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Disorder and details Infertility ● Affects 1 in 4 couples ● Increase correlated with increase in age (the older you are the more comorbidities and harder to get preggo) ● Approx. 85-90% of couples are treated with some form of medication or surgery ● If cause if known, goal of tx is to address that cause o Ex: Hypothyroidism-treat with levothyroxine o Ex: STI or other Infectionstreat with abx or antifungal o Ex: Pelvic inflammatory disease Treatment w/RX: ● Controlled ovarian stimulation Female Infertility: (more cases are female) ● Anovulatory ● Anovulatory + insulin Resistant ● Unresponsive to Clomid Male Infertility ● Spermatogenesis

Type of Infertility: Anovulatory (including intermittent) ▪ DOC:*Clomiphene citrate (Clomid) Anovulatory and InsulinResistant (PCOS) ▪ Treat with Clomid and metformin ▪ PCOS has high rates of infertility

Unresponsive to Clomid

Drug and dose Clomiphene (Clomid) ● Anovulatory (including intermittent) ● Promote follicular maturation & ovulation ● *PO – start day 5 of menses with 50mg q5days o Can increase dose with next cycle if ovulation doesn’t occur o Variable ● Can lead to hyperstimulation and increased chance of multifetal pregnancy (it can cause a release of more than one egg) ● **FIRST LINE – inexpensive and less sideeffect profile**

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Spermatogenesis (needed due to low sperm count)

Human menopausal gonadotropic (HMG) FSH rFSH (for follicle stimulation)

FSH, HMG, and Clomid

Unique characteristics MOA: binds to estrogen receptors in the pituitary gland, blocking them from detecting estrogen (Stimulates ovulation) ▪ Keeping estrogen at lower level it tells body to release egg In men – treats hypogonadotropic hypogonadism SE: vasomotor flushes, abd discomfort, N/V, breast tenderness, ovarian enlargement (BIG DEAL it will cause lots of abdominal pain) NI: will need lots of education for infertility patients, explain how to give injection and how to monitor levels** ▪ ▪

If someone cant ovulate this is the DOC Can least to hyper stimulation that’s why people can have multiples

MOA: ▪ ▪

HCG: to induce or promote ovulation Gonadotropin-releasing hormone (GnRH) o Daily ultrasounds with monitoring ovaries and estradiol in blood Require more follow up with provider: ▪ Progesterone(quiets the luteal phase) ▪ Bromocriptine (decreases prolactin) MOA: Blocks estrogen which increases testosterone which helps with spermatogenesis

Disorder and details Antepartum (during pregnancy) ● Pregnant women get sick! ● Less than 10% of medications have been adequately studied for risks ● Some medications have greater risk to fetus based on timing, some are dose dependent (categories A,B,C,D,X) o Ex: Isotretinoin o Category X (teratogenic) ● Important to know how to treat common discomforts of pregnancy* o Pain: Acetaminophen o GERD: Calcium carbonate (Tums) o Constipation: Docusate sodium (Colace) o Allergies: Antihistamines

Classification Tocolytics ● Decrease uterine contractility ● Promote uterine relaxation ● AKA delaying delivery ● Suppress/delay preterm labor (not prevent) ● Really only suppress labor briefly (48 hours) ● Help buy time to treat infections if present ● Work better if combined with glucocorticoid

Pre-term Labor: ● Before 37 weeks ● Leading cause of newborn morbidity and mortality ● Antibiotics help slow down pre-term labor* o Penicillin G (IV q4hrs until delivery) o gentamicin, ampicillin, clindamycin ● Goal is to stop uterine contractions*

Glucocorticoid

Drug and dose Terbutaline (Brethine) ● Beta2-adrenergic agonist ● Subq 0.25 mg every 20 min for up to 3 hrs (q1-6hrs) ● MAX 1mg/4hr subq x 48-72 hrs

Nifedipine (Procardia) ● Calcium channel blocker ● PO 10 mg q20min ● MAX 4 doses Indomethacin (Indocin) ● COX inhibitor ● 2nd line agent (use for extremely early labor) ● PO 50-100mg loading dose ● 25mg PO q4-6hr ● Short term use!!! Magnesium Sulfate ● IV 6g loading dose ● Then 2g/hr ● High dose is dangerous! Cause respiratory distress

