womens health Flashcards
1
Q
menstrual cycle
A
LH and FSH peak at ovulation estradiol drops off at ovulation progesterone rises after ovulation follicular phase: menstruation - ovulation luteal phase - ovulation - menstruation
2
Q
changes to ADME during menstrual cycle
A
A: no change
D: no change
M: variable effects
renal elimination: Dec. GFR early follicular phase, Inc. GFR in luteal phase
3
Q
changes to ADME during pregnancy
A
A: Dec. motility/ intestinal blood flow, Inc. gastric pH
D: Inc. blood volume, Dec. albumin
M: Dec. 1A2, 2C19, Inc. 2A6, 2C9, 2D6 (3rd tri), 3A4
renal elimination: Inc. renal blood flow and GFR
4
Q
changes to ADME to elderly women
A
A: Inc. gastric pH, Dec. gastric emptying, Dec. GI blood flow
D: Dec. Vd for hydrophilic, Inc. Vd for lipophilic, Dec. protein binding
M: Variable influences on CYP
renal elimination: decreased creatinine clearance
5
Q
well woman visit
A
vital signs: BP, weight/BMI
breast exam: visual inspection, manual exam
pelvic exam: external inspection, speculum exam, pap smear
6
Q
pap smear recommendations
A
Every 3 years starting at age 21
Co-test with human papillomavirus (HPV) every 5 years after age 30
Not needed if under 21 years old, 65 years old if low risk, After hysterectomy with cervix removal if no history of pre-cancer/cancer
7
Q
screening and counseling
A
Cervical cancer Substance abuse Domestic violence Hyperlipidemia Hypertension Diabetes Sexually transmitted infections (STIs) Thyroid function Vaccine history Osteoporosis Colorectal cancer Breast cancer Obesity Eating disorders Pelvic organ prolapse Incontinence Sexual dysfunction Depression Contraception
8
Q
contraception overview
A
62 million women of reproductive age in US
43 million are sexually active and do not want to become pregnant
Average woman must use for around 30 years throughout life
46% of women with an unintended pregnancy did not use contraception
9
Q
methods of contraception
A
Abstinence
Non-hormonal
Hormonal
10
Q
nonhormonal methods of contraception
A
Behavioral - Coitus interruptus, Lactation amenorrhea method (LAM), Fertility awareness methods (FAM) and natural family planning (NFP)
11
Q
basal body temp (BBT)
A
predicts ovulation of regular cycles
reaches low point during ovulation (around 97) then spikes to 98 within 2 days
12
Q
billings ovulation method
A
cervical mucous
irregular cycles
13
Q
calendar/rhythm method
A
based on past cycles
shortest cycle - 18 = first fertile day
longest cycle - 11 = last fertile day
14
Q
standard days method
A
26-32 day cycles
track cycle and difference colored beads tell when pregnancy is most likely
15
Q
two day method
A
cervical secretion
secretions either today or yesterday = fertile
16
Q
FAM and NFP overview
A
Effectiveness: 3 – 22% failure rate
Advantages: No effect on hormones/cycle, No side effects!, Inexpensive (except for electronic monitor), Acceptable to many cultures/religions
Disadvantages: No STI protection, Difficult if irregular cycles
17
Q
nonhormonal contracteptives
A
male condom
-advantages: low cost, HIV/STI protection
-disadvantages: used dependent, slippage/breakage
female condom
-advantages: insert up to 8 hours before, HIV/STI protection
-disadvantages: user dependent
vaginal sponge
-advantages: protect for 24 hours from insertion
-disadvantages: no HIV/STI protection, user dependent
spermidide
-advantages: rapid onset
-disadvantages: no HIV/STI protection, short duration, resupply for repeated intercourse
diaphragm (w. spermicide)
-advantages: insert 6-8 hours before no systemic SEs
-disadvantges: must be properly fitted, no HIV protection, UTI/TSS risk
cervical cap
-advantages: protect for up to 48 hours, no systemic SEs
-disadvantages: must be properly fitted, no HIV protection, UTI/TSS risk
copper IUD
-advantages: long term
-disadvantages: insert/remove by HCP, $$$ up front, no HIV protection, SEs
18
Q
hormonal contraception
A
progestin:
-Prevent LH surge - inhibit ovulation
-Thicken cervical mucus - inhibit sperm penetration/transport
-Change motility of fallopian tubes - impair transport of sperm/ova
-Atrophy of endometrium
estrogen:
-Suppress FSH production - prevent selection/emergence of dominant follicle
-Increase sex-hormone binding globulin - increase binding of free androgens
19
Q
combined oral contraceptives (COC)
A
Monophasic vs. multiphasic Estrogen component: -Majority contain 20 – 35 mcg ethinyl estradiol (EE) -Some contain up to 50 mcg EE -Some contain mestranol (50 mcg mestranol = 35 mcg EE) Very low dose = 20-25 mcg EE Low dose = 30-35 mcg EE High dose = 50 mcg EE
20
Q
side effects of too much estrogen
A
Bloating Breast tenderness Mood changes Headache Nausea Heavy menses Fibroid growth Melasma Vision changes Cyclic weight gain
21
Q
side effects of not enough estrogen
A
Breakthrough bleeding early in cycle Light menses Vaginal dryness Spotting No withdrawal bleeding
22
Q
progestin component effects
A
Progestational -Prevent ovulation -Lessen bleeding -Desire high selectivity Androgenic -acne -hirsuitism -desire lower activity estrogenic -decrease androgenic side effects
23
Q
progestin component exampes
A
estranes - derivateives of norethidrone: Norethindrone, norethindrone acetate, ethynodiol diacetate
gonanes - derivates or norgestrel: norgestrel, lovenorgestrel, desogestrel, norgestimate
drospirenone - analogue of spironolactone
24
Q
SEs from too much progestin
A
Acne Hirsutism Change in sex drive Depression Increased appetite Noncyclical weight gain Less energy Cholestatic jaundice Yeast infections Hair loss Swelling in arms/legs
25
SEs from not enough progestin
Breakthrough bleeding late in cycle
No withdrawal bleeding
Heavy menses
26
serious SEs from COC
ACHES
A – Abdominal pain - liver problem, gallbladder, clot
C – Chest pain (SOB, coughing) - PE, MI
H – Headache (severe HA, dizziness) - HTN, stroke, migraine
E – Eye problems (double vision, blurry vision) - Stroke, HTN
S – Severe leg pain (calf or thigh) - DVT
27
COC and antibiotics
Controversial!!
Potential mechanisms: Altered intestinal flora, Increased nausea/vomiting/diarrhea as a side effect of antibiotic, Altered metabolism
Rifampin & rifabutin are known 3A4 inducers
Better safe than sorry - recommend backup plan!!
