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📚 KMTC Pharmacology - Exam-Oriented Notes

Source: Lippincott Illustrated Reviews: Pharmacology

WEEK 12 - DRUGS ACTING ON THE RESPIRATORY SYSTEM

1. Bronchodilators - β2-Adrenergic Agonists

Drug Class	Drugs	Mechanism	Uses	Key Side Effects
Short-acting β2 agonists (SABAs)	Albuterol, Levalbuterol	Activate β2 receptors → relax airway smooth muscle	Acute bronchospasm, exercise-induced asthma (as needed)	Tachycardia, tremors, hypokalemia, hyperglycemia
Long-acting β2 agonists (LABAs)	Salmeterol, Formoterol	Same as SABAs but longer duration (12 hrs)	Long-term asthma control, COPD maintenance	Same as SABAs; do NOT use as monotherapy in asthma

Exam tip: SABAs = quick relief ("rescue"). LABAs = long-term control. LABAs must always be combined with an ICS in asthma.

2. Methylxanthines

Drug Class	Drugs	Mechanism	Uses	Key Side Effects
Methylxanthines	Theophylline, Aminophylline	Inhibit phosphodiesterase → ↑ cAMP → bronchodilation; also antagonize adenosine receptors	Asthma (less preferred), COPD, apnea of prematurity	Narrow therapeutic index: nausea, seizures, arrhythmias, tachycardia

Exam tip: Theophylline has a narrow therapeutic index - toxicity is a common exam question. Monitor serum levels.

3. Inhaled Corticosteroids (ICS)

Drug Class	Drugs	Mechanism	Uses	Key Side Effects
Inhaled corticosteroids	Budesonide, Fluticasone, Beclomethasone	Decrease airway inflammation (↓ eosinophils, macrophages, T-lymphocytes); reverse mucosal edema; inhibit leukotriene release	Persistent asthma (first-line maintenance)	Oropharyngeal candidiasis, hoarseness (local); systemic effects rare with inhaled form

Exam tip: Patients must rinse mouth after use to prevent oral candidiasis. ICS does NOT give immediate relief.

4. Leukotriene Modifiers

Drug Class	Drugs	Mechanism	Uses	Key Side Effects
Leukotriene receptor antagonists	Montelukast, Zafirlukast	Block CysLT1 receptors → prevent bronchoconstriction and inflammation from leukotrienes	Mild persistent asthma, allergic rhinitis, aspirin-induced asthma	Headache, GI upset; rare: neuropsychiatric effects (nightmares, depression)
5-Lipoxygenase inhibitor	Zileuton	Inhibits 5-lipoxygenase → blocks leukotriene synthesis	Asthma	Hepatotoxicity - monitor LFTs

5. Anticholinergics (Respiratory)

Drug	Mechanism	Uses	Key Side Effects
Ipratropium (short-acting)	Block muscarinic receptors → reduce bronchoconstriction	COPD (first-line), acute asthma (add-on)	Dry mouth, urinary retention, blurred vision
Tiotropium (long-acting)	Same; once daily	COPD maintenance	Same as ipratropium

6. Mast Cell Stabilizers

Drug	Mechanism	Uses	Key Side Effects
Cromolyn sodium	Inhibits mast cell degranulation → prevents release of histamine and leukotrienes	Prophylaxis of asthma, allergic rhinitis	Minimal; throat irritation, cough

Exam tip: Cromolyn has NO bronchodilator effect - prophylaxis only, not for acute attacks.

WEEK 13 - DIURETICS

Overview: Where Diuretics Act in the Nephron

Site of Action	Drug Class
Proximal convoluted tubule	Carbonic anhydrase inhibitors (e.g., Acetazolamide)
Loop of Henle (thick ascending limb)	Loop diuretics (e.g., Furosemide)
Distal convoluted tubule	Thiazide diuretics (e.g., Hydrochlorothiazide)
Collecting duct	Potassium-sparing diuretics (e.g., Spironolactone, Amiloride)
Glomerulus	Osmotic diuretics (e.g., Mannitol)

1. Thiazide Diuretics

Feature	Details
Drugs	Hydrochlorothiazide (HCTZ), Chlorthalidone, Indapamide, Metolazone
Mechanism	Block Na+/Cl- cotransporter in distal tubule → ↑ Na+ and water excretion
Uses	Hypertension (first-line), mild oedema, hypercalciuria (kidney stones), heart failure
Side effects	Hypokalemia, hyponatremia, hyperuricemia (gout!), hyperglycemia, hyperlipidemia, hypercalcemia
Contraindications	Severe renal failure (GFR <30), gout, sulfa allergy

Exam mnemonic - Thiazide side effects: "HHGGG" - Hypokalemia, Hyperuricemia, Hyperglycemia, Hyperlipidemia, Hypercalcemia

2. Loop Diuretics

Feature	Details
Drugs	Furosemide (most used), Bumetanide, Torsemide, Ethacrynic acid
Mechanism	Block Na+/K+/2Cl- cotransporter in thick ascending limb of Loop of Henle
Uses	Pulmonary oedema, heart failure, hypertension in renal failure, hypercalcemia
Side effects	Hypokalemia, hyponatremia, hypocalcemia, hyperuricemia, ototoxicity (especially ethacrynic acid), dehydration
Key point	Most potent diuretics; effective even in renal failure (unlike thiazides)

Exam tip - Loop vs Thiazide: Loops cause hypocalcemia; Thiazides cause hypercalcemia. NSAIDs reduce loop diuretic efficacy.

3. Potassium-Sparing Diuretics

Drug	Mechanism	Uses	Side Effects
Spironolactone, Eplerenone (aldosterone antagonists)	Block aldosterone receptors in collecting duct → retain K+, excrete Na+	Heart failure, hyperaldosteronism, liver cirrhosis (ascites)	Hyperkalemia, gynecomastia (spironolactone), menstrual irregularities
Amiloride, Triamterene (ENaC blockers)	Block epithelial Na+ channels → retain K+	Used with thiazides/loops to prevent hypokalemia	Hyperkalemia, GI upset

Exam tip: Potassium-sparing diuretics are WEAK diuretics but SAVE potassium. Never combine with ACE inhibitors without close monitoring (risk of fatal hyperkalemia).

