Gyne and Obs Rx Guide 2024 IST EDITION
BY Dr Zeeshan
Introduction
This guide provides a quick reference for commonly prescribed medications in gynecology and obstetrics, highlighting their key indications and examples. It is designed to assist healthcare professionals in making informed decisions for patient care in these specialties.
1 FEVER WITH DRY COUGH IN PREGNANCY Rx 1
2 FEVER WITH PRODUCTIVE COUGH IN PREGNANCY Rx 2
3 TYPHOID (ENTERIC FEVER) IN PREGNANCY Rx 3
4 MALARIA FEVER (FALCIPARUM MALARIA) IN PREGNANCY Rx 6
5 UTI(URINARY TRACT INFECTION) IN PREGNANCY Rx 9
6 NEPHROLITHIASIS (RENAL STONES) IN PREGNANCY Rx 12
7 COMMUNITY ACQUIRED PNEUMONIA (CAP) IN PREGNANCY OPD Rx 13
8 COMMUNITY ACQUIRED PNEUMONIA (CAP) IN PATIENT(WARD) IN PREGNANCY RX 18
9 VAGINAL YEAST INFECTION (VULVO-VAGNINAL CANDIDIASIS) Rx 20
10 CHLAMYDIAL INFECTION Rx 21
11 LEUKORRHEA Rx 22
12 PELVIC INFLAMMATORY DISEASES (PID) Rx 24
13 TRICHOMONIASIS Rx 28
14 ATROPHIC VAGINITIS Rx 29
15 PRIMARY DYSMENORRHEA(MENSTRUAL PAIN)Rx 30
16 SECONDARY DYSMENORRHEA Rx 31
17 PREMENSTRUAL SYNDROME (PMS) Rx 33
18 MITTELSCHMERZ Rx 35
19 MENORRHAGIA Rx 36
20 OLIGOMENORRHEA Rx 37
21 ENDOMETRIOSIS Rx 38
22 UTERINE LEIOMYOMAS (UTERINE FIBROIDS)Rx 40
23 FEMALE INFERTILITY Rx 43
24 POLYCYSTIC OVARY SYNDROME (PCOS) Rx 47
25 BENIGN OVARIAN CYST Rx 53
26 POSTPARTUM HEMORRHAGE(PPH)Rx 55
27 NAUSEA AND VOMITING OF PREGNANCY Rx 60
28 HYPEREMESIS GRAVIDARUM (HG)Rx 61
29 CHRONIC HYPERTENSION IN PREGNANCY Rx 63
30 MIGRAINE IN PREGNANCY Rx 65
31 GASTROESOPHAGEAL REFLUX DISEASE (GERD) IN PREGNANCY Rx 66
32 PEPTIC ULCER DISEASE IN PREGNANCY Rx 67
33 HELICOBACTER PYLORI IN PREGNANCY Rx 68
34 CONSTIPATION IN PREGNANCY Rx 69
35 HEMORRHOIDS IN PREGNANCY CONSERVATIVE Rx 70
1 FEVER WITH DRY COUGH IN PREGNANCY Rx
▲ Upper RTI
C/C:
Cough (Dry)
Sore throat
Runny nose
Nasal congestion
Headache
Low-grade fever
Facial pressure
sneezing
Investigation:
CBC
Chest X-ray (CXR) P.A view
Rule out COVID-19 if suspected send Covid protocol test
Rx
1. Tab. Co-Amoxiclav 625mg, 1g (Augmentin, Calamox) 1-1-1,1-0-1(625mg = TDS, 1g = BD)
Or Tab. Azithromycin 500mg (Macrobac, Azomax, Zetro) 0-0-1(OD)
2. Syp. Diphenhydramine (Benadryl) 2 Teaspoonful x TDS
3. Tab. Paracetamol (Panadol, Calpol, Febrol) 1-1-1
2 FEVER WITH PRODUCTIVE COUGH IN PREGNANCY Rx
Lower RTI
C/C:
Fever
Cough with Sputum production
Post nasal drip
Rapid breathing or difficulty breathing.
Wheezing
Skin turning a blue color due to lack of oxygen.
Chest pain or tightness
Investigation:
CBC
>> Urea, creatinine and electrolytes
ESR
Chest X-ray (CXR) P.A view
Sputum culture
>> Rule out COVID-19 if suspected send Covid protocol test
Rx
1. Tab. Co-Amoxiclav 625mg, 1g (Augmentin, Calamox) 1-1-1,1-0-1 (625mg = TDS, 1g = BD) Or Tab. Azithromycin 500mg (Macrobac, Azomax, Zetro) 0-0-1(OD)
Or Cap. Cefixime 400mg (Cefim, Cefspan, Cefiget) 0-0-1(OD)
2. Tab. Loratadine 10mg (Softin, Lorin NSA, Loril) 0-0-1(OD)
3. Tab. Paracetamol (Panadol, Calpol, Febrol)
4. Syp. Koflet (Cough suppressants)
2 teaspoonful x TDS Better to avoid in 1st trimester) Or Syp. Diphenhydramine (Benadryl)
3 TYPHOID (ENTERIC FEVER) IN PREGNANCY Rx
C/C:
▲ Enteric fever
Fever low then gradually
increases to 104.9 F
Headache
vomiting
Weakness and fatigue
Muscle aches
Relative bradycardia
Loss of appetite
Abdominal pain
Rash (Rose spot)
Diarrhea
Hepatosplenomegaly
Incubation period: 5-30 days (most commonly 7-14 days)
Treatment duration: 7-14 days
Diagnosis: Mnemonic 'BASU'
1st week: Blood culture
2nd week: Antigen test/Widal
3rd week: Stool culture
4th week: Urine culture
Blood culture is the most important diagnostic test at disease onset, as stool cultures are often negative despite active infection.
Gold standard test is Bone Marrow culture
>> Complete Blood Count (CBC)
Anemia
Leukopenia or leukocytosis
Absolute eosinopenia
Relative lymphocytosis
"LFTs: maybe Abnormal
> Ultrasound whole abdomen: Hepatosplenomegaly
Rx
1. Cap Cefixime 400 mg (Cefspan, Cefiget, Cefim) 0-0-1(OD), 1-0-1 (BD) - [Dose: Cefixime 20 mg/kg] Or Tab Azithromycin 500mg (Zetro, Bactizith, Azomax) 0-0-1(OD)-(Dose: 10/kg/day x 7 days]
2. Tab Paracetamol 500mg (Calpol, Febrol, Panadol) 1-1-1(TDS)
3. Syp. Lysovit or Syp. Leaderplex 2-0-2 (2 tsp. two times a day)
If Epigastric upset
4. Tab. Pantoprazole 40 mg (Zopent) 0-0-1(OD) 30 minutes before meals
If Nausea/vomiting then add
5. Tab. Metoclopramide 10mg (Metacion, Maxolon) 1-1-1(TDS)
Or Tab. Ondansetron 4mg (Onset, Onseron) x BD/TDS 1-0-1 (BD) or 1-1-1(TDS) 30 minutes before meals
Rx
For severe Enteric infection
Inj. Ceftriaxone 2g (Titan, Rocephin, Oxidil) x IV x OD/BD
Dose: 50-60 mg/kg
Dilution: Diluted in 100 ml 0.9% N/S
If Fever: Inj. Paracetamol 1g/100ml (Provas) x 8 hourly Or SOS
If vomiting: Inj. Metoclopramide 10mg/2ml (Metoclon) x IV x TDS
Correct dehydration and electrolytes imbalance
Prevention:
Salmonella infection is best prevented by protecting the water supply, preventing fecal contamination during food production, cooking and refrigerating foods, pasteurizing milk and milk products, and handwashing before preparing foods.
4 MALARIA FEVER (FALCIPARUM MALARIA) IN PREGNANCY Rx
Malaria fever in pregnancy
C/C:
Symptoms
Fever with chill and rigor
Headache/Body ache
Sweats, Fatigue, general malaise
Nausea, vomiting and Diarrhea
General malaise
Cough, Dyspnea
Muscle or back pain
Loss of appetite
Signs
Increase temperature
Sweating
Pallor
Jaundice
>> Respiratory distress
Splenomegaly
Investigation:
Microscopy of thick and thin blood films (gold standard test for peripheral blood for malaria).
In pregnant women, placental histology is the gold standard for diagnosis of malaria
Malaria parasite Rapid detection tests (Low sensitivity)
Routine test: CBC, LFTS, RBS, BUN, RFT, S/electrolytes, serum Lactate and ABGS
Urine D/R
Blood/Urine C/S
Rx
Uncomplicated malaria Rx for first trimester
Treat malaria in pregnancy as an emergency
Admit pregnant women with uncomplicated malaria to hospital and pregnant women with severe and complicated malaria to an intensive care unit.
1
. Tab Quinine 300mg x TDS PLUS Cap. Clindamycin 300 mg x TDS for 7 days Or Inj. Quinine 10 mg/kg (Diluted) x BD PLUS Clindamycin 5 mg/kg x BD
Alternative:
(Artem DS Plus, Artheget DS Plus, Gen-M 80/480mg)
Tab. Artemether 80 + Lumefantrine 480mg
1-0-1 (BD) for 3 days
2.
Tab. Paracetamol (Panadol, Calpol, Febrol)
1-1-1 (TDS), increase if not respond or adv cold sponging
3
. Syp. Multivitamins (Lysovit, Leaderplex)
2-0-2 (2 teaspoonful twice daily)
Rx
Complicated Severe malaria
Preferred treatment for Severe malaria in All trimesters
Inj. Artesunate 30mg, 60mg or 120mg (Gen-M) x IV or IM at dose 2.4 mg/kg
at 0, 12, 24 hours, and daily thereafter
(see Falciparum Malaria in ER section for IV dilution or follow GEN-M leaflet info)
Treat for at least 24 hrs, or until able to tolerate oral medication
Complete treatment with 3 days of Artemisinin based combined therapy
(ACT) = Artemether + Lumefantrine (Artem DS Plus) x BD
If Artesunate is not available:
Inj. Artemether 40mg/ml or 80 mg/ml (Artem) at dosage of 3.2 mg/kg as loading dose, followed by 1.6 mg/kg daily until able to tolerate oral drugs
Complete treatment with three days of artemisinin-based combined therapy (ACT) = Artemether + Lumefantrine
Treat fever with Inj. Paracetamol 1g/100ml (Provas) x IV x TDS
Correct hypoglycemia
5 UTI(URINARY TRACT INFECTION) IN PREGNANCY Rx
UTI in pregnancy
C/C:
>> Mild fever -/+ with chills
>> Burning micturition
>> Abdominal (Suprapubic) pain
>>> Painful urination (Dysuria)
>>> Frequent urination but very little urine comes out
>>> Urgent urination
>> Malaise
>> Stress/Anxiety
Investigation:
Urine D/R
Urine C/S
U/S KUB
Antibiotics consider safe in pregnancy (Category-B)
>> Ampicillin
Amoxicillin
Augmentin
>>> Cephalosporins: cephalexin, ceftriaxone, Cefixime etc.