28
COC dosing considerations of start date
start date: day 1 - take on first day of period, don't need back-up method
state date: sunday start - first sunday during or immediately following menstrual cycle, use back-up method for 7 days
start date: quick start - start immediately regardless of paint in menstrual cycle, use back-up method of 7 days
29
COC other dosing considerations
Continuous use
-Skip placebo pills
-Decreased chance of side effects with monophasic COC
21 day vs. 28 day pack
Switching brands/types
-Generally start new product on same day a new pack of previous COC would have been started
30
skipped pill in first week?
use back up for 7 days
31
skipped pill in weeks 2-3?
take when remember, then continue
| skipped 2 pills? take one with next dose and leave the other in the pack - use a back up method for 7 day
32
transdermal hormonal contraceptive
Ortho-Evra
EE 35 mcg/day + norelgestromin 150 mcg/day
One patch per week x 3 weeks then one week patch-free
Sites: upper outer arm, abdomen, buttock or back
Size: 1.75 inches x 1.75 inches
Less effective if over 198 lbs (90 kg)
same starting info as COCs
If switching: apply first patch on day you would start new pack or new ring cycle
Edge lifts up: Press down firmly for 10 seconds; smooth out wrinkles, If does not stick completely, remove and apply replacement patch
Off/partially off:
-less than 1 day: try to reapply but use new patch if does not stick completely; no back up method needed
-over 1 day: apply new patch and restart 4 week cycle; use back up method for 7 days
33
transvagnial ring hormonal contraceptive
NuvaRing
EE 0.015 mg/day + etonogestrel 0.12 mg/day
Insert and use continuously for 3 weeks; remove for 1 week
Diameter = 54 mm (2.1 inches)
Day 1 vs. Day 2-5 Start vs. Quick Start
-Recommended to be started by day 5 of cycle (not Sunday)
-Backup method needed if day 2-5
Switching: can start at any point
Backup method should NOT be a diaphragm
No “proper” position for ring as long as fully inserted in vagina
What if NuvaRing falls out?
-less than 3 hours: rinse with cool water and reinsert
-over 3 hours & week 1 or 2: reinsert ring and use backup method for 7 days
-over 3 hours & week 3: discard Nuvaring; insert new ring and restart 21 day cycle OR wait up to 7 days and start next ring cycle; use backup method for 7 days following new ring insertion
34
risks of hormonal contraception
```
Breast cancer: conflicting evidence
Ovarian cancer: decreased risk
Uterine cancer: decreased risk
Cervical cancer: conflicting evidence
Cardiovascular/circulatory system:
-Increased risk of VTE
-Conflicting evidence for stroke/MI
-Increased blood pressure
```
35
contraindications with COC
less than 21 days postpartum
Severe decompensated cirrhosis
VTE
Diabetes and vascular disease
Migraine with aura
HTN and BP over 160/100 or vascular disease
Smoking over 15 cigarettes per day and age over 35
Hx of stroke
Major surgery with prolonged immobilization
IHD (current or hx)
Liver tumor (adenoma or malignant)
Peripartum cardiomyopathy
Complicated solid organ transplant
SLE and positive antiphospholipid antibodies
Complicated valvular heart disease
36
precautions with COC
Hx of breast cancer (over 5 years)
21-30 days postpartum (42 if VTE risk factors)
VTE (lower risk for recurrence)
Superficial venous thrombosis
Diabetes and vascular disease
HTN controlled or 140-159/90-99
Smoking, under 15 cigarettes per day and over 35 years old
Inflammatory bowel disease
Multiple risk factors for ASCVD
Hx of malabsorptive bariatric surgery
Hx of COC related cholestasis
Multiple sclerosis with prolonged immobility
Peripartum cardiomyopathy over 6 months
Antiretroviral, anticonvulsant, rifampin or rifabutin therapy
37
progestin only contraceptives - oral norethindrone or norgestrel
- “Minipill”
- Taken continuously - no placebo pills or breaks
- Doses must be taken within 3 hours of scheduled time
- If late/missed then use backup method for 48 hours
- Failure rate slightly higher in those over 154 lbs (70 kg)
- Metabolized via CYP450 - interactions (esp. inducers)
- Recommended for breast-feeding women
38
progestin only contraceptives - injectable medroxyprogesterone acetate
Intramuscular
-Depo-Provera CI (150 mg medroxyprogesterone acetate)
-Gluteal or deltoid muscle
Subcutaneous
-Depo-SubQ Provera 104 (104 mg medroxyprogesterone acetate)
-Anterior thigh or abdomen
Initial injection within 5 days of start of period
Q3 months
Consider limiting use for less than 2 years
-Impact on bone mineral density
-Weight gain
39
progestin only contraceptives - subdermal
Nexplanon (68 mg etonogestrel)
Rod inserted into inner side of non-dominant upper arm
Up to 3 years
Initial insertion within 5 days of start of period
Other timing = backup method for 7 days
40
side effects of progestin only contraceptives
```
Irregular bleeding
Irritation at injection/implant site
Weight increase
Bone loss (IM)
Return to fertility prolonged (IM/implant)
```
41
precautions and contraindications for progestin only contraceptives
Current breast cancer
Caution in:
-Hx of breast cancer
-Severe decompensated cirrhosis
-Malabsorptive bariatric surgery procedure
-Liver tumors
-SLE
-Ritonavir-boosted protease inhibitor HAART
-In combination with certain anticonvulsants
-In combination with rifampin or rifabutin
42
intrauterine devices (IUD) overview
Disruption in tubal transport of sperm and ovum & prevention of implantation
Thickening of cervical mucus & alteration of the endometrium
Insert during first 7 days of cycle
non-hormonal: copper, up to 10 years
hormonal:
-mirena - 52 mg levonorgentral, up to 5 years
-skyla - 13.5 mg levonorgestrel, up to 3 years
-liletta - 52 mg levonorgestel, up to 3 years
43
side effects of IUDs
```
Infection
Perforation of uterus
Irregular bleeding
Dysmenorrhea/amenorrhea
Lower abdominal pain
Acne
Breast tenderness
Headaches
Mood changes
Nausea
```
44
precautions and contraindications of IUDs
Distorted uterine cavity
Current breast cancer (progesterone only – can use copper)
Cervical cancer not yet treated
Endometrial cancer
Current pelvic inflammatory disease (PID)
Within 3 months of septic abortion
Postpartum puerperal sepsis
Current STI (purulent cervicitis, chlamydia, gonorrhea)
Pelvic tuberculosis
Unexplained vaginal bleeding
45
emergency contraception
Prevention of pregnancy after intercourse
- Prevent/delay ovulation
- Prevent fertilization
- Prevent implantation
46
four methods of emergency contraception
Levonorgestrel emergency contraceptive pills (ECPs)
Combined ECPs
Ulipristal acetate
Copper IUD
47
levonorgestrel ECP
Single dose: Plan B One-Step, Next Choice One-Step, 1.5 mg levonorgestrel
Two doses: Next Choice, Plan B (being phased out), 0.75 mg levonorgestrel q 12 h x 2
Use within 72 hours (up to 120 hours?)
