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Pharmacotherapeutics in Obstetrics: Deepthy P. Thomas I Year MSC Nursing Govt College of Nursing Alappuzha
Pharmacotherapeutics in Obstetrics: Deepthy P. Thomas I Year MSC Nursing Govt College of Nursing Alappuzha
OBSTETRICS
DEEPTHY P. THOMAS
I YEAR MSC NURSING
GOVT COLLEGE OF NURSING
ALAPPUZHA
OXYCTOCICS IN OBSTETRICS
OXYTOCIN
ERGOT DERIVATIVES
PROSTAGLANDINS
OXYTOCIN
Preparations used
Synthetic oxytocin
Syntometrine
Desamino oxytocin
Effectiveness
Compromised fetus.
Previous history of caesarean section.
Complications likely to produce preterm labour.
APH.
INTERPRETATION :CST
Positive: persistent late deceleration of FHR following
50 % or more uterine contrations.
Negative: no late deceleration or significant variable
deceleration.
Suspicious: inconsistent but definite decelerations do
not persist with more uterine contractions.
Unsatisfactory: poor quality of recording or adequate
uterine contraction is not achieved.
Hyperstimultaion:
Deceleration of FHR with uterine contraction lasting >
90 seconds or occurring more frequently than every 2
minutes.
OXYTOCIN STIMULATION TEST
Procedure
Inference
Contraindications of oxytocin:
Pregnancy:
Grand multipara.
Contracted pelvis.
Labour:
All the contraindications in pregnancy.
Obstructed labour.
Fetal distress.
Any time:
Hypovolemic state.
Cardiac disease.
OXYTOCIN STIMULATION TEST
Methods of administration:
Controlled intravenous infusion
For induction in labour
Use in labour
Intramuscular
5-10 units after the birth of the baby
as an alternative to ergometrine
ADVERSE EFFECTS
MATERNAL
Uterine hyperstimulation
Uterine rupture
Water intoxication
Hypotension
Anti-diuresis
FETAL
Fetal distress, fetal hypoxia and fetal death
NURSE’S RESPONSIBILITIES
Assess
Intake output ratio.
Uterine contractions and FHR.
Blood pressure, pulse and respiration.
Administer
By IV infusion. Monitor drop rate.
Make crash cart available.
Evaluate
Length and duration of contractions.
Notify physician of contractions lasting over 1 minute or
absence of contrcations.
Teach
To report increased blood loss, abdominal cramps or
increased temperature.
ERGOT DERIVATIVES
Mode of action:
Ergometrine acts directly on the myometrium
Effectiveness
Therapeutic:
To stop the atonic uterine bleeding following delivery,
abortion or expulsion of hydatidiform mole.
Prophylactic:
Against excessive haemorrhage following delivery.
ERGOT DERIVATIVES
CONTRAINDICATIONS:
Prophylactic:
Suspected plural pregnancy.
Therapeutic:
Heart disease or severe hypertensive disorders
ERGOT DERIVATIVES
Administer
Orally or IM in deep muscle mass.
Evaluate
Therapeutic effect: decreased blood loss.
Teach
To report increased blood loss, abdominal cramps,
headache, sweating, nausea, vomiting or dyspnoea.
PROSTAGLANDINS
Source
arachidonic acid
Mechanism of action
PGF2α promotes myometrial
contractility
PGE2 helps cervical maturation
PROSTAGLANDINS
Use in obstetrics
Induction of abortion.
Termination of molar pregnancy.
Induction of labour.
Uterine scar.
Preparations
Tablet.
Vaginal suppository
Vaginal pessry
Prostin E2.
Parentral
PROSTAGLANDINS
Advantages:
It has got a powerful oxytocic effect,
irrespective of period of pregnancy. As such
it can be used independently specially in the
induction of abortion with success.
In later months it can be used for
acceleration of labour.
It has got no anti diuretic effect.
PROSTAGLANDINS
Drawbacks:
It is costly.
Mechanism of action
-Drugs of first choice
-Central and peripheral anti-adrenergic action
-Effective and safe for both mother and fetus.
Contraindications
-hepatic disorders
-psychic patients
-CCF
Dose
-orally 250mg bid may be increased to 1 gm tid
depending upon the response.
-IV infusion 250-500mg
METHYLDOPA
Side effects
-maternal:
postural hypotension
haemolytic anemia
sodium retension
excessive sedation
-fetal:
intestinal ileus
LABETALOL
Mechanism of action
Combined alpha and beta adrenergic blocking agents.
