azythromycin 1 g PO single dose

OR

doxycycline 100 mg PO BID x 7 days

ceftriaxone 250 mg IM single dose (#1)

OR

Cefixime 400 mg PO single dose

OR

cephalosporin single dose IM PLUS azithromycin 1 g PO single dose OR doxy 100 mg PO BID x 7days (this combo technically covers chlamydia and gonorrhea)

empiric therapy should be initiated in sexually active women if they experience pelvic or lower abdominal pain, if no other cause of illness other than PID can be identified, and if one or more of the following minimum criteria are present on exam:  

cervical motion tenderness OR uterine OR adnexal tenderness

oral temp > 100 F

abnml cervical or vaginal mucopurulent d/c

abundant #a of WBCs on vaginal saline microscopy

elevated CRP or sed rate

lab documentation of GC or chlamydia infection

surgical emergency cannot be excluded (appendicitis)

pt cannot tolerate oral meds

pt does not respond to oral meds

pt is pregnant

pt has severe illness (N/V, high fever)

pt has tubo-ovarian abscess

cefotetan 2 g IV Q 12 hrs  OR  Cefoitin 2 g IV q 6 hrs PLUS doxycycline 100 mg PO or IV Q 12 hrs

clindamycin 900 mg IV Q 8 hrs PLUS Gentamicin IV or IM (loading doses and based on weight)

*the lecture notes do not say if those two lines are an either/or type thing or if both are required

ceftriaxone 250 mg IM single dose PLUS doxy 100 mg PO BID x 14 days w/ or w/o metronidazole 500 mg PO BID x 14 days  (most common)

OR

cefoxitin 2 g IM single dose / probenecid 1 g PO concurrently single dose PLUS doxy BID x 14 days w/ or w/o metro BID x 14 days

*there are others, just to be aware, but didn't add them*

f/u w/in 3 days of initiating oral tx

metrinidazole 2 g PO single dose

OR

tinidazole 2 g PO single dose

alternate: metronidazole 500 mg PO BID x 7 days

acyclovir 400 mg PO TID or QID x 7 - 10 days

OR

famciclovir 250 mg PO TID x 7 - 10 days

OR

valacyclovir 1 g PO BID x 7 - 10 days

acyclovir 400 mg PO TID x 5 days OR 800 mg PO BID x 5 days OR 800 mg PO TID x 2 days

OR

famcyclovir 125 mg PO BID x 5 days or 1 g PO BID x 1 day

OR

valacyclovir 500 mg BID x 3 days or 1 g PO QD x 5 days

acyclovir 400 mg PO BID

OR

famciclovir 250 mg PO BID

OR

valacyclovir 500 - 1000 mg PO QD

azithromycin 1 g PO single dose

OR

ceftriaxone 250 mg IM single dose

OR

erythromycin 500 mg PO TID x 7 days

OR

cipro 500 mg PO BID x 3 days

doxycycline 100 mg PO BID (recommended)

OR

azithromycin 1 g PO once weekly

OR

cipro 750 mg PO BID

3 weeks duration or until all lesions have healed

doxycycline 100 mg PO BID x 21 days (recommended)

OR

erythromycin 500 mg PO QID x 21 days

treatment of primary, secondary, and early latent syphilis

treatment of late latent syphilis

treatment of neurosyphilis

benzathine penicillin G 2.4 million units IM single dose

benzathine penicillin G 2.4 million units IM x 3 @ 7 day intervals

aqueous penicillin G 18 - 24 million units IV once daily (3-4 million units Q 4 hrs or continuous) for 10 - 14 days

rapid rehydration

antistaph drugs

manage kidney or heart failure

addressing sources of toxins (removal or tampon or draining abscess)

cryotherapy - two cycles every 2 - 4 weeks for several visits

podophyllum resin - paint each wart q 2 - 3 weeks

trichloroacetic acid and bichloroacetic acid - weekly

surgical removal

podofilox 0.5% sol or gel - inexpensive (usually given during provider tx of podophyllum resin)

imiquimod 5% cream - immune enhancer

best tx is by curettage or applications of liquid nitrogen

ligh electrosurgery w/a fine needle is also effective

dysfunctional uterine bleeding

dysmenorrhea

endometriosis and adenomyosis

PCOS

acne

ovarian dysgenesis, turner's

premature menopause

menopause

blood dyscrasia

implanted subcutaneously in the upper arm

releases progestin for 3 years

progestin only methods of birth control

(mini pill, depo, implanon/nexplanon)