Failure rate of 0.4% - 2.7%
Available OTC
48
combination ECP
No marketed product but 22 COCs declared safe and effective by FDA
At least EE 100 mcg and levonorgestrol 0.50 mg per dose - 2-4 tablets = 1 dose
Norgestrel preferred over norethindrone
1 dose q12 h x 2
First dose within 120 hours
Failure rate of 0.5% - 4.2%
49
ulipristal acetate
```
ella
Selective progesterone receptor modulator
30 mg tablet x 1 dose - Rx ONLY
Within 120 hours
Failure rate of 0.9% - 1.8%
```
50
copper IUD for emergency contraception
Insert within 5 days
| Failure rate of 0.1%
51
side effects of emergency contraception
```
Nausea and vomiting
Spotting
Changes in next menses
Headache
Breast tenderness
Mood changes
Abdominal pain
```
52
precautions and contraindications of ECPs
contraindications: pregnancy (known or suspected)
precautions: hx of actopic pregnancy, use w CYP3A4 inducers
53
return of fertility
Combined hormonal contraceptives: 1-2 weeks
Injectable progestin: 10 months
Progestin implant: 30 days
IUD: 30 days
Emergency contraception: immediate
Postpartum: around 21 days; may be extended with breastfeeding
54
non-contraceptive uses of hormonal products
```
Regulation of menstrual periods
Treatment of
-Heavy periods (menorrhagia)
-Painful periods (dysmenorrhea)
-Endometriosis
-PMS and PMDD
-Acne, hirsutism and alopecia
```
55
COC monophasic doses
very low dose: EE 20 mcg + progestin
low dose: EE 30-35 mcg + progestin
high dose: EE 50 mcg + progestin
56
biphasic, triphasic, four phasic
biphasic: varying doses of EE or progestin; 2 strengths throughout cycle
triphasic: varying doses of EE or progestin; 3 strengths throughout cycle
four phasic: varying doses of EE and progestin; 4 strengths throughout cycle
57
"other" product hints
extended cycle COC: monophasic or biphasic, active pill up to 84 days
progestin only COC: no estrogen component, norethindrone 0.35 mg daily
non-oral hormone: EE + progestin = nuvaring or patch; progestin only = IUD, IM/SQ inj or rod
emergency contraception: typically no estrogen, 1-2 doses depending on product
58
pharmacist "prescribing" of oral contraceptives
legislation in california and oregon
| considering legislation in hawaii, missouri, SC, tennessee, washington
59
california law
```
Oral hormonal contraceptives
Hormonal contraceptive patches
Vaginal hormonal rings
Hormonal depot injections
Training:
-1-hr board-approved CE program
-Curriculum-based training post-2014
```
60
oregon law
Oral hormonal contraceptives
Hormonal contraceptive patches
Training:
-5-hr board-approved CE program
61
procedure for prescribing contraceptives
1. patient completes self-screening tool
2. RPh review/clarify responses
3. recommend product or refer
4. measure/record seated BP if combined hormonal product
5. train on administration
6. provide appropriate counseling and fact sheet
62
product selection
Based on CDC’s US Medical Eligibility Criteria (USMEC)
May select any product listed as Category 1 or 2 within scope of the law
If Category 3-4 OR wants product that is not self-administered
-Refer to PCP
-If no PCP, refer to nearby clinic
63
pharmacist conscience clause
Refusal to fill a prescription on religious or moral grounds
Some states have laws allowing pharmacists to refuse to fill - Arizona, Arkansas, Georgia, Idaho, Mississippi, South Dakota
Some states have laws requiring pharmacists to fill - California, Illinois, New Jersey
64
HPV
Most common STI in United States
-over 6 million people newly infected each year
-At least 50% of sexually active people infected at some point during lifetime
over 200 serotypes identified
-15 high-risk
-3 most likely high-risk
-12 appear low-risk
Can be spread via vaginal, anal and oral sexual contact
Treatment for warts, not eradication of virus
65
complications of HPV
```
Genital warts: types 6 & 11
Cervical cancer: types 16 & 18
Anal cancer: type 16
Vulvar, vaginal and penile cancer: types 16 & 18
Oropharyngeal cancer: type 16
```
66
HPV vaccines
cervarix: serotypes 16 and 18, administration at 0, 1 and 6 months, indicated for females 9-25
gardasil: serotypes 6, 11, 16 and 18, administration at 0, 2 and 6 months, indicated for females 9-26 and males 9-26
gardasil 9: serotypes 6, 11, 16, 18, 31, 33, 45, 52, and 58, administration at 0, 2 and 6 months, indicated for females 9-26 and males 9-15 (9-26)
67
SE of HPV vaccine
```
Injection site reaction
Fever
Headache
Nausea
Muscle/joint pain
Syncope
Dizziness
Guillain-Barre syndrome
Complex regional pain syndrome (CRPS)
Postural orthostatic tachycardia syndrome (POTS)
```
68
Premenstrual Syndrome (PMS) & Premenstrual Dysphoric Disorder (PMDD)
Recurrent moderate psychological and physical symptoms
Occur during luteal phase
Resolve with menstruation
over 200 symptoms
69
prevalence of PMS and PMDD
70-90% Premenstrual symptoms at some point in their life
20-40% experience premenstrual syndrome
3-8% have premenstrual dysphoric disorder
70
pathophys of PMS/PMDD
not well understood
reduced levels of: serotonin, GABA and allopregnanolone
fluctuations in: estrogen and progesterone
71
common sxs of PMS
physical/somatic: breast tenderness, *abdominal bloating, HA, swelling of extremities, body aches, *fatigue
affective/emotional: depression, angry outbursts, irritability, anxiety, confusion, *mood swings
cognitive: difficulty concentrating, sleep disturbances
behavioral: reduced interest in usual activities, appetite changes, social withdrawal
72
normal premenstrual symptoms
One or more mild emotional or physical symptoms
One to two days before the onset of menses
Do not cause distress or functional impairment
73
PMS
At least one symptom associated with “economic or social dysfunction”
Five days before the onset of menses
Present in at least three consecutive menstrual cycles
74
PMDD
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) full category/diagnostic code
At least five symptoms in final week before menses
Improve within a few days of onset of menses
Become minimal or absent in week post-menses
Present in majority of cycles
Confirmed by prospective daily rating during at least 2 symptomatic cycles
75
PMDD sxs for diagnosis
at least one: Affective lability, Irritability, anger or interpersonal conflicts, Depressed mood, feelings of hopelessness or self-deprecating thoughts, Anxiety, tension or feelings of being keyed up/on edge
at least one: Decreased interest in usual activities, Difficulty in concentration, Lethargy, easily fatigued or lack of energy, Change in appetite, overeating or specific food cravings, Hypersomnia or insomnia, Feeling overwhelmed or out of control, Physical symptoms (breast tenderness/swelling, joint or muscle pain, bloating, weight gain)
**total symptoms greater than or equal to 5
76
summary of normal v PMS v PMDD
Normal: 1 or more symptoms, mild/no functional impairment, sxs occur 1-2 days before menses
PMS: 1 or more sxs, economic or social impairment, sxs occur 5 days before menses for 3 consecutive cycles
PMDD: 5 or more sxs, cause significant distress/interference w daily life, start 7 days before menses and resolves within a few days for at least 2 cycles
77
nonpharm treatment for PMDD
```
Aerobic exercise
Relaxation techniques
Calcium carbonate 1200 mg/day
Vitamin B6 50-100 mg/day
Reduced caffeine, refined sugars, and sodium
```
78
pharmacologic therapy for PMDD
first line: SSRIs
second/third line: GnRH agonists, alprazolam
potential effectiveness: COC, spironolactone
last line: surgery
79
SSRIs for PMDD
FDA approved: fluoxetine 20 mg daily, sertraline 50-150 mg daily, paroxetine CR 12.5-25 mg daily
not FDA approved: citalopram 20-30 mg daily, escitalopram 10-20 mg daily
intermittent dosing: Start on day 14 of cycle, Stop 1-2 days after onset of menses, Consider weekly dosing of fluoxetine 90 mg twice during luteal phase
continuous/daily dosing: Mood symptoms outside of luteal phase, Irregular menstrual cycle, Intolerable side effects upon discontinuation, Difficulties with on/off schedule
80
SSRI considerations
Black Box Warning: Increased risk of suicidal thinking and behavior in children, adolescents and young adults with major depressive disorder and other psychiatric disorders
SEs: Nause, Fatigue, Somnolence, Decreased libido, Sweating, Insomnia, Anxiety, Diarrhea, Headache
81
alprazolam
2nd-3rd line option
Dose: 0.25mg PO BID-QID during the luteal phase
Does not improve physical/somatic symptoms
Used to augment SSRI therapy
Risk of dependence and tolerance
Side effects: cognitive dysfunction, fatigue, irritability, decreased libido, weight loss/gain, change in appetite, constipation, decreased salivation
82
gonadotropin-releasing hormone analogs
Leuprolide, goserelin, nafarelin, histrelin
-PMS and PMDD non-FDA approved indications
Reductions in psychoemotional and physical symptoms
Difficult to tolerate
Must use add-back therapy after 6-9 months because of reductions in bone mass
83
COCs for PMDD
FDA approved for PMDD
-drospirenone 3mg/ethinyl estradiol 20mcg (Yaz, Yasmin, etc.)
