Tell me all drugs that include in gynaecology and obstetrics for table viva

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Drugs in Gynaecology & Obstetrics - Table Viva Guide

1. UTEROTONICS (Drugs that stimulate uterine contractions)

Used for: induction of labor, PPH prevention/treatment, incomplete/missed abortion

Drug	Class	Mechanism	Uses	Key Side Effects
Oxytocin	Posterior pituitary hormone	Binds oxytocin receptors (Gq-PLC-IP3) → ↑ intracellular Ca²⁺ → myometrial contraction	Induction/augmentation of labor, PPH prevention, 3rd stage management	Hypotension, water intoxication (antidiuretic effect), fetal distress, uterine hyperstimulation
Ergometrine (Ergonovine)	Ergot alkaloid	α-adrenergic + 5-HT receptor agonist → sustained tonic uterine contraction	PPH (3rd stage), subinvolution	Hypertension, nausea, vomiting - CONTRAINDICATED in hypertension/pre-eclampsia
Methylergometrine (Methergine)	Ergot alkaloid	Same as ergometrine	PPH, 3rd stage	Same as ergometrine
Misoprostol (PGE₁ analogue)	Prostaglandin	PGE₁ receptor → ↑ Ca²⁺ in myometrium	Cervical ripening, induction, PPH, MTP	Diarrhea, fever, shivering, hyperstimulation
Carboprost (15-methyl PGF₂α)	Prostaglandin	FP receptor → uterine contraction	Refractory PPH, MTP (2nd trimester)	Bronchospasm - CONTRAINDICATED in asthma
Dinoprostone (PGE₂)	Prostaglandin	PGE₂ receptor	Cervical ripening, induction, MTP	Hypotension, fever, GI upset
Carbetocin	Oxytocin analogue (long-acting)	Same as oxytocin but longer half-life (~40 min vs 4-6 min)	PPH prevention in C-section	Similar to oxytocin, less water retention

2. TOCOLYTICS (Drugs that inhibit uterine contractions)

Used for: Preterm labor (to delay delivery 48h for corticosteroids/transfer)

Drug	Class	Mechanism	Notes
Ritodrine	β₂-adrenergic agonist	↑ cAMP → PKA → phosphorylates/inactivates MLCK	Only tocolytic with FDA approval; withdrawn from US market
Terbutaline	β₂-adrenergic agonist	Same as ritodrine	Used off-label; SC/IV/oral; delays birth only first 48h; causes maternal tachycardia, hypotension, pulmonary edema
Nifedipine	Ca²⁺ channel blocker	Blocks voltage-sensitive Ca²⁺ channels → ↓ MLCK activation	First-line tocolytic; better fetal outcomes, fewer maternal side effects than β₂ agonists
Indomethacin	COX inhibitor (NSAID)	Inhibits PG synthesis → ↓ PGF₂α-driven contraction	Used <32 weeks; risk of premature closure of ductus arteriosus, oligohydramnios
Atosiban	Oxytocin receptor antagonist	Blocks OXTR → prevents IP3/Ca²⁺ signaling	Licensed in Europe; fewer cardiovascular side effects
Magnesium sulfate (MgSO₄)	Inorganic salt	Competes with Ca²⁺, blocks Ca²⁺ influx; also neuroprotective for fetus	Also used in eclampsia prophylaxis/treatment; monitor for toxicity (loss of reflexes, respiratory depression)
NO donors (e.g., GTN patches)	Nitric oxide donor	↑ cGMP → PKG → MLCK inactivation	Experimental; riociguat (sGC activator) is CONTRAINDICATED in pregnancy

3. DRUGS FOR PRE-ECLAMPSIA / ECLAMPSIA

Drug	Use	Key Point
Magnesium sulfate	Eclampsia seizure prophylaxis & treatment	Gold standard; Pritchard or Zuspan regimen; antidote = calcium gluconate
Labetalol	Acute severe hypertension in pregnancy	α+β blocker; IV preferred
Hydralazine	Acute severe hypertension	Direct arteriolar dilator; IV bolus or infusion
Nifedipine (oral)	Acute severe hypertension	Avoid sublingual (precipitous BP drop)
Methyldopa	Chronic hypertension in pregnancy	Drug of choice for chronic HTN in pregnancy
Clonidine	Chronic hypertension	Central α₂ agonist; second-line
Amlodipine	Chronic hypertension	Ca²⁺ channel blocker; safe in pregnancy

