DRUG PRESENTATION

ON
ANTIHYPERTENSIVE DRUGS AND
ANTICONVULSANT DRUGS

PRESENTED BY
MS.SANTOSH KUMARI
M.SC.NURSING 1ST YEAR
 ANTIHYPERTENSIVE DRUGS
DURING PREGNANCY
OVERVIEW OF DRUG CATEGORY AND absorption
IN PLACENTA
CATEGORIZATION OF DRUGS IN PREGNANCY (
ACCORDING TO FDA)
How Drugs Cross the Placenta

 Fetus's blood vessels are contained in tiny

hair like projections (villi) of the placenta that
extend into the wall of the uterus.
 The mother's blood passes through the space
surrounding the villi (intervillous space).
 Only a thin membrane (placental membrane)
separates the mother's blood in the
intervillous space from the fetus's blood in
the villi.
 Drugs in the mother's blood can cross this
membrane into blood vessels in the villi and
pass through the umbilical cord to the fetus
 HYPERTENSION

 Hypertension is defined as having a

blood pressure greater than 140/90 mm
Hg
 Normal blood pressure is 120/80 mm/hg.
 GESTATIONAL HYPERTENSION

 is the development of new

hypertension in a pregnant woman
after 20 weeks.
 Rise of blood pressure to
140/90mm/hg.
CATEGORY OF ANTIHYPERTENSIVE
DRUGS ACCORDING TO FDA
 Category B.
 Category C.
 Category D.
 INTRODUCTION
 ANTIHYPERTENSIVE- Work against the
hypertension.
 Antihypertensive drugs are essential when
the BP is 160/110 mm of Hg to protect mother
from
 Eclampsia.
 Cerebral hemorrhage.
 Cardiac failure.
 Placental abruption.
 Risk of large organ damage ( kidney)
antihypertensives are given to maintain BP <-
140 mm of Hg.
 First line therapy is either methyldopa or
labetalol.
 Second line drug is nifedipine.
 ACH inhibitors/ ARB are avoided in
pregnancy.
These drugs are used in two clinical conditions.

 Pre- eclampsia and eclampsia.

 Chronic hypertension.
PRE-ECLAMPSIA AND ECLAMPSIA

 Rise of blood pressure specially where the

diastolic pressure is above 110mm Hg. The
use is more urgent with proteinuria.
 Severe pre- eclampsia to bring down the
blood pressure during continued pregnancy
and during the period of induction of labour.
DRUGS MODE OF DOSE
ACTION
METHYLDOPA Central and 250-500 mg TID or
peripheral anti QID.
adrenergic action.
LABETATOL Adrenoceptor 100 mg TID or QID
antagonist (alpha or
beta blocker).

NIFEDIPINE Calcium channel 10-20 mg BID

blocker.

HYDRALIZINE Vascular smooth 10-20 mg BID.

muscle relaxant.
 CHRONIC HYPERTENSION

 Routine use of antihypertensive drugs is not

favoured.
 Antihypertensive drugs should be used only
when the pressure is raised beyond 160/100
mm Hg.
 To prevent target organ damage.
 HYPERTENSIVE CRISIS

 Drugs can be used when the BP is _>160/110

mm Hg or the mean arterial pressure (MAP)
is _> 125 mm Hg.
 MAP is the average arterial pressure during a
single cardiac cycle.
 Avoid labetalol I woman having asthma or
cardiac failure.
DRUG ONSET OF DOSE MAXIMUM MAINTENANCE
ACTION SCHEDULE DOSE DOSE

LABETALOL 5 MIN 12-20 mg IV 300 mg IV 40 mg/hr

every 10 min.