Azithromycin
Erythromycin
Clindamycin
>> Metronidazole
(avoid in 1st Trimester)
Vancomycin
Nitrofurantoin
Meropenem
Fosfomycin
Safe in breastfeeding (Lactation)
Same as above
Penicillin
Ampicillin
Amoxicillin
Augmentin
Cephalosporins: Cephalexin, Cefuroxime, ceftriaxone etc.
Azithromycin
Vancomycin
Nitrofurantoin
Meropenem
Rx
Best choice Empirical: 1st line Rx
1. Tab Nitrofurantoin 100mg (Nitrofurantoin, Furantin) 1-0-1 (BD for 3 days, after 48 hours, the results of urine culture will allow a definitive choice of antibiotics) - women with G6PD deficiency should avoid Nitrofurantoin (also should avoided in 3rd Trimester - Risk of neonatal hemolysis)
2. Tab Paracetamol 500mg (Panadol, Calpol) 1-1-1 (TDS)
Rx
Alternative Rx 1
1. Cap Amoxicillin 250mg, 500mg, 1g (Zeemox, Ospomox, Amoxil) Tab. Co-Amoxiclav 375mg, 625mg, 1g (Augmentin/Amclav) 1-1-1, 1-0-1 (TDS/BD)
2. Tab Paracetamol 500mg (Panadol, Calpol) 1-1-1 (TDS)
3. Cranberry extract sachets (Cranmax pro, Abocran) One sachets in a glass water x BD
Rx
Alternative Rx 2
6. Cap. Cephalexin 250mg, 500mg (Keflex, Ceporex) 1-1-1, 1-0-1 (TDS/BD)
Or Cap. Cefixime 400mg (Cefspan, Cefim, Cefiget) 0-0-1(OD)
7. Tab Paracetamol 500mg (Panadol, Calpol) 1-1-1 (TDS)
8. Cranberry extract sachets (Cranmax pro, Abocran) One sachets in a glass water x BD
IF NAUSEA/VOMITING
9. Tab. Metoclopramide 10mg (Metacion, Maxolon) 1-1-1 (TDS)
Or Tab. Ondansetron 4mg (Onset, Onseron) x BD/TDS 1-0-1 (BD) or 1-1-1 (TDS)
6 NEPHROLITHIASIS (RENAL STONES) IN PREGNANCY Rx
Nephrolithiasis in Pregnancy
C/C:
Tiny real stone <8-10mm in size
Sudden onset of severe U/L and colicky flank pain (renal colic)
Radiates anteriorly to the lower abdomen, groin, labia, testicles, or
perineum
Nausea vomiting
Hematuria
Dysuria, frequency, and urgency
>> Passage of gravel or a stone
Investigation
CBC-WBCs increases
Serum Urea, creatinine & Electrolyte
Uric acid, Calcium & phosphorus level
Urine D/R & Urine C/S
U/S KUB
>> Low-dose CT or MRI KUB
Low-dose CT and MRI are more informative and comparatively safer in pregnancy, while conventional high-dose CT scan is contraindicated.
Rx
Antibiotics indicated in case of concomitant UTI
1. Cap. Amoxicillin 500mg (Amoxil, Zeemox) x TDS Or Tab. Co-Amoxiclav 625mg (Augmentin) x TDS Or Cap. Cephalexin 500mg (Ceporex, Keflex) x BD Or Cap. Cefixime 400mg (Cefspan, Cefiget) 0-0-1(OD)
2. Tab. Paracetamol (Panadol, Calpol) 1-1-1 (TDS)
For spasm/colicky pain
3. Tab. Phenazopyridine 100mg (Urilef, Uropin) x BD (Category-B) Or Tab. Drotaverine 80mg (Relispa forte, Nospa forte) 1-0-1(BD)
Expulsive therapy can reduce ureteral spasm and increase spontaneous passage rates by about 50%.
4. Cap. Tamsulosin 0.4mg (Tamsolin, Maxflow, Prostreat) 0-0-1(OD) (Category-B)
5. Adequate Oral Hydration: Increase oral fluid intake
7 COMMUNITY ACQUIRED PNEUMONIA (CAP) IN PREGNANCY OPD Rx
CAP
C/C:
Typical pneumonia: It is characterized by a sudden onset of symptoms caused by lobar infiltration.
>> Severe malaise
>> High fever and chills
>> Productive cough with purulent sputum
(yellow-greenish)
Crackles and bronchial breath sounds on auscultation
Decreased breath sounds
Enhanced bronchophony,
egophony, and tactile fremitus
>>> Dullness on percussion
>> Tachypnea and dyspnea (nasal flaring, thoracic retractions)
>> Pleuritic chest pain when breathing, often accompanying pleural effusion
>>> Pain that radiates to the abdomen and epigastric region (particularly in children).
Atypical pneumonia: typically has an indolent course (slow onset) and commonly manifests with extrapulmonary symptoms.
>> Nonproductive, dry cough
>> Dyspnea
>> Auscultation often unremarkable
>> Common extrapulmonary features include fatigue, headaches, sore throat, myalgias, and malaise
Diagnosis
Pneumonia is a clinical diagnosis based on history, physical examination, laboratory findings, and CXR findings. Consider microbiological studies and advanced diagnostics based on patient history, comorbidities, severity, and entity of pneumonia.
Laboratory findings:
>> CBC: Leukocytosis
>> Inflammatory markers: ↑ CRP, ↑ ESR
>↑ Serum procalcitonin (PCT): PCT is an acute phase reactant that can help to
diagnose bacterial lower respiratory tract infection.
>>> ABGS: PaO2, deranged LFTs & Urea, creatinine & electrolytes.
Chest x-ray (PA & lateral view)
Indications: all patients suspected of having pneumonia
Findings
>>> Lobar pneumonia
Opacity of 1 or more pulmonary lobes
Presence of air bronchograms:
appearance of translucent bronchi inside opaque areas of alveolar consolidation
>> Bronchopneumonia
Poorly defined patchy infiltrates
scattered throughout the lungs
Presence of air bronchograms
>> Atypical or interstitial pneumonia
Diffuse reticular opacity
Absent (or minimal) consolidation
>> Parapneumonic effusion
Chest CT (usually without contrast)
Advantages: more reliable evaluation of circumscribed opacities, pleural empyema, or sites of consolidation Indications
>>> Inconclusive chest x-ray
>> Recurrent pneumonia
>> Poor response to treatment
Duration of treatment: 5 to 7 days of therapy is usually sufficient.
Criteria for hospitalization
Every patient should be assessed individually and clinical judgment is the most important factor.
The pneumonia severity index (PSI) and the CURB-65 score are tools that can help to determine whether to admit a patient.
CURB-65 score
Confusion (disorientation, impaired consciousness) 1
Serum Urea > 7 mmol/L (20 mg/dL) 1
Respiratory rate ≥30/min 1
Blood pressure: systolic BP ≤ 90 mmHg or diastolic BP≤ 60 mmHg 1
Age ≥ 65 years 1
Interpretation: Each finding is assigned 1 point.
CURB-65 score 0 or 1: The patient may be treated as an outpatient.
CURB-65 score≥2: Hospitalization is indicated.
CURB-65 score ≥ 3: Consider ICU level of care.
Pneumonia severity index (PSI/PORT score)
Patients are assigned to one of five risk classes based on a
more complex point system than in CURB-6.
Points are distributed based on patient age, comorbidities, and lab results.
Criteria for ICU admission
The decision of whether to admit a patient to the ICU should be based on clinical judgment.
The IDSA/ATS criteria for severe CAP can be used to help triage patients with CAP and guide empiric antibiotic treatment decisions.
IDSA/ATS criteria for severe CAP
"The Infectious Disease Society of America (IDSA) & the American Thoracic Society (ATS)
Major criteria
>> Septic shock/need for vasopressors
>>> Mechanical ventilation
>> Confusion
>> Body temperature < 36°C
>> Hypotension requiring fluid resuscitation
>> Respiratory rate ≥ 30/min
Minor criteria
>>> PaO2/FiO2 ≤ 250
>> Leukopenia (WBC < 4,000/mm3)
>> Thrombocytopenia (platelet count < 100,000/mm3)
>> BUN ≥ 20 mg/dL
>> Multilobar infiltrates
Interpretation
Severe CAP: one major criterion or ≥ 3 minor criteria
Rx
CAP IN PREGNANCY
Previously healthy patients without comorbidities or risk factors for resistant pathogens
✓ Cap. Amoxicillin 500mg x 2 (Amoxil) 1g x Three time daily (TDS) Or Tab. Azithromycin 500mg (Azomax) x 500mg on day-1,
followed by 250 mg once daily for 4 days or 500 mg OD for 3 days.
Or Cap. Cefixime 400mg (Cefspan, Cefim, Cefiget) x OD
Patients with comorbidities or risk factors for resistant pathogens Combination therapy
Tab. Amoxicillin/clavulanic acid 1g (Augmentin) x BD
>> Or Cap. Cefuroxime 250mg (Zinacef, Zecef) x 500mg x BD
Or Tab. Cefpodoxime 200mg (Prelox, Orelox) x BD
PLUS one of the following:
>> Tab. Azithromycin 500mg (Azomax) x 500mg on day-1, followed by 250 mg OD for 4 days or 500 mg OD for 3 days.
Supportive treatment
> Supportive care: Adequate hydration, nutrition, and rest
> Fever: Tab. Paracetamol 500mg (Panadol) x 1-2 x TDS
Calcium/vitamins supplement: Abocal or CAC-1000 x daily
> Antihistamine: Tab. Loratidine 10mg x OD
8 COMMUNITY ACQUIRED PNEUMONIA (CAP) IN PATIENT(WARD) IN PREGNANCY RX
Rx
1. Airway:
Ensure patient is maintaining own airway
Assess and secure stable airway
2. Breathing: Check SpO, if <94 administer 02 therapy via nasal canula: 1-6 L O2/minutes
3. Circulation:
30 Maintain 2 large bore intravenous line (IV cannula)
Vitals monitoring: Check BP, PR, RR, Temperature, SpO
Send labs: CBC, UCE, LFTS, PT, INR, LDH, CRP, ESR, RBS, Cardiac Enzyme, Procalcitonin, D-dimer.
Hydration with PO fluids or IV fluids: Ringer Lactate or 0.9% Normal saline x 1L x IV x stat
Empiric antibiotic therapy for community-acquired pneumonia
Duration of therapy 5-7 days is usually sufficient.