4. Osmotic Diuretics

Drug	Mechanism	Uses	Side Effects
Mannitol	Freely filtered; draws water into tubule by osmosis → diuresis	Raised intracranial pressure, raised intraocular pressure, acute renal failure prevention	Fluid overload initially, hyponatremia, headache

5. Carbonic Anhydrase Inhibitors

Drug	Mechanism	Uses	Side Effects
Acetazolamide	Inhibit carbonic anhydrase in PCT → ↓ HCO3- reabsorption → Na+ and water loss	Glaucoma, altitude sickness, epilepsy (absence), metabolic alkalosis	Metabolic acidosis, hypokalemia, sulfa allergy reaction, kidney stones

WEEKS 14-16 - DRUGS ACTING ON THE CARDIOVASCULAR SYSTEM

A. CARDIAC GLYCOSIDES

Feature	Details
Drug	Digoxin (Lanoxin)
Mechanism	Inhibits Na+/K+-ATPase pump → ↑ intracellular Na+ → ↑ intracellular Ca2+ via Na+/Ca2+ exchanger → positive inotropy (↑ contractility). Also: ↑ vagal tone → ↓ HR and ↓ AV conduction (negative chronotropy and dromotropy)
Uses	Heart failure with reduced EF, atrial fibrillation/flutter (rate control)
Side effects	Narrow therapeutic index! GI (nausea, vomiting), CNS (visual disturbances - yellow-green halos), arrhythmias (any type), bradycardia
Toxicity precipitated by	Hypokalemia (most common), hypomagnesemia, hypercalcemia, renal failure
Contraindications	Hypertrophic cardiomyopathy, Wolff-Parkinson-White syndrome
Antidote	Digoxin-specific antibody fragments (Digibind)

Exam tip: Hypokalemia potentiates digoxin toxicity. Check K+ before giving digoxin!

B. ANTI-ANGINAL DRUGS

1. Nitrates (Organic Nitrates)

Feature	Details
Drugs	Nitroglycerin (sublingual/patch/IV), Isosorbide dinitrate, Isosorbide mononitrate
Mechanism	Converted to nitric oxide (NO) → activates guanylyl cyclase → ↑ cGMP → smooth muscle relaxation → venodilation (primarily) and arterial dilation → ↓ preload and afterload → ↓ O2 demand
Uses	Stable angina (acute + prophylaxis), unstable angina, variant/Prinzmetal angina, acute MI, acute heart failure
Side effects	Headache (most common), reflex tachycardia, hypotension, flushing, tolerance with continuous use
Contraindicated with	Phosphodiesterase-5 inhibitors (sildenafil/tadalafil) - severe hypotension!

2. Beta-Blockers (Anti-anginal use)

Feature	Details
Drugs	Propranolol, Metoprolol, Atenolol, Bisoprolol
Mechanism	Block β1 receptors → ↓ heart rate, ↓ contractility, ↓ O2 demand
Uses	Stable angina, post-MI cardioprotection, hypertension, arrhythmias, heart failure
Side effects	Bradycardia, fatigue, bronchospasm (avoid in asthma), cold extremities, masking of hypoglycemia symptoms
Contraindications	Asthma/COPD (non-selective), bradycardia, acute decompensated heart failure

3. Calcium Channel Blockers (Anti-anginal use)

Feature	Details
Dihydropyridines	Amlodipine, Nifedipine - mainly vasodilators; little effect on heart rate
Non-dihydropyridines	Verapamil, Diltiazem - slow AV node, reduce HR + contractility
Mechanism	Block L-type Ca2+ channels → vasodilation → ↓ afterload; non-DHP also ↓ HR
Uses	Stable and Prinzmetal/variant angina (all CCBs), hypertension, SVT (verapamil, diltiazem)
Side effects	Peripheral oedema, headache, flushing; verapamil: constipation, bradycardia; non-DHP: worsen heart failure with reduced EF

C. ANTIHYPERTENSIVE DRUGS

1. ACE Inhibitors

Feature	Details
Drugs	Captopril, Enalapril, Lisinopril, Ramipril (all end in "-pril")
Mechanism	Inhibit ACE → ↓ Angiotensin II → vasodilation + ↓ aldosterone → ↓ Na+/water retention; also ↓ bradykinin breakdown
Uses	Hypertension, heart failure, post-MI, diabetic nephropathy, CKD
Side effects	Dry cough (bradykinin accumulation - most common!), angioedema, hyperkalemia, teratogenic
Contraindications	Pregnancy, bilateral renal artery stenosis, history of angioedema

2. Angiotensin Receptor Blockers (ARBs)

Feature	Details
Drugs	Losartan, Valsartan, Irbesartan, Candesartan (all end in "-sartan")
Mechanism	Block AT1 receptors → same hemodynamic effects as ACEi but bradykinin not affected
Uses	Same as ACE inhibitors; used when ACEi-induced cough is intolerable
Side effects	Hyperkalemia, teratogenic; no cough (key difference from ACEi)

3. Beta-Blockers (Antihypertensive)

Feature	Details
Drugs	Propranolol (non-selective), Metoprolol, Atenolol (β1-selective), Carvedilol (α+β blocker), Labetalol (α+β, used in hypertensive emergencies in pregnancy)
Mechanism	Block β1 → ↓ CO; block β1 in JGA → ↓ renin
Uses	Hypertension, angina, post-MI, heart failure, arrhythmias, thyrotoxicosis
Side effects	Bradycardia, bronchospasm, fatigue, erectile dysfunction, mask hypoglycemia

4. Calcium Channel Blockers (Antihypertensive)

Feature	Details
Drugs	Amlodipine, Nifedipine (DHP); Verapamil, Diltiazem (non-DHP)
Mechanism	Block L-type Ca2+ channels → ↓ vascular smooth muscle tone → ↓ peripheral resistance
Uses	Hypertension, angina; verapamil/diltiazem also for SVT
Side effects	Ankle oedema, flushing, headache; verapamil = constipation

5. Central Acting Antihypertensives

Drug	Mechanism	Uses	Side Effects
Methyldopa	α2 agonist in CNS → ↓ sympathetic outflow	Hypertension in pregnancy (drug of choice)	Sedation, dry mouth, haemolytic anaemia, positive Coombs test
Clonidine	α2 agonist in CNS → ↓ sympathetic outflow	Hypertension (second-line), opioid withdrawal	Rebound hypertension on abrupt withdrawal, dry mouth, sedation

6. Alpha-1 Receptor Blockers (Adrenergic Neuron Blocking / Alpha Adreno-receptor Blockers)

Drug	Mechanism	Uses	Side Effects
Prazosin, Doxazosin, Terazosin	Block α1 receptors → vasodilation	Hypertension, benign prostatic hyperplasia (BPH)	First-dose hypotension (orthostatic), reflex tachycardia, dizziness

Exam tip: Methyldopa = drug of choice for hypertension in pregnancy. Prazosin also treats BPH.