Improve physical symptoms, social functioning and productivity
Shortened pill-free interval (4 day vs 7 day) - greater reduction in symptoms
84
spironolactone
Non-FDA approved indication
Antimineralocorticoid and antiandrogenic effects interfere with testosterone synthesis
Dose: 25-200 mg/day during luteal phase
Decreases weight gain, somatic symptoms (breast tenderness, bloating), and negative mood
Side effects: hyperkalemia, somnolence, irregular menses, diarrhea, nausea, headache
85
surgery for PMDD
Total abdominal hysterectomy with bilateral oophorectomy
Reserved for severe and debilitating symptoms
Last resort
No longer wish to have children
Extremely effective and permanent cure of PMS/PMDD
Trial of GnRH analog before surgery is recommended to confirm response
86
summary of treatment options for PMDD
SSRIs: helps mood/emotional and physical symptoms, psychosocial functioning, work performance and overall quality of life
alprazolam: helps premenstrual depression, tension, anxiety, irritability, hostility, social withdrawal
GnRH agonists: help irritability, pain, breast tenderness, fatigue, variable effects on depression
COCs: help physical symptoms (bloating, HA, abdominal pain, breast tenderness-however they may also cause these symptoms), social functioning and productivity
spironolactone: helps breast tenderness, bloating, and negative mood
87
DSM5 classifications of sexual disorders in women
Female orgasmic disorder
| Female sexual interest/arousal disorder
88
female orgasmic disorder
Symptoms in 75-100% of sexual activity occasions
-Marked delay in, marked infrequency of, or absence of orgasm
-Markedly reduced intensity of orgasmic sensations
Minimum of 6 months
Cause clinically significant distress
Not explained by mental disorder or severe relationship distress or other significant stressors
89
female orgasmic disorder treatment
```
Cognitive-behavioral therapy
EROS-CTD
No FDA-approved medications
Bupropion
Apomorphine SL
```
90
female sexual interest/arousal disorder
Absence or reduction in at least three:
-Interest in sexual activity
-Sexual/erotic thoughts or fantasies
-Initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate
-Sexual excitement/pleasure during sexual activity in 75-100% of sexual encounters
-Sexual interest/arousal in response to any internal or external sexual/erotic cues
-Genital or nongenital sensations during sexual activity in 75-100% of sexual encounters
Minimum of 6 months
91
female sexual interest/arousal disorder treatment
```
Hormone therapy
-Estrogen (systemic or topical)
-testosterone
Addyi (flibanserin)
-FDA-approved August 2015
-Mixed 5HT1A agonist/5HT2A antagonist
```
92
addyi (flibanserin)
100 mg at bedtime
Contraindications: Alcohol use, Strong/moderate CYP3A4 inhibitors, Hepatic impairment
Adverse effects: Dizziness, Nausea, Fatigue
REMS and certified prescriber programs
93
point of prenatal care?
```
Accurate assessment of gestational age
Screening tests
BP surveillance
Assessment of fetal heart rate and growth
General counseling
```
94
frequency of prenatal visits
Initial visit at 8-10 weeks gestation then…
Every 4 weeks until 24 weeks gestation then…
Every 2 weeks until 36 weeks gestation then..
Every 1 week until delivery
95
gestational age
```
Pregnancy divided into three trimesters
Think of in weeks
-40 weeks is full gestation
-Week 3 is when first missed period occurs
-Viable after 24 weeks
-Excellent survival after 34 weeks
-37 – 42 weeks is “term”
```
96
week 4 embryo development
Heart begins to beat
Arm buds appear
Organs begin to form
97
week 5 embryo development
Eyes start to form
Leg buds appear
Blood circulates
Facial features begin to form
98
week 6 embryo development
Lungs start to form
| Fingers/toes start to form
99
week 7 embryo development
Hair follicles start to form
| Visible elbows and toes
100
week 8 embryo development
Face begins to look human
| External ears start to form
101
weeks 9-15 embryo development
```
Reproductive organs form
Teeth begin to form
Eyelids form
Brain activity detectable
Fetal activity
```
102
weeks 16-26 embryo development
```
Rapid brain development
Alveoli in lungs form
Internal eyes/ears form
Eyebrows, eyelashes, and nails
Muscles develop
```
103
weeks 27-38 embryo development
Increase in body fat
Bones complete development
Hair gets coarser/thicker
Brain is continuously active
104
prenatal counseling
```
Air travel
Breastfeeding
Childbirth education
Exercise
Fetal movement counts
Hair treatments
Heavy metals
Herbal therapies
Hot tubs and saunas
Labor and delivery
Medications
Radiation
Seat-belt use
Sex
Solvents
Substance use
Workplace issues
```
105
prenatal diet - supplementations
```
Calories
Folate / folic acid
Iron
Calcium
Omega-3 fatty acids
```
106
prenatal diet - calories
```
prepregnancy: underweight
weight gain (single): 28-40 pounds
prepregnancy: normal weight
weight gain (single): 25-35 pounds
weight gain (multiple): 37-54 pounds
prepregnancy: overweight
weight gain (single): 15-25 pounds
weight gain (multiple): 31-50 pounds
prepregnancy: obese
weight gain (single): 11-20 pounds
weight gain (multiple): 25-42 pounds
```
107
prenatal diet - folate
Neural tube defects around 8% of birth defects
-Spina bifida (no closing of spinal cord) 1:3000 births
-Anecephaly (no brain formation) 1:5000 births
Adequate folic acid decreases risk by over 50%
Neural tube formation occurs during first 4 weeks of development
All women of childbearing age: 0.4 mg folic acid daily
High risk or history of pregnancy with NTD: 4 mg daily
Begin at least 1 month prior to conception
Continue through entire pregnancy
Dietary sources: fortified foods, green leafy vegetables, citrus fruits, liver, legumes, whole wheat bread
108
prenatal diet - iron
Increased RBCs to carry extra oxygen
Iron deficiency linked to preterm birth and low birth weight
CDC recommendation: 27-30 mg of iron for all pregnant women
Dietary sources: lean red meat, fish, poultry, dried fruits, iron fortified cereals
109
prenatal diet - calcium
Inadequate calcium absorbed from maternal bones
Adequate intake:
-14 – 18 yo: 1300 mg daily
-19 – 50 yo: 1000 mg daily
May decrease risk of HTN and preeclampsia
110
prenatal diet - omega 3 fatty acids
Necessary for production of prostaglandins
Primary source: fish and other seafood
FDA/EPA recommendation: avoid consumption of king mackerel, shark, swordfish and tilefish
Avoid: refrigerated smoked seafood & raw fish
Recommend: 12 oz of seafood per week
-Low in mercury!