Combination therapy for Non-ICU/non-severe & ICU/severe patients
Inj. Ampicillin-Sulbactam 1.5g to 3g (Ambac) x IV x QID (every 6 hours)
Or Inj. Amoxicillin-Sulbactam 1.5g to 3g (Bactamox) x IV x QID (every 6 hours) Or Inj. Ceftriaxone 1-2g (Titan, Rocephin) x IV x BD/OD (every 12-24 hours)
Or Inj. Cefotaxime1-2g (Claforan, Cefotax) x IV x TDS/BD (every 8-12 hours)
PLUS one of the following:
Or Inj. Azithromycin 500 mg/vial (Azitma) x IV x OD (can also be given Per orally in tablet form)
Empiric antibiotic therapy for Risk factors for Pseudomonas aeruginosa
Combination therapy
Inj. Piperacillin + Tazobactam 4.5g (Tanzo, Tazocin EF) x IV x QID (every 6 hours)
Or Inj. Ceftazidime 1g to 2g (Fortum) x IV x (every 8 hours) Or Inj. Cefepime 1g to 2g (Uceph) x IV x TDS (every 8 hours)
Or Inj. Meropenem 1g (Meronem, Penro) x IV x TDS (every 8 hours)
Or Inj. Imipenem-cilastatin 500mg to 1g (Cilapen, Tienam) x IV x QID (every 6 hours)
PLUS one of the following:
Inj. Azithromycin 500 mg/vial (Azitma) x IV x OD
If indicated Corticosteroids: (Corticosteroids are not routinely recommended as adjunct therapy.)
Inj Dexamethasone 4mg/1ml (Decadron) 4-6 mg x IV x BD for 5-7 days
Fever: Inj. Paracetamol 1g/100ml (Provas) x IV x TDS Inj. Pantoprazole 40 mg (Zopent) x IV x OD
* Thromboprophylaxis (high risk patient)
Inj Enoxaparin sodium 40mg (Clexane) x SC x OD
Disability & Exposure
Admit to ICU and initiate intubation if any of the following are present: Signs of respiratory failure,
Dyspnea with hypoxemia and Tachypnea (RR > 30/min)
Monitor pupillary reflexes and GCS level
Supportive care: Adequate hydration, nutrition, and rest
Correct underlying cause
9 VAGINAL YEAST INFECTION (VULVO-VAGNINAL CANDIDIASIS) Rx
▲ Vaginal Candidiasis
Epidemiology: Second most common cause of vulvovaginitis (17-39% of all cases)
Pathogen: primarily Candida albicans (In immunosuppressed patients also Candida glabrata)
Pathophysiology: overgrowth of C. albicans.
Can be precipitated by the following risk factors: Pregnancy, Immunodeficiency, Both systemic (Diabetes mellitus, HIV, immunosuppression) and local (Topical corticosteroids) and Antimicrobial treatment (after systemic antibiotic treatment)
C/C:
> White, crumbly, and sticky vaginal discharge that may appear like cottage cheese and is typically odorless
> Erythematous vulva and vagina
> Vaginal burning sensation, strong pruritus, dysuria, dyspareunia
Diagnostics
> Pseudohyphae on wet mount with potassium hydroxide (KOH)
> Vaginal pH within normal range (4-4.5)
Rx
1. Cap. Fluconazole 150mg (Diflucan)
0-0-1 (OD) x single dose
2. Tab Metronidazole 400mg (Flagyl, Metrozine) 1-0-1(BD)
For married female only
3. Clotrimazole Vaginal Cream (Canesten, Gynosporin) OR Miconazole Vaginal Cream (Gyno-Daktarin, Myzovag) One applicatorful Intravaginally for 6 days at night OR twice daily for 3 days OR as per physician instruction
10 CHLAMYDIAL INFECTION Rx
▲ Chlamydia
C/C:
> Fever
> Pelvic pain
> Vaginal odor.
> Vaginal itching.
> Burning during urination
> Vaginal discharge
Rx
1. Cap. Doxycycline 100mg (Doxyn, Vibramycin) 1-0-1(BD)
2. Tab. Metronidazole 400mg (Flagyl, Metrozine) 1-1-1 (TDS)
3. Cap. Fluconazole 150mg (Diflucan, Fungone) 0-0-1 once orally single-dose only
4. Clotrimazole Vaginal Cream/Tablet (Canesten, Gynosporin) 0-0-1(HS)
11 LEUKORRHEA Rx
TYPES OF LEUKORRHEA
1. Physiologic Leukorrhea: It is not a major issue but is to be resolved as soon as possible.
➤ It can be a natural defense mechanism that the vagina uses to maintain its chemical balance, as well as to preserve the flexibility of the vaginal tissue. The term "physiologic leukorrhea" is used to refer to leukorrhea due to estrogen stimulation.
➤ Leukorrhea may occur normally during pregnancy. This is caused by increased blood flow to the vagina due to increased estrogen. Female infants may have leukorrhea for a short time after birth due to their in- uterine exposure to estrogen.
2. Inflammatory Leukorrhea
➤ It may also result from inflammation or congestion of the vaginal mucosa. In cases where it is yellowish or
gives off an odor, a doctor should be consulted since it could be a sign of several disease processes,
including an organic bacterial infection (aerobic vaginitis) or STD. ➤ After delivery, Leukorrhea accompanied by backache and foul-smelling lochia (postpartum vaginal discharge, containing blood, mucus, and placental tissue) may suggest the failure of involution (the uterus returning to pre-pregnancy size) due to infection. A number of investigations such as wet smear, Gram stain, culture, Pap smear and biopsy are suggested to diagnose the condition.
3. Parasitic Leukorrhea: Leukorrhea is also caused by trichomonads, a group of parasitic protozoans, specifically Trichomonas vaginalis. Common symptoms of this disease are burning sensation, itching and discharge of frothy substance, thick, white or yellow mucus.
▲ Leucorrhea
C/C:
Fever
Pelvic pain
Vaginal odor.
Vaginal itching.
Burning during urination
Vaginal Discharge
Leukorrhea may be caused by sexually transmitted diseases, therefore, treating the STD will help treat the leukorrhea.
Leukorrhea can be confirmed by finding >10 WBC under a microscope when examining vaginal fluid.
Intimate wash helps balance vaginal pH level, which in turn helps in preventing itchiness and bacterial infection in the vaginal area. It also supports the growth of good bacteria, Lactobacillus, which is important for a healthy vagina
Rx
1. Tab. Metronidazole 400mg (Flagyl, Klint) 1+1+1 (TDS)
2. Cap. Doxycycline (Doxyn, Vibramycin) Or Cap. Clindamycin 150mg or 300mg (Dalacin-C) Or Cap. Azithromycin 250 mg (Azomax, Zetro) 1+0+1 (BD)
For Abdominal/pelvic Pain
3. Tab. Diclofenac sodium 50mg (Voren, Voltral) Or Tab. Diclofenac Potassium 50mg (Caflam, Maxit) 1+0+1 (BD)
4. Feminine intimate cleanser (Enriched with Lactic acid, Triclosan and tea tree oil)
How to use an intimate wash?
Take a small quantity of the solution in your hand and apply it on the external part of the vaginal area during toilet usage or a shower. Apply it gently and then rinse it with clean water. Dry the area with a clean towel. You can use the intimate wash everyday but use a gentle product that contains natural ingredients.
12 PELVIC INFLAMMATORY DISEASES (PID) Rx
Risk factors
Multiple sexual partners, unprotected sex
History of prior STIs and/or adnexitis
Intrauterine devices
Risk is lower during pregnancy; PID development during pregnancy increases the risk of maternal morbidity and preterm births.
Vaginal dysbiosis
Possible sites of infection
Cervix: Cervicitis
Endometrium: Endometritis
Fallopian tubes: Salpingitis
Ovaries: Oophoritis
Uterine adnexa: Adnexitis
Surrounding pelvic structures (parametritis) or, in some cases, the peritoneum: Peritonitis
PID
C/C:
> Fever, chills
>Lower abdominal pain (generally bilateral), which may progress to acute abdomen
> Menstrual disturbance (Menorrhagia, metrorrhagia)
> Pain during sexual intercourse
> Post coital pain.
> Vaginal odor & itching.
> Abnormal Vaginal discharge (yellow/green color)
> Dysuria, urinary urgency
Microbes involve:
Most common:
> Chlamydia trachomatis 1/3
> Neisseria gonorrhoeae 1/3
Less common (consider coinfections):
> E. coli
> Ureaplasma
> Mycoplasma
> Endogenous aerobes
> Anaerobes
Investigation:
Blood test: ↑ ESR, Leukocytosis (↑TLC)
Pregnancy test: To rule out an (Ectopic)
pregnancy
Cervical and urethral swab
> Gonococcal and chlamydial DNA (PCR) and culture sensitivity.
> Giemsa stain of discharge can show cytoplasmic inclusions in Chlamydia trachomatis infections, but not in N. gonorrhoeae infection.
Pelvic Ultrasound: Bulky uterus, free fluid in cul de sac, abscesses, tubo ovarian cyst, pyosalpinx/hydrosalpinx.
Important diagnostic criteria
> Patient history: Most often a sexually active young woman
> Lower abdominal pain
> Vaginal examination
► Chandelier sign (Cervical motion tenderness): severe cervical pain elicited by pelvic examination
► Uterine and/or adnexal tenderness
- Purulent, bloody cervical and/or vaginal discharge
Duration of therapy: 14 days
Rx
First line Rx (Regimen A)
1. Cap. Doxycycline 100mg (Vibramycin, Doxyn) 1-0-1(BD)
2. Tab. Metronidazole 400mg (Flagyl, Metrozine) 1-1-1 (BD)
3. Tab. Ciprofloxacin 250mg (Novidat, Ciplet)
1-1-1 (TDS)
4. Cap. Omeprazole 20mg or 40mg (Ruling, Risek) 0-0-1(OD)
5. Clindamycin phosphate Vaginal Cream (Vagibact, Clycin-V) 0-0-1(HS)
Rx
Regimen B
1. Tab. Levofloxacin 250mg (Leflox, Levofin, Levoxin) x 14 days Or Cap. Azithromycin 250 mg (Azomax, Zetro) x 7 days only 1-0-1(BD)
2. Tab. Metronidazole 400mg (Flagyl, Metrozine)
1-0-1 (BD)
3. Cap. Esomeprazole 20mg or 40mg (Esso, Nexum) 0-0-1(OD)
4. Clindamycin phosphate Vaginal Cream (Vagibact, Clycin-V) 0-0-1(HS)
Rx
Regimen C
1. Inj. Ceftriaxone 2g (Titan), diluted in 100 ml 0.9% normal saline x IV x Once in hospital/clinic setup.
2. Cap. Doxycycline 100mg (Vibramycin, Doxyn) 1-0-1(BD)
3. Tab. Metronidazole 400mg (Flagyl, Klint) 1-0-1(BD)
4. Clindamycin phosphate Vaginal Cream (Vagibact, Clycin-V) 0-0-1(HS)
Rx
If mass persist, Or Abscess is > 4-6 cm
Drainage of a Tubo-ovarian/Pelvic abscess is appropriate
Mass in cul-de sac in midline, Drain through the vagina
If patient condition deteriorates
LAPAROSCOPY OR LAPAROTOMY
13 TRICHOMONIASIS Rx
▲ Trichomoniasis
C/C:
> Pelvic pain
> Foul-smelling, frothy, yellow-green, purulent vaginal discharge.