7. Direct Vasodilators

Drug	Mechanism	Uses	Side Effects
Hydralazine	Arteriolar vasodilation (direct)	Hypertension (especially in pregnancy combined with methyldopa), heart failure	Reflex tachycardia, fluid retention, lupus-like syndrome
Sodium Nitroprusside	Releases NO → arteriolar and venous dilation	Hypertensive emergencies (IV only)	Cyanide toxicity with prolonged use
Minoxidil	K+ channel opener → arteriolar dilation	Severe refractory hypertension	Hirsutism, fluid retention, reflex tachycardia

D. ANTIARRHYTHMIC DRUGS (Vaughan-Williams Classification)

Class	Mechanism	Drugs	Uses	Key Side Effects
Class IA	Block Na+ channels + K+ channels → ↑ action potential duration	Quinidine, Procainamide, Disopyramide	Atrial and ventricular arrhythmias	Quinidine: cinchonism (tinnitus, headache), torsades de pointes; Procainamide: lupus-like syndrome
Class IB	Block Na+ channels (inactivated state) → ↓ action potential duration	Lidocaine, Mexiletine	Ventricular arrhythmias (post-MI); lidocaine IV for acute VT/VF	CNS toxicity: seizures, confusion
Class IC	Strong Na+ channel blockers → ↓ conduction velocity (no effect on duration)	Flecainide, Propafenone	SVT, atrial fibrillation (no structural heart disease)	Proarrhythmic (avoid in structural heart disease!)
Class II	β-blockers → ↓ automaticity, ↑ AV node refractoriness	Metoprolol, Propranolol, Esmolol, Atenolol	SVT, atrial flutter/fibrillation, post-MI	Bradycardia, bronchospasm, fatigue
Class III	Block K+ channels → ↑ refractory period	Amiodarone, Sotalol, Dofetilide	Severe VT/VF, atrial fibrillation	Amiodarone: pulmonary fibrosis, thyroid dysfunction, hepatotoxicity, corneal deposits, blue-gray skin
Class IV	Block Ca2+ channels (non-DHP) → ↓ AV conduction	Verapamil, Diltiazem	SVT, atrial flutter/fibrillation (rate control)	Bradycardia, AV block, hypotension, constipation (verapamil)
Other	Inhibit Na+/K+-ATPase	Digoxin	Rate control in AF, heart failure	Arrhythmias, GI/CNS toxicity, visual changes
Other	Activates K+ channels → slows SA/AV node	Adenosine	Acute SVT (drug of choice)	Flushing, chest pain, transient asystole (seconds)

Exam mnemonic - Amiodarone toxicity: "PALE SKIN" - Pulmonary fibrosis, Abnormal thyroid, Liver toxicity, Eye (corneal deposits), Skin (blue-gray), K+ prolongation (QT), Iodine content, Neurological effects

E. DRUGS FOR DYSLIPIDAEMIA

Drug Class	Drugs	Mechanism	Uses	Side Effects
Statins	Atorvastatin, Simvastatin, Rosuvastatin	Inhibit HMG-CoA reductase → ↓ cholesterol synthesis → ↑ LDL receptors	High LDL, primary/secondary CVD prevention	Myopathy/rhabdomyolysis, hepatotoxicity, teratogenic
Fibrates	Gemfibrozil, Fenofibrate	Activate PPARα → ↑ LPL → ↓ triglycerides, ↑ HDL	High triglycerides, low HDL	Myopathy (especially with statins), cholelithiasis
Niacin (Nicotinic acid)	Inhibits lipolysis in adipose; ↓ VLDL synthesis	↓ TG, ↑ HDL	Flushing (most common - reduced by aspirin pretreatment), hyperglycemia, hyperuricemia
Bile acid sequestrants	Cholestyramine, Colestipol	Bind bile acids in gut → ↑ bile acid synthesis from cholesterol → ↓ LDL	High LDL (safe in pregnancy)	Constipation, bloating, ↓ fat-soluble vitamin absorption
Ezetimibe	Inhibits NPC1L1 → ↓ cholesterol absorption from gut	High LDL (add-on to statins)	GI upset, myopathy (rare)

F. ANTICOAGULANTS

Drug	Mechanism	Uses	Antidote / Reversal	Key Side Effects
Heparin (unfractionated)	Activates antithrombin III → inhibits IIa (thrombin) and Xa	DVT, PE, acute MI (IV/SC)	Protamine sulfate	HIT (Heparin-Induced Thrombocytopenia), bleeding
Low Molecular Weight Heparin (LMWH)	Activates antithrombin III → primarily inhibits Xa	DVT prophylaxis and treatment, ACS, pregnancy	Protamine sulfate (partial)	HIT (less common than UFH), bleeding
Warfarin	Inhibits vitamin K epoxide reductase → ↓ clotting factors II, VII, IX, X, Protein C and S	DVT, PE, AF, prosthetic valves (oral)	Vitamin K (slow); FFP/PCC (rapid)	Bleeding, teratogenic (crosses placenta), skin necrosis
Direct Oral Anticoagulants (DOACs)	Rivaroxaban, Apixaban (anti-Xa); Dabigatran (anti-IIa/direct thrombin inhibitor)	AF, DVT/PE prophylaxis and treatment	Andexanet alfa (anti-Xa); Idarucizumab (dabigatran)	Bleeding

Exam tip: Heparin antidote = Protamine sulfate. Warfarin antidote = Vitamin K (slow) or Fresh Frozen Plasma (emergency).

