thera women health

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coal
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259591
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thera women health
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2014-02-15 08:33:28
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thera women health
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  1. functional incontinence
    difficulty accessing toileting facilities in a reasonable amount of time
  2. MOA of stress incontinence
    urethral sphincter is weakened
  3. risk factors for stress UI
    • childbirth
    • pregnancy
    • cognitive impairment
    • menopause
    • obesity
    • age
    • uncommon in males
  4. affect of ACh on urinary tract
    • primary neurotransmitter for lower uti
    • activates detrusor muscle leading to urination
  5. affect of alpha receptors on urinary tract
    • control urethral smooth muscle
    • stimulation constricts urethra keeping urine in
  6. MOA of overflow urinary incontinence
    • bladder underactivity or urethral overactivity 
    • bladder full at al times but unable to empty = urine leaks
  7. S&S of overflow UI
    • lower abdominal fullness
    • hesitancy
    • straining to void
    • decreased force of stream
    • interrupted stream
    • sense of incomplete bladder emptying
    • post-void residual volume
    • more common in males
  8. MOA of urge UI
    involuntary bladder contractions of detrusor muscle
  9. S&S of urge UI
    • nocturia and/or nocturnal incontinence
    • urinary frequency
    • urgency
  10. mechanism of mixed UI
    • bladder overactivity and urethral underactivity
    • most common in elderly
  11. stress UI
    • no nocturia
    • most common type
    • no UI with inactivity
  12. diuretics affect of UI
    • AChEI
    • increased urination, frequency, urgency
  13. CCB affect on UI
    urinary retention
  14. narcotics affect on UI
    urinary retention
  15. sedatives affect on UI
    delirium, immobility = urinary retention
  16. antipsychotics affect on UI
    urinary retention - anticholinergic effects
  17. TCA
    • urinary retention - anticholinergic effects 
    • urination - alpha antagonist effects
  18. alcohol affect on UI
    increased urination, frequency, urgency - sedation, delirium
  19. ACEI affect on UI
    increased urination - increased abdominal pressure (cough)
  20. some non-pharm Tx of UI
    • lifestyle modifications
    • timed/scheduled voiding
    • prompted voiding
    • bladder training
    • pelvic floor muscle exercises (Kegels)
    • biofeedback
    • vaginal weight training
    • acupuncture
    • electrical or magnetic stimulation
    • pessaries (close sphincter)
  21. Tx of functional UI
    • help pt reach the toilet
    •   bedside commode
    •   schedule bathroom visits
    •   use of walkers
    • drugs not helpful
  22. Some aggravating agents of stress UI
    • alpha blockers
    • clonidine
    • guanfacine
    • ACEI
  23. Tx of stress UI
    • Duloxetine (Cymbalta) 40-80mg DOC - increases urethral sphincter tone
    • alpha agonists last line (SE and contraindications) - pseudohedrine, phenylephrine
    • estrogens (topical) useful if vaginitis is involved also
  24. CI of alpha agonists for stress UI
    increased BP, cardiovascular risk, decreased renal fxn
  25. medications that can precipitate overflow UI
    • alpha agonist
    • beta blockers
    • TCA's
    • anticholinergics
    • CCB
    • diuretics
    • muscle relaxants
  26. Tx of overflow UI
    • bethanechol - urecholine
    • cholinergic stimulation
    • treat underlying cause - BPH
    •   alpha blockers
    •   5-alpha reductase inhibitors
  27. Tx of Urge
    • 1st line anticholinergics
    •   oxybutynin - Ditropan
    •   tolterodine - Detrol
    •   fesoterodine - toviaz
    •   trospium - sanctura
    •   solidenacin - vesicare
    •   darifenacin - enablex
  28. SE of oxybutynin - ditropan
    • cognitive dysfunction
    • orthostatic HTN
  29. anticholinergics for UI with renal adjusting doses
    • fesoterodine - toviaz: CrCl < 30 max dose is 4mg
    • trospium - sanctura: CrCl <30 reduce IR dose by 1/2, avoid ER
    • solifenacin - vesicare: CrCl < 30 max dose 5mg
  30. anticholinergics for UI with hepatic adjusting doses
    • tolterodine - Detrol:
    • fesoterodine - toviaz: avoid in severe hepatic impairment, prodrug
    • solifenacin - vesicare: avoid in severe hepatic impairment
  31. anticholinergics for UI with age adjustments
    tropsium - sanctura: > 75yo reduce IR dose by 1/2
  32. anticholinergics for UI with CYP 3A4 inhibition
    • fesoterodine - toviaz
    • solifenacin - vesicare
  33. anticholinergics for UI with CYP 2D6 inhibition
    tolterodine - detrol
  34. tolterodine - Detrol drug-drug interactions
    • CYP 2D6
    • antacids - 2 hrs before or 4 hrs after
    • PPIs
  35. M3 selective antagonists for UI
    • solifenacin - vasicare
    • darifenacin - enablex
  36. mirabegron - myrbetriq
    • beta 3 adrenergic agonist - allows for bladder relaxation during filling
    • use with caution in pts with bladder outlet obstruction or on antimuscarinic therapy due to potential urinary retention
    • AE - HTN, CYP 2D6
  37. pt population who could be a candidate for mirabegron - myrbetiq
    alzheimers - no anticholinergic effects
  38. timeline for exposure to a teratogen w/pregnancy
    • first 2 weeks - all or nothing
    • 18-60 days structural abnormalities
    • >60 days retardation of growth, central nervous system abnormalities, or death
  39. bottom line summary for pregnancy catergory ratings
    • A - safe
    • B - no evidence of risk in humans
    • C - don't know, risk vs benefit
    • D - increased risk
    • X - unsafe
  40. pregnancy related medications CI in pregnancy
    • anastrozole
    • misoprostol
    • clomiphene
    • combination contraceptives
  41. non-pregnancy related medications CI in pregnancy
    • ASA (3rd trimester)
    • ergotamines
    • liver vaccines
    • melatonin
    • statins
    • warfarin