> Vulvo-vaginal pruritus/itching.
> Burning sensation
> Dyspareunia, Dysuria
> Strawberry cervix (erythematous mucosa with petechiae)
Diagnostics
> Saline wet mount of vaginal smear: motile trophozoites with multiple flagella.
> If a wet mount is inconclusive, perform culture.
> pH of vaginal discharge > 4.5
Rx
Oral metronidazole Or tinidazole for the patient and sexual partners and Check for other sexually transmitted infections
1. Tab. Metronidazole 400mg (Flagyl, Klint)
1-0-1 (BD), Or 2g x Once
Recommended Regimen: Metronidazole 2g per oral by single dose Or twice daily for 7 days
Alternative
>> Tab. Tinidazole 500mg (Fasigyn, Trichogen, Prevent)
1-0-1 (BD), Or 2g x Once
Recommended Regimen: Tinidazole 2g per oral by single dose Or twice daily for 7 days
If women is pregnant (after first trimester for metronidazole) or breast feeding:
Cap. Clindamycin 300mg per oral twice a day for 7 days Or Tab. Metronidazole 200mg per oral 3 times a day for 7 days Or metronidazole 0.75% vaginal applicator (Metni-V) x intra-vaginally twice a day for 5 days
14 ATROPHIC VAGINITIS Rx
Etiology
Low estrogen levels: after menopause, bilateral oophorectomy, radiotherapy, chemotherapy,
immunological disorders
Atrophy of epithelium in vagina and vulva
▲ Atrophic vaginitis
C/C:
Decreasing labial fat pad
Vaginal soreness, dryness
Dyspareunia, burning sensation after sex
Discharge, occasional spotting
Commonly associated with receding pubic hair
Diagnostics: primarily a clinical diagnosis, additional tests (e.g., pH test, wet mount) are often nonspecific
Rx
If Mild symptoms lubricants gel Non-hormonal vaginal moisturizers and
Himalaya EveGel Or Vagisil Or Sesderma Or Membrasin Intimate Moisture Cream
Vaginal estrogen therapy if moderate to severe symptoms
Conjugated Estrogen Vaginal Cream (Premarin, Estromarin)
Systemic hormone therapy if vasomotor symptoms
Tab Conjugated Estrogen 0.3mg (Premarin)
Tab. Tibolone 2.5mg
15 PRIMARY DYSMENORRHEA(MENSTRUAL PAIN)Rx
PRIMARY DYSMENORRHEA: Recurrent lower abdominal pain shortly before or during menstruation (in the absence of pathologic findings that could account for those symptoms). Prostaglandin-F (PGF) is the main contributor to the cause of dysmenorrhea. The time of the endometrial shedding during the beginning of menstruation is when the endometrial cells release PGF. Prostaglandin (PG) causes uterine contractions, and the intensity of the cramps is proportional to the amount of PGs released after the sloughing process that started due to dropping hormonal surge.
△ Primary dysmenorrhea
C/C:
Recurrent, crampy, suprapubic pain occurring just before or during menses and lasting two to three days
Spasmodic, crampy pain in the lower abdominal and/or pelvic midline may radiate into the lower back and thighs
Headaches, diarrhea, fatigue, nausea, bloating and flushing are common accompanying symptoms.
Normal pelvic examination findings
Rx
1. Maintaining an active lifestyle and a balanced diet that is rich in vitamins and minerals, boiled eggs, hot milk, turmeric powder in hot milk → useful to reduce the intensity of the dysmenorrhea.
2. Tab Mefenamic Acid 500 mg (Mefnac DS, Ponstan Forte) 1-1-1 (TDS) Or Tab Naproxen sodium 500mg (Neoprox, Flexin) Or Tab Lornoxicam 8mg (Xika Rapid, Atcam)
1-0-1 (BD) → Initially 500mg BD day 1-3, then 250mg x BD
16 SECONDARY DYSMENORRHEA Rx
SECONDARY DYSMENORRHEA: Recurrent lower abdominal pain shortly before or during menstruation due to an underlying disease, disorder, or structural abnormality either within or outside the uterus. There are many common causes of secondary dysmenorrhea, which include endometriosis, fibroids (endometriomas), adenomyosis, endometrial polyps, pelvic inflammatory disease, and maybe even the use of an intrauterine contraceptive device.
▲ Secondary Dysmenorrhea
C/C:
Depend on the underlying cause
Secondary dysmenorrhea should be suspected in the following cases:
.
Abnormal pelvic examination (e.g., uterine size, cervical motion tenderness, adnexal tenderness, masses, vaginal/cervical discharge)
The pain tends to get worse over time.
No previous history of pain with menstruation
Infertility (Adhesions, endometriosis, PID)
Irregular cycles
Heavy menstrual flow (e.g., adenomyosis, fibroids, polyps)
Dyspareunia or postcoital bleeding
Partial or no response to therapy with NSAIDs and/or hormonal contraceptives
Diagnosis
Depend on the underlying cause
Initial laboratory testing
CBC with differential (rules out infection)
Urinalysis (rules out UTIs)
Other
β-hCG (rules out ectopic pregnancy), Gonococcal/chlamydial swabs (rule out STDs and PID)
Pelvic ultrasound
Rx
Treatment: depends on the underlying cause
17 PREMENSTRUAL SYNDROME (PMS) Rx
>> Occurs in up to 12% of female individuals.
>> Age of onset: 20-30 years of age
Diagnosis
Diagnosis is based on history and self-assessment (maintaining a PMS diary)
Pre Existing thyroid disorders and psychiatric (major depressive disorder) conditions should be ruled out.
Premenstrual syndrome (PMS)
Definition
>> The onset of severe discomfort or functional impairment prior to menstruation
Diagnostic criteria
>> Present in the 5 days prior to the beginning of menstruation for at least 3 consecutive cycles
End within 4 days after the beginning of menstruation
>>> Interfere with normal daily life activities
Premenstrual dysphoric disorder (PMDD)
Definition
>> Severe affective symptoms and behavioral changes that cause clinically significant disturbance of daily life
Diagnostic criteria
>> Present up to 7 days prior to the onset of menstruation for the majority of cycles within one year
>> ≥ 5 symptoms that are marked and/or persistent (e.g., depressed mood, anxiety, anger, affective lability, sleep disturbances, change in appetite, pain, headache)
>> Significant interference in daily life (work, home, social activities, interpersonal relationships
▲ Premenstrual syndrome (PMS)
C/C:
>>> Onset of symptoms 5 days before menstruation
>>> Pain: dyspareunia, breast tenderness, headache, back pain, abdominal pain
>>>> Gastrointestinal changes: nausea, diarrhea, changes in appetite (food cravings)
>>>> Bloating and weight gain
>> Tendency to edema formation
>> Neurological: migraine, increased sensitivity to stimuli
>> Psychiatric: mood swings, drowsiness, lethargy, exhaustion, depression, anxiety, aggressiveness, social withdrawal
Progesterone for the treatment of premenstrual syndrome and post-natal depression: → The recommended dose is 200 mg once a day or 400 mg twice a day by vaginal or rectal insertion.
Rx
1. Lifestyle changes can be beneficial
cognitive behavioral therapy -a talking therapy
Regular exercise, healthy diet & dietary supplements
Avoiding individual triggers like alcohol, caffeine, nicotine and smoking
Get plenty of sleep - 7 to 8 hours is recommended
keep a diary of your symptoms for at least 2 to 3 menstrual cycles - you can take this to a GP appointment
2. Tab Mefenamic acid 500 mg (Mefnac DS, Ponstan Forte) 1-1-1(TDS)
Or Tab. Naproxen sodium 500 mg (Flexin, Synflex) 1-0-1, Initially 500mg BD day 1-3, then 250mg x BD
Consider Oral contraceptive pills (OCPs)
Tab. Yaz or Tab. Famila 28-F Once daily on day 3rd to 7th on menstrual cycle
(Calone-D, Osnate-D)
3. Tab. Ossein mineral complex + Vitamin-D3 Or Tab. Multivitamins (Theragran ultra, Vitrum, Surbex-Z)
4. SSRIs in the case of severe PMS and PMDD.
Cap. Fluoxetine 20mg (Depex, Flux, Prozac) 1-0-0 (Once daily after breakfast), May consider gradually increasing the dose after several weeks by 20 mg/day. Maximum dose is 60-80mg.
18 MITTELSCHMERZ Rx
Physiological preovulatory pain in female individuals of reproductive age
Also referred to as ovulatory or mid cycle pain
Epidemiology: occurs in approx. 40% of female individuals of reproductive age
Mittelschmerz
C/C:
>> Recurrent unilateral lower abdominal pain (can mimic appendicitis)
Pain occurs during midcycle in individuals with regular menses.
Dull and achy pain which can become cramp-like
Can last up to 3 days
>> Physical examination: lower abdominal pain on palpation
Rx
1. Tab. Phloroglucinol and Trimethylphloroglucinol
(Anafortan Plus, Spasfon, Spasrid)
Consider NSAIDs if severe or not respond
2. Tab Mefenamic acid 500 mg (Mefnac DS, Ponstan Forte) 1-1-1 (TDS)
Or Tab. Naproxen sodium 500 mg (Flexin, Synflex)
1-0-1, Initially 500mg BD day 1-3, then 250mg x BD
19 MENORRHAGIA Rx
Rx
Treat underlying cause (see etiology of secondary dysmenorrhea)
1. Tab Mefenamic acid 500 mg (Mefnac DS, Ponstan Forte) x TDS
Or Tab. Naproxen sodium 500 mg (Flexin, Synflex) x Initially 500mg BD day 1-3, then 250mg x BD
2. Consider to stop acute bleeding: Cap. Tranexamic acid 500mg (Transamine) x BD/TDS
3. Other medications
COCP (Tab. Yaz, Tab. Diane-35, Tab. Progyluton) x once daily for 21 days then 7 days break x 3 months Norethisterone 5mg (Tab. Primolut-N, Tab. Noregyn) x TDS
Norethisterone Guidelines: 1 tablet x TDS (15 mg) for 10 days. After stop taking the tablets, patients will usually have bleeding like a period. To stop periods causing problems again, Doctor may tell to patient to take
Norethisterone Tablets for a few days after your next two periods. Advice to take 1 tablet twice a day (10 mg)
for 8 days. Patients will need to start taking these tablets 19 days after your last period began.
20 OLIGOMENORRHEA Rx
Definition: Influent menstrual periods
『 Causes: PCOS, Cushing syndrome, Prolactinoma, PID, Asherman syndrome, hyperthyroidism, CAH.
▲ Oligomenorrhea
C/C:
> Menstrual period at an interval of > 35 days.