Betamethasone ● IM ● 12mg q24hrs x2 doses ● 23-34 weeks estimated gestational age

Unique characteristics MOA: stimulates beta-2 androgenic blockers, relaxing smooth muscle of the uterus NI: monitor maternal and fetal HR (this med makes it feel like their heart is beating out of their chest, Tachycardia) ● Hold RX if mom HR >120 SE: Mom-Pulmonary edema, hypotension, and hyperglycemia; Babytachycardia MOA: blocks Ca flow into smooth muscle NI: Monitor s/s of hypoTN (don’t want them to bottom out) SE: Mom-tachycardia, facial flushing, hypotension, hepatotoxicity; Baby- hypotension Mom doesn’t have to have HTN; this is used to decreases spasm MOA: blocks prostaglandin (these help with contraction) synthesis Caution against long-term use due to fetal closing of DA (leads to pulmonary HTN in the fetus) SE: Mom-nausea, GI upset, prolonged postpartum bleeding (rare); Baby- in utero closer of ductus arteriosus *higher risk for neonatal complications!! MOA: probably competes with Ca to decrease contractions Not most effective method of tocolysis NI: monitor s/s of toxicity* ***on WHO’s list of most dangerous meds*** Not evidence based! The above medications are more effective -----------protect fetal development-------------IV: Neuroprotective, in low doses it protects against cerebral palsy Stabling cerebral blood flow in the fetus Will see this given more for this than for contractions --------------------------others------------------------DOC: to treat and prevent seizures associated with pre-eclampsia by decreased Ca activity Prevent preterm labor – neuroprotective for preterm infant MOA: -----------protect fetal development-------------Use: Promotes fetal surfactant development ● Lungs are the last thing to develop in babies ● Need surfactant to help with lung development

Disorder and details Intrapartum (during labor) ● GOAL: soften the cervix to prepare it for dilation and delivery ● Sometimes not ready on it’s own so we need to help it along ● Prostaglandin synthesis (helps soften the cervix and prepare for dilation)

Classification Prostaglandins: ● Act on cervix to promote ripening ● Act on uterus to promote contractions ● Can be used for medical abortion and also to prepare cervix for delivery

Antiemetic: ● Ondansetron (IV, Zofran), ● Metoclopramide (IV, Reglan) ● sodium citrate/citric acid (PO, Bicitra)=give sometimes before Csection so they don’t aspirate during

Drug and dose Dinoprostone (Cervidil) ● E2-vaginal suppository ● 10mg q12hrs until onset of labor ● Most commonly used agent (less expensive) ● Stored frozen Endocervical gel (prepidil) ● 1 mg in posterior fornix ● Can repeat 1x/6hrs (most women require at least 2 doses) ● “Gel form of Cervidil” ● Must be refrigerated Misoprostol (Cytotec) ● Oxytocic/Uterotonic Drug ● PO or vaginal ● 25-50 mcgs vaginally q3-4hrs ● 50 mcgs PO q4hrs **not recommended for those with prior uterine surgery**

Unique characteristics MOA: activates enzyme that breaks down collagen network similar to compound produced by fetal membranes and placenta Use: shortens the duration of labor, allows reduction in oxytocin usage, and decreases need for cesarean delivery NI: Patient needs the be monitored after placement; lay supine for 1 hour, monitor uterine activity and fetal HR prior to RX, during, and 2 hours after SE: tachysystole

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Peptide hormone: ● Induction/augmentation of labor ● If contractions are inadequate with prostaglandins alone, then oxytocin is given to strengthen contractions

Also used to control bleeding postpartum by causing uterine contractions to clamp down on blood vessels (given rectally) Oxytocin (Pitocin) ● Oxytocic/Uterotonic Drug ● Nurse titrated ● IV or IM ● Begin 30 min after Cervidil suppository has been removed ● DOC: induction of near term labor **one of WHO’s most dangerous medications** Only use once cervix has ripened and if fetal lungs have developed (do NOT give if these have not happened) Also used 1st line to control bleeding postpartum by causing uterine contractions to clamp down on blood vessels