    • 5 alpha-reductase inhibitors
    • isotretinoin
    • itraconazole
    • methotrexate
    • taloxifene
    • ribaviron
    • thalidomide
  42. lactation catergories
    • L1 - safe
    • L2 - safe, limited # of women have taken
    • L3 - moderately safe, no controlled studies
    • L4 - possible hazard
    • L5 - unsafe
  43. drugs contraindicated during lactation
    • dicyclomine
    • dronedarone
    • fenofibrate
    • ketorolac
    • methimazole
    • methotrexate
    • statins
  44. dosing schemes for lactation
    • QD - administer HS
    • multiple dosing - administer immediately after breastfeeding
  45. diagnosing criteria for gestational diabetes
    • 1 of the 3
    • fasting > 92 mg/dL
    • 1 hour > 180 mg/dL
    • 2 hour > 153 mg/dL
  46. testing criteria for GDM
    • high risk - 1st prenatal visit, if normal repeat at 24-28 gestational weeks
    • moderate to low risk - 24-28 gestational weeks
  47. high risk factors for GDM
    • 1st degree relative with DM
    • previous baby over 9lbs
    • previous GDM
    • HTN
    • dyslipidemia
    • obesity
    • Hx of cardiovascular disease
    • high risk ethnicity
  48. GDM testing
    • one step - 24-48 weeks 75 g OGTT, measurement fasting, 1 & 2 hours
    • two step - 24-48 weeks 50g nonfasting, 1 hour glucose > 140 mg/dL proceed to 100g. 100g am after overnight fast. diagnosis if 3 hour glucose level is > 140 mg/dL
  49. GDM Tx
    • 1st line - nonpharm
    • 2nd line - insulin
    • alternate - oral glyburide
  50. criteria of chronic HTN in pregnancy
    • BP > 140/90 mm Hg
    •  prior to pregnancy or before 20 weeks  gestation
    •  persists > 12 weeks postpartum
  51. criteria of preeclampsia in pregnancy
    • BP > 140/90 w/ proteinuria (>300mg albumin/24hr)
    • begins after 20 weeks gestation
    • can progress to eclampsia (seizures)
  52. criteria for chronic HTN w/superimposed preeclampsia
    • new onset proteinuria after 20 weeks in a woman w/chronic HTN
    • in a woman w/HTN and proteinuria prior to 20 weeks
  53. criteria for gestational HTN
    HTN after 20 weeks w/o proteinuria
  54. nonpharm Tx of HTn in pregnancy
    • sodium restriction
    • avoid alcohol & tobacco
    • restrict aerobic exercise
    • weight loss is NOT recommended
  55. 2 preferred Tx of HTN in prego
    • labetalol - decreased side effects
    • methyldopa - safety in long term trials
  56. 2 Tx's that are CI for HTN in prego
    • ACEI
    • ARBs
  57. 2 drug groups that are generally safe in the Tx of HTN in prego
    • beta blockers (metoprolol)
    • CCB - NO IR nifedipine
  58. preferred Tx of HTN and lactation
    propranolol and labetalol
  59. 1st line Tx of anticoagulation in pregnancy
    • LMWH
    • dalteparin - fragmin
    • enoxaparin - lovenox
  60. 2nd line Tx of anticoagulation in pregnancy
    UFH
  61. 2 general guidelines of anticoagulation therapy in prego
    • discontinue LMWH 24 hours prior to elective induction of labor
    • Tx should occur for the duration of pregnancy and be continued a least 6 weeks after delivery
    • AVOID warfarin
  62. 1st line Tx of depression in lactation
    sertraline - zoloft
  63. 2nd line therapy for depression in lactation
    • paroxetine - paxil
    • nortriptyline - pamelor
  64. preferred Tx of depression in lactation
    psychotherapy
  65. preferred antidepressant in prego
    SSRI - all are catergory C except paroxetine (cardiovascular defects) D
  66. Tx of mild intermittent asthma in prego
    SABA
  67. Tx of persistent asthma in prego
    • ICS - budesonide
    • LABA - safe if used in combination with ICS, salmeterol
  68. Tx of severe/exacerbations of asthma in prego
    systemic corticosteroids

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