-Shrimp, canned light tuna, salmon, pollock, catfish
111
prenatal diet - limitations
```
Artificial sweeteners
Dairy (unpasteurized)
Deli meats
Eggs (raw)
Unwashed fruits/veggies
Herbal teas
Undercooked meat
```
112
prenatal diet - caffeine
High levels may be linked to: infertility, miscarriage, low birth weight
Studies conflicting/low quality
Recommend: low to moderate consumption, if at all - under 200 mg/day
113
prenatal diet - alcohol
```
AAP recommends no alcohol consumption
Alcohol ingestion linked to:
-Miscarriage
-Placental abruption
-Preterm deliveries
-Stillbirth
-Fetal alcohol syndrome (0.3-2:1000 births)
```
114
fetal alcohol syndrome
```
Small head size
Shorter-than-average height
Low body weight
Poor coordination
Hyperactive behavior
Difficulty with attention
Poor memory
Difficulty in school (math)
Learning disabilities
Speech and language delays
Intellectual disability / low IQ
Poor reasoning/judgment skills
Sleep and sucking problems as baby
Vision or hearing problems
Heart, kidney, or bone problems
```
115
prenatal diet - tobacco
Maternal effects: Premature rupture of membranes, Placental abruption, Placenta previa, Miscarriage, Ectopic pregnancy, Cancer, Cardiovascular disease, Pulmonary disease
Fetal effects: Brain, heart and nervous system damage, Low birth weight, Premature birth, Fetal death, Possible nicotine addiction - Irritability, Poor sleep
116
tobacco cessation
Pregnancy planning for current tobacco users
Tobacco-free prior to conception
Counseling and behavioral interventions are first line
FDA-approved cessation aids have not been studied in pregnancy
117
early prenatal tests
```
Blood type and Rh
Antibody screen
CBC
HbA1c
HIV
Syphilis
Depression
Alcohol use
Chlamydia
Hepatitis B Surface Antigen
Rubella immunity
Varicella immunity
Urine testing for UTI
TSH
Pap test
Others with specific risks - STIs
```
118
prenatal genetic screening
Sickle cell
Cystic fibrosis
Population specific - Ashkenazi Jewish descent
Aneuploidy- Sequential screen, Nuchal translucency, Quad screen, Cell free fetal DNA
119
third trimester testing
```
Glucose tolerance test
CBC
HIV
Syphilis
Group B Beta Strep (35-36 weeks)
```
120
group B beta strep
Normal flora of vagina/rectum in 25% of women
Leading cause of infections, morbidity, and mortality in neonates
Prophylaxis has reduced incidence of early onset neonatal sepsis by 80%
121
group B beta strep prophylaxis
```
First line
-Penicillin G 5 million units IV then 2.5 – 3 million units IV q4 hours
-Ampicillin 2 g IV then 1 g IV q4 hours
Penicillin allergy and no anaphylaxis
-Cefazolin 2 g IV then 1 g IV q8 hours
Penicillin allergy with anaphylaxis (and sensitivities available)
-Clindamycin 900 mg IV q8 hours
-Vancomycin 1 g IV q12 hours
```
122
vaccination in pregnancy
Routine vaccinations pre-conception
Live vaccines are generally contraindicated
-Risk of potential transmission to the fetus
-Wait 4 weeks before trying to conceive
Consider benefit v risk
123
special situations for vaccinating during pregnancy
```
Travel
-Plan and vaccinate prior to pregnancy
-Weigh risks vs. benefits
Outbreak
-Post-exposure vaccination may be provided
```
124
risks of medication use
```
Birth defects / malformations
-20-25% genetic factors
-10% environmental factors
-60-65% unknown factors
-Teratogen = agent that can cause fetal malformation
Pregnancy loss
Prematurity
Infant death
Developmental disabilities
Neonatal withdrawal
```
125
timing of medication exposure
First 2 weeks after conception: all or nothing
Weeks 3-10: organogenesis - critical time if exposed to teratogen
Weeks 11+: changes in cellular growth rate, change to previously formed structure, stillbirth
teratogen:
-thalidomide: 24-36 weeks post-conception: limb defects
-ACE inhibitor: 2nd/3rd trimester: fetal hypotension, renal tubular dysplasia, growth restriction, death
-warfarin: 6-12 weeks post-conception: “fetal warfarin syndrome” (facial dysmorphism, congenital heart defects, growth retardation)
126
traditional risk categories
A: Adequate and well-controlled studies, No demonstrable risk to fetus in first trimester, Examples: folic acid, magnesium sulfate, levothyroxine
B: No adequate and well-controlled studies in human, Animal studies fail to show risks, Examples: metformin, amoxicillin, pantoprazole
C: Animal reproduction studies show adverse effects, No adequate and well-controlled studies in human, Examples: fluconazole (single-dose), sertraline, amlodipine
D: Evidence of human fetal risk, Potential benefit may warrant use, Examples: paroxetine, lithium, phenytoin
X: Studies show fetal abnormalities, evidence of human fetal risk, Risks definitely outweigh benefits, Examples: atorvastatin, warfarin, istotretinoin (Accutane)
127
risk category 8.1
```
Pregnancy (Label section 8.1)
Pregnancy Exposure Registry contact information
Risk Summary
Clinical Considerations
-Maternal and fetal risks
-Dose Adjustments during pregnancy and postpartum
-Maternal and fetal adverse reactions
-Labor or delivery
Data: Human data, Animal data
```
128
risk category 8.2
```
Lactation (Label section 8.2)
Risk Summary
-Presence in human milk
-Effects on breastfed child
-Effects on milk production
Clinical Considerations
-Counseling information
-Minimizing exposure
-Monitoring reactions
Data
```
129
risk category 8.3
```
Females and Males of Reproductive Potential (Label section 8.3)
Pregnancy Testing
-Recommendations
-Requirements
Contraception
-Before, during, or after therapy
Infertility
-Human and/or animal data on effects on fertility
```
130
OTC medications in pregnancy
Consult with OB and/or pharmacist prior to use
Limit use!