Contraindication
hepatic disorders.
Dose
orally: 100mg tid. May be increased upto 800 mg daily.
Contraindication
bronchial asthma.
renal insufficiency.
diabetes.
Cardiac failure
Mechanism of action
Arteriolar vasodilator.
Contraindication
Because of the variable sodium retention, diuretics should
be used.
Dose
orally: 100mg/day in 4 divided doses.
-IV : 5mg bolus followed by 25g in 200 ml NS at a rate of
2.5 mg/hr to be doubled every 30 mts.
Side effects
-maternal: hypotension,tachycardia, arrhythmia,
palpitation, lupus like syndrome.
-fetal: reasonably safe.
-neonatal: thrombocytopenia
NIFEDIPINE
Mode of action:
Direct arteriolar vasodilation.
Dose:
Orally 5-10 mg TID.
Contraindications:
Simultaneous use of magnesium sulphate could
be hazardous due to synergic effect.
Side effects:
Flushing
Hypotension
Head ache
Tachycardia
Inhibition of labour.
SODIUM NITROPRUSSIDE
Mechanism of action:
Direct vasodilator.
Dose:
Orally 6.25 bid.
Side effects:
Maternal
Nausea
Vomiting
Fetal
Oligohydramnios
IUGR
Fetal and neonatal renal failure.
NITROGLYCERINE
Mechanism of action
Release mainly venous but also arteriolar smooth
muscles.
Dose:
Given as IV infusion 5µg/min. to be increased at
every 3-5 min. upto 100µg/min.
Side effects:
Tachycardia
Headache
Methaemoglobinaemia
DIURETICS
Mechanism of action
Acts o loop of the Henle by increasing excretion of
sodium and chloride.
Dose
40 mg tab, daily following breakfast for 5 days a
week. In acute conditions, parentrally 40-120 mg
daily.
Contraindications:
Hypersensitivity
FUROSEMIDE
Maternal fetal
Weakness fetal compromise due
hypokalemia
hypochloremic
alkalosis
postural hypotension
HYDROCLOROTHIAZIDE
Mechanism of action:
Acts on distal tubule by increasing excretion of
water, sodium, chloride and potassium. It is used in
edema and hypertension.
Dose:
PO 25-100 mg/day.
Side effects:
Polyuria, glycosuria, frequency.
Betamimetics
prostaglandin synthetase inhibitors
magnesium sulphate
antibiotics.
BETAMIMETICS
Commonly used drugs:
Terbutaline
Ritodrine
Isoxurpine
Mechanism of action:
Activation of the intracellular enzymes [adenylate
cyclase, cAMP, protein kinase] reduces intracellular
free calcium [Ca++] and inhibits the activation of
MLCK
BETAMIMETICS
Dose:
Ritodrine is given by IV infusion, 50µg/min. and
increased by 50µg every 10 min. until contractions
cease. Maximum dose of 350µg/ min. may be given.
Infusion is continued for about 12 hours after
contraction cease.
Terbutaline has longer half life and has fewer side
effects. Subcutaneous injection of 0.25 mg every 3-4
hours is given.
Isoxurpine is given as IV drip 100 mg in 5D. Rate 0.2
µg/minute. To continue for at least 2 hours after
contraction ceases. Maintenance is by IM 10mg six
hourly for 24 hours, tab 10 mg 6-8 hourly.
BETAMIMETICS
Side effects:
Maternal:
Headache
Palpitation
Tachycardia
Pulmonary edema
Hypotension
Cardiac failure
BETAMIMETICS
Side effects
Hyperglycemia
ARDS
Hyperinsulinemia
Lactic academia
Hypokalemia
Even death
Neonatal:
Hypoglycaemia
Intraventricular haemorrhage
INDOMETHACIN
Mechanism of action:
Reduces synthesis of PGs thereby reduces intracellular
free Ca++, activation of MLCK and uterine contractions.
Dose:
Loading dose , 50 mg P.O. or .P.R. followed by 25mg
every 6 hrs for 48 hours.
Side effects:
Maternal
Heart burn
G.I. bleeding
Asthma
Thrombocytopenia
Renal injury.
CALCIUM CHANNEL BLOCKERS
Nifedipine
Nicardipine
Mechanism of action:
Nifedipine blocks the entry of calcium inside the cell.
Compared to β- mimetics, effects are less. It is
equally effective to MgSO4.