Use: off label to promote cervical ripening Pros: More effective, more convenient, less expensive, stored at room temp Cons: higher incidence of uterine tachysystole, that’s why its contraindicated in women with a history of major uterine surgery or cesarean delivery (do not want to rupture old incision) NI: fetal HR and uterine activity should be monitored continuously

MOA: stimulates contractions by activating G-protein-coupled receptors that trigger increases in intracellular Ca levels in uterine myofibrils Use: Establish regular and adequate labor pattern ● Cause really strong uterine contractions ● Increase frequency and duration of contractions AE: can cause tachysystole (contracting WAY too much and baby needs oxygen) or uterine rupture if not carefully monitored and managed ● Bad for baby because can’t get adequate O2 if constantly being squeezed NI: monitor moms BP & HR and uterine activity, monitor fetal HR and rhythm ● Always monitor mom and baby ● Stop RX: contractions >90 seconds OR contractions < 2 min apart, significant maternal or fetal distress

Disorder and details Postpartum ● GOAL: prevent PP bleeding & pain ● Postpartum hemorrhage 2nd leading cause of maternal mortality (preeclampsia is the 1st) ● #1 complication of hemorrhage=hysterectomy * ● RX used: o Oxytocin (1st line) o Misoprostol o Carboprost tromethamine o Methylergonovine

Classification Oxytocic/Uterotonic

Drug and dose Carboprost Tromethamine (Hemabate) ● IM 250mcg q15-90min PRN ● MAX 8 doses ● Preferred agent for controlling PPH

Ergot Alkaloids

Methylergonovine (Methergine) ● IM 0.2mg q2-4hrs PRN ● 2nd line RX

Pain management: o depends on route of delivery, surgical anesthesia, degree of tears to perineal area Pain management during labor: ● Narcotics (IV) – usually short acting o can enhance synergistic meds(Phenergan to potentiate and enhance drugs) o caution giving close to delivery (b/c can cause respiratory depression in newborn) o Ex: nalbuphine (Nubain), butorphanol (Stadol), morphine ● Epidural/spinal – long acting for labor/surgery ; Most common PCA pump o Local anesthetic + opioid= increase effectiveness without prolonging motor function (mom will be able to walk within a few hours) o SE: hypoTN in mom and baby o NI: give IV bolus/fluids to prevent from happening, mom bedbound until labor is over!! o EX: bupivacaine and fentanyl ● General (rarely used) o used for C-sections OR in emergent situations where time is a factor of if epidural/spinal is contraindicated o EX: scoliosis

Unique characteristics MOA: increase uterine contractility ; intense uterine contractions; direct vasoconstriction Contraindicated: pts with asthma d/t bronchoconstriction* or in patient with acute PID, heart failure, DM SE: lots of GI disturbances(N,V,D) NI: Combine w/ Lomotil (Atropine/Diphenoxylate)when giving this drug to decrease GI upset MOA: increase uterine contractility Use: generally revered for patients who did not respond to the other PPH Rx SE: cramping, HTN Contraindicated: severe risk for pts with HTN (before or after) and CAD due to increased risk of vasospasm (can make HTN worse)*

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Pain management Postpartum: ● Vaginal delivery: ● NSAID (Ibuprofen) o 600mg PO q6hrs for most o Might only use this is PMH of substance abuse ● Opioids o PO depending on situation o Norco: (hydrocodone/acetaminophen) ▪ 5mg/325mg o Tylenol #3: (codeine/acetaminophen) ▪ 1-2 tabs PO q4-6hrs PRN ● C-Section: ● Ketorolac (Toradol) o 30mg IV q6hrs o Really strong NSAID ● Oxycodone/acetaminophen 5mg/325mg (Percocet) o 1-2 tabs PO q4-6 for the first 24 hours ● Postpartum C-Section 24 hours: o switch to ibuprofen and Norco or Tylenol #3 protocol described above o AKA: vaginal delivery pain regimen

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Hemorrhoids: o Witch hazel pads (Tucks) o OTC Pain from stitches: o Benzocaine spray (Dermoplast) o OTC o Spray on peritoneum to help with pain from stitches also if they are burning when they go to bathroom o NI: make sure patient knows/learns how to spray; and does not breathe it in...