lack of monogamy, high risk for STIs

abnormal uterine bleeding

current pelvic infection (GC, chlamydia)

actinomyces on pap

pregnancy

wilson's dz, copper allergy - don't use paragard (can use mirena)

venous thrombosis

coronary vascular dz

CVA

current pregnancy

breast CA w/in last 5 years

endometrial CA

hepatic tumor or abnormal liver function

unexplained abnormal uterine bleeding

age > 35 + smoking

uncontrolled HTN

hx of melanoma

complicated, prolong DM

estrogen dependent neoplasms

depression

severe varicose veins

hypertriglyceridemia

an induced abortion in the first trimester is relatively safe

safest if performed at 8 weeks or sooner

medical abortion is an option w/in the first 49 days

oral antiprogestin (RU-486) followed by oral misoprostol 48 hours later

or

oral methotrexate followed by vaginal misoprostol 3 - 7 days later

intra-amniotic instillation of hypertonic NaCl (or hyperosmolar urea w/oxytocin or prostaglandin, or PG alone)

OR

vaginal prostaglandin

OR

dilation and evacuation (modified suction curettage)

topical vaginal antifungal preparations (OTC or Rx)

oral diflucan (fluconazole) 150 mg PO x 1 - repeat dose after 3 days if symptoms persist

if severe inflammation - combo azole and steroid

treatment of recurrent candidiasis

(4 or more episodes in 1 year)

metronidazole (flagyl) 500 mg BID x 7 days

OR

metrogel .75% 1 applicator qhs x 5 days

OR

clindamycin crm 2% 1 app qhs x 7 days

metro 500 mg PO BID x 7 days

OR

metro 250 mg PO TID x 7 days

OR

clindamycin 300 mg PO BID x 7 days

intravaginal estrogen

1/3 can get absorbed systemically, so it may be contraindicated in women w/hx of breast or endometrial cancer

GnRH agonists - limit growth

myomectomy - preserved fertility

hysteretomy

uterine fibroid emolization - recurrence less than w/myomectomy

endometrial ablation, myolysis, laparoscopic uterine artery occlusion, MR guided focused US surgery

hysterectomy w/ or w/o oophorectomy

hormonal therapy w/GnRH agonists

OCP

for infertility, clomid is effective

metformin may improve fertility rates

weight loss, diet, exercise - help w/insulin resistance

progestins

oral contraceptives (COCs) - most commonly prescribed therapy

GnRH agonists - inhibits the pulsatile GnRH release to induce anovulation

pelvic floor strengthening exercises/PT

pessary use

surgery

medroxyprogesterone acetate 5 - 10 mg / day for 10 - 14 days/month

medroxyprogesterone acetate 150 mg IM depo

norethindrone 5 - 20 mg/day

mirena IUD

premarin 25 mg IV q 4 - 6 hrs until bleeding stops or for 24 hours

conjugated estrogens 1.25 - 2.5 mg or 2 mg estradiol PO q 6 hrs until bleeding controlled

1 - 2 mg estradiol QD for 7 - 10 days

combo oral contraceptive pills

varied doses of estrogen dependent on cause of bleeding

monophasic less breakthrough bleeding

consider continuous use of combo OCPs

history and symptom diaries

consider ruling out thyroid disease, anemia conditions

treatment of premenstrual syndrome

non-pharm and pharm

nonpharm: increase Ca, limit caffeine/alcohol, increase complex carbs, Mg, Vit B6, Vit E

pharm: NSAIDs, spironolactone, SSRIs, hormonal (ovulation suppression

NSAIDs (consider narcotics)

heat pads

ibuprofen (400 - 800 mg PO Q 6 hrn PRN) naproxen 500 mg or naproxen sodium 550 mg PO q 12 hrs PRN

oral contraceptives - consider continuous use OCPs

consider surgical options is medical management fails and childbearing complete

transvaginal US - endometrial stripe < 4 mm, no need for biopsy

can consider endometrial biopsy

both can be done at the same time (clinical preference)

or is endometrial stripe is not able to be evaluaed (ex - fibroids) can then do further eval with a biopsy

hypothalamic amenorrhea:

GnRH deficiency, female athletes, eating d/o's

pituitary amenorrhea:

hyperprolactinemia, pituitary destruction

ovarian amenorrhea:

menopause, premaure failure, anovulation (PCOS)

PCOS

(aka Stein-Leventhal Syndrome)

what helps confirm the diagnosis of PCOS

(what ancillary study supports the typicaly physical findings?)