HYDRALAZINE 10 MIN 5 mg IV every 30 mg IV 10mg/hr

30 min

NIFEDIPINE 10 MIN 10-20 mg 240 4-6 hour interval

ORAL, can mg/24hr
repeat 30 min

NITROGLYCERI- 0.5- 5 MIN 5ug /min IV Other drugs Other drugs

NE. have failed. failed

SODIUM 0.5- 5 MIN 0.25-5 Other drugs Other drugs

NITROPRUSSID- ug/kg/min IV have failed. failed.
E.
 COMMONLY USED DRUGS

CATEGORY C
 Sympatholytics
 Methyl-dopa
 Reserpine
 Calcium channel blocker
 Nifedipine
 Nicardipine
CATEGORY B
 Andrenergic receptor blocking agents
 Labetalol
 Propranolol
 Vasodilators
 Hydralazine
 Nitroglycerin
 Sodium nitroprusside
CATEGORY D
 5. ACE inhibitors/ ARB.
 Captopril
 Trlmisartan
Avoided during pregnancy because it can cause
various kind of deformities in fetus.
 PHARMACOKINETICS

 These drugs transported actively by intestinal

amino acid carrier, less than 1/3 of an oral
dose absorbed.
 It is partly excreted unchanged in urine.
 Antihypertensive effect develop over 4-6
hours and lasts for 12-24 hours.
 METHYLDOPA
Mechanism of action/ Pharmacodynamics:
Central or peripheral antiadrenergic action as false
transmitter, resulting in reduction of arterial pressure.
Effective and safe for mother and the fetus.
Indication:
Hypertension.
Dose:
Orally- 250mg TID - may be increased to 1 g QID
depending upon the response. IV infusion – 250-
500mg.
Contraindications and precautions:
Hepatic disorders, psychic patients, congestive
cardiac failure, Postpartum ( risk of depression.
SIDE EFFECTS
Maternal-
 Postural hypotension, haemolytic anaemia,
sodium retension.
 Nausea, vomiting, diarrhea, constipation.
 Bradycardia, angina, weight gain.
 Drowsiness, dizziness, headache, depression,
excessive sedation.
Fetal – Intestinal ileus.
Nursing consideration
Assess
 Blood values: Neutrophils, platelets.
 Renal studies: Protein, creatinine.
 Blood pressure before beginning treatment and
periodically thereafter.
Perform/ Provide
 Storage of tablets in tight containers.
Evaluate
 Decrease in blood pressure .
 Allergic reaction: Rash, fever.
Teach client/ Family
 To avoid hazardous activities.
 Administer one hour before meals.
 To rise slowly to sitting or standing
position to minimize orthostatic
hypotension.
 Not to skip or stop drug unless directed by
physician.
 Notify physician of untoward signs and
symptoms.
HYDRALAZINE

Mechanism of action:
 Acts by peripheral vasodilators as it relaxes the
arterial smooth muscle. Orally it is weak and
should be combined with methyldopa or
beta- blockers. It increases the cardiac output
and renal blood flow.
Preparations:
Aspresoline, Hydralyn, Rolazine.
Dose:
 Orally: 100mg/day in four hours divided doses
IV: 5-10 mg every 20 minute maximum 20 mg.
Indication:
 Essential hypertension.
Contraindications and precautions
 Coronary artery diseases, mitral valvular
rheumatic heart disease.
 Because of variable sodium retention,
diuretics should be used. To control
arrhythmias, propranolol may be
administered intravenously.
Side effects

Maternal - hypotension, tachycardia,

arrhythmia, palpation, lupus like syndrome,
fluid retention, muscle cramps, headache,
dizziness, depression, anorexia, diarrhea.
Fetal: reasonably safe.
Neonatal: thrombocytopenia.
Nursing Consideration
Assess
 BP every 15 minutes initially for 2 hours then
every hour for 2 hours, and then q4h, pulse
q4h.
 Blood studies: Electrolytes, CBC and serum
glucose.
 Intake: Output and weight daily.
Administer
 To patient in recumbent position, keep in that
position for one hour after administration.
Evaluate
 Edema in feet and legs daily.
 Skin and mucosa membrane for hydration.
 Dyspnea, orthopnea.
 Joint pain, tachycardia, palpitation, headache
and nausea.
Teach Client/ Family
 To take with food to increase bio- avail-ability.
 To notify physician if chest pain, severe fatigue,
muscle or joint pain occurs.
LABETALOL

Mechanism of action: Combined with alfa and

beta adrenergic blocking agent.
Preparations: Trandate, Normodyne.
Dose: Orally – 100mg TID may be increased up
to 2400 mg daily.
IV- infusion ( Hypertensive crisis) 20-40 mg
every 10-15 min until desired effect,
maximum up to 220 mg.
Indication: Hypertension
Contraindications and precautions- Hepatic
disorders, Asthma, congestive cardiac failure.