> Usually light menstrual flow
>>> Irregular menstrual periods with unpredictable flow
>> Fever than 6 to 8 periods over year
Investigations: Coc, HBA1C, TSH, T3, T4, LH, FSH, Serum prolactin, testosterone level and USG pelvis
Rx
Treat underlying cause
First line drug if no underlying pathology
Tab. Dydrogesterone 10mg (Duphaston) 1-0-1(BD)
21 ENDOMETRIOSIS Rx
Clinical presentation typical symptoms involvement of GIT + Bladder symptoms
>> Cyclical pelvic
Chronic pelvic pain that is worse before and after periods (menses).
Deep pain during or after sexual intercourse (Deep dyspareunia)
>> Infertility
Menstruation Irregularities
Cyclic symptomatic
Period-related or cyclical gastrointestinal symptoms
Abdominal pain
>> GIT Upsets
Tenesmus
Diarrhea
Per rectal bleed
Period-related or cyclical urinary symptoms
Pain passing urine
Blood in urine (Haematuria)
Obstruction
Diagnostics workup:
Patient history
Physical examination:
Rectovaginal tenderness and Adnexal masses.
Best initial test: Transvaginal
ultrasound the uterus is generally not enlarged, Evidence of ovarian cysts (chocolate cysts), Nodules in bladder or rectovaginal septum.
>> Confirmatory test: Laparoscopy
→ may show endometriotic implants and adhesions.
Additional: CA125 to rule-out CA
Rx
First line Rx
Shut down hypo-pituitary ovarian axis 6-12 months → Combined oral contraceptive pills (COCP)
1. Tab. Ethinyl estradiol 0.03mg + Levonorgestrel 0.15mg + Ferrous Fumarate 75mg (Tab. Famila-28F, Tab. Novodol) OR Tab. Ethinyl Estradiol 0.02mg + Drospirenone 3mg (Tab. Yaz) Start from the 1st day of periods and continue it according to instructions over the pack.
Duration: 6 months
Rx
Second line Rx
Androgenic agonists
1. Cap. Danazol 200 mg (Danazol, Danocrine) 1-0-1 (BD)
Duration: 3-6 months according to response.
Rx
Third line Rx
Gonadotropin-releasing hormone (GnRH) agonist analogue
1. Inj. Leuprolide acetate 3.75 mg (Lutrate Depot) Intramuscular (IM) x used every month for 3 months OR Inj. Leuprolide acetate 22.5 mg (Lutrate Depot) Intramuscular (IM) x used once in three months.
Alternative for severe symptoms
Goserelin Acetate 3.6mg (Zoladex)
Injected subcutaneous (SC) into the anterior abdominal wall,
every 28th day.
Goserelin Acetate 10.8mg (Zoladex)
Injected subcutaneous (SC) into the anterior abdominal wall, once in a month.
PLUS estrogen-progestin OCPs
Duration: 6 months, Repeat course should not be given due to concern about loss of bone mineral density
NOT RESPONSE TO MEDICAL THERAPY GO FOR SURGICAL RX
First-line: Laparoscopic excision and ablation of endometrial implants.
Reproductive (fertile) female
To confirm the diagnosis and exclude malignancy
If there is a lack of response to medical therapy
Treat expanding endometriomas and complications (bowel/bladder obstruction, rupture of endometrioma, infertility)
Second-line: Open surgery with hysterectomy with or without bilateral salpingo-oophorectomy
Treatment-resistant symptoms
No desire to bear additional children (completed family)
22 UTERINE LEIOMYOMAS (UTERINE FIBROIDS)Rx
Most women have small, asymptomatic fibroids. 15-45 years, common 30-45 years Symptomatic <50%, Symptoms depend on the number, size, and location of leiomyomas.
> Abnormal menstruation: Hypermenorrhea, Heavy menstrual bleeding; Metrorrhagia (possibly associated anemia), Dysmenorrhea
Features of mass effect
Pelvic mass along with Dragging sensation due to Back or pelvic pain/discomfort
Urinary tract or bowel symptoms (Urinary frequency, Urinary retention, Constipation, hemorrhoids, Features
of hydronephrosis). Reproductive abnormalities: Infertility; (difficulty conceiving and increased risk of miscarriage), Dyspareunia, Post
coital bleed
>> On Examination: Pallor, varicose vein, pedal edema, Enlarged, firm and irregular uterus, ↑ fundal height, during bimanual pelvic examination
▲ Uterine Fibroids C/C:
Best initial test:
Ultrasound Concentric, hypoechoic, heterogeneous tumors Calcifications or cystic areas suggest necrosis
Additional baseline: CBC, RFTs, Urine D/R.
Saline-infused sonography:
Better visualize submucosal and intramural fibroids
Hysteroscopy: to assess submucosal fibroids
MRI: to evaluate the uterus and ovaries for potentially complicated surgical cases and visually differentiate between leiomyomas, adenomyomas, and adenomyosis
Rx
If asymptomatic Observation Fibroids can shrink substantially postpartum and after menopause.
If symptomatic
Correction of Anemia: Iron supplementation x IV/Per Orally
Tab. Iberet Folic x once daily
For dysmenorrhea: NSAIDS
Tab. Mefenamic acid 500mg (Mefnac DS, Ponstan Forte) x TDS
Or Tab. Naproxen sodium 500 mg (Flexin, Neoprox) x BD
Drug which Blood loss but do not have any effect on size of fibroid: OCPs, Progesterone IUCD /Mirena, Tranexamic acid
Cap. Transamine 500mg (Transamine) x BD/TDS
Or Ethinyl Estradiol 0.02mg + Drospirenone 3mg (Tab. Yaz)
Dose: Start from 1 day of periods and continue it according to instructions over the pack.
Drug which blood loss by decreasing the size of fibroid by which either decreases estrogen or progesterone production.
Estrogen: GnRH agonist to shrink fibroids before surgery
Inj. Leuprolide (Lucrin Depot, Lorelin Depot, Lectrum)
Dose: 3.75mg x monthly dose or 11.25mg x 3 monthly x IM
These drugs are not recommended for more than 6 months
Decrease Progesterone:
>> Progesterone antagonist: Mifepristone at dose 2.5mg to 10mg orally for 3-6 months.
SPERM: Tab. Ulipristal acetate: the efficacy of this same as GnRH agonist, Dose: 5 mg or 10 mg x orally daily dose
Surgical management
2) Preserves childbearing potential Surgical Myomectomy
Treatment options that will affect fertility
Interventional therapy → Uterine artery embolization: a
percutaneous, radiologic procedure in which an embolic agent is injected into the uterine artery in order to block the blood supply to the fibroids
Definitive treatment: Hysterectomy with/without bilateral salpingo- oophorectomy
23 FEMALE INFERTILITY Rx
ETIOLOGY
Ovary-related causes
Premature ovarian failure
Menstrual cycle abnormalities (Functional hypothalamic amenorrhea)
Hyperprolactinemia
Thyroid disorders
Systematic Conditions: Diabetes mellitus, hypertension, obesity, chronic hepatic or renal disease
Pituitary adenoma
Diminished Ovarian Reserve: A decline in functioning oocytes (either reduced number or impaired development), a normal consequence of age, but can also be caused by an underlying disorder (Endometriosis)
Hypogonadotropic hypogonadism
Cushing syndrome
Polycystic Ovary Syndrome (PCOS)
Tubal/Pelvic causes
Pelvic inflammatory disease (PID)
Endometriosis
Fallopian tube adhesions and/or obstruction
Following tubal or pelvic surgery
Following Infections: appendicitis, chronic chlamydia infection, acute salpingitis, inflammatory bowel disease.
Uterine causes
Anatomical anomalies (septate uterus, bicornuate uterus, Mayer-Rokitansky- Kuster-Hauser syndrome)
>>> Uterine leiomyoma
Endometrial polyps
>>> Asherman Syndrome: Mostly iatrogenic (scarring, fibrosis, and/or adhesions of the endometrium caused by curettage), Reduces the sensitivity of the endometrium to progestogens
Cervical causes
Cervical anomalies (e.g., insufficient cervical mucus production)
Trauma (following cryotherapy, conization)
Immune factors (antisperm antibodies in the cervical mucus)
DES exposure in utero
Psychiatric causes:
Vaginismus,
Sexual arousal disorder
DIAGNOSTICS
Medical history of both partners, especially gynecological history (Children, family history)
Assess ovulatory function
Menstrual history
Body temperature analysis to monitor menstrual cycle
Hormone tests (between the 3rd and 5th day of the menstrual cycle)
Mid-luteal serum progesterone levels: progesterone should increase shortly after ovulation leading to failure of progesterone levels to rise indicates anovulation
Ovulation prediction test (detect LH levels)
Androgen levels: elevated levels induce negative feedback to the hypothalamus inhibition GnRH
secretion decreased estrogen levels and suppression of ovulation
Ovarian reserve
Early follicular FSH levels: elevated in ovarian insufficiency and indicate reduced ovarian reserve
Early follicular estradiol levels
Anti-Müllerian hormone levels
TSH levels: elevated levels in hypothyroidism
Prolactin levels: hyperprolactinemia
Ovarian sonography: antral follicle count
Endometrial biopsy
Usually performed 1-3 days before menstruation to determine thickness of endometrium
A flat endometrial lining indicates a defect in the luteal phase of the menstrual cycle.
Radiological Imaging: assess the patency of fallopian tubes and uterus
Indications
If the initial workup does not reveal any abnormalities and no history suggestive of tubal obstruction Screen for tubal occlusion and structural uterine abnormalities (septate uterus, submucous fibroids, intrauterine adhesions)
>> Hysterosalpingography: an imaging technique involving the injection of contrast dye into the cervical canal and serial radiographs to evaluate the uterine cavity and Morphology/Patency of the fallopian tubes
Sonohysterosalpingography: an ultrasound technique in which fluid is inserted into the uterus via the cervix to examine the uterine lining
Hysteroscopy and/or laparoscopy: Indicated if there is evidence of intrauterine abnormalities or tubal occlusion. Can also be used therapeutically to remove small adhesions or mucous plugs obstructing the tubal lumen
* Examine cervix: Physical examination, Pap smear, Testing for antisperm antibodies in cervical mucus
▲ Female Infertility
C/C:
Female infertility may manifest with symptoms of anovulation (e.g., amenorrhea, irregular menses).
Reference
>> Amboss
>>> roswellobgyn.org/letrozole-guideline
ASSISTED REPRODUCTIVE TECHNOLOGY In vitro fertilization
>>> The most common form of assisted reproduction technology
>>> Involves hormonal follicular stimulation followed by a transvaginal follicular puncture for oocyte retrieval with ultrasound monitoring
>> The recovered oocytes are mixed with processed spermatozoa and incubated.
>> Two (in young women) to a maximum of five embryos (in women over 40 years of age) are transferred into the uterus.