US findings of 10+ cystic follicles between 2 - 8 mm ("string of pearls")

increased LH levels

elevated DHEAS levels

metformin for pt's insulin resistance

OCPs or progesterone for acne and hirsutism and w/drawal bleeds

spironolactone - blocks androgen receptors

lipid lowering agents as appropriate

weight loss

surgery (oophorectomy, hysterectomy) for high CA risk pts

treatment of sertoli-leydig cell tumors

(ovarian cause of hirsutism)

total ABD hysterectomy w/bilateral salpingo-oophorectomy (those who don't want to get pregnant)

unilateral oophorectomy (for those desiring to get pregnant)

treatment of metastatic or recurrent sertoli-leydig cell tumors

(ovarian cause of hirsutism)

semen analysis (abstain for ejaculation for 2 - 3 days before) to check for sperm count and motility

if abnormal, repeat in a few weeks

anotomical abnormalities

sperm penetration assay

confirm ovulation w/serum progesterone assay (during luteal phase)

(looking for ovulatory factors - PCOS/anovulation, endometriosis)

pelvic exam - r/o abnormalities (PID, tubal pregnancies, DES exposure, fibroids)

hysterosalpingogram - assess tubal patency

laparoscopy

treat underlying causes (hypothyroidism,etc)

surgically correct varicoceles if present

ICIS (intracytoplasmic sperm injection into cytoplasm of oocyte)

use donor sperm

ovulation induction w/ovarian stimulant clomiphene citrate (clomid)

direct stimulation of ovary w/ human menopausal gonadotropin (hMG)

(ovary must be functional though)

tubal surgery if tubal disease present

artificial insemination

IVF

GIFT

as early as 10 weeks w/fetal dopper

w/fetoscope, heard at 20 weeks

with a normal rate of 120 - 160 bpm

TVUS in early pregnancy (5 - 13 weeks) 

measuring the crown to rump length

uterus is palpable where at:

8 weeks

12 weeks

16 weeks

20 weeks

8 weeks: at pubic symphysis

12 weeks: in the ABD

16 weeks: at midpoint b/t symphysis and umbilicus

20 weeks: at the umbilicus

by US - failure to visualize a fetal pole w/cardiac activity at the appropriate gestational age

serial serum beta-hCG levels may be helpful

first sign typically detected by mom - absence of fetal movement

absence of FHT by doppler

then real-time US virtually 100% accurate in determining absence of fetal heart motion

acceptable weight gain during pregnancy, in a pt w/normal BMI pre-pregnancy

acceptable weight gain in a pt w/obese BMI pre-pregnancy

normal BMI: up to 25 lbs

obese BMI: 10 - 15 lbs

hemodynamically significant heart dz

restrictive lung dz

incompetent cervix/cerclage

multifetal gestation at risk for PTL

persistent bleeding in 2nd and 3rd trimesters

placenta previa after 26 weeks

PTL in current pregnancy

ruptured membranes

pre-eclampsia or pregnancy induced HTN

severe anemia

unevaluated maternal cardiac arrhythmia

chronic bronchitis

poorly controlled T1 DM

extereme morbid obesity

extreme underweight (BMI < 12)

hx of extremely sedentary lifestyle

FGR in current pregnancy

poorly controlled HTN

orthopedic limitations

poorly controlled seizure d/o or hyperthyroidism

how many prenatal visits during 0 - 32 weeks

between 32 - 36 weeks

36+ weeks

0 - 32 weeks: prenatal visit every 4 weeks

32 - 36 weeks: every 2 weeks

36+ weeks: weekly

when is the 1 hr GTT test performed

triple or quad screening

CVS or Amnio

grop b strep swam

1 hr GTT: 24 - 28 weeks

triple or quad: 16 - 18 weeks +/- fetal survery

CVS/amnio: 16 - 20 weeks (correlate w/quad screening)

group b strep: 35 - 37 weeks

treatment of URI in pregnancy

treatment of UTI

PCNs generally well accepted

macrobid (but if pt has gone to pyelonephritis, can no longer use macrobid)

treatment of candidiasis in pregnancy

bacterial vaginosis

trichomoniasis

candidiasis:

topical miconazole or nystatin suppositories

BV:

oral clindamycin or metronidazole

trich:

metronidazole

treatment of chlamydia in pregnancy

gonorrhea

HSV

syphilis

HIV 

chlamydia:

erythromycine or single dose of azithromycin

GC:

ceftriaxone

HSV:

topical acyclovir to reduce symptoms

oral acyclovir for recurrent outbreaks

syphilis:

PCN, w/monthly seroligic testing to assess tx response

HIV:

highly active anti-retroviral therapy; intrapartum infusion of AZT

no lesion found at time of delivery 

no prodromal symptoms at time of delivery

if either of these are present - indications for c-sesction

fetal maturity confirmation is required prior to induction:

exact pregnancy dating

first trimester US measurements

and/or

amniotic fluid analysis

pre-eclampsia

diabetes

heart disease

hx of fast labors

prolonged pregnancy

Rh incompatibility

fetal abnormality

chorioamnionitis

premature ROM

placental insufficiency

suspected IUGR

contracted pelvis

placenta previa

uterine scar from classical c-section (transverse scar is a precaution)

myomectomy entering endometrium

hysterotomy

unification surgery

transverse lie

prostaglandins for induction at term (misoprostol or dinoprostone, followed by oxytocin)

relaxin (80% ripen and 1/3 induce labor as well in 12 hrs)

balloon catheter (passed into endocervix, ripens in 8 - 12 hrs, leaves cervix dilated 2-3 cm)

hygroscopic dilators (laminaria tents placed in endocervix for 6 - 12 hrs)

oxytocin (pitocin) - the most effective means of labor induction

amniotomy (but not effective as SOLE means of induction in most pts)

station zero (in terms of labor) is at the level of what anatomical position (of the woman)

a negative station ("minus") is above or below station zero?

a positive station ("plus") is above or below station zero?

station zero is the level of the ischial spines

minus is above this level

plus is below this level

presumed fetal compromise (cord prolapse, lack of fetal movement)

prolonged labor (poss dystocia, malpresentation, incompetent cervix)

maternal compromise (change in VS or LOC, seizure, placental abruption)

previous c-section

pathologic lie

fetal demise (twinning)

some multiples

possible macrosomia

typically caused by staph aureus

dicloxacillin empirically

should treat because 10% of these pts can progress to breast abscess

surgical drainage along langer lines

packing with gauze and daily dressing changes

some may heal w/simple aspiration

women who use street drugs or do not control alcohol use

infant w/galactosemia

infections: HIV, active untreated TB, Hep B ok if baby given Hep B IVIG

medications secreted in breast milk

acebutolol

atenolol

pentasa

bromocriptine

ASA

ergotamine

lithium

phenobarbital

primidone

sulfasalazine

choose drugs w/lower half life, poorer oral absorption or lower lipid solubility

gestational DM: Class A

pre-existing DM: Class B and higher

done at 24 - 28 weeks

done earlier if RFs for pre-existing DM:

prior GDM, prior macrosomic baby, maternal obesity, FHx of DM, PCOS

if pt has RFs, do it early, if that is neg, repeat at normal time (24 - 28 weeks)

3 hour GTT - 100 g glucose load, fasting

checking serum glucose at:

fasting, 1 hour, 2 hours, 3 hours

24 hour urine protein collection:

mild range: 300 mg - 5 g

severe range: > 5 g

BP elevated on bedrest 6 hrs apart:

mild: >140/90, but < 160/110

severe: > 160/110

AST > 69

LDH > 600

PLT < 100k

T bili: > 1.2

*an elevated uric acid may complement your dx but is not part of the diagnostic criteria

magnesium sulfate (when evaluating and when delivering)

bed rest

serial exams and BP monitoring

treat with hydralazine IV

labetalol IV

*must be on continuous external fetal monitoring

goal is to promote fetal lung maturity

betamethasone

timing of delivery in a pt w/ gestational HTN

mild pre-eclamptic pt

severe pre-eclampsia

CHTN w/superimposed pre-eclampsia

HELLP

eclampsia

GHTN: at term, 37 weeks

mild pre-eclampsia: at term, 37 weeks

severe pre-e:at 34 weeks or sooner, if end organ dz

CHTN w/pre-e:at 34 weeks or sooner, if end organ dz

HELLP: immediately

eclampsia: immediately

what additional prenatal workup is typically done in a pregnant pt with either gestational DM, pre-existing DM, or chronic HTN in pregnancy