Dose:
Oral 10-20 mg every 6-8 hours.
CALCIUM CHANNEL BLOCKERS
Side effects:
Maternal
Hypotension
Headache
Flushing
Nausea
MAGNESIUM SULPHATE
Mechanism of action:
inhibition to calcium ion
Contraindications:
Myasthenia gravis
Dose:
Loading dose: 4-6 gm I.V. over 20-30 min. followed
by an infusion of 1-2 gm/hr to continue tocolysis for
12 hours after contarctions have stopped.
MAGNESIUM SULPHATE
Side effects:
Maternal
Flushing
Perspiration
Headache
Muscle weakness
Pulmonary edema rarely
Neonatal
Lethargy
Hypotonia
Respiratory depression rarely.
OXYTOCIN ANTAGONISTS:
Atosiban
Mechanism of action:
It blocks myometrial oxytocin receptors.
Dose:
I.V.infusion 300µg/min. initial bolus may be needed.
Side effects:
Nausea
Vomiting
Chest pain
ANTICONVULSANTS
1. MAGNESIUM SULPHATE:
Mode of action:
Side effects:
MgSO4 is relatively safe and is the drug of choice.
Muscular paresis[ diminished knee jerks],
respiratory failure. Renal function to be monitored.
Antidote:
Injection of calcium gluconate 10% 10 ml IV.
DIAZEPAM
mode of action:
central muscle relaxant and anticonvulsant.
Dose:
20-40 mg IV
Side effects:
Maternal:
Hypotension
Fetal
Respiratory depression
Hypotonia
Thermoregulatory problem
PHENYTOIN
Mode of action:
Centrally acting anticonvulsant
Dose:
10 mg/ kg IV at the rate not more than 50 mg/ min
followed 2 hrs later by 5 mg/kg. In epilepsy 300-
400 mg daily orally in divided doses.
Side effects:
Maternal
Hypotension
Cardiac arrhythmias
Phlebitis at injection site.
Fetal
Fetal hydantoin syndrome
ANTICOAGULANTS:HEPARIN
Mechanism of action:
It inhibits action of thrombin
Dose:
5000-10000 I.U. to be administered parenterally [SC or IV].
Side effects:
Maternal:
Haemorrhage
Urticarial
Thrombocytopenia
Osteopenia.
Fetal
It does not cross the placenta
WARFARIN
Mechanism of action:
Interferes with synthesis of vit K dependent factors.
Dose:
10 mg orally
Side effects:
Maternal
Haemorrhage
Fetal
Contradi’s syndrome [skeletal and facial anomalies]
Optic atropy
Microcephaly
Chondrodisplasia punctate.
ANALGESIA AND ANAESTHESIA IN
OBSTETRICS
Dizziness
Confusion
Headache
Sedation
Nausea
Vomiting
Fetal
Respiratory depression
Asphyxia
FENTANYL
Mechanism of action:
Inhbits ascending pathways in CNS, increases pain
threshold and alters pain perception.
Indications:
Moderate to severe pain in labour, post operative
apin an dadjunct to general anaesthetic.
Dose:
0.05 to 0.1 mg IM q1-2 hrs prn. Available in
injectable form, 0.05 mg/ml.
Side effects:
Dizziness
Delirium
Euphoria
Nausea
Vomiting
Muscle rigidity
Blurred vision
PENTACOZIN
dose of 30-40 mg
Naloxone is an efficient and reliable antagonist.
Adverse effects
Neonate respiratory depression secondary to the
medication crossing the placenta and affecting
the fetus.
Unsteady ambulation of the client.
Inhibition of the mother’s ability to cope with the
pain of labor.
TRANQUILIZERS
DIAZEPAM:Usual dose is 5-10 mg.
Trichloroethylene
Respiratory depression.
Fetal bradycardia.
Fetal bradycardia.
Mechanism of teratogenicity
Folic acid deficiency.
Epoxides or arena oxides
Environmental and genes
abnormalities.
Maternal disease and drugs
Homebox genes
Maternal-fetal drug transfer and the hazards:
before D 31:
Lipid solubility.
Placental solubility.
GUIDELINES
A Adequate studies in pregnant woman have failed to show a risk to the fetus in Thyroid hormone
the first trimester of pregnancy; there is no evidence of risk in last trimester.
B Animal studies have shown an adverse effect on the fetus. But, there are no Insulin
adequate studies on humans. Pregnancy risk is