Side effects - Tremors, headache, asthma,

congestive cardiac failure. Efficacy and safety
with short term use appear equal to
methyldopa.
Nursing Considerations:

Assess
 Intake output and weight daily.
 Blood pressure and pulse check q4h.
 Apical or radial pulse before administration.
Administer
 PO, before food and h.s.
 IV, keep client recumbent for 3 hours.
Perform/ provide
 Storage in dry area at room temperature.

Evaluate
 Therapeutic response: Decreased BP after 1
to 2 weeks.
 Edema in feet, legs daily.
 Skin turgor and dryness of mucus membranes
for hydration status.
Teach Client/ Family
 Not to discontinue drug abruptly, taper over 2
weeks.
 To report bradycardia, dizziness, confusion or
depression.
 To avoid alcohol, smoking and excess sodium
intake.
 Take medication at bedtime to prevent the
effect of orthostatic hypotension.
 NIFEDIPINE
Preparations - Adalat, Procardia.
Mechanism of action: Direct arteriolar
vasodilation by inhibition of slow inward calcium
channels in vascular smooth muscle.
Dose: Orally- 5-10 mg tid maximum dose 60-120
mg/ day.
Indication – Hypertension, angina pectoris.
Contraindications and precautions:
Simultaneously use of magnesium sulfate could
be hazardous due to synergistic effect.
Side effects- Flushing, hypotension, headache,
tachycardia, inhibition of labour, fatigue,
drowsiness, nausea, vomiting.
Nursing Considerations

Assess
 Blood levels of the drug, therapeutic levels 0.025 to
0.1ug/ml.
Administer
 Before meals and night.
Evaluate
 Therapeutic response, cardiac status, BP, pulse,
respiration and ECG.
Teach Client/ Family
 To limit caffeine consumption.
 Stress patient compliance to all aspects of drug use.
SODIUM NITROPRUSSIDE

Preparations – Nipride, Nitropress.

Mechanism of action: Direct vasodilator (
arterial and venous), directly relaxes
arteriolar, venous smooth muscle, resulting in
reduction of cardiac preload and afterload.
Indications
 Hypertension crisis.
 To decrease bleeding by creating
hypotension during pregnancy
Contraindication and precaution: Drug of last
resort for acute hypertension. Should be used
in critical care unit for very short time ( 10
minutes)
Dose: IV infusion 0.25-8 ug/kg/min.
Side effects: Maternal- Nausea, vomiting,
severe hypotension, restlessness, decreased
reflexes, loss of consciousness.
 Fetal toxicity due to metabolites- cyanide
and thiocyanate
Nursing Considerations

Assess
 Serum electrolyte, BUN and creatinine.
 Hepatic function.
 BP and ECG.
 Weight and intake output.
Administer
 Using and infusion pump only.
 Wrap bottle with aluminum foil to protect
from light.
Evaluate
 Therapeutic response: Decreased BP, absence
of bleeding.
 Edema – feet and legs.
 Hydration status.
NITROGLYCERINE
Mechanism of action: Relaxes mainly the
venous but also arterial smooth muscle.
Dose- Given as IV infusion 5 ug/ min to be
increased at every 3-5 min up to 100ug /min.
Side effect: Tachycardia, headache,
methaemoglobinaemia.
Contraindication and precautions: Used in
hypertensive crisis for short time only.
Contraindicated in hypertensive
encephalopathy as it increases blood flow
and intracranial pressure
Nursing Consideration
Assessment
 Monitor patient closely for change in levels of
consciousness and for dysrhythmias.
 Assess for headaches. Approximately 50% of all
patients experience mild to severe headaches
following nitroglycerin.
 Take base line BP and heart rate.
 Assess for and report blurred vision and dry mouth.
Patient and Family Education
 Take care of the adverse effect of headache.
 Report blurred vision if present.
 Change position slowly and avoid prolonged
standing.
PROPRANOLOL