CONTRAINDICATED in pregnancy:

ACE inhibitors (captopril, enalapril) - fetal renal agenesis, oligohydramnios
ARBs - same as ACE inhibitors
Atenolol - fetal growth restriction
Nitroprusside - cyanide toxicity to fetus (avoid prolonged use)

4. DRUGS FOR MEDICAL TERMINATION OF PREGNANCY (MTP)

Regimen	Drug	Dose
1st trimester	Mifepristone (RU-486) 200 mg oral + Misoprostol 800 mcg vaginal/sublingual (48h later)	Most effective <9 weeks
1st trimester surgical prep	Misoprostol alone	Cervical priming before MVA
2nd trimester	Mifepristone + Misoprostol or Carboprost (PGF₂α)	13-24 weeks
Mifepristone	Antiprogestogen; blocks progesterone receptors → sensitizes uterus to prostaglandins	-

5. HORMONAL CONTRACEPTIVES

Combined Oral Contraceptive Pill (COCP)

Estrogen component: Ethinylestradiol (EE) 20-35 mcg (low dose)
Progestogen components: Levonorgestrel, Norethisterone, Desogestrel, Gestodene, Norgestimate, Drospirenone

Mechanism: Inhibit LH surge (ovulation suppression), thicken cervical mucus, thin endometrium

Absolute contraindications (WHOMEC Cat 4): Active VTE, migraine with aura, >35 years + smoking ≥15 cigs/day, breast cancer, liver disease

Progestogen-Only Pill (POP / Mini-pill)

Desogestrel 75 mcg (most effective POP - inhibits ovulation)
Levonorgestrel 30 mcg, Norethisterone 350 mcg

Injectables

Depot medroxyprogesterone acetate (DMPA / Depo-Provera): 150 mg IM every 3 months
Norethisterone enantate: 200 mg IM every 2 months

Implants

Etonogestrel implant (Nexplanon/Implanon): Subdermal, 3 years, most effective reversible method

Emergency Contraception

Drug	Dose	Window	Mechanism
Levonorgestrel (Plan B)	1.5 mg oral single dose	Within 72h (up to 120h)	Delays/inhibits ovulation
Ulipristal acetate (EllaOne)	30 mg oral	Within 120h	Selective progesterone receptor modulator
Cu-IUD	Insertion	Within 120h	Most effective EC (>99%); also ongoing contraception

Intrauterine Devices

Levonorgestrel IUS (Mirena): 52 mg LNG, releases 20 mcg/day; 5-8 years; reduces menorrhagia
Copper IUD (Cu-T 380A): Non-hormonal; 10 years; Cu ions toxic to sperm

6. DRUGS FOR ENDOMETRIOSIS

Drug	Class	Mechanism	Use
GnRH agonists (Leuprolide, Goserelin, Buserelin)	GnRH analogue	Downregulate pituitary GnRH receptors → ↓ FSH/LH → medical castration	Endometriosis, fibroids, IVF
Danazol	Androgen derivative	Inhibits gonadotrophins; androgenic/anabolic	Endometriosis, menorrhagia; causes virilization, weight gain
Progestogens (MPA, norethisterone, dienogest)	Progestogen	Decidualization → atrophy of endometriotic implants	First-line hormonal Rx
COCP	Combined OC	Suppresses endometrium, reduces retrograde menstruation	Mild-moderate endometriosis
LNG-IUS (Mirena)	Intrauterine progestogen	Local endometrial suppression	Endometriosis-associated menorrhagia
Letrozole	Aromatase inhibitor	↓ local estrogen production in endometriotic tissue	Recurrent/refractory cases