Avoid herbal supplements
Virtually no data
131
"morning" sickness
Nausea & vomiting of pregnancy (NVP)
-Can occur any time of day
Hyperemesis gravidarum: persistent vomiting leading to weight loss, electrolyte disturbances and fluid loss
Potential causes: hCg, Estrogen, Hyperthyroidism
Usually stops at end of 1st trimester
132
NVP risk factors
```
History of: Motion sickness, Migraine headaches, Nausea with COCs
Psychologic predisposition
High fat diet prior to conception
Older age at conception
Genetics
```
133
NVP nonpharm treatment
Avoid triggers: Smells, foods, motion
Eat small, frequent, low-fat meals
Drink chilled beverages
134
NVP pharmacologic treatment
Vitamin B6 (pyridoxine)10-25 mg q8h
Diclegis (doxylamine 10 mg/pyridoxine 10 mg) 2 tabs at bedtime
-Symptoms controlled? Continue 2 tabs at bedtime
-Symptoms uncontrolled? Titrate up to 1 tab in AM, 1 tab midafternoon, and 2 tabs at bedtime
Ginger extract 125-250 mg q6h; ginger tea/ale
Promethazine 12.5-25 mg q4-6h
Metoclopramide 10 mg q6h
Ondansetron 4-8 mg q6h
Methylprednisolone 16 mg q8h x 3 days then taper over 2 weeks
135
heartburn in pregnancy
```
30-50% of pregnant women
Peaks in third trimester
Long-term complications are rare
-Self-resolves after delivery
Causes
-Increased progesterone
-Enlarging uterus
```
136
heartburn in pregnancy - nonpharmacologic therapy
```
Diet
-Avoid trigger foods
Eat small, well-balanced meals
Raise head of bed 6-8 inches
Chewing gum
```
137
pharmacologic therapy for heartburn in pregnancy
```
Antacids – Calcium containing
H2 blockers (i.e.: ranitidine)
PPIs (i.e.: pantoprazole)
Sucralfate
Metoclopramide
```
138
constipation in pregnancy
```
New development or worsening of prior issues
11-38% of pregnancies
Causes
-Dietary changes
-Decreased physical activity
-Iron-containing vitamins
-Mechanical factors
-Progesterone
```
139
nonpharm treatment for constipation in pregnancy
```
Dietary changes
-Increased fiber
-Increased fluids
-Avoid constipating foods
Regular exercise
Limit stress
Avoid constipating medications (if possible)
```
140
pharmacologic treatment for constipation in pregnancy
```
Osmotic laxatives (i.e.: polyethylene glycol, lactulose)
Bulk-forming laxatives (i.e.: psyllium)
Stimulant laxatives (i.e.: bisacodyl, senna)
Stool softener (i.e.: docusate)
```
141
UTI in pregnancy
Incidence of around 10%
Increased risk from weeks 6 – 24
Most common organisms:
-E. coli (80-90%)
-Proteus mirabilis
Klebsiella pneumoniae
Concerns:
-Untreated may progress to pyelonephritis** - risk to mom and baby
-Associated with preterm labor, transient renal failure, hematologic abnormalities, ARDS, sepsis and shock
Asymptomatic bacteriuria
-over 105 CFU/mL = “significant bacteriuria”
-Routine screening recommended
Acute cystitis
-Symptoms present: dysuria, urgency and frequency, no fever, no systemic illness
Pyelonephritis
-Bacteriuria + systemic symptoms or fever, chills, nausea, vomiting and flank pain
142
nonpham treatment of UTI in pregnancy
```
Hydration
Proper wiping (front to back)
Void before and after sex
Avoid scented feminine products
Wear cotton underwear
Avoid tight-fitting clothes
```
143
physiologic changes that lead to UTI
Ureters dilate
Larger volume of urine
Decreased tone in bladder
144
pharm treatment of UTI in preg
Cephalexin 250 mg BID – QID
Nitrofurantoin 50-100 mg QID
Ampicillin (or amoxicillin) 250-500 mg QID
Sulfisoxazole 1-2 g QID
Consider local resistance patterns**
Avoid:
-Fluoroquinolones (cipro, levo) - not appropriate
-Tetracyclines (doxycycline) - AEs
-Sulfamethoxazole/trimethoprim - creates problems in fetus
145
pain/fever/HA in pregnancy
Chronic pain should be adequately treated in pregnancy
Fever - See OB if unresolved in 24-36 hours d/t potential fetal harm
Headache - If persistent, or occurs after 20 weeks, see OB
146
nonpharm treatment of pain/fever/HA in pregnancy
```
Cool compress
Avoid triggers
Manage stress
Practice relaxation techniques
Eat regularly
Adequate sleep schedule
```
147
pharm treatment of pain/fever/HA in pregnancy
For all agents: USE LOWEST EFFECTIVE DOSE! for shortest amount of time
Drug of choice: acetaminophen (risk of asthma/ADHD??)
NSAIDs: Category C, Avoid use after 32 weeks (premature ductal closure)
Opioids: Category C, Monitor infant for signs of withdrawal after birth, Risk of neural tube defects?
148
thromboembolism in pregnancy
Leading cause of maternal death in US**
Risk factors: over 35 years old, Obesity (BMI over 30), Grand multiparity, Personal/family history of VTE or thrombophilia, Bed rest, Immobility for 4+ days, Hyperemesis, Dehydration, Preeclampsia, Surgery/trauma
149
DVT in pregnancy
Equal frequency among 3 trimesters and postpartum
More likely in left leg and ilio-femoral vein
Symptoms: unilateral leg pain and swelling
Difficult to distinguish from gestational edema
Venous (doppler) ultrasound is test of choice
150
PE in pregnancy
More common during postpartum period
Symptoms: postpartum dyspnea and tachypnea
Spiral CT is test of choice
151
nonpharm treatment of thromboembolism in pregnancy
```
Inferior vena cava (IVC) filter
-Anticoagulation is contraindicated
-Prevention of clot dislodging and causing PE while anticoagulated
Thrombectomy
-Emergent cases
Compression stockings
-Prophylaxis
```
152
pharmacologic theraoy of thromboembolism in pregnancy
```
Low-molecular weight heparin (LMWH)
-Enoxaparin, dalteparin
-Full treatment dose, weight adjusted
-Can monitor anti-Xa levels - 12 hour dosing goal: 0.6 – 1 unit/mL; 24 hour doing goal: 1-2 units/mL
Unfractionated heparin (UFH)
-Risk of HIT and osteoporosis
-aPTT monthly goal: 1.5 – 2x control
Oral agents
-Category B: apixaban
-Category C: rivaroxaban, edoxaban, dabigatran
-Category X: warfarin
```
153
management of thromboembolism in pregnancy (delivery)
Scheduled induction or C-section at 37 weeks
-Stop LMWH 24 hours prior
-Stop oral Factor Xa 24-48 hours prior
-Stop oral direct thrombin inhibitor 24-48 hours prior
Switch to UFH at 36-37 weeks gestation
-Shorter half-life
-Closely monitor aPTT
-Protamine available if aPTT significantly prolonged at time of labor/delivery
154
management of thromboembolism in pregnancy (postpartum)
Restarting anticoagulation
-6 hours after natural delivery
-12 hours after epidural removal
-24 hours after C-section
Start LMWH concurrently with warfarin - other orals are appropriate, if using warfarin bridge with lovenox
Continue for at least 6 weeks post-partum
Treat for a total duration of at least 6 months**
155
preterm birth
```
Before 37 weeks gestation
Spontaneous labor with intact membranes: 50%
Premature rupture of membranes: 25%
“Elective” preterm delivery: 25%
-Hypertensive disease
-Growth restriction
-Placental abruption
-Non-reassuring fetal surveillance
```
156
risk factors for premature birth
```
Maternal Characteristics:
-Non-Hispanic black race
-less than 6 months between pregnancies
-Physically strenuous/stressful work
-Pre-pregnancy BMI under 19
-Medical conditions (thyroid disease, diabetes, hypertension)
Pregnancy History
-Previous preterm delivery
Pregnancy Characteristics:
-Infection (bacterial vaginosis, chlamydia, intrauterine)
-Cocaine/heroin use
-Multiple gestation
-Shortened cervix
-Tobacco use
-Uterine anomalies
-Placental abruption/placenta previa
```
157
prevention of preterm birth
Identify those at risk
Address/control factors as much as possible - Smoking cessation, treatment of infections, etc.
Progesterone
-History of preterm birth? 17-alpha hydroxyprogesterone 250 mg IM qweek (weeks 16-36)
-No history of preterm birth? Vaginal micronized progesterone suppository 200 mg daily (as early as 18 weeks based on cervix)
158
preterm labor and contractions
30-60% with preterm contractions deliver prematurely
Determine likelihood of true labor - Fetal fibronectin testing (negative? not going into labor for 7-14 days), Cervical ultrasonagraphy
Medications!
-Fetal neuroprotection
-Corticosteroids
-Group B strep prophylaxis
-Tocolytics to delay delivery
159
fetal neuroprotection in preterm labor
```
Prevent cerebral palsy
Meta-analysis showed RR 0.71 with magnesium sulfate
Dose of magnesium sulfate:
-4-6 g IV load
-1 g/hr for 12 hours
-Resume infusion if delivery imminent
```
160
corticosteroids in preterm labor
```
Administered from 24-34 weeks - ONE TIME COURSE!!!
