
Action = As an NSAID works to inhibit PG production. Needs to be taken a couple days before menstruation for best effect
Efficacy = Reduces menstrual blood loss by up to 30%. Therefore highly effective
Side effects = Same as other NSAIDs
2) Tranexamic acid = Anti-fibrinolytic drugs which blocks conversion of plasminogen to plasmin and reducing fibrinolysis.
Efficacy = Reduces menstrual blood loss by 40-55% .
Side effect = Mild GI upset, caution needed in women with pre-existing heart disease (more clots)
Describe the main 2 first line medications for urge incontinence. Describe their mechanisams of action, efficacy, and side effect profile
Tolteridine + Oxybutynin = Both are antimuscarinic, mainly on M3 receptor.
Efficacy = Both effective in reducing urge and frequency up to 60-70%. Work to reduce symptoms of detrusor over activity.
Side effects = Antimuscarinic things like dry mouth, eyes, constipation, dizziness.
What is the second line medication used in urge incontinence, and name a further 3 meds that can be helpful for some women
Imipramine = Second line. Can also be effective through antimuscarinic effect
3 other drugs that help some women = Trospium chloride, propiverine, desmopressin
What medication is used for stress urinary incontinence, what is the mechanism of action, efficacy, and side effects
Duloxetine = SNRI. Works to increase urinary sphincter tone and show to reduce (but not sure) stress incontinence by approx 50%.
Side effects = Nausea, dizziness, insomnia occur in 10-20% of patients.
List 5 common types of cytotoxic agent with their mechanism of action, and examples for each one
1) Antimetabolites = Interfere with DNA and RNA synthesis = 5-FU, methotrexate
2) Akylating agents = Form covalent bones with DNA bases = Cyclophosphamide, isofosfamide
3) Intercalating agents = Bind to DNA, thus inhibiting replications = Cisplatin, Carboplatin
4) Anti-tumour antibiotics = Inhibit DNA synthesis through complicated mechanisms = Bleomycin, Doxorubicin, Etoposide
5) Drugs directed against spindle microtubules = Paclitaxel, Vincristine
Describe the common chemo regimen for ovarian cancer
Ovarian cancer = Usually sensitive to platnium based regimens.
Carboplatin (intercalating agent) +/- Paclitaxel (spindle angent) = Can be used neoadjuvant, adjuvant or palliatively.
Most patients require further treatment due to late stage of disease on presentation
Describe the common chemo regimen for Endometrial cancer
Chemo has a more limited role for endomterial = Usually only for recurrent or metastatic disease
Carboplatin +/- Paclitaxel or doxorubicin (anti tumour antibiotic) + Cisplatin (intercalting agent) are commonly used ones = Almost same as ovarian cancer
Describe the common chemo regimen for cervical cancer
Cisplatin + Radiotherapy = Reduces risk of relapse for those getting adjuvant radiotherapy
Cisplatin + methotrexate = For metastatic disease. But poor response
Describe the common chemo regimen for vulval cancer
5-FU (antimetabolite) +/- cisplatin = for patients unfit for surgery or for symptom control in metastatic disease
Describe the common chemo regimen for trophoblastic disease
Chemo alone here is highly curative
Metrotrexate = For simple trophoblastic disease.
EMA-CO = Etopside (anti-tumour antibiotic), methotrexate, Dactimomycin, Cyclophosphamide, Vincristine (spindle drug) for high risk trophoblastic disease
Both cure rates = 99%
Describe the side effects for Chemo = Haematological, GI, Alopecia, Neuro, Constitutional
Haem = Bone marrow supression that recovers. Cellular Nadir is lowest cell count poin, which is usually around day 7-14 and is neutropaenia, anaemia, and thrombocytopaenia
GI = Side effects occur due to loss of epithelial rapidly dividing cells.
Nausea and vomiting = Give antimetics
Mucositis = esp with methotrexate. Causes mouth ulcers
Diarrhoea = Transient
Alopecia = Taxanes like paclitaxel (spindle) cause temporary hair loss.
Less commonly can get alopecia with carboplatin and cisplatin (Intercalating agents and platniums)
Neuro = These are usually dose related and improve on stopping/dose reduction
Peripheral neuropathy = With paclitaxel (spindle) and cisplating (platnium)
Tinnitus = with Cisplatin
Constitutional = Lethargy and anorexia