Intracytoplasmic sperm injection: a type of assisted reproductive technology, in which a single spermatozoon is introduced into an oocyte under a microscope using an injection pipette
Intrauterine insemination (IUI): a procedure in which washed and concentrated sperm are introduced directly into the uterine cavity Oocyte donation
Surgery: removal of tubal, cervical, or uterine adhesions, myomas, and/or scar tissue
Rx
Lifestyle modifications: cessation of alcohol, smoking, nicotine, and recreational drug use as they contribute to subfertility.
Treatment of underlying causes
For Hypothyroidism: Tab. Levothyroxine 25mcg, 50mcg, 75mcg and 100mcg (Thyronorm)
For Hyperprolactinemia: Tab. Bromocriptine 2.5mg (Brotin, Parlodel)
For PCOS: Tab. Metformin 500mg or 850mg (Glucophage) x BD
Ovulation induction
1. Tab. Clomiphene citrate 50mg (Clomid, Ovafin, Ovi-F) from the 2nd to 6th day of Menstrual cycle, can be used up to 6-12 cycle. Dosage may be increased to 200mg per day depending upon the response. Monitoring is done by TVUSS. Ovulation rate 70%.
2. Aromatase Inhibitors: Tab. Letrozole 2.5mg (Femara, Lets, Letocor) x 2.5mg to 5mg x OD from the 2nd to 6th day of cycle. Ovulation should occur between days 14 to 19 (so please have intercourse beginning around day 12 and don't skip two days in a row through at least day 20). In the first cycle of Letrozole, you should have a blood progesterone level drawn 5-7 days after ovulation. If you get an excellent response from Letrozole (ovulation & excellent progesterone level) we'll continue Letrozole for 3-4 cycles.
3. Pulsatile GnRH analogue: Stimulation of FSH and LH release Follicle maturation.
4. Gonadotropins (Recombinant hCG, Recombinant LH): stimulate final oocyte maturation - Ovulation
5. Selective Estrogen Receptor Modulator (SERM): Tab. Tamoxifen 10mg, 20mg (Nolvadex, Zymoplex)
6. Gonadotropin-releasing hormone (GnRH) antagonists
24 POLYCYSTIC OVARY SYNDROME (PCOS) Rx
Pathophysiology of Polycystic Ovary Syndrome (PCOS)
The exact pathophysiology is unknown.
Strong association with obesity→↑ in peripheral estrogen synthesis from adipose tissue and in peripheral sensitivity to insulin
Reduced insulin sensitivity (peripheral insulin resistance) and the consequent hyperinsulinemia result in Epidermal hyperplasia and hyperpigmentation (acanthosis nigricans)
↑ Androgen production in ovarian theca interna cells → imbalance between androgen precursors and the resulting estrogen produced in granulosa cells
↑LH secretion disrupts the LH/FSH balance impaired follicle maturation with cyst formation due to lack of follicle rupture and anovulation/oligoovulation → infertility
↑ Androgen precursor release and↑ estrogen production in adipose tissue
Inhibition of SHBG in the liver→ ↑ Free androgens and estrogens
↑ Unopposed estrogen (lack of progesterone) during anovulatory cycles→ endometrial hyperplasia →↑ Risk of endometrial carcinoma
Diagnostic Approach
Send important laboratory tests: CBC, LFTS, FSH, LH, FBS, HbA1c Total and free testosterone level, Estrogen, fasting lipid profile, Free T3, Free T4 and TSH (TFTs).
USG Pelvic for any pathology (Ovarian ultrasonography)
Rotterdam criteria: According to the American Association of Clinical Endocrinologists, at least two of three of the criteria below are required for diagnosis of PCOS after excluding other causes of irregular bleeding and elevated androgen levels.
1. Hyperandrogenism (clinical or laboratory)
2. Oligoovulation and/or anovulation
3. Enlarged polycystic ovaries on transvaginal ultrasound → 12 Or more (sclerotic) cystic follicles with a diameter between 2 and 9 mm with "String of Pearls" appearance OR Relative increase of stromal tissue with increased ovarian size (at least 10 mL)
Blood hormone levels
↑ Testosterone (both total and free) or free androgen index
↑LH (LH:FSH ratio > 2:1)
Estrogen is normal or slightly elevated
Evaluate for metabolic disease
➤ Test for hypertension
Monitor Body mass Index (BMI).
➤ Assess for insulin resistance or type-2 diabetes mellitus with an oral glucose tolerance test, FBS, HbA1c Assess for Hyperlipidemia: Measure serum lipids and cholesterol
Clinical features
Onset of symptoms typically occurs during adolescence.
Menstrual irregularities: Primary or secondary amenorrhea, Oligomenorrhea, Menorrhagia Insulin resistance and associated conditions: Metabolic syndrome (especially obesity) →↑ risk of sleep
apnea, Non-alcoholic fatty liver disease
Skin conditions: Hirsutism: Androgenic alopecia, Acne vulgaris, Oily skin, Acanthosis nigricans
Psychiatric conditions: Depression, Anxiety disorders
Infertility or difficulties conceiving
Features associated with PCOS (e.g., obesity, Hyperandrogenism, difficulties conceiving) can have a negative psychosocial impact. If symptoms of anxiety and/or depression are identified, further mental health assessment and a referral to a mental health professional should be offered to the patient.
Treatment of PCOS
Recommendations for all PCOS patients
Encourage exercise and healthy eating (especially through caloric restriction), and consider behavioral strategies and modifications (setting goals, eating more slowly)
Weight loss: if a patient is overweight (BMI ≥ 25 kg/m²), target BMI <25 kg/m² can reduce estrone production by the adipose tissue.
Screen for comorbidities and provide specific treatment.
Tailor additional therapeutic interventions based on:
Reproductive goals
Comorbidities
Individual risk factors
Patients not planning to conceive: For patients who do not wish to conceive, the therapeutic goals are to control menstrual irregularities and hyperandrogenism, treat comorbidities, and improve quality of life.
1. Combined oral contraceptives (COCs)
Indication:First-Line Treatment for hyperandrogenism and/or menstrual cycle abnormalities
Additional benefits: Endometrial hyperplasia → reduced risk of endometrial carcinoma, decreases Menstrual bleeding, decreases Acne, Treatment of hirsutism
2. Tab. Metformin: improves menstrual irregularities, metabolic outcomes, and weight (especially when combined with lifestyle modifications)
Second-Line Treatment for menstrual irregularity in patients unable to take or tolerate COCS
May be added to COCs and lifestyle modification to improve metabolic outcomes
3. Antiandrogens: controversial role
Examples: Tab. Spironolactone (Aldactone), Tab. Finasteride (Genesis), Tab. Flutamide (Flutamide)
Indications: can be considered for treatment of hirsutism and androgen-related alopecia in patients unable to take or tolerate COCs
Additional recommendation: When using Anti Androgens as an alternative to COCs, it is advisable to use other forms of contraception.
4. Additional measures, like anti-obesity medications or bariatric surgery, may be considered on a case-by case basis.
Patients planning to conceive: The goals of treatment for patients who wish to conceive are management of comorbidities (e.g., weight loss for overweight or obese patients) and induction of ovulation
1. Tab. Letrozole: first-line therapy for ovulation induction Improves pregnancy and live birth rates in patients with anovulatory infertility with no other causes
Mechanism of action: aromatase inhibition reduces estrogen production, stimulating FSH secretion and inducing ovulation
2. Tab. Clomiphene citrate: alternative to letrozole
May be preferred over metformin monotherapy in obese women with anovulatory infertility
Mechanism of action: inhibits hypothalamic estrogen receptors disruption of the negative feedback mechanism governing estrogen production→↑ pulsatile secretion of GnRH → FSH and LH → stimulation of ovulation
3. Exogenous gonadotropins (see below drug brand portion): The low-dose regimen is the second-line treatment for ovulation induction.
Agents: exogenous FSH and human menopausal gonadotropin
*Indication: typically used if first-line therapies are unsuccessful; occasionally used as first-line if the drug and monitoring requirements are accessible
4. Tab. Metformin
Can be used as second-line monotherapy for fertility treatment.
Combination with clomiphene may increase pregnancy rates, especially in obese women. First-line therapy for insulin resistance
5. Additional fertility interventions
Laparoscopic ovarian drilling: A laparoscopic procedure in which ovarian tissue is reduced with a laser beam or surgical needle to decrease its volume and androgen production. This hormonal shift can induce FSH secretion and improve ovarian function in patients with polycystic ovary syndrome. Second-line treatment for ovulation induction; can be performed as a first-line treatment if other indications for laparoscopy exist
In vitro fertilization: can be offered as third-line therapy
Bariatric surgery: no evidence of benefit in the treatment of infertility
6. Management of other PCOS manifestations
Hirsutism: Non-pharmacological therapy is first line (electrolysis, light-based hair removal via laser or photoepilation)
Acne: Consider topical therapies (Benzoyl peroxide, topical antibiotics)
Rx
Patients not planning to conceive
1. Life-style modifications: regular exercise, weight loss, healthy diet and control risk factors.
2. Combined oral contraceptives (COCs)
Tab. Ethinyl Estradiol 0.02mg + Drospirenone 3 mg (Tab. Yaz)
Or Tab. Ethinyl estradiol 0.03mg + Levonorgestrel 0.15mg + Ferrous Fumarate 75 mg (Tab. Famila- 28F, Tab. Novodol)
Or Tab. Cyproterone Acetate 2mg + Ethinylestradiol 35 mcg (Tab. Diane-35, Tab. Divestra)
Start from 1 day of periods and continue it according instruction over the pack x once daily
21 days according to cycle then leave for 7 days
Duration: 3-6 months
Or Second-line treatment for menstrual irregularity in patients unable to take or tolerate COCs
Tab. Metformin 500mg or 850mg (Glucophage, Neophage) x Twice daily
3. For Acne: Benzoyl peroxide + clindamycin topical gel (Duac gel, Benzaclin Gel) x twice daily
4. For Facial hairs/Hirsutism: Non-pharmacological therapy is first line (electrolysis, light-based hair removal via laser or photoepilation) +/- Eflornithine Cream (Depilus, Eflogen) x apply once/twice daily on facial hair
Rx
Patients planning to conceive
1. Life-style modifications: regular exercise, weight loss, healthy diet and control risk factors 2. Tab. Letrozole 2.5mg (Femara, Lets, Letocor) → first-line therapy for ovulation induction
Dosage: 2.5mg to 5mg x OD from the 2nd to 6th day of cycle. Ovulation should occur between days 14 to 19 (so please have intercourse beginning around day 12 and don't skip two days in a row through at least day 20). In the first cycle of Letrozole, you should have a blood progesterone level drawn 5-7 days after ovulation. If you get an excellent response from Letrozole (ovulation & excellent progesterone level) we'll continue Letrozole for 3-4 cycles.