Action
 Beta adrenergic blocker: Decreases preload,
afterload, which is responsible for decreasing
left ventricular end diastolic pressure and
systemic vascular resistance.
Indication – Hypertension, prophylaxis of
angina pain.
Contraindication – Bronchial asthma, renal
insufficiency, diabetes mellitus, cardiac
failure.
Side effect/ Adverse Reactions
Maternal
 Sever hypotension, sodium retention,
bradycardia, bronchospasm, cardiac failure.
 Fetal
 Bradycardia and impaired fetal responses to
hypoxia, IUGR with prolonged therapy.
Doses and routes of administration
 Orally 80 to 240 mg divided doases.
Nursing Consideration
Assess
 BP, pulse and respirations during therapy.
 Weight daily and report excess weight gain.
 Intake output ratio.
Administer
 Administer with 240 ml of water on empty stomach.
Evaluate
 Tolerance if taken for long period.
 Headache, light- headedness, decreased BP.
Teach Client/ Family
 There may be stinging sensation when the drug
comes in contact with mucus membranes.
 To make position changes slowly to prevent fainting.
DIAZOXIDE

Preparation – Hyperstat.
Action – Vasodilator.
Indication – Hypertensive crisis when urgent
decrease of diastolic pressure is required.
Contraindications – Diabetes, heart disease,
diuretics should be used simultaneously.
Side effect
Maternal
 Fluid and sodium retention.
 Inhibition of uterine contraction.
 Hyperglycemia.
 Severe hypotension.
 Palpitations.
Fetal
 Hypoxia.
Dosage and routes of administration
 IV- 30 to 50 mg, may be repeated every 10 to 15
minutes or continuous infusion.
Nursing Consideration

Assess
 BP q5min for 2 hours, then q1hr for 2 hours and
then q4h.
 Pulse, jugular venous distention q4h.
 Serum electrolytes, CBC, serum glucose.
 Weight daily and intake output.

Administer
 To patient in recumbent position, keep in that
position for one hour after administration.
 Perform/ provide
 Protection from light.
Evaluate
 Therapeutic responses: Primarily decreased diastolic
pressure.
 Edema in feet and legs.
 Hydration status.
 Dyspnea and orthopnea.
 Postural hypotension: Take BP sitting and standing.

Teach Patient/ Family

 To limit caffeine consumption.
 To report side effects if present.
 To comply with the regimen.
ACE inhibitors/ Angiotensin-
II receptor blocker (ARB
Mechanism of action - ACE inhibitors, inhibits
formation of angiotensin- II from
angiotensin- I. ARB blocks angiotensin- II
receptors.

Dose- Captopril orally 6.25 mg bid

 Telmisartan orally 20-40 mg a day.
Side effect - Maternal- Hypotension, headache,
asthma, arrhymias.
 Fetal- Oligohydraminios, IUGR, fetal tubular
dysgenesis, neonatal renal failure, pulmonary
hypoplasia.

Contraindication and precaution: Should for

chronic hypertension in non- pregnant state
or postpartum.
TITLE-
The effect of calcium channel blockers on
prevention of preeclampsia in pregnant
women with chronic hypertension.