7. DRUGS FOR POLYCYSTIC OVARY SYNDROME (PCOS)

Drug	Use	Mechanism
Metformin	Insulin resistance; restore ovulation	Activates AMPK → ↓ hepatic glucose production, ↑ insulin sensitivity
Clomiphene citrate	Ovulation induction	Competitive estrogen receptor antagonist at hypothalamus → ↑ GnRH/FSH/LH
Letrozole	Ovulation induction (1st line)	Aromatase inhibitor → ↑ FSH via negative feedback; superior to clomiphene in PCOS
Gonadotrophins (FSH/hMG)	Ovulation induction	Direct ovarian stimulation; risk of OHSS
COCP	Symptom control (hirsutism, menstrual irregularity)	Suppresses androgens, regulates cycle
Spironolactone	Anti-androgen (hirsutism/acne)	Blocks androgen receptors; also aldosterone antagonist
Cyproterone acetate	Anti-androgen	Androgen receptor blocker; component of Diane-35

8. DRUGS FOR MENORRHAGIA

Drug	Mechanism	Notes
Tranexamic acid	Antifibrinolytic (inhibits plasminogen activation)	Non-hormonal; reduces blood loss ~50%
Mefenamic acid	COX inhibitor (NSAID)	Reduces PG-driven vasodilation; also dysmenorrhea
LNG-IUS (Mirena)	Local progestogen → endometrial atrophy	Most effective medical treatment
COCP	Endometrial suppression	Regular cycles, reduced blood loss
Norethisterone	Progestogen	5 mg TDS day 5-26; used for cycle control
Danazol	Androgen derivative	Endometrial atrophy; significant side effects

9. DRUGS IN INFERTILITY / ART

Drug	Use	Notes
Clomiphene citrate	Ovulation induction	Anti-estrogen; 50-150 mg day 2-6; SERM
Letrozole	Ovulation induction (PCOS preferred)	Aromatase inhibitor; fewer multiple pregnancies
FSH (Follitropin α/β)	Controlled ovarian hyperstimulation	Gonal-F, Puregon; monitor for OHSS
hMG (Menotropin)	Ovarian stimulation	FSH + LH; Merional, Menopur
GnRH agonists	Pituitary downregulation in IVF	Leuprolide, Buserelin; "long protocol"
GnRH antagonists	Prevent premature LH surge	Cetrorelix, Ganirelix; "antagonist protocol" - more convenient
hCG (Choriogonadotropin)	Trigger ovulation (LH surge mimic)	Given when follicle ≥18 mm; also luteal support
Progesterone	Luteal phase support	Vaginal gel (Crinone), pessaries; post IVF/embryo transfer
Cabergoline	Hyperprolactinemia	D₂ agonist; reduces prolactin; first-line over bromocriptine
Bromocriptine	Hyperprolactinemia	D₂ agonist; older drug, more side effects

10. CORTICOSTEROIDS IN OBSTETRICS

Drug	Indication	Dose	Effect
Betamethasone	Antenatal corticosteroid (ACS)	12 mg IM x2 doses, 24h apart	Fetal lung maturation (induces surfactant); reduces RDS, IVH, NEC - given 24-34 weeks when preterm birth expected within 7 days
Dexamethasone	Alternative to betamethasone	6 mg IM x4 doses, 12h apart	Same; preferred if betamethasone unavailable; also used in HELLP syndrome
Hydrocortisone	Addisonian crisis in pregnancy	Stress dosing	-

11. ANTIEMETICS IN PREGNANCY (Nausea/Vomiting/Hyperemesis Gravidarum)

Drug	Class	Safety
Pyridoxine (Vitamin B6)	Vitamin	First-line; safe in 1st trimester
Doxylamine + Pyridoxine (Diclegis/Bonjesta)	Antihistamine + B6	FDA Category B; first-line combination
Metoclopramide	D₂ antagonist (prokinetic)	Safe; IV for hyperemesis
Ondansetron	5-HT₃ antagonist	Widely used; small risk of cardiac septal defects if used in 1st trimester (controversial)
Prochlorperazine	Phenothiazine	Second-line
Promethazine	Antihistamine	Sedating; second-line
Thiamine (Vit B1)	Vitamin	MANDATORY in hyperemesis before IV dextrose (prevents Wernicke's encephalopathy)

12. DRUGS FOR GESTATIONAL DIABETES

Drug	Notes
Insulin	Gold standard; all types safe (NPH, aspart, lispro, glargine)
Metformin	Used in some guidelines (NICE); crosses placenta but safe evidence accumulating
Glibenclamide (Glyburide)	Used in some countries; crosses placenta more than metformin - not preferred