G. ANTIPLATELET DRUGS

Drug	Mechanism	Uses	Side Effects
Aspirin	Irreversibly inhibits COX-1/COX-2 → ↓ thromboxane A2 (TXA2) → ↓ platelet aggregation	ACS, post-MI, stroke prophylaxis, antianginal	GI irritation/ulcers, Reye syndrome in children, aspirin-exacerbated asthma
Clopidogrel, Ticagrelor, Prasugrel	Block ADP P2Y12 receptor → ↓ platelet aggregation	ACS, post-PCI/stent placement (dual antiplatelet therapy with aspirin)	Bleeding; clopidogrel: resistant if CYP2C19 poor metabolizer
Dipyridamole	Inhibits phosphodiesterase + adenosine uptake → ↑ cAMP → ↓ platelet aggregation	Stroke prophylaxis (with aspirin)	Headache, flushing, dizziness
GPIIb/IIIa inhibitors	Abciximab, Eptifibatide	Block fibrinogen binding to platelets → prevent aggregation	Acute PCI, ACS

H. FIBRINOLYTIC (THROMBOLYTIC) DRUGS

Drug	Mechanism	Uses	Contraindications	Side Effects
Streptokinase, Alteplase (tPA), Tenecteplase	Activate plasminogen → plasmin → dissolves fibrin clot	Acute MI (STEMI), massive PE, acute ischaemic stroke (within window)	Recent surgery, active bleeding, haemorrhagic stroke history, uncontrolled hypertension	Haemorrhage (major risk), allergic reactions (streptokinase)

Exam tip: Streptokinase is antigenic (derived from streptococci) - contraindicated if given in the past 12 months or recent strep infection.

I. HAEMATINICS (Iron, B12, Folate)

Drug	Mechanism	Uses	Side Effects
Ferrous sulfate/gluconate (Iron)	Replaces iron stores → ↑ haemoglobin synthesis	Iron-deficiency anaemia	Constipation, dark stools, GI irritation; overdose: hepatotoxicity (antidote = deferoxamine)
Vitamin B12 (Cyanocobalamin, Hydroxocobalamin)	Cofactor for DNA synthesis and myelin maintenance	Pernicious anaemia, B12 deficiency	Injection site reactions; essentially non-toxic
Folic Acid	Required for DNA synthesis (1-carbon transfer)	Megaloblastic anaemia, pregnancy (neural tube defect prevention), methotrexate toxicity	Masks B12 deficiency neurological symptoms if given without B12

Exam tip: Always give B12 AND folate together in pernicious anaemia. Folate alone can correct the anaemia but worsen the neurological damage of B12 deficiency.

QUICK SUMMARY TABLE - KEY ANTIDOTES & REVERSALS

Drug	Antidote/Reversal
Heparin	Protamine sulfate
Warfarin (slow)	Vitamin K
Warfarin (emergency)	Fresh Frozen Plasma (FFP) / PCC
Digoxin	Digoxin-specific Fab antibody (Digibind)
Iron overdose	Deferoxamine
Opioids	Naloxone
Benzodiazepines	Flumazenil
Paracetamol	N-acetylcysteine

EXAM PATTERN - HIGH-YIELD POINTS

Topic	Most Common Exam Trap
Digoxin	Hypokalemia → toxicity; narrow TI; yellow-green vision
ACE inhibitors	Dry cough (bradykinin); contraindicated in pregnancy
ARBs vs ACEi	ARBs = no cough; both = hyperkalemia and teratogenic
Loop vs Thiazide	Loop = hypocalcemia; Thiazide = hypercalcemia
Potassium-sparing diuretics	Hyperkalemia; do NOT combine with ACEi
Heparin	Protamine antidote; HIT = thrombocytopenia
Amiodarone	Pulmonary fibrosis + thyroid dysfunction + blue skin
Methyldopa	Drug of choice in pregnancy HTN
Statins	Myopathy/rhabdomyolysis; teratogenic
Aspirin	Irreversible COX inhibitor; avoid in children (Reye syndrome)

Source: Lippincott Illustrated Reviews: Pharmacology - KMTC KMT/QP-07/COL syllabus coverage, Weeks 12-16These notes cover your full syllabus (Weeks 12-16) with tables organized by drug class, mechanism, uses, and side effects - exactly the format examiners test. A few things to note:

What's included:

Week 12 - Respiratory drugs: β2 agonists, methylxanthines, ICS, leukotriene modifiers, anticholinergics, mast cell stabilizers
Week 13 - All 5 diuretic classes with nephron site of action
Weeks 14-16 - Full cardiovascular coverage: cardiac glycosides, anti-anginals (nitrates, beta-blockers, CCBs), antihypertensives (ACEi, ARBs, alpha blockers, central agents, vasodilators), antiarrhythmics (all 4 Vaughan-Williams classes + digoxin + adenosine), dyslipidaemia drugs, anticoagulants, antiplatelets, fibrinolytics, and haematinics

For your exam, prioritize:

Protamine sulfate as heparin antidote
Hypokalemia + digoxin toxicity link
ACEi dry cough vs ARBs (no cough)
Loop = hypocalcemia / Thiazide = hypercalcemia
Amiodarone's many side effects
Methyldopa for pregnancy hypertension

Reproductive health kmtc 2.1 topics

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📚 KMTC REPRODUCTIVE HEALTH 2.1 - Exam-Oriented Notes

Sources: Ganong's Review of Medical Physiology | Textbook of Family Medicine | Creasy & Resnik's Maternal-Fetal Medicine | The Developing Human (Embryology)

TOPIC 1 - FEMALE REPRODUCTIVE ANATOMY & PHYSIOLOGY

External Genitalia (Vulva)