AUTHOR –
Jiang N, Liu Q, Liu L, Yang WW, ZengY.
BACKGROUND:
This study aims to investigate whether
calcium channel blockers plus low dosage
aspirin therapy can reduce the incidence of
complications during pregnancy with chronic
hypertension and improve the prognosis of
neonates.
MATERIALS AND METHODS:
 From March 2011 to June 2013, 33 patients were
selected to join this trial according to the chronic
hypertension criteria set by the Preface Bulletin
of American College of Obstetricians and
Gynecologists.
 Patients were administrated calcium channel
blockers plus low-dosage aspirin and vitamin C.
The statistic data of baseline and prognosis from
the patients were retrospectively reviewed and
compared.
RESULTS:
 Blood pressure of patients was controlled by
these medicines.
 39.4% patients complicated mild
preeclampsia; however, none of them
developed severe preeclampsia or eclampsia,
or complicate placental abruption. 30.3%
patients delivered at preterm labour; 84.8%
patients underwent cesarean section.
 The neonatal average weight was 3,008 ±
629.6 g, in which seven neonatal weights
were less than 2,500 g. All of the neonatal
Apgar scores were 9 to 10 at one to five
minutes. Small for gestational age (SGA)
occurred in five (15%).
CONCLUSIONS:
 Calcium channel blockers can improve the
outcome of pregnancy women with chronic
hypertension to avoid the occurrence of
severe pregnancy complication or neonatal
morbidity.
ANTICONVULSANTS DRUGS
DURING PREGNANCY
 INTRODUCTION

 Due to eclampsia. Other causes are –

epilepsy, meningitis, cerebral malaria
and cerebral tumours.
 Proved by history, examination and
investigations.
 Commonly used anticonvulsant is
magnesium sulfate.
 Diazepam, Phenytoin and
Phenobarbitone are also used.
 IN 2013 ACCORDING TO FDA
 FROM CATEGORY A
 TO CATOGORY D
 BECAUSE OF THE RISK OF FETAL
DEMINERALIZATION.
 PHARMACOKINETICS

 Absorption by oral route is slow, mainly

because of its poor aqueous solubility.
 Widely distributed in the body and is 80-
90% bound to plasma proteins.
 Metabolized in liver.
 Excreted by the kidney.
MAGNESIUM SULFATE

Action –
 Decrease acetylcholine in motor
nerve terminals, which is responsible
for anticonvulsant properties, thereby
reduces neuromuscular irritability.
 It also decreases intracranial edema
and helps in diuresis.
 Its peripheral vasodilatation effect
improves the uterine blood supply.
Use –
 It is a valuable drug lowering seizure
threshold in women with pregnancy –
induced hypertension.
 The drug is used in preterm labor to
decrease uterine activity.
Dosage and Route

 For control of seizures, 20 ml of 20%

solution IV slowly in 3 to 4 minutes and
10ml of 50 percent solution IM, and
continued 4 hourly for 24 hours
postpartum.
 Repeat injections are given only if the
knee jerks are present, urine output
exceeds 100ml in previous 4 hours
and the respirations are more than
10/minute.
 The therapeutic levels of serum
magnesium is 4 to 7 mEq/L.
 4 gm IV slowly over 10 min, followed
by 2 gm/ hr and then 1 gm/hr in drip of
5 percent dextrose for tocolytic
effect.
Side effects
 Maternal – Severe CNS depression (
respiratory depression and circulatory
collapse), evidence of muscular
paresis ( diminished knee jerks).
 Fetal – Tachycardia, hypoglycemia.