13. ANTIBIOTICS SAFE IN PREGNANCY

Safe	Use with Caution	Contraindicated
Penicillins (amoxicillin, ampicillin)	Metronidazole (avoid 1st trimester - limited data)	Tetracyclines (teeth/bone)
Cephalosporins	Clindamycin	Fluoroquinolones (cartilage damage)
Azithromycin	Vancomycin (ototoxicity)	Aminoglycosides (ototoxicity) - avoid if possible
Nitrofurantoin (avoid at term - haemolysis)	-	Trimethoprim (folate antagonist - avoid 1st trimester)
Clindamycin (BV in pregnancy)	-	Chloramphenicol (grey baby syndrome at term)

14. DRUGS FOR CERVICAL RIPENING / INDUCTION

Drug	Route	Notes
Dinoprostone (PGE₂)	Vaginal gel/pessary	Bishop score <6; contraindicated in previous CS (uterine rupture risk)
Misoprostol (PGE₁)	Vaginal/sublingual/oral	Cheaper; used cautiously in previous CS
Oxytocin	IV infusion	When cervix favorable (Bishop ≥6); titrated infusion
Mifepristone	Oral	Cervical ripening; sensitizes uterus to PGs
Mechanical methods	Foley catheter, balloon	Non-pharmacological; reduces hyperstimulation risk

15. ANTIFIBRINOLYTICS & HAEMOSTATICS IN OBSTETRICS

Drug	Use	Dose
Tranexamic acid	PPH treatment	1g IV slowly; repeat after 30 min if needed; within 3h of birth (WOMAN trial)
Fibrinogen concentrate	PPH with DIC	Replaces fibrinogen when <2 g/L
Fresh frozen plasma (FFP)	Coagulopathy in PPH	10-15 mL/kg

16. DRUGS FOR VULVOVAGINAL INFECTIONS

Condition	Drug of Choice	Alternative
Bacterial vaginosis	Metronidazole 400 mg oral BD x5d	Clindamycin vaginal cream
Candidiasis	Clotrimazole 500 mg vaginal pessary (single) or Fluconazole 150 mg oral	Miconazole vaginal cream
Trichomoniasis	Metronidazole 2g oral single dose (+ treat partner)	Tinidazole 2g
Chlamydia	Azithromycin 1g single dose	Doxycycline 100 mg BD x7d (avoid in pregnancy)
Gonorrhoea	Ceftriaxone 500 mg IM single dose	-
Genital herpes	Aciclovir 200-400 mg TDS	Valaciclovir
Syphilis	Benzathine penicillin G 2.4 MU IM	Erythromycin (if penicillin allergy in pregnancy)

17. DRUGS FOR GYNAECOLOGICAL CANCERS

Drug/Class	Indication
Paclitaxel + Carboplatin	Ovarian cancer (first-line)
Bevacizumab (anti-VEGF)	Ovarian cancer (add-on/maintenance)
PARP inhibitors (Olaparib, Niraparib, Rucaparib)	BRCA-mutated ovarian cancer maintenance
Cisplatin + Radiotherapy	Cervical cancer (concurrent chemoradiation)
5-Fluorouracil (topical)	VIN/VAIN
Imiquimod (topical)	HPV-related VIN, condylomata
Medroxyprogesterone acetate	Endometrial cancer (low grade, fertility-sparing)
Tamoxifen	Breast cancer (ER+); note: increases endometrial cancer risk

QUICK RECALL TABLE - Drug Classes & Prototype

Category	Prototype Drug
Uterotonic (oxytocic)	Oxytocin
Ergot oxytocic	Ergometrine
PG uterotonic	Carboprost (PGF₂α)
Tocolytic (β₂ agonist)	Terbutaline
Tocolytic (Ca²⁺ blocker)	Nifedipine
Tocolytic (OT antagonist)	Atosiban
Anti-eclamptic	MgSO₄
Antenatal corticosteroid	Betamethasone
MTP drug	Mifepristone + Misoprostol
COCP progestogen	Levonorgestrel
Emergency contraceptive	Levonorgestrel
Ovulation induction	Clomiphene citrate / Letrozole
Hyperprolactinemia	Cabergoline
Endometriosis (medical)	GnRH agonist (Leuprolide)
Menorrhagia (non-hormonal)	Tranexamic acid
PPH (refractory)	Carboprost
Hyperemesis gravidarum	Pyridoxine + Doxylamine