Reduces risk and severity
-Respiratory distress syndrome (RDS)
-Intracranial hemorrhage
-Necrotizing enterocolitis
-Death
Betamethasone 12 mg IM q24h x 2 doses
Dexamethasone 6 mg IM q12h x 4 doses
```
161
group B strep prophylaxis in preterm labor
If screened and negative: no treatment needed
Not screened? Obtain culture or rapid test and start prophylaxis
Recommended prophylaxis
-Penicillin G 5 million units IV then 2.5 million units IV q4h until delivery
162
tocolytics in preterm labor
```
Only short term use* from 24-34 weeks
Used to allow time for steroids and transfer to a tertiary care facility*
Common agents
-Magnesium
-Indomethacin
-Nifedipine
-Terbutaline
```
163
nifedipine in preterm labor as tocolytic
could be DOC
maternal side effects: Dizziness, flushing, hypotension. Surpession of heart rate, contractility, and LV pressure when used with Mg SO4. Elevation of LFTs
fetal or newborn AEs: no known
contraindications: Hypotension, preload dependient cardiac pathology (aortic insufficiency)
dose: 10 mg po q 20 min x 3 doses, then 20 mg po q 4-6 hours
164
indomethacin in preterm labor as a tocolytic
maternal side effects: Nausea, reflex, gastritis, emesis
fetal or newborn AEs: Constriction of PDA, oligohydramnios, necrotizing enterocolitis
CIs: Peptic ulcer disease, renal failure, platelet dysfxn
dose: 50-100 mg PO or PR, then 25 mg-50 mg q 6 hours
165
terbutiline in preterm labor as a tocolytic
maternal side effects: Tachycardia, hypotension, tremor, palpitations, dyspnea, chest pain, pulmonary edema, hypokalemia, hyperglycemia
fetal or newborn AEs: fetal tachycardia
CIs: maternal tachycardia
dose: 0.25 mg subcut every 15-30 minutes
166
magnesium sulfate in preterm labor as a tocolytic
maternal side effects: Flushing, diaphoresis, nausea, loss of DTRs, repiratory depression, supresses heart rate and contractility, neuromuscular blockade
fetal or newborn AEs: neonatal depression
CIs: myastenia gravis
dose: 4-6 g loading dose, 2 gram/hr
167
preterm membrane rupture
```
Before onset of labor and under 37 weeks
Unknown cause
Administer corticosteroids and magnesium sulfate
Limited role for tocolytics
Treat with “latency” antibiotics
-Not proven to prevent chorioamnionitis
-Significantly prolong pregnancy
```
168
latency antibiotics
Ampicillin 2 g IV q6h x 48 hrs then amoxicillin 250 mg q8h x 5 days
PLUS
Erythromycin 250 mg IV q6h x 48 hrs then erythromycin 333 mg q8h x 5 days
PLUS
Azithromycin 1 g PO x 1 dose
can add 3 additional weeks to pregnancy
169
preterm labor complications summary
less than 37 weeks?
labor and intact membranes - MgSO4 4-6g IV x 1 then 1g/hr x 12 hours, penicillin G 5 million units IV x 1 then 2.5 mill IV q4h
24-34 weeks? betamethasone 12 mg IM QD x2 OR dexamethasone 6 mg IM q12h x4
nifedipine, indomethacin, turbutaline, OR MgSO4
no labor but membrane rupture - MgSO4 4-6 g IV x1 then 1g/hr x12, ampicillin x 2 days, then amox x5 days plus erythromycin x7 days +/- azith x1
if less than 34 weeks gestation: betamethasone or dexamethasone
170
hypertensive disorders of pregnancy
```
Chronic hypertension
Gestational hypertension
Preeclampsia
HELLP syndrome
Eclampsia
```
171
chronic HTN in pregnancy
```
Before 20 weeks gestational age - over 140/90 on 2 occasions
Pre-existing hypertension
Goal of treatment: prevent end organ damage
Common medications:
-Labetalol
-Amlodipine
-Nifedipine
-HCTZ
-Hydralazine
-Methyldopa
```
172
gestational HTN
```
Elevated BP after 20 weeks
No evidence of preeclampsia
Risk factors
-Gestational diabetes
-History of preeclampsia
-Obesity
-Age
Generally no treatment if under 160/110
May be indication for delivery/induction at 37 weeks
```
173
preeclampsia
New onset BP over 140/90 and proteinuria of over 300 mg/24 hours
Unknown pathophysiology
Risk factors
-Microvascular disease (diabetes, HTN, vascular disorders)
-Antiphospholipid antibody syndrome
-Nephropathy
-Age under 20 or over 35 years
-Family/personal history of preeclampsia
-First pregnancy
Delivery is only “cure”
No severe features? Manage until 37 weeks
Severe symptoms
-Neurologic (headache, blurry vision)
-End organ damage (kidney function, liver function, placental function)
-Deliver at 34 weeks (or earlier)
-Goals: prevent seizures, lower blood pressure, avoid maternal end-organ damage
174
seizure prophylaxis
```
Magnesium sulfate 4-6 g IV bolus then 2 g/hour
Caution/contraindication: myasthenia gravis or other neuromuscular disease
Alternatives:
-Phenytoin
-Benzodiazepines
serum mag and effect:
5-9: therapeutic
over 9: loss of deep tendon reflexes
over 12: respiratory paralysis
over 30: cardiac arrest
```
175
HELLP syndrome
```
Variant of severe pre-eclampsia
*Hemolysis
*Elevated Liver enzymes
*Low Platelets (under 100,000)
Symptoms
-RUQ or epigastric pain
-Nausea
-Vomiting
Diagnosis via lab abnormalities
Immediate delivery after antenatal corticosteroids
```
176
eclampsia
Seizure(s) caused by elevated blood pressure in pregnancy
May be preceded by severe preeclampsia or appear unexpectedly
Usually last 60-90 seconds
Delivery ASAP after occurrence
Magnesium sulfate to prevent additional seizures
-On continuous infusion? Give additional 2 g IV
-No infusion? Give 6 g IV loading dose over 15-20 min then 2 g/hr infusion
177
preexisting diabetes
```
Fetal risk:
-Miscarriage
-Stillbirth
-Birth injury
-Neonatal hypoglycemia and hyperbilirubinemia
-Congenital anomalies - Cardiac and neural tube defects
Maternal risk
-Cesarean delivery
-Preeclampsia
-Kidney disease
-retinopathy
SMBG 4 times daily
More stringent goals
-Fasting under 95 (normal under 130)
-2-hour postprandial under 120 (normal under 180)
Commonly used orals
-Metformin
-Glyburide
Increased fetal surveillance
-Ultrasounds
-Non-stress tests
Early delivery/induction
```
178
gestational diabetes
Prevalence of 1-25%
50% chance of developing T2DM within 5 years postpartum!!