Structure	Description / Function
Mons pubis	Fatty pad over symphysis pubis; covered by pubic hair after puberty
Labia majora	Two folds of skin with fat and sebaceous glands; outer protection
Labia minora	Inner folds; no fat; rich in nerve endings and blood vessels
Clitoris	Erectile tissue; highly sensitive; analogue of penis
Vestibule	Area between labia minora; contains urethral and vaginal openings
Bartholin's glands	(Greater vestibular glands) - produce lubricating mucus during arousal
Hymen	Thin membrane partially covering vaginal opening

Internal Reproductive Organs

Organ	Structure & Function
Vagina	8-10 cm fibromuscular tube; birth canal; acidic pH (3.5-4.5) due to lactobacilli - protects against infection
Uterus	Pear-shaped; 3 layers: perimetrium (outer), myometrium (middle - smooth muscle), endometrium (inner - shed in menstruation)
Cervix	Lower part of uterus; produces mucus; dilates during labour; 3-4 cm long
Fallopian tubes	10 cm; site of fertilisation (ampulla); fimbriae pick up ovum; cilia and peristalsis move ovum to uterus
Ovaries	Paired female gonads; produce ova + estrogen and progesterone

Exam tip: Parts of uterus: Fundus (top), Body (middle), Isthmus (junction), Cervix (bottom). The ampulla of the fallopian tube is the commonest site of ectopic pregnancy.

Ovarian Cycle (28-day cycle)

Phase	Days	Events	Key Hormones
Follicular phase	Days 1-13	FSH stimulates follicle development; dominant (Graafian) follicle selected by day 6; granulosa cells produce estrogen	FSH rising, Estrogen rising
Ovulation	Day 14	LH surge triggers rupture of Graafian follicle; ovum released into peritoneal cavity; picked up by fimbriae	LH surge (peak)
Luteal phase	Days 15-28	Ruptured follicle becomes corpus luteum → secretes estrogen + progesterone; if no fertilisation, corpus luteum degenerates → corpus albicans	Progesterone dominant

Endometrial (Uterine) Cycle

Phase	Days	Events
Menstrual phase	Days 1-4	Shedding of functional layer of endometrium; blood loss ~30-80 mL
Proliferative phase	Days 5-13	Estrogen causes endometrial regrowth and thickening
Secretory phase	Days 15-28	Progesterone causes glands to secrete glycogen; prepares for implantation
Ischaemic phase	Day 27-28	Corpus luteum degenerates → progesterone/estrogen fall → spiral arteries constrict → endometrium ischaemic → menstruation begins

Hormonal Control Summary

Hormone	Source	Action
GnRH	Hypothalamus	Stimulates anterior pituitary to release FSH and LH
FSH	Anterior pituitary	Stimulates follicle growth; stimulates estrogen production by granulosa cells
LH	Anterior pituitary	Mid-cycle surge triggers ovulation; stimulates corpus luteum formation and progesterone secretion
Estrogen	Granulosa cells / corpus luteum	Endometrial proliferation; positive feedback on LH at mid-cycle; breast development; secondary sexual characteristics
Progesterone	Corpus luteum (+ placenta in pregnancy)	Endometrial secretory changes; maintains pregnancy; inhibits uterine contractions; raises BBT
hCG	Trophoblast (after fertilization)	Maintains corpus luteum in early pregnancy; basis of pregnancy test

Exam tip: Basal Body Temperature (BBT) rises 0.2-0.5°C after ovulation due to progesterone. Useful in detecting ovulation.

TOPIC 2 - MENSTRUAL DISORDERS

Condition	Definition	Common Causes	Management
Amenorrhoea (Primary)	No menstruation by age 16	Gonadal dysgenesis (Turner syndrome 45X0), imperforate hymen, hypothalamic dysfunction	Investigate: karyotype, hormone levels
Amenorrhoea (Secondary)	Cessation of periods for ≥3 months in previously menstruating woman	Pregnancy (rule out first!), PCOS, hypothyroidism, hyperprolactinaemia, stress/weight loss	Pregnancy test, TFTs, prolactin levels
Dysmenorrhoea (Primary)	Painful periods without pelvic pathology	Excess prostaglandins → uterine contractions	NSAIDs (e.g., ibuprofen), COCPs
Dysmenorrhoea (Secondary)	Painful periods with pelvic pathology	Endometriosis, fibroids, PID	Treat underlying cause
Menorrhagia	Heavy periods (>80 mL/cycle) or >7 days	Fibroids, endometrial polyps, PCOS, coagulopathy, IUD	Norethisterone, COCPs, tranexamic acid; investigate cause
Metrorrhagia	Irregular uterine bleeding between periods	Cervical polyps, cancer, pregnancy complications	Pelvic exam, ultrasound, biopsy
Oligomenorrhoea	Infrequent periods (cycle >35 days)	PCOS (most common), thyroid disease, hyperprolactinaemia	Hormone profile, ultrasound

TOPIC 3 - FAMILY PLANNING / CONTRACEPTION

Methods Classification

Category	Methods	Mechanism	Efficacy (Pearl Index)
Natural/Fertility Awareness	Calendar/Rhythm, Cervical mucus (Billings), Symptothermal, LAM	Identify fertile days; abstain	Low - 10-20% failure rate with typical use
Barrier	Male condom, Female condom, Diaphragm + spermicide, Cervical cap	Physical/chemical block to sperm	Condom: 85-98%; also STI protection
Combined Oral Contraceptive Pill (COCP)	Ethinyl estradiol + progestin	Inhibit LH surge → prevent ovulation; thicken cervical mucus; thin endometrium	>99% with perfect use
Progestin-Only Pill (POP / Mini-pill)	Norethindrone	Thicken cervical mucus; may suppress ovulation	~99% with perfect use; used in breastfeeding mothers
Injectable	DMPA (Depo-Provera) 150mg IM every 3 months	Suppress ovulation, thicken cervical mucus	>99%
Implant	Etonogestrel (Implanon/Nexplanon) - subdermal, upper arm, 3 years	Suppress ovulation, thicken cervical mucus	>99.9% - most effective reversible method
Intrauterine Device (IUD)	Copper IUD (non-hormonal); Levonorgestrel-IUS (Mirena)	Copper: toxic to sperm; LNG-IUS: thicken mucus + thin endometrium	>99%
Emergency Contraception	Levonorgestrel (Plan B) within 72 hrs; Copper IUD within 5 days	Delay/prevent ovulation; does NOT cause abortion	LNG: 75-89%; Copper IUD: >99%
Permanent / Surgical	Female tubal ligation; Male vasectomy	Prevent sperm-egg meeting	>99.9%

COCP: Side Effects & Contraindications

Side Effects	Contraindications
Nausea, breast tenderness, headache, mood changes	History of DVT/PE or thromboembolic disorders
Breakthrough bleeding	Migraine with aura
↑ risk VTE (estrogen component)	Smoking + age >35
Hypertension	Uncontrolled hypertension
↓ libido	Hepatic disease / active liver disease
Rarely: stroke (especially with migraine + aura)	Breastfeeding <6 weeks postpartum

Exam tip: Copper IUD is the most effective form of emergency contraception. DMPA is safe in breastfeeding. Tubal ligation is done via minilaparotomy or laparoscopy.