Sources: Goodman & Gilman's The Pharmacological Basis of Therapeutics; Berek & Novak's Gynecology; Creasy & Resnik's Maternal-Fetal Medicine

Create a visual flowchart for drug selection in infertility management

Generating Image

A detailed medical flowchart titled "Drug Selection in Infertility Management" with a clean clinical white background. The flowchart starts at the top with "INFERTILITY WORKUP COMPLETE" box, then branches into multiple pathways: LEFT BRANCH - "ANOVULATION / OVULATORY DYSFUNCTION" leading down to: - PCOS box → "1st Line: Letrozole 2.5-5mg (Day 2-6)" → "2nd Line: Clomiphene Citrate 50-150mg" → "Add Metformin if insulin resistant" → "3rd Line: Gonadotrophins (FSH/hMG)" → "Laparoscopic Ovarian Drilling" MIDDLE BRANCH - "HYPERPROLACTINEMIA" leading to: - "Cabergoline 0.25-0.5mg twice weekly" → "Bromocriptine (if cabergoline unavailable)" → "Normalize prolactin → reassess ovulation" RIGHT BRANCH - "HYPOGONADOTROPHIC HYPOGONADISM" leading to: - "Pulsatile GnRH (gold standard)" → "OR Gonadotrophins: FSH + hCG" BOTTOM SECTION - "ASSISTED REPRODUCTIVE TECHNOLOGY (ART / IVF)" large box containing: - Controlled Ovarian Hyperstimulation protocols side by side: LEFT: "LONG PROTOCOL: GnRH Agonist (Leuprolide/Buserelin) Day 21 → Downregulation → FSH injections" RIGHT: "ANTAGONIST PROTOCOL: FSH from Day 2 → GnRH Antagonist (Cetrorelix/Ganirelix) when follicle ≥14mm" - Both lead to: "Trigger Shot: hCG 10,000 IU or GnRH Agonist (antagonist protocol)" - Then: "Oocyte Retrieval → Fertilisation → Embryo Transfer" - Then: "Luteal Phase Support: Progesterone vaginal pessaries/gel" SPECIAL BOXES on the side: - "OHSS PREVENTION: Cabergoline, GnRH agonist trigger, freeze-all strategy" - "MALE FACTOR: Gonadotrophins (FSH+hCG) if hypogonadotrophic" Color coding: Blue boxes for diagnosis, Green boxes for first-line drugs, Orange for second-line, Red for warnings/contraindications. Arrows connecting all steps. Professional medical textbook style.

Drug Selection in Infertility Management Flowchart

Here's a summary of the flowchart logic for quick viva recall:

Flowchart Logic - Drug Selection in Infertility

Step 1 - Identify the Cause

After complete workup, three main pharmacological pathways branch out:

Diagnosis	First Drug
Anovulation / PCOS	Letrozole (now preferred over clomiphene)
Hyperprolactinemia	Cabergoline
Hypogonadotrophic hypogonadism	Pulsatile GnRH or Gonadotrophins
Unexplained / tubal / male factor (severe)	Straight to ART/IVF

Step 2 - Ovulation Induction Ladder (PCOS)

Letrozole → Clomiphene → ± Metformin → Gonadotrophins → LOD (surgical)

Step 3 - ART Protocol Choice

Long protocol (GnRH agonist): Better synchronisation, more eggs - used in poor/normal responders
Antagonist protocol (GnRH antagonist): Shorter, lower OHSS risk - now preferred in many centres, especially high responders

Step 4 - Trigger & Luteal Support

hCG trigger - standard, but raises OHSS risk
GnRH agonist trigger - preferred in high OHSS risk (antagonist cycle only)
Progesterone (vaginal) - mandatory luteal phase support after ART

Key Viva Point

"Letrozole has overtaken clomiphene as first-line ovulation induction in PCOS because it gives higher live birth rates with fewer multiple pregnancies" - based on the landmark Legro et al. NEJM 2014 RCT.

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