(the work up is virtually the same for all of these)

US at 18 - 20 weeks for fetal anatomy survey (looking for anomalies)

*this is done for pre-existing and CHTN pts only, NOT GDM*

US at 28 weeks for fetal growth and then every 4 weeks

*for CHTN  it is started 4 weeks after the above US at 18-20 weeks, aka sooner*

NST weekly at 32 weeks

AFI weekly at 32 weeks, dopplers if IUGR

ACE-Is and ARBs

try to avoid in reproductive aged women, because 50% of all pregnancies are not planned - use alternative anti-HTN

what is the most common drug used for the medical management of a spontaneous abortion

whta is the surgical management

Medical: misoprostol

surgical: dilation and curettage (<12 weeks) or

dilation and evacuation (> 12 weeks)

unruptured

< 3.5 cm

no fetal cardiac activity

b hCG < 6500

abnormal renal/liver function

renal/liver dz

blood dyscrasia

PUD

active pulmonary dz

unreliable pt

what is typically given to a pt in preterm labor, between 24 - 34 weeks, to promote fetal lung maturity

what is given for neuroprotection (to try and prevent CP if < 32 weeks)

lung maturity: antenatal steroids - betamethasone

neuroprotection: magnesium

betamethasone

Abx for GBS prophy

tocolysis

Mg

bed and pelvic rest

monitoring

treatment of preterm PROM between 24 - 34 weeks

> 34 weeks

24 - 34 weeks:

antenatal steroids, abx for GBS prophy, +/- tocolysis, bed and pelvic rest, Mag, inpt management until delivery

deliver at 34 weeks or at onset of development of chorioamnionitis

> 34 weeks:

deliver

Rh neg non-sensitized pts get treated with:

rhogam at 28 weeks gestational age and at delivery if indicated or if any potential mixing of fetal/maternal blood (SAB, ectopic, vaginal bleeding)

pt is Rh negative and HAS the anti D antibody

refere to MFM for management - determine paternal antigen status - if father of child is negative, not at risk

treatment is for screening of fetal anemia, if fetal anemia is noted:

if < 34 weeks: steroids/serial PUBS fetal transfusion

if > 34 weeks: delivery and neonatal transfusion post-delivery

for all PPH's (not just atonic hemorrhage):

2 large bore IVs, begin IVF bolus

Stat CBC and coags

blood: crossmatch or emergency release

specific to atony:

uterotonics

uterine massage

evacuate clot

pitocin (restores tone)

cervical cerclage - in selected pts

placed at around 14 - 16 weeks, removed at term

sreial US's for growth q 4 weeks

antenatal testing begins once dx'ed:

consult OBGYN or MFM

weekly NST, AFI and dopplers for assessment of fetal well being

if well being not assured - perform next level of testing

if still not assured - possible delivery (give steroids if < 34 weeks)

> 5000 g in non-DM mother

> 4500 g in DM mother

dichorionic, diamniotic

(two placentas and two amnions)

monochorionic, diamniotic

(one placenta, two amnions)

there is a donor twin - IUGR and oligohydramnios

and there is a recipient twin - plethoric, polyhydramnios

a complete mole is the most common

*has higher risk for post molar malignancy than a partial mole*

US is used to establish the dx:

diffuse mixed echogenic pattern - "snowstorm appearance"

get CBC, CMP, TSH, FT4, CXR

evacuate the uterus with suction D&C:

have 2 large bore IVs

BRING blood products

bring uterotonics

prepare for hysterectomy

prepare for thyroid storm

ensure reliable contraception

check b hCG w/in 48 hours of evacuation

follow b hCG weekly x 1 month

then monthly x 1 year

*if plateaus or increases - needs eval for post molar malignancy sequelae - consult GYN ONC for management*

most common type of primary vaginal cancer

of primary vulvar cancer

BOTH: squamous cell carcinoma

careful inspection

colposcopy PLUS biopsy (gold standard)

hallmark treatment for VIN

follow-up

surgery is hallmark treatment

(wide excision, laser ablation, topical 5-FU/imiquimod, superficial vulvectomy)

follow up: pelvic exam + colposcopy q 3-4 months until dz free for 2 years, then q 6 months

