Espresso: Medical Management of Postpartum Hemorrhage

/

Welcome to our first Espresso Episode! Just like an espresso, this should be a short, sweet, but highly caffeinated review of more familiar topics. These are intended for rapid-fire review — perfect for while you’re running up to that postpartum hemorrhage!

In today’s episode, we really just stick to the medication management for postpartum hemorrhage, though as anyone with experience with these might remember, there are a lot more components than just these medicines to make hemorrhage management successful. That said, an exam, bimanual massage, and uterotonic agents will resolve many of the cases you’ll see on the floor. More important for CREOGs are likely the dosing and side effects of these medicines, which we also review today. The ACOG PB 183 table on these medicines is also below for visual learners.

For when you have a bit more time to sit and breathe after the run up the stairs, check out ACOG PB 183 to review postpartum hemorrhage in full (ACOG membership required).

ACOG PB 183


Nausea and Vomiting of Early Pregnancy

/

On today’s episode, we discuss one of the most common ailments of early pregnancy, and recommendations for diagnosis and therapy. ACOG PB 189 (ACOG membership required) goes into all the details and makes for excellent further reading, and to learn all about that PUQE scale!

Probably the highest yield piece of information from PB 189 is the recommended therapy algorithm, which you’ll find below. For your practice, don’t forget about helpful adjunct therapies for acid reflux symptoms, like ranitidine or famotidine.

ACOG PB 189

Polycystic Ovarian Syndrome (PCOS)

/

Big shout out to Andrey Dolinko, MD, who suggested today’s topic!
ACOG PB 194 is an excellent resource for your studying on PCOS (membership required).

PCOS is a syndrome, diagnosed clinically by at least 2/3 of the Rotterdam criteria:
1. Hyperandrogenism - hirsutism, male pattern baldness.
2. Oligo- or amenorrhea - 3+ months without menses.
3. Polycystic ovaries on ultrasound - 12+ follicles or increased ovarian volume.

In terms of treatment, the big take home message is to understand whether your patient is planning on pregnancy or not. CHCs are the mainstay therapy of patients not desiring pregnancy due to their multimodal method of action - regulation of HPO axis, increased SHBG, and endometrial protection. Also remember metformin (insulin sensitization) and spironolactone, finasteride, or flutamide (anti-androgens) as other adjuncts in patients not desiring pregnancy.

In those desiring pregnancy, oftentimes the complaint will be infertility. While letrozole is now preferred for ovulation induction over clomiphene due to a higher live-birth rate, letrozole does not yet enjoy FDA approval. For the other symptoms of PCOS in patients desiring pregnancy, the first line therapy is lifestyle modification! The literature doesn’t support metformin for ovulation induction, but some may use it for its other benefits prior to pregnancy.

We didn’t discuss laparoscopic ovarian drilling in this episode, but that would be another surgical treatment for PCOS-related infertility.

Pregnancy Risk Factors and Pregnancy Dating

/

For today’s episode, we envisioned the “new OB visit,” trying to target two goals from the perspective of the provider.

The first is to look at risk factors in a new pregnancy, and we go over some recommended screenings at the new OB visit to that effect.

The second is to establish an optimal due date, and what to do with suboptimally-dated pregnancies. ACOG CO 700 and CO 688 may be helpful reading in this regard. We also place the table from ACOG CO 700 below in terms of allowed discrepancies between ultrasound and first day of LMP. Remember that your individual institution may have differing policies with respect to suboptimal dating.


Diagnosis and Workup of Secondary Amenorrhea

/

Today's topic will be a follow up of last week: diagnosis and workup of secondary amenorrhea. This will be a broad overview, with much more detail to follow in the future! 

Again, the ASRM guidelines for amenorrhea are a helpful resource for further reading.

Additionally, the American Academy of Family Physicians (AAFP) has a guideline publication on amenorrhea. While it’s a bit outdated, they do supply a chart that can be a helpful framework for your studying or diagnostic evaluation!

And remember… did you get that pregnancy test yet?