Practice advisories Flashcards
When is RSV vaccine administered?
single dose of Pfizer’s RSV vaccine (Abrysvo) btw 32w0d and 36w6d to prevent RSV in infants. takes 2 weeks until development and transplacental transfer of antibodies so all infants born <34 weeks should get antibody even if maternal vaccine.
- monoclonal Ab nirsevimab : one dose for all infants < 8 months. infants don’t need maternal vaccine AND antibody.
What is zuranolone?
treatment of postpartum depression
- GABA A receptor modulator. oral medication - tx for depression with onset in 3rd trimester or within 4 weeks PP.
- take 50mg dose daily for 14 days.
- need contraception while taking.
- SE: dizziness, fatigue, drowsiness, cold-like sx and UTI
other option: brexanolone - IV med x 2.5d
what are recs for HPV vaccination if undergoing treatment for CIN2
current CDC recommendation: hPV vaccination if age 9-26 and consider adjuvant vaccine for previously unvaccinated people aged 27-45 undergoing treatment for CIN2.
- results in improved QOL and cost savings due to fewer paps/colposcopies.
What are recommendations for vaccines in pregnancy?
Tdap, inactive influenza, pneumococcal, menongococcal, Hep A and Hep B. Covid-19 in any trimester (and booster).
What are recommendations for flu treatment?
If suspected infection, give Oseltamivir (Tamiflu). If also have covid, give Paxlovid.
Illness severity assessment: SOB, new chest pain/pressure, unable to tolerate liquids, dehydration (dizziness), less responsive/confused, symptoms improved then returned? If yes»_space;go to ER. If moderate risk (comorbidities), see in ambulatory setting asap. need H&P, CXR, pulse ox.
Tamiflu: 75mg PO BID x5d or Peramivir 600mg IV once.
– can also do post-exposure chemoprophylaxis: 75mg once daily x 7d (if within 48hr exposure).
Paxlovid: 3 tablets (2 meds combined) twice daily x 5d.
What is PMS and PMDD?
PMS: cyclically occurring physical and mod sx occurring during luteal phase and resolve during/shortly after menstruation. sx=irritability, bloating, mood swings, breast tenderness, anxiety and tension.
– tx: Lifestyle modifications: decrease sugar/salt
Meds: SSRI, cyclic birth control pills (containing drospirenone bc least androgenic)
PMDD: depressive disorder, cyclic severe changes in affect occur in luteal phase and resolve during/shortly after menses. sx=mood lability, irritability, dysphoria, anxiety.
diagnosis of exclusion. based on sx present most months in past yr and on 2 months of prospective symptom diary.
diagnosis: at least 5 sx (onset before menses, improve within few days of menses, minimal/absent after menses)
1 or more of following
- marked lability, irritability/anger, depressed mood, anxiety/tension
1 or more of following
anhedonia, concentration, lethargy, appetite changes, hypersonic, overwhelmed, physical (breast tenderness, muscle pain, bloating).
What is management of PMDD?
-SSRI: start in luteal phase or within sx onset or continuous
- combined OCPs: suppress ovulation nd hormonal fluctuations
- GnRH agonists w/ hormonal add-back: if severe refractory
-CBT
- exercise
- acupuncture
- NSAIDs: inhibit production of prostaglandins
- patient education
- calcium supplementation: manage physical and affective sx. 1000-1200mg/day
- surgery: BSO +/- hyst if severe and failed medical management. do 2mo trial of GnRH agonist before surgery to predict response to surgery.
What is counseling for spousal abuse?
screen for IPV/counsel at annual exams, new OB and qtrim.
- advise that exists among all SES and high as 3%
- ensure confidentiality, let pt use office phone to call hotline. offer materials and info about community resources. be supportive. assist pt in developing a safety plan.
What are details on rape?
incidence 20% in women.
- screen with SAVE (screen for hx sexual violence, ask direct ?s, validate pt, evaluate, educate and refer).
- rape exam must be done in 48-72hrs. obtain consent, document injuries.
- tests: scalp hair, saliva, comb pubic hair, GC/CT/trich, HCG, HIV, RPR, hep B&C, vaginal/rectal swabs, fingernail scrapings.
Tx: emergency contraception, STI prophylaxis (500mg IV ceftriaxone, 100mg doxy BID x7d, 500mg flagyl BID x7d), hep B/HPV vaccines, if assailant HIV +, start HAART. If HIV unknown and within 72hr, consider 28d HAART.