if there is no underlying carcinoma, treat it the same as VIN

(diagnosis by a generous vulvar biopsy)

complete surgical removal of all tumor:

wide radial local excision or primary tumor, w/inguinal node dissection

OR

radical vulvectomy and regional lymphadenectomy

if extensive dz: pelvic exenteration w/radical vulvectomy

surgical excision or laser ablation (VAIN II or III, CIN)

multifocal - topical 5-FU (most regress after 1 - 2 courses of treatment)

primary vaginal CA cannot be established unless METS are eliminated

(cervical cytology, endometrial biopsy, complete inspection of vagina (colposcopy and biopsy of vaginal tumor), bimanual exam)

biopsy must first confirm disease

if primary - treat with XRT (whole pelvis external supplemented by internal)

if coitus a factor, consider surgery

indications for colposcopy

*said we definitely need to know for exam*

abnl pap w/ +HR HPV testing

DES exposure

visible lesion

+ screening test (HPV)

persistent unsatisfactory cells on pap

unexplained vaginal d/c

unexplained vulvar or cervical bleeding

surveillance s/p neoplasia

post-tx surveillance

ablation:

cryotherapy

laser ablation

excisional procedure:

cold knife conization

laser cone excision

LEEP

pap every 6 months for 18 - 24 months (endocervical curettage if endocervix involved)

OR

HPV testing performed w/first pap smear, and if both negative, f/u in 1 year

cytologic smears can MISS invasive carcinomas

biopsy of any abnormal lesion by colposcopy or conization in setting of in situ dz

staging is by clinical exam (FIGO)

adequate tx of precancerous conditions

early stage: radical hysterectomy and pelvic lymphadenectomy

OR primary radiation + chemo

local nodal dz:surgery + post-op XRT

locally advanced dz: primary XRT w/therapy

disseminated/persistent/recurrent:

limited use for chemo; if local recurrrence: total pelvic exenteration

if no atypia: may spontaneously resolve, or most regress w/progestin therapy

with atypia: most regress with progestin; if relapse, consider vaginal or ABD hysterectomy

surgery - total hysterectomy, BSO, staging

XRT pre-op

primary chemo - reserved for advanced dz's

doxorubicin or cisplatin

emergency - possible severe hemorrhage

surgery = cornerstone

total hysterectomy, BSO

adjuvant chemo (doxorubicin)

surgery PLUS chemo

cyclical (6) combo therapy most effective

radiation NOT useful

dx is clinical but supported by US to determine location and extend of abruption

(retroplacental having the worst prognosis)

few lab studies assist in diagnosis

treatment of a small placental abruption remote from term

abruptions at or near term

severe abruptions w/coagulopathy

small abruption: manage expentantly

at or near term: undergo delivery (perferably vaginally)

severe w/coagulopathy: ultimate delivery, but tx of coagulopathy should be first aim

all pts get 2 large bore IVs

no cervical exam

no sex

outpt: asymptomatic pts only, compliance, proximity to hospital, availability of emergency transportation

inpt: initially- CBC, T&S and coag studies, two large bore IVs, antenatal steroids in < 34 weeks

if stable: monitor

if unstable/persistent bleeding: c-section

may consider vaignal delivery for low-lying placenta

c-section for all pts with placenta previa (complete, partial, marginal)

what is the most common indication for c-section deliverty

the second most common

a previous c-section delivery is the most common indication for c-section

dystocia (lack of progress of labor for any reason) is the second most common indication for c-section

external cephalic version - typically reserved until full term

delivery - usually c-section; vaginal if butt is presenting, or twins

emergent c-section delivery

*must keep fetus elevated off prolapsed cord until delivery*

gentle downward traction of fetal head

mcroberts - maternal legs hyperflexed

suprapubic pressure from direction of fetal occiput

rotational maneuvers (wood's screw and reverse)

delivery of posterior fetal arm

gaskin's maeuver (all fours)

try these more than once before trying:

intentional fetal clavicle fracture

zavanelli (replacing baby - c-section)

uterotonics:

oxytocin (pitocin)

misoprostol

methylergonovine

uterine tamponade

interventional radiology aterial embolization

manual exploration of the uterus and removal of products (diagnostic and therapeutic)

uterine curettage

replacement of fundus:

manual

surgical

analgesics (oral)

caffeine

epidural blood patch