Infertility and Pregnancy I

What is the definition of infertility in a 28-year-old woman?

Failure to conceive after 12 months of unprotected intercourse

What is the definition of infertility in a 37-year-old woman?

Failure to conceive after 6 months of unprotected intercourse

What is the most important predictor of infertility treatment success?

Maternal age

Which ovulation induction agent is preferred in women with PCOS?

Letrozole

What is the mechanism of clomiphene?

Blocks estrogen receptors in hypothalamus → increases GnRH → increases FSH and LH

What is the mechanism of letrozole?

Inhibits aromatase → decreases estrogen production → increases FSH release

How many cycles of clomiphene should be attempted?

Maximum of 6 cycles

What is the major risk of injectable gonadotropin therapy?

Ovarian Hyperstimulation Syndrome (OHSS)

What is ICSI?

Intracytoplasmic sperm injection — single sperm injected directly into egg

When is ICSI indicated?

Severe male factor infertility (low count or poor motility)

What is the purpose of GnRH agonists/antagonists in IVF?

Prevent premature LH surge and ovulation

What triggers ovulation in IVF protocols?

hCG trigger injection

What are the 7 steps of IVF in order?

GnRH suppression → FSH stimulation → oocyte maturation → trigger → retrieval → fertilization → transfer

Why is pregnancy hypercoagulable?

Increased clotting factors, decreased protein S, venous stasis

What is the treatment dose of enoxaparin in pregnancy?

1 mg/kg SC every 12 hours

What is the standard prophylactic dose of enoxaparin?

40 mg SC daily

What lab monitors UFH?

aPTT

What is the initial bolus dose of IV UFH for DVT?

80 units/kg

What is the infusion rate of IV UFH?

18 units/kg/hour

Does LMWH cross the placenta?

No

Which anticoagulant is contraindicated in pregnancy?

Warfarin

Are DOACs recommended in pregnancy?

No

What is the anti-Xa goal for treatment dosing?

0.5-1 IU/mL (peak 4 hours after dose)

How long must you wait before epidural placement after prophylactic LMWH?

12 hours

How long must you wait after therapeutic LMWH before epidural?

24 hours

When can anticoagulation resume after vaginal delivery?

4-6 hours after epidural removal

When can anticoagulation resume after C-section?

6-12 hours

Which antibiotic class is contraindicated in pregnancy due to tooth and bone effects?

Tetracyclines

Why should sulfonamides be avoided near term?

Risk of kernicterus

Why avoid trimethoprim in first trimester?

Folate antagonist → teratogenic risk

Which antibiotics are generally low risk in pregnancy?

Penicillins, cephalosporins, clindamycin, metronidazole, vancomycin

Which vaccines are avoided in pregnancy?

Live vaccines

When should Tdap be given in pregnancy?

27-36 weeks every pregnancy

What CFU defines asymptomatic bacteriuria?

≥10⁵ CFU/mL

Why is ASB treated in pregnancy?

Prevents pyelonephritis and preterm labor

How long is ASB treated?

7-10 days

Name 3 options for ASB treatment.

Cephalexin, Nitrofurantoin, Augmentin

Common symptoms of cystitis?

Dysuria, urgency, frequency, afebrile

First-line empiric option for cystitis?

Nitrofurantoin 100 mg BID

Treatment duration for cystitis?

7-10 days

Is pyelonephritis inpatient or outpatient in pregnancy?

Inpatient

Classic symptoms of pyelonephritis?

Fever, flank pain, nausea/vomiting

Serious complications of pyelonephritis?

Sepsis, ARDS, preterm labor

Initial treatment without ARDS risk factors?

Cefazolin OR Gentamicin

Initial treatment with ARDS risk factor?

Cefazolin AND Gentamicin

Total treatment duration for pyelonephritis?

10-14 days

When can IV therapy transition to oral?

After afebrile for 24 hours

When do you use suppressive therapy (nitrofurantoin)?

If same organism present for at least 6 weeks

What does ARDS stand for?

Acute respiratory distress syndrome

What causes ARDS?

Inflammatory lung injury causing alveolar fluid leakage and severe hypoxemia

List ARDS risk factors in pregnant pyelonephritis patients.

Temp ≥103°F, HR ≥110, RR ≥28, >3 febrile days, >20 weeks gestation, fluid overload >3L, terbutaline use, transfusion

If visible genital HSV lesions are present at labor, what is required?

C-section

When should HSV suppression begin?

36 weeks

Acyclovir suppression dose?

400 mg TID

Valacyclovir suppression dose?

500 mg BID or 1 g daily

What is chorioamnionitis?

Infection of the chorion and amnion (outer fetal membranes)

Is chorioamnionitis diagnosed during pregnancy or postpartum?

During pregnancy (patient is still pregnant)

What is the most common route of infection in chorioamnionitis?

Ascending infection from the lower genital tract

What are the classic clinical signs of chorioamnionitis?

Maternal fever, fetal tachycardia, uterine tenderness, malodorous amniotic fluid

What are maternal complications of chorioamnionitis?

Maternal bacteremia, wound infection, sepsis

What are neonatal complications of chorioamnionitis?

Neonatal sepsis, preterm birth

What is the gold standard antibiotic treatment for chorioamnionitis?

Ampicillin + Gentamicin

What is the standard ampicillin dose for chorioamnionitis?

2 g IV every 6 hours

What is the gentamicin dosing option for chorioamnionitis?

1.5-2 mg/kg IV every 8 hours OR 5 mg/kg IV every 24 hours

How long should antibiotics be continued for chorioamnionitis?

Until afebrile and asymptomatic for 24-48 hours

Are discharge antibiotics required for chorioamnionitis?

No

If postpartum endometritis develops after chorioamnionitis, what is added?

Clindamycin (Triple Therapy)

What is the definitive treatment for chorioamnionitis if near term?

Delivery

What is endometritis?

Infection of the endometrium (uterine lining) postpartum

When does endometritis most commonly occur?

Within first 24 hrs post childbirth

Which type of delivery increases risk of endometritis?

C-section

What are the classic symptoms of endometritis?

Fever, uterine tenderness, purulent or malodorous lochia, leukocytosis, lower abdominal pain

What are serious complications of endometritis?

Sepsis, septic thrombophlebitis, abscess formation, wound infection

What is the gold standard antibiotic regimen for endometritis?

Ampicillin + Gentamicin + Clindamycin

What is a single-agent alternative regimen for endometritis?

Unasyn (ampicillin/sulbactam)

How long should endometritis be treated?

Until afebrile and asymptomatic for 24-48 hours

If bacteremia is present, how long is total therapy required?

14 days total