Antidote – Injection calcium gluconate

10% 10 ml IV.
 Nursing Considerations
Assess
 Vital signs 15 min after IV dose.
 Monitor magnesium levels.
 If using during labour, time contractions,
determine intensity.
 Urine output should remain 30 ml/hr or
more, if less notify physician.
Administer
 Only after calcium gluconate is
available for treating magnesium
toxicity.
 Using infusion pump or monitor
carefully IV at less then 150 mg/min,
circulatory collapse may occur.
 Only dilution.
Perform/Provide
 Seizer precautions, place client in
single room with decreased stimuli,
padded side rails.
 Positioning of the client in left lateral
recumbent position to decrease
hypotension and increase renal blood
flow.
Evaluate
 Mental status, sensorium, memory.
 Discontinue infusion if respirations
are below 12/min or fetal distress.
Teach Client/ Family
 On all aspects of the drug: action, side
effects and symptoms of
hypermagnesemia.
 To remain in bed during infusion.
 DIAZEPAM ( VALIUM)
Action -
Depresses subcortical levels of CNS,
anticonvulsant, and antianxiety.
Dosage and Route of Administration
 PO, 2 to 10 mg tid – qid.
 IV, 5 to 20 mg ( bolus), 2mg/min, may
repeat q5 – 10 min, not to exceed 60
mg, may repeat in 30 min if seizures
reappear.
Side effect
 Mother – Hypotension, dizziness,
drowsiness, headache.
 Fetus - Respiratory depressant effect,
which may last for even three weeks
after birth.
Nursing Consideration
Assess
 BP in lying and standing positions, if
systolic pressure falls 20 mmHg, hold
drug and inform physician.
 Blood studies: CBC.
 Hepatic studies.
Administer
 IV into large vein to decrease chance
of extravasation.
 PO with milk or food to avoid GI
symptoms.
Provide
 Assistance with ambulation during
beginning therapy since drowsiness and
dizziness may occur.
 Safety measures include side rails.
Evaluate
 Therapeutic response
 Mental status, sleeping pattern.
 Physical dependence, headache,
nausea, vomiting.
Teach Patient/ Family
 Drug may be taken with food.
 To avoid alcohol ingestion.
 Not to discontinue medication
abruptly.
 To rise slowly as fainting may occur.
 PHENYTOIN ( DILANTIN)

Action – Inhibits spread of seizure

activity in motor cortex.
Dosage and route of administration
 Eclampsia: 10 mg/kg IV at the rate not
more than 50mg/minute, followed 2
hours later by 5 mg/kg.
Side effects
 Maternal
 Hypotension, cardiac arrhythmias and
phlebitis at injection site.
Fetal
 Prolonged use by epileptic patients
may cause craniofocal abnormalities,
mental retardation, microcephaly and
growth deficiency.
Nursing Consideration
 Blood studies: CBC, Platelets every 2
weeks until stabilized.
 Discontinue drug if neutrophils<
1600/mm2
 Administer
 After diluting with normal saline, never
water.
Evaluate
 Mental status, memory.
 Respiratory depression.
 Sore throat, brushing.
Teach Patient/ Family
 All aspect of drug administration,
when to notify physician.
PHENOBARBITONE ( LUMINAL)

Action - Decreases impulse

transmission and increases seizure
thresholds at cerebral cortex level.
Dose and Route of Administration –
120 to 240mg/day in divided doses.
Side effects
 Maternal – Sedation, drowsiness,
hangover headache, hallucination.
 Fetal – Withdrawal syndrome.
Nursing consideration
Assess
 Blood studies, liver function tests during
long term treatment.
 Therapeutic level 15 to 40 mg/ml.
Evaluate
 Mental status, mood affect and
memory.
 Respiratory depression.
 Fever, sore throat bruising, rash.
Teach Patient/ Family
 All aspects of drug administration and
when to notify physician.
Effect of magnesium sulphate on
fetal heart rate parameters : a
systematic review.

AUTHOR –
Nensi A, De Silva DA, von Dadelszen P,
Sawchuck D, Synnes AR, Crane J, Magee LA
ABSTRACT

To examine the potential effects of

intravenous magnesium sulphate
(MgSO4) administration on
antepartum and intrapartum fetal
heart rate (FHR) parameters
measured by cardiotocography (CTG)
or electronic fetal monitoring (EFM).
They took a systematic review of
randomized controlled trials,
observational studies, and case series,
by qualitatively analyzed. Result of 18
included studies, all changes were
small and not associated with adverse
clinical outcomes
Maternal administration of MgSO4
for eclampsia have a small negative
effect on FHR, variability, and
accelerative pattern, but is not
sufficient clinically to warrant medical
intervention.