Glucose screening at 24-28 weeks
-Two step process: 50-g oral glucose challenge - BG over 130-140 100-g OGTT
-One step process: 75-g OGTT
179
gestational diabetes risk factors
```
Higher Risk
-Obesity
-Increased maternal age
-History of gestational diabetes
-Family history of diabetes
-Ethnicity: Hispanic, Native American, South or East Asian, African American, Pacific Island
lower risk:
-BMI under 25
-Age under 25 years
-No history of glucose intolerance
-No family history of diabetes
-White
First-line treatment: non-pharmacologic (diet, exercise, SMBG)
Second-line treatment: pharmacologic (insulin, metformin, glyburide)
```
180
postpartum hemorrhage
losing over 500 mL of blood after delivery
around 18% of births
Can be immediate or delayed over 24 hours
181
tone - postpartum hemorrhage
uterus cannot stop bleeding
Oxytocin 10 int. units IM or 20 int. units/1 L IV
Carboprost 0.25 mg IM or intramyometrially q15 min (max of 2 mg)
Misoprostol 1000 mcg rectally
Methylergonovine 0.2 mg IM q2-4 hours
182
trauma - postpartum hemorrhage
Suture lacerations
Drain hematomas over 3 cm
Replace inverted uterus
183
tissue - postpartum hemorrhage
Manual removal
Curettage
Methotrexate
184
thrombin - postpartum hemorrhage
Replace factors Platelet transfusion
| Fresh frozen plasma Recombinant factor VIIa
185
nonpharm management of labor pain
```
Primary goal: prevention of suffering
Approaches:
Childbirth education
Relaxation and breathing
Birth environment
Continuous labor support
Maternal movement and positioning
Birth ball
Water immersion
Acupuncture and acupressure
Hypnosis
Music
Aromatherapy
```
186
pharmacologic management of labor pain
Primary goal: eliminating physical sensation of pain
Approaches:
-Systemic analgesics: Opioids (i.e.: morphine, fentanyl, meperidine), Sedatives (i.e.: pentobarbital, midazolam) and analgesic adjuncts (i.e.: promethazine, hydroxyzine), Nitrous oxide
-Pudendal nerve block
-Neuraxial analgesia (i.e.: spinal block, epidural)
187
neuraxial analgesia
```
Absolute contraindications
-Patient refusal
-Uncorrected coagulopathy
-Infection of the lower back
-Uncorrected hypovolemia
-Increased intracranial pressure
Epidural
-Local anesthetics via continuous infusion pumps
-Bupivicaine 0.03 – 0.125%
-Ropivacaine 0.075 – 0.2%
Spinal
-Single shot
-Opioids +/- local anesthetic
```
188
breastfeeding
American Academy of Pediatrics (AAP) and WHO: exclusive breastfeeding for first 6 months
AAP: continued breastfeeding through 12 months, or as long as mutually desired
WHO: continued breastfeeding through 24 months, or longer
189
benefits of breastfeeding
Maternal
-Faster healing from childbirth
-Weight loss
-Reduced risk of: Type 2 diabetes, Breast cancer, Ovarian cancer, Osteoporosis, Rheumatoid arthritis, Cardiovascular disease
-Economic
Infant
Reduced risk of: Infection, Asthma, Childhood cancers, Childhood obesity, Ear infections, Eczema, Diarrhea and vomiting, Lower respiratory tract infections, Necrotizing enterocolitis, Sudden infant death syndrome (SIDS), Type 1 & 2 diabetes, Hospitalization
190
transfer of meds from mother to infact
```
orally available to mother
absorbed into bloodstream
cross into breastmilk
orally available to infant
absorbed into infant bloodstream
effect???
```
191
relative infant doses
```
Can be used to calculate potential exposure
If range, use highest number*
Examples:
-Ranitidine 1.3 – 4.6%
-Codeine 8.1%
-Enalapril 0.2%
-Propranolol 0.3 – 0.5%
-Aspirin 2.5 – 10.8%
-Lorazepam 2.5%
-Tetracycline 0.6%
-Doxycycline 4.2 – 13.3%
```
192
relative infant dose practice
total dose for day/weight = mg/kg/day for mom
max availability = (x mg/kg/day)/(mom mg/kg/day)
x?
193
if RID unkown
Theoretical infant dose can be used to calculate RID
Determined from concentrations in breastmilk**
Medication specific
Levothyroxine 0.000006 mg/kg/day
Aspirin 0.25 mg/kg/day
Lamotrigine 0.45 mg/kg/day
194
theoretical infant dose example
total dose/kg = mom mg/kg/day
| theoretical dose/(mom mg/kg/day) = x(100) = % available
195
mother considerations for breastfeeding and meds
```
Medication
Indication
Safe(r) alternatives?
Dose
Duration
Effect on milk supply
```
196
what does RID tell us?
under 2% = minimal transer to milk
2-5% = small transfer to milk
5-10% = moderate transfer
over 10% = large transfer - risk of effects in infants
197
infant considerations for breastfeeding and meds
```
Age
Weight
Preterm vs. term
Other health conditions
Percentage of diet composed of breastmilk
```
198
hale's lactation risk category
L1 : Safest (i.e.: acetaminophen, amoxicillin)
L2: Safer (i.e.: diphenhydramine, fluoxetine)
L3: Moderately safe (i.e.: pseudoephedrine, hydrocodone)
L4: Possibly hazardous (i.e.: colchicine, dapsone)
L5: Contraindicated (i.e.: amiodarone, chemotherapy agents)
199
antidepressants, anxiolytics, antipsychotics
RID
Bupropion (L3) 2 – 10%
Diazepam (L3/L4) 2 – 2.3%
Fluoxetine (L2/L3) < 12%
Citalopram (L3) 3-10%
Lithium (L4) ~10%
Lamotrigine (L3) ~10%
Venlafaxine (L3) 6-9%
Data not available on excretion in human milk for up to 1/3
Long term effects of exposure are unknown
Monitor growth and neurodevelopment of infant
200
drugs of abuse and lactation
alcohol - Impaired motor development or postnatal growth; decreased milk consumption; sleep disturbances
amphetamines - Hypertension, tachycardia, seizures; learning and memory deficits
benzos - Apnea, cyanosis, withdrawal, sedation, seizures
cocaine - Intoxication, seizures, irritability, vomiting, diarrhea
heroin - Withdrawal symptoms, tremors, restlessness, vomiting, poor feeding
marijuana - Neurodevelopmental effects, delayed motor development, lethargy, less frequent/shorter feedings
201
drugs for substance abuse
Methadone:
-Infant risks: lethargy, respiratory difficulty, poor weight gains
-Academy of Breastfeeding Medicine encourages breastfeeding if enrolled in methadone-maintenance program
Buprenorphine:
-Infant risks: lethargy, respiratory difficulty, poor weight gains
-Maternal risk: decreased milk production
Disulfiram & naltrexone:
-Use discouraged by FDA labeling
202
tobacco and breastfeeding
Increased SIDS with tobacco use
Nicotine replacement therapy
-Use dose less than the number of cigarettes smoked
-Short acting products recommended (gum, lozenge)
Bupropion
-Exposure may be RID > 10%
-Case report of seizure in breastfed infant
Varenicline
-Very limited data available
203
pain medications and breastfeeding
Preferred non-narcotics: acetaminophen or ibuprofen
Aspirin: low dose may be acceptable, high dose is not
Opioids: morphine, codeine, hydrocodone, fentanyl and hydromorphone moderately safe
-Morphine preferred
204
increasing milk supply
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Herbal supplements
-Fenugreek
-Blessed thistle
-Fennel seed
Oatmeal
Brewer’s yeast
Metoclopramide
Pumping
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205
breast pumps
Why?
-“Extra” breast milk for occasional use
-Building supply for when mother needs to be away
-Work!
When?
-Greatest milk supply first thing in the morning
-After nursing increases supply
-At normal times of nursing when away from baby
How?
-Basic parts: Breast shield (a), Pump (b), Milk container (c)
Types of pumps: Manual, Battery-powered, Electric
Single vs. double