TOPIC 4 - ANTENATAL CARE (ANC)

Goals of ANC

Monitor maternal and fetal well-being
Detect and manage complications early
Provide health education and counseling
Prepare woman for labour, delivery, and postnatal care
Reduce maternal and perinatal morbidity and mortality

ANC Schedule (WHO Recommended - Focused ANC)

Visit	Timing	Key Activities
1st visit	As soon as pregnancy confirmed (before 12 weeks)	History, physical exam, BP, weight, height, fundal height; lab tests; calculate EDD; begin iron + folic acid
2nd visit	16 weeks	Review lab results; check fetal growth; screen for pre-eclampsia
3rd visit	24-28 weeks	Fundal height; glucose screening (GDM); Hb; fetal movement
4th visit	32 weeks	Presentation (lie/presentation), fetal wellbeing; review birth plan
5th visit	36 weeks	Fetal presentation, referral if abnormal; preparation for delivery
6th-8th visits	38-40 weeks	Cervical assessment, fetal wellbeing, delivery planning

First Antenatal Visit - Routine Investigations

Investigation	Reason
Blood group + Rh factor	Identify risk of haemolytic disease of newborn
Full blood count (FBC)	Detect anaemia
Urinalysis	Detect UTI, proteinuria (pre-eclampsia), glycosuria (GDM)
VDRL/RPR	Screen for syphilis
HIV test (with consent)	PMTCT (Prevention of Mother-to-Child Transmission)
Malaria blood film	In endemic areas (e.g., Kenya)
Blood glucose / HbA1c	Screen for diabetes
Pap smear (if due)	Screen for cervical cancer

Calculating EDD (Naegele's Rule)

EDD = LMP + 9 months + 7 days (or LMP - 3 months + 7 days + 1 year)

Example: LMP = 1st August → EDD = 8th May (next year)

Fundal Height as Gestational Age Guide

Weeks Gestation	Fundal Height Location
12 weeks	Just above symphysis pubis
16 weeks	Midway between symphysis and umbilicus
20 weeks	At umbilicus
28 weeks	4 fingers above umbilicus
36 weeks	At xiphisternum
40 weeks	Slightly lower (lightening - head engages)

Exam tip: Fundal height in cm ≈ weeks of gestation after 20 weeks (McDonald's rule). Discrepancy of >2 cm needs investigation.

Physiological Changes in Pregnancy

System	Change
Cardiovascular	↑ cardiac output (40-50%); ↓ BP in 2nd trimester; ↑ HR; physiological anaemia (plasma volume increases more than RBC mass)
Respiratory	↑ tidal volume; ↓ residual volume; mild hyperventilation (respiratory alkalosis)
Renal	↑ GFR and renal blood flow; glycosuria can be normal; mild hydronephrosis (right > left)
Haematological	↑ plasma volume → dilutional anaemia; ↑ WBC; hypercoagulable state (↑ clotting factors) → DVT risk
GI	Morning sickness (hCG); constipation (progesterone slows motility); heartburn (relaxation of LOS)
Skin	Linea nigra, melasma (chloasma), striae gravidarum, spider naevi

Danger Signs in Pregnancy (refer urgently)

Vaginal bleeding at any time
Severe headache, visual disturbances, oedema of face/hands → pre-eclampsia
Fever > 38°C
Reduced/absent fetal movements after 28 weeks
Leaking liquor before labour (PROM)
Severe abdominal pain
Convulsions/fitting

TOPIC 5 - NORMAL LABOUR AND DELIVERY

Definition of Labour

Regular, painful uterine contractions causing progressive cervical effacement and dilation, with descent of the presenting part.

True vs False Labour

Feature	True Labour	False Labour (Braxton-Hicks)
Contractions	Regular, increasing frequency and intensity	Irregular, do not intensify
Cervical change	Progressive dilation and effacement	No cervical change
Location of pain	Starts in back, radiates to front	Mainly abdominal
Walking	Contractions intensify	Contractions may stop

Stages of Labour

Stage	Definition	Duration (Primigravida)	Duration (Multigravida)
1st Stage	Onset of regular contractions → full cervical dilation (10 cm)	~12 hours	~7 hours
- Latent phase	0 - 3 cm dilation	Slow progress
- Active phase	4 - 10 cm dilation	~1 cm/hour expected
2nd Stage	Full dilation → delivery of baby	~50 minutes	~20 minutes
3rd Stage	Delivery of baby → expulsion of placenta	15-30 minutes	Same
4th Stage	First 1-2 hours post-delivery	Monitoring for PPH	Same

Active Management of 3rd Stage of Labour (AMTSL)

Oxytocin 10 IU IM immediately after delivery of baby (within 1 minute)
Controlled cord traction (Brandt-Andrews manoeuvre) after signs of placental separation
Uterine massage after placenta delivered

Exam tip: AMTSL reduces risk of PPH by 60%. Signs of placental separation: lengthening of cord, gush of blood, uterus becomes globular and rises.