- then follow up in 6 wks: STI, psychotherapy, pregnancy.
What is treatment for depression in pregnancy?
psychotherapy=1st line
Meds: SSRI (sertraline 25mg then escitalopram). Fluoxetine 3rd line.
- SCREEN FOR BIPOLAR DISORDER TO AVOID MANIA
Anxiety: SSRI=1st line (sertraline or escitalopram) - start at 1/2 lowest dose to avoid SE (Agitation, insomnia).
- avoid benzos but can use as bridge until SSRI/SNRI effective. use for 2-4wks. use lorazepam.
- SE: nausea, dry mouth, insomnia, diarrhea, HA, dizziness, anxietation - decrease over time. sexual dysfunction persists.
- track sx q4wks (PHQ9, EDPS, GAD). If sx resolve, continue 6-12mo to avoid relapse.
What is management of bipolar disorder in pregnancy?
continue mood stabilizers (except valproate bc teratogenic- NTD, craniofacial/limb anomalies).
- untreated BPD has incr risk PP psychosis, APO (FGR, PTD).
- screen for GDM if using antipsychotics
Lithium: if in 1st tri, detailed anatomy US (Ebstein’s anomaly). monitor dosing 2/2 narrow therapeutic window (goal 0.6-1.0). Crosses the placenta and neonatal high levels=hypotonia, lethargy, respiratory difficulties. breastfeeding controversial.
Mood stabilizers: lithium
Anti-convulsant: lamotrigene
Anti-psychotic: haldol, olanzapine, quetiapine, risperidone
Pre-concepcion: incr folate to 4mg/day.
What are neonatal risks with SSRI?
- persistent pulmonary hypertension of newborn (PPHN) - rare but potentially fatal. respiratory distress 2/2 vasoconstriction in lung. sertraline=least likely to cause this!
- Neonatal adaptation syndrome: irritability, restlessness, poor feeding, hypothermia. resolves within 2 weeks. 10-30% incidence. common w/ fluoxetine and paroxetine. Need Peds to eval.
What are screening tools for depression and anxiety?
EPDS: positive screen is >10
PHQ9 > 15
GAD-7: score 15 is severe
screen at IPV and each trimester. screen for bipolar disorder before starting tx for anxiety/depression because can precipitate mania if underlying depression.
if positive screen: r/o thyroid dysfunction, anemia, substance use (TSH, Hgb, folate, B12, iron), counseling, pharmacotherapy.
Risk factors for perinatal depression: race, IPV, family/personal hx anxiety/depression. Young age, lack of social support, insomnia.
What is postpartum psychosis?
1-2/1000 births. sx within 2wks of birth.
Symptoms: hallucinations, delusions, mania, depression, loss of inhibitions, restlessness.
- incr risk if hx bipolar disorder!!
- tx: emergent psych consultation, r/o delirium or drug-induced. initiation short term benzos or antipsychotic. Foregoing overnight breastfeeding.
What are causes of severe HA in pregnancy?
- PEC-SF
- PRES: posterior reversible encephalopathy syndrome, MRI w/ cerebral edema. vomiting, AMS, blurred vision, seizures.
- Epidural puncture HA: blood patch
- CVST: central venous sinus thrombosis, rare form of stroke. more common if thrombophilias. occurs 3rd try or PP. constant nonspecific HA w/ seizures and focal deficits. MRI. workup for thrombophilia/APLS.
- RCVS reversible encephalopathy vasoconstriction syndrome - abnormal cerebral angiography on MRI/CT. diffuse vasoconstriction of cerebral arteries. sudden HA, transient blindness and confusion, rapid improvement postpartum.
Why are UTIs common in pregnancy and what are recs?
progesterone induced ureteral dilation + mechanical compression of bladder by gravid uterus causes urinary states. incr risk of ascending infection.
- screen for asymptomatic bacteria w/ UCx at IPV.
- tx: abx if >100k.
What are antibiotics for ASB or acute cystitis in pregnancy?
Nitrofurantoin 100mg BID 5-7d
Cephalexin 250-500mg QID x 5-7d
Bactrim: BID 5-7d
Fosfomycin 3g once
Amoxicillin 875 BID 5-7d (high resistance, don’t start before UCx results)
Amoxicillin-Clavulanate 875 BID 5-7d (high resistance, don’t start before UCx results)