Alternative to letrozole
Tab. Clomiphene Citrate 50mg (Clomid, Ovafin, Ovi-F)
Start according to the menstrual cycle in between day 3rd to day 7th of menstrual cycle x once daily 3. Tab. Metformin 500mg or 850mg (Glucophage, Neophage) 1-0-1 (Twice daily)
Combination of Tab. Clomiphene 50mg and Tab. Metformin 500mg might increase pregnancy rates 4. Dietary Supplement: Myo-Inositol + Folic Acid (Slix, Myofolic, Inofolic, Inofer plus)
Use once or twice daily, Dissolve contents in a glass of water (200 mL)
25 BENIGN OVARIAN CYST Rx
Benign Ovarian Cyst
C/C:
>> Pressure symptoms in lower abdomen
>> Bloating
>> Swelling
>>> Pain Sharp or Dull
>> Cyst can be one side or both
>> Small size cyst might be Asymptomatic
>> Symptoms depend on size of cyst
>> Sometime symptomatic with menstrual cycle
Treatment is depend on size that is measured in pelvis USG
Benign ovarian cyst finding: Mobile, cystic, unilateral, smooth
On Transvaginal Ultrasound: size <8cm, Septation Uni ocular
Investigation
>>> Ultrasound (Abdomino-Pelvic Or Transvaginal)
>>> Urine Pregnancy test (UPT): to exclude pregnancy
>> Laparoscopy:
>> CA125: To check or evaluate ovarian
cancer/malignant tumor
>> Tumor marker: AFB, HCG, LDH, inhibin and Oestradiol (<40years female)
First line Rx
Rx
Maintain healthy lifestyle
Regular Exercise for 20-30 min
use healthy food, green vegetables, salad, fruits
increase fresh juice intake, increase water intake
Less use of fatty foods
Avoid/no use broiler chicken, cold drinks, junk food
1. Tab. Multivitamins (Theragran ultra, Surbex-z, Revital Multi)
0-0-1
2. Tab. Ciprofloxacin 500mg (Ciplet, Novidat, Ciproxen)
1-0-1
Or Cap. Cefixime 400mg (Cefim, Cefiget, Cefspan) Or Tab. Azithromycin 500mg (Zetro, Azomax, Macrobac)
0-0-1
3. If abdominal Pain/spasm
(Anafortan Plus, Spasrid, Spasfon)
>> Tab. Phloroglucinol + Trimethylphloroglucinol
Rx
2nd line Rx
1. Tab. Ethinyl estradiol 0.03mg + Levonorgestrel 0.15mg + Ferrous Fumarate 75 mg (Tab. Famila-28F, Tab. Novodol)
Or
Tab. Ethinyl Estradiol 0.02mg + Drospirenone 3 mg (Tab. Yaz)
Start from 1st day of periods and continue it according
instruction over the pack. Duration: 2-3 months
26 POSTPARTUM HEMORRHAGE(PPH)Rx
Postpartum hemorrhage is defined as: Estimated blood loss (EBL) >500 mL for a vaginal delivery or >1,000 ml for a cesarean delivery; or 10% drop in hematocrit between admission and the postpartum period.
Primary PPH (Early): Most common, blood loss after birth of the baby up to 24 hours of delivery.
Causes (4T's):T one (Uterine atony),T issue (retained products of conception), Trauma to genital tract (Laceration, hematoma, inversion, Rupture) and Thrombin (DIC, coagulopathies)
Secondary PPH (Late): Blood loss from 24 hours to 6 weeks after delivery
Causes: usually due to infection (endometritis), retained product of conception, abnormal placentation.
Postpartum hemorrhage
C/C:
>> Rapid, heavy vaginal bleeding
>>> Possible signs of hypovolemia/blood loss: decreased BP, increased heart rate, dizziness
Diagnosis
>>> Laboratory measure:
Hematocrit, Hb to estimate
blood loss
>> Physical examination findings: e.g., lacerations, hematoma, any other visible cause of bleeding, boggy uterus
>> Speculum examination: to diagnose the following
* Uterine inversion
* Retained placental tissue or membranes
>>> Ultrasound (Abdomen/Pelvic):
Used to determine the correlation between the placenta and the cervical os
Helpful to diagnose the following:
Uterine atony:
showing, e.g., an echogenic endometrial stripe.
Abnormal placental attachment: showing, e.g., thinning of uterine myometrial wall
>>>> Color Doppler ultrasound: to
confirm abnormal placental attachment (showing, e.g., turbulent blood flow)
Complications of PPH
Anemia
Hypovolemic shock
✓ Thromboembolism
Sheehan syndrome
Infection
Maternal death
Fetal death (velamentous cord insertion)
Abdominal compartment syndrome
Reference:
>> ACOG
> RCOG
>>> PPH Amboss
>> PPH Queensland clinical guidelines.
WHO guidelines for the management of postpartum hemorrhage and retained placenta
Rx
Maintain ABCDE
Establish large bore intravenous (IV) cannula
Check SPO2 and Administer Supplemental O2 as appropriate.
Send labs: CBC, Urea, creatine and Electrolytes, PT, INR.
Order cross-matched blood. Blood transfusion should be considered after 1-2L EBL. Coagulation factors (FFP and cryoprecipitate) & platelets should be replaced with massive blood loss. One unit of FFP is given for every 4-6 units of packed RBC to reduce dilutional and citrate coagulopathy. Consider platelet transfusion as the platelet count drops below 50,000/μL.
After these initial steps, examine the patient to determine the underlying cause and address the problem expeditiously.
Initiate IV fluid resuscitation.
* Warm IV fluids during resuscitation
Main aim is to promote tissue perfusion and oxygen carrying capacity, Avoid dilutional coagulopathy-preferentially give red blood cells (RBC) Until RBC arrive:
Up to 2L of crystalloids
Up to 1.5L colloid
Fluid monitoring: Aim for urinary output of 30 mL/hour or more
Give Inj. tranexamic acid 500mg/5ml (Transamin) 1g, Undiluted x IV stat over 10 minutes, If bleeding persists after 30 minutes or stops and restarts within 24 hours of the first dose, a second dose may be administered. Should be administered as soon as possible after bleeding onset to stop fibrinolysis and reduce the likelihood of mortality
Inj. Oxytocin 5IU/1ml (Syntocinon) x 5-10 IU IV over 1-2min or IM and at the same time 20-40 international units in 500ml to 1 L of 0.9% NS or R/L administered at the rate of 160 drops per minute.
Inj. Methyl-Ergometrine 0.2mg/1ml (Methergine) x IM every 2 to 4 hours or IV diluted in up to 5 ml of 0.9% N/S over 1-2 min.
Tab. Misoprostol 200 mcg (Cytotec), Use when Syntocinon and Methergine are not successful, due to slow onset of action or useful when injectable uterotonic agents are unavailable or contraindicated Tab Cytotec 600-1000 mcg x Per Rectal, Per Oral or Sublingual Repeat dose not recommended.
Antibiotics for 2º infection: Inj Ceftriaxone 2g (Titan) x IV x OD Controlled umbilical cord traction (Brandt-Andrews maneuver)
One hand is placed on the abdomen, securing the uterine fundus
and preventing uterine inversion.
The other hand applies steady downward traction on the umbilical cord.
External compression of the uterus and bimanual uterine massage: a manual technique to promote uterine contractions and to tamponade
the vascular sinuses in the uterus
A clenched fist is inserted into the anterior vaginal fornix and exerts pressure on the anterior wall of the uterus.
The other hand is positioned externally and presses against the inner fist, located in the uterine body.
Fritsch maneuver
1. One hand grasps the labia majora and presses it firmly into the vulva.
2. Simultaneously, the second hand is positioned at the posterior side of the uterus (as in Credé maneuver) and is pushed distally against the other hand.
3. The placenta is manually removed.
4. Fundal massage
» Credé maneuver
1. The cranial part of the uterus is held with four fingers positioned at the posterior side of the uterus and the thumb at the anterior surface.
2. The pressure compresses the uterine vessels and aids in the expulsion of the placenta.
3. Avoidance of unnecessary episiotomy and instrumented delivery Avoidance of unnecessary episiotomy and instrumented delivery
Surgical procedures for uterine atony
1. Uterine balloon tamponade or packing: if severe bleeding persists, regardless of adequate general measures
2. Compression sutures (e.g., B-Lynch suture)
3. Surgical ligation of uterine or internal iliac arteries
4. Last resort: Hysterectomy
Retained product of conception
Manual removal of placenta
>> Consider administering nitroglycerin.
» Perform under adequate regional or general anesthesia.
Administer prophylactic antibiotics.
Technique
1. Keep fingers tightly together and use the edge of the hand to make a space between the placenta and the uterine wall to detach the placenta completely.
2. After the placenta is detached, withdraw the hand from the uterus, bringing the placenta with it.
3. With the other hand, perform countertraction to the fundus by pushing it in the opposite direction of the hand that is removing the placenta.
Surgical management
Indicated in cases where manual extraction fails
*Preferred method: suction curettage (associated with a risk of uterine perforation)
Uterine balloon tamponade or packing: if severe bleeding persists
27 NAUSEA AND VOMITING OF PREGNANCY Rx
▲ Nausea and vomiting of pregnancy
C/C:
>>> Clinical diagnosis
>> Nausea and/or vomiting
>> Normal vital signs, lab findings, and normal physical examination
Reference RCOG guideline
AMBOSS
NICE
Rx
Rehydration (oral hydration is usually sufficient)
Adapt diet and avoid triggers.
Advice Ginger tea, if patient unable to take anti-emetics
Replace iron-containing supplements with folate-containing prenatal vitamins. (Cap. Iberet folic, Cap. Fefol Vit or Tab. Maltofer Fol)
Antiemetic therapy for nausea and vomiting of pregnancy: If the response to an antiemetic from one class is inadequate, add an antiemetic from another class in a stepwise manner, as shown below.
1. Tab. Doxylamine 10mg + Vitamin-B6 10mg (Envepe, Femiroz) x TDS/BD Or Tab. Meclizine 25 mg + Vitamin-B6 50mg (Navidoxine) x BD
2. For refractory symptoms despite combination therapy above, add one of the following:
>> Tab. Dimenhydrinate 50mg (Gravinate) x TDS
Or Tab. Metoclopramide 10mg (Maxolon, Metoclon) x TDS
Or Tab. Ondansetron 8mg (Onset, Onseron) x 4-8mg x TDS
Or Tab. Prochlorperazine 5mg (Stemetil) x TDS
Or Tab. Promethazine 25mg (Avomine) x TDS
Consider also: Change oral Dimenhydrinate (Gravinte) to IV.
3. Last resort: Add methylprednisolone (see Hyperemesis Gravidarum)
28 HYPEREMESIS GRAVIDARUM (HG)Rx
▲ Hyperemesis Gravidarum
C/C:
>>> Clinical diagnosis
>>> Characterized by severe, protracted nausea & vomiting associated with Weight loss more than 5% from before pregnancy weight, dehydration and electrolyte imbalances.