Cardinal Movements of Labour (Mechanism of Normal Delivery - Vertex Presentation)

Movement	Description
1. Engagement	Biparietal diameter passes through pelvic inlet
2. Descent	Fetal head descends through pelvis
3. Flexion	Head flexes (chin to chest) to present smallest diameter
4. Internal rotation	Occiput rotates to front (OA position)
5. Extension	Head extends as it passes under symphysis pubis
6. Restitution	Head rotates back to align with shoulders
7. External rotation	Shoulders rotate to AP diameter
8. Expulsion	Delivery of shoulders and rest of body

Partograph - Key Points

Monitors progress of labour graphically
Alert line: cervical dilation at 1 cm/hour
Action line: 4 hours to the right of alert line
Also records: FHR, contractions, descent, BP, pulse, urine, medications
Cervical dilation crossing the action line = need for intervention/referral

TOPIC 6 - POSTNATAL CARE (PUERPERIUM)

Definition

Period from delivery of placenta to 6 weeks postpartum when body returns to pre-pregnant state.

Normal Postnatal Changes

System	Change	Timeline
Uterus (involution)	Uterus shrinks back to pre-pregnancy size	By 6 weeks; descends ~1 cm/day; not palpable abdominally by 2 weeks
Lochia (vaginal discharge)	Lochia rubra (red) → lochia serosa (pink/brown) → lochia alba (yellow-white)	Rubra: days 1-4; Serosa: days 5-10; Alba: days 10-21
Cervix	Returns to pre-pregnant state (external os remains slightly open)	By 6 weeks
Pulse	Drops within 24 hours	First 24 hrs
Temperature	May be slightly raised (<38°C) in first 24 hrs due to dehydration	Day 1
WBC	Marked leukocytosis (up to 20,000/μL) in first 24 hrs	Normalises by 1 week
Diuresis	Marked - body eliminates excess fluid of pregnancy	Days 2-5
Breastfeeding	Colostrum initially → mature milk by day 3-4	Oxytocin causes milk ejection ("let-down") and uterine contractions

Postnatal Care Schedule

Timing	Assessment
Immediately (0-24 hrs)	Vital signs, uterine tone, blood loss, lochia, perineum, bladder function, initiate breastfeeding
24-48 hrs	Same as above + bowel function, episiotomy healing, ambulation, emotional wellbeing
Day 3-5	Uterine involution, lochia, breastfeeding assessment, cord care
6 weeks	Full postnatal check: uterine involution, cervical smear if due, family planning counselling, immunisation, infant wellbeing

Postnatal Complications

Complication	Definition	Cause	Management
Primary PPH	Blood loss ≥500 mL (vaginal) or ≥1000 mL (CS) within 24 hours of delivery	The "4 T's": Tone (uterine atony - 80%), Trauma, Tissue (retained placenta), Thrombin (coagulopathy)	Oxytocin, ergometrine, misoprostol; bimanual compression; blood transfusion; surgery
Secondary PPH	Excessive bleeding 24 hrs to 12 weeks postpartum	Retained products of conception, endometritis	Antibiotics, oxytocics, ERPC
Puerperal pyrexia	Temperature ≥38°C on any 2 of days 1-10 postpartum	Endometritis (most common), UTI, wound infection, mastitis, DVT	Identify source; antibiotics
Endometritis	Uterine infection	Ascending infection; risk after prolonged labour, PROM, CS	Broad-spectrum antibiotics (ampicillin + gentamicin + metronidazole)
Mastitis	Breast inflammation	S. aureus; milk stasis	Continue breastfeeding; flucloxacillin; analgesia
Postnatal depression	Persistent low mood >2 weeks after delivery	Hormonal, psychosocial	Counselling, antidepressants (sertraline safe in breastfeeding)

Exam tip: "Baby Blues" (days 3-5, transient tearfulness) is NORMAL and resolves spontaneously. Postnatal depression is prolonged (>2 weeks) and requires treatment. Puerperal psychosis is a psychiatric emergency.

TOPIC 7 - OBSTETRIC COMPLICATIONS

Hypertensive Disorders of Pregnancy

Condition	Definition	Features	Management
Gestational hypertension	BP ≥140/90 after 20 weeks; NO proteinuria	No systemic features	Monitor closely; antihypertensives if severe
Pre-eclampsia (mild)	BP ≥140/90 after 20 weeks + proteinuria ≥0.3g/24hrs	Headache, oedema	Bed rest, antihypertensives, close monitoring, MgSO4 seizure prophylaxis
Pre-eclampsia (severe)	BP ≥160/110 + significant proteinuria >5g/24hrs + end-organ damage	Visual disturbances, RUQ pain, oliguria, pulmonary oedema	IV MgSO4; antihypertensives (IV hydralazine/labetalol); DELIVER
Eclampsia	Convulsions in woman with pre-eclampsia	Grand mal seizures; may occur before, during or after labour	IV MgSO4 (4g loading dose, 2g/hr maintenance); control BP; deliver
HELLP Syndrome	Complication of severe pre-eclampsia	Hemolysis, Elevated Liver enzymes, Low Platelets	Urgent delivery; steroids; supportive care
Chronic hypertension	Pre-existing HTN before 20 weeks	BP elevated from early pregnancy	Methyldopa (drug of choice in pregnancy); labetalol

Exam tip - MgSO4 toxicity signs: Loss of deep tendon reflexes (first sign) → respiratory depression → cardiac arrest. Antidote = Calcium gluconate 10 mL of 10% IV.

Antepartum Haemorrhage (APH) - bleeding after 24 weeks

Condition	Definition	Clinical Features	Management
Placenta praevia	Placenta lying over or near internal os	Painless bright red vaginal bleeding; soft uterus; abnormal lie	NO vaginal examination! Ultrasound; C-section if grade III/IV or bleeding
Abruptio placentae	Premature separation of normally sited placenta	Painful dark bleeding; woody hard/tender uterus; fetal distress	Emergency C-section if severe; blood transfusion

Exam mnemonic: Placenta praevia = Painless; Abruptio = Agonizing. Couvelaire uterus (blue-purple bruised uterus) occurs in severe abruptio.

Postpartum Haemorrhage - The 4 T's

Cause	Frequency	Example	Specific Treatment
Tone (uterine atony)	80%	Uterus fails to contract	Oxytocin, ergometrine, misoprostol; bimanual compression
Trauma	10%	Perineal/vaginal/cervical tears, uterine rupture	Suture lacerations; surgery
Tissue	5-10%	Retained placenta or membranes	Manual removal of placenta, ERPC
Thrombin	Rare	DIC, coagulopathy	FFP, cryoprecipitate, platelets

Other Obstetric Emergencies

Emergency	Cause / Definition	Management
Shoulder dystocia	Head delivered but shoulders impacted; associated with macrosomia, GDM, obesity	McRoberts manoeuvre (hyperflexion of thighs); suprapubic pressure; episiotomy; Rubin/Woods screw; Zavanelli
Cord prolapse	Umbilical cord slips through cervix before baby	Emergency: elevate presenting part; knee-chest position; urgent C-section
Uterine inversion	Uterus turns inside out after delivery	Manual replacement (Johnson's manoeuvre); IV fluids; oxytocin only AFTER replacement
Ruptured ectopic	Ectopic pregnancy in fallopian tube ruptures	Emergency surgery; resuscitation

TOPIC 8 - BREASTFEEDING

Benefits

For Baby	For Mother
Best nutrition (perfect composition)	Uterine involution (oxytocin)
Passive immunity (secretory IgA in colostrum)	Reduced risk of breast/ovarian cancer
Reduces infections (diarrhoea, LRTI)	Promotes weight loss
Bonding	Natural contraception (LAM)
Reduces SIDS risk	Cost-free

WHO Recommendations

Exclusive breastfeeding for first 6 months (no water, formula, or solids)
Continue breastfeeding up to 2 years alongside complementary foods

Lactational Amenorrhoea Method (LAM) - Valid when ALL 3 criteria met:

Baby is <6 months old
Mother is fully/exclusively breastfeeding
Mother is amenorrhoeic

Efficacy: >98% if all 3 criteria met.

TOPIC 9 - SEXUALLY TRANSMITTED INFECTIONS (STIs) IN REPRODUCTIVE HEALTH

STI	Causative Agent	Key Features	Treatment
Syphilis	Treponema pallidum	Primary: painless chancre; Secondary: rash on palms/soles; Tertiary: gummas, cardiovascular, neurosyphilis	Benzathine penicillin G (drug of choice)
Gonorrhoea	Neisseria gonorrhoeae	Purulent discharge; dysuria; PID; neonatal conjunctivitis (ophthalmia neonatorum)	Ceftriaxone 250mg IM single dose
Chlamydia	Chlamydia trachomatis	Often asymptomatic; most common STI; can cause PID, ectopic, infertility	Azithromycin 1g single dose OR doxycycline 7 days
Trichomonas	Trichomonas vaginalis	Frothy yellow-green offensive discharge; strawberry cervix; pruritus	Metronidazole 2g single dose (treat both partners)
Bacterial Vaginosis	Gardnerella vaginalis (not an STI)	Fishy-smelling greyish discharge; clue cells; positive whiff test; pH >4.5	Metronidazole 400mg BD x 7 days
Candidiasis	Candida albicans (not an STI)	Thick white "cottage cheese" discharge; pruritus; no odour	Clotrimazole (topical) or Fluconazole 150mg PO

HIGH-YIELD EXAM POINTS - REPRODUCTIVE HEALTH 2.1

Topic	Key Exam Fact
Most effective reversible contraception	Implant (>99.9%)
Emergency contraception - best	Copper IUD within 5 days
Drug of choice - HTN in pregnancy	Methyldopa
Drug of choice - eclampsia seizures	Magnesium sulphate (MgSO4)
MgSO4 toxicity antidote	Calcium gluconate 10% IV
Antidote for PPH	Oxytocin (first line); Ergometrine (if not hypertensive)
Most common cause of PPH	Uterine atony (80%)
Painless APH	Placenta praevia
Painful APH	Abruptio placentae
Dangerous sign: Lochia rubra lasting >2 weeks	Retained products of conception
HELLP acronym	Haemolysis + Elevated Liver enzymes + Low Platelets
Naegele's Rule	EDD = LMP + 9 months + 7 days
Fundal height at 20 weeks	Level of umbilicus
LAM - 3 criteria	<6 months + exclusive breastfeeding + amenorrhoea
Colostrum immunoglobulin	Secretory IgA (passive immunity to newborn)
Most common cause puerperal pyrexia	Endometritis
Candidiasis discharge type	Thick white "cottage cheese"
BV (Bacterial Vaginosis) sign	Positive Whiff test (fishy smell + KOH)
Syphilis drug of choice	Benzathine Penicillin G

Sources: Ganong's Review of Medical Physiology | Textbook of Family Medicine 9e | Creasy & Resnik's Maternal-Fetal Medicine | The Developing Human (Clinically Oriented Embryology) | Goldman-Cecil MedicineThese notes cover all standard KMTC Reproductive Health 2.1 topics with 9 complete sections:

What's included:

Female Reproductive Anatomy & Physiology - internal/external organs, ovarian cycle, endometrial cycle, hormones (FSH, LH, estrogen, progesterone, hCG)
Menstrual Disorders - amenorrhoea, dysmenorrhoea, menorrhagia, oligomenorrhoea
Family Planning / Contraception - all methods, efficacy, COCP contraindications, emergency contraception
Antenatal Care - ANC schedule, investigations, Naegele's rule, fundal height guide, physiological changes, danger signs
Normal Labour - stages of labour (durations for primi vs multi), cardinal movements, partograph, AMTSL
Postnatal Care (Puerperium) - lochia changes, uterine involution, complications (PPH, endometritis, mastitis, PND)
Obstetric Complications - pre-eclampsia/eclampsia/HELLP, APH (placenta praevia vs abruptio), PPH 4 T's, obstetric emergencies
Breastfeeding - benefits, WHO recommendations, LAM criteria
STIs in Reproductive Health - gonorrhoea, chlamydia, syphilis, trichomonas, BV, candidiasis

Top exam tips to remember:

Methyldopa = HTN in pregnancy; MgSO4 = eclampsia; Calcium gluconate = MgSO4 antidote
Painless bleeding = placenta praevia; Painful = abruptio
Uterine atony causes 80% of PPH - treat with oxytocin first
LAM requires ALL 3 criteria to be effective

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