Laboratory analysis
>> Electrolyte disturbances (hypokalemia & hypochloremic metabolic alkalosis)
>>> Signs of dehydration (↑hematocrit)
>>> Ketonuria (urine ketone 2++)
>>> Urea increase
Reference
RCOG guideline
AMBOSS
NICE
Rx
Admit the patient (Inpatient admission) → Consult OB/GYN
IV fluid resuscitation/replacement: Start IV fluids containing Dextrose 5%, Ringer lactate or Normal saline to replete volume and reverse ketonuria.
IV Electrolyte repletion: if K+ add 25ml KCL in 1L NS or calculate deficit
IV Thiamine repletion (Inj. Neurobion), considered in patients with severe recurrent vomiting, better add in Ringer Lactate.
IV Antiemetic Therapy
Inj. Dimenhydrinate 50mg (Gravinate) x IV x TDS
Or Inj. Metoclopramide 10mg (Metoclon) x IV x TDS
If fail: Inj. Ondansetron 8mg x IV over 10-15 min. x BD/TDS
>> If fail: Inj. Hydrocortisone 100mg x IV x BD Or Inj. methylprednisolone 16 mg x IV x TDS for 3 days/once improvement occurs, then convert it to Tab. Prednisolone 5mg (Deltacortril) x 40-50 mg daily PO, with the dose gradually tapered down until the lowest maintenance dose that controls the symptoms is reached.
Consider enteral tube feeding (nasogastric/nasoduodenal) or TPN.
Closely monitor vitals and urine output.
Monitor urine ketones, Urea, creatinine & electrolytes, and BMI.
Check other comorbidities that causes severe nausea/vomiting
29 CHRONIC HYPERTENSION IN PREGNANCY Rx
C/C:
Chronic hypertension in pregnancy is defined as a systolic BP of 2140 mmHg or a diastolic BP of 290 mmHg that existed prior to pregnancy, is diagnosed before the 20th week of gestation, or persists longer than 12 weeks after delivery With or without end-organ dysfunction
Severe chronic hypertension is systolic BP >160 mmHg or diastolic BP >110 mmHg. Women with chronic hypertension are at increased risk for placental abruption, preeclampsia, low birth weight, cesarean delivery, premature birth, and fetal demise.
Presentation:
>> Asymptomatic hypertension
>>> Nonspecific symptoms (e.g., morning headaches, fatigue, & dizziness) can occur.
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are not recommended in pregnancy due to severe fetal malformations and neonatal renal failure, pulmonary hypoplasia, and fetal death
For acute management of hypertensive emergencies, Inj. hydralazine 5 mg IV stat, Inj. labetalol 10-20 mg IV stat, or nifedipine 10 to 30 mg PO
Source data from: NICE Guidelines, RCOG The FIGO Textbook of Pregnancy Hypertension (2016) p142 and The John Hopkins Manual of gynae & Obst 4th edition.
Rx
Sodium restriction of ≤2.4 g/day. Dietary modifications with increased fruits and vegetables and decreased total and saturated fats can be encouraged.
Smoking and alcohol cessation.
Mild activity restrictions, due to concern for decreased uteroplacental blood low increasing risk of preeclampsia.
Dieting and weight loss are not advised in pregnancy, even for obese women.
Safe hypertensive in pregnancy are labetalol, methyldopa, nifedipine, and hydralazine.
Tab. Methyldopa 250mg (Aldomet)
Starting dose: 250mg x PO three or four times daily.
Maximum dose: 2000mg/day.
Side effects: Hepatic damage should be monitored LFTs at least once per trimester.
Or
Tab. Labetalol 100mg (Zafa Pharma)
Starting dose: 100 mg PO twice a day, and the usual maintenance dose is 200 to 400 mg PO twice a day.
Maximum dose: 2,400 mg/day and Can be used as monotherapy or combined with hydralazine or a diuretic.
Contraindicated in patients with greater than first-degree heart block. Chronic beta-blocker use in pregnancy has a mild association with IUGR.
Long-acting nifedipine may be added if BP is not controlled with methyldopa or labetalol. (Adalat retard 20 mg, Adalat LA 30mg, & 60mg)
Tab. Nifedipine 30 mg
The initial dose of nifedipine is 30 mg PO once daily or 10- 20mg BD/TDS. The dose can be increased to 60 mg daily if adequate response is not seen in 7 days.
Maximum daily dose is 120 mg to 180mg
Thiazide diuretics-inhibit renal sodium and chloride reabsorption. A large meta-analysis found no adverse outcomes in pregnancy, however decreased plasma volume from diuresis carries a theoretic risk of placental insufficiency, which deters its use as a 1st line agent The initial dose of Hydrochlorothiazide (HCTZ) is 12.5 to 25 mg daily, titrated every 2 to 3 weeks to a maximum daily dose of 50 mg daily. Diuretics are not recommended in the setting of preeclampsia, uteroplacental insufficiency, or IUGR. Serum uric acid increases with thiazide diuretics, limiting diagnostic options for preeclampsia
30 MIGRAINE IN PREGNANCY Rx
C/C:
One sided Throbbing head pain (Pulsating)
Sensitivity to light (Photophobia)
Sensitivity to sound (Phonophobia)
Nausea & vomiting
visual or neurologic auras
Duration: 4-72 hrs
Rx
1. Tab. Paracetamol 665mg (Panadol Extend) x TDS 1-1-1(TDS)
2. Tab. Metoclopramide 10mg (Maxolon, Metoclon) x TDS 1-1-1(TDS)
31 GASTROESOPHAGEAL REFLUX DISEASE (GERD) IN PREGNANCY Rx
GERD
C/C:
>>> Gastroesophageal reflux disease is extremely common in pregnancy
>> Characterized by epigastric pain or burning radiating into the chest and neck, pain with recumbency, and pain exacerbated by acidic foods.
>> Symptoms increase in the second trimester and peak in the third trimester due to loosening of the lower esophageal sphincter and delayed gastric emptying from pregnancy-related hormones.
Endoscopy is considered if therapeutic measures are unsuccessful and symptoms are very severe.
Rx
Always reinforce lifestyle modifications
Elevating the head of the bed at night
Not eating 3 hours before bedtime
Eating light meals, Eliminating trigger foods.
Dietary modification is recommended, including reduced consumption of fatty foods, chocolate, and caffeine.
Cigarette smoking and alcohol consumption can exacerbate GERD and are discouraged in all patients.
1. Tab. Famotidine 20mg, 40mg (Famot, Acicon, Famobex) 1-0-1(BD)
Or Cap. Esomeprazole 20mg, 40mg (Nexum, Esso, Esante) Or Tab. Pantoprazole 20mg, 40mg (Zopent, Neege, Protium) 1-0-1,0-0-1 (PPIs = 20mg x BD, 40mg x OD)
2.
(Mylanta-2, Manacid, Mucain, Maalox)
Syp. Aluminum + Magnesium hydroxide 2 teaspoonful x BD
Other agent: Syp/Tab. Sucralfate 1g x TDS, Tab. Metoclopramide
32 PEPTIC ULCER DISEASE IN PREGNANCY Rx
PUD
C/C:
Peptic ulcer disease (PUD) is not common in pregnancy, and the hormonal changes of pregnancy usually decrease PUD severity and symptoms.
>> Treatment during pregnancy is similar to treatment for GERD and consists of diet modification
>>> Avoiding nonsteroidal anti- inflammatory drugs (NSAIDs), and starting H2 blockers or proton pump inhibitors. Avoid indomethacin for tocolysis of patients with PUD
Rx
1. Tab. Famotidine 20mg, 40mg (Famot, Acicon, Famobex) 1-0-1 (BD) Or Cap. Esomeprazole 20mg, 40mg (Nexum, Esso, Esante) Or Tab. Pantoprazole 20mg, 40mg (Zopent, Neege, Protium) 1-0-1,0-0-1 (PPIs = 20mg x BD, 40mg x OD)
(Mylanta-2, Manacid, Mucain, Maalox)
2. Syp. Aluminum + Magnesium hydroxide 2 teaspoonful x BD
Other agent: Syp/Tab. Sucralfate 1g x TDS, Tab. Metoclopramide
33 HELICOBACTER PYLORI IN PREGNANCY Rx
C/C
Burning pain in your abdomen
Nausea & vomiting
Loss of appetite
Weight loss
Bloating
Frequent Belching
Feeling hunger in Normal diet
Heartburn & indigestion Depression & Anxiety
(14 Or 21 DAYS TREATMENT)
1. H.Pylori stool Ag
2. Urea Breath Test
3. Upper Endoscopy: UGD
Rx
1. Cap. Amoxicillin 1g (Amoxil, Zeemox, Ospamox) 1-0-1(BD)
2. Tab. Clarithromycin 500mg (Claritek, Klaricid, Ultima) 1-0-1(BD)
3. Cap. Esomeprazole 20mg (Nexum, Esso, Esante) Or Tab. Pantoprazole 20mg (Zopent, Neege, Protium) 1-0-I(BD)
34 CONSTIPATION IN PREGNANCY Rx
C/C:
>>> Abdominal pain or discomfort
>> Difficult and infrequent bowel movements
>> The passage of hard stools.
Constipation in pregnancy is common complaint due to
1. High hormone levels especially of progesterone which slow down the intestinal rhythm.
2. Increased pressure of growing fetus on intestinal loops.
3. Less water due to less fluid intake and emesis.
4. Side-effects of iron supplementation
Rx
Drink a Lot of Fluids: Drink 10 to 12 cups of fluids each day.
Exercise routinely: Schedule exercise three times a week for 20- 30 minutes each.
Eat a High Fiber Diet: Choose high-fiber foods, such as fruits, vegetables, beans and whole grains.
Reduce or eliminate iron supplements
(Category B)
1. Psyllium fiber supplement powder (Fibracol, Metamucil, Fibo) 2-3 times a day along with water
If not respond or moderate to severe constipation than add on
>> Syp. Lactulose (Duphalac, Lilac) x 30ml HS
Other drugs for constipation safe during pregnancy
Polyethylene glycol (MiraLAX)
>> Cap./soft gel Docusate sodium (Colace)
Tab. Sennoside (Clearlax) 15mg
>> Methylcellulose (Citrucel)
35 HEMORRHOIDS IN PREGNANCY CONSERVATIVE Rx
C/C:
>> It is common in pregnancy and is due to the effect of progesterone vasodilation and pressure on the superior rectal vein by the gravid uterus.
>> Many small sized hemorrhoids are asymptomatic
>>> Painless bleeding (bright red) that can be mild or severe.
>> Mucous discharge, prolapse of piles and occasionally pain due to proctitis
>> Chronic cases develop anemia due to continuous blood loss.
Rx
1. Topical Lidocaine 2% jelly (Xyloaid, Lignocaine)
1-0-1 (apply twice daily with the help of using finger or applicator)
2. Topical Posterisan forte ointment Or Hadensa forte Ointment
1-0-1 (apply twice daily with the help of using finger or applicator)
3. If Constipation is a problem:
Give stool softeners and increase roughage in diet
>> Psyllium fiber supplement powder (Fibracol, Metamucil, Fibo)
2-3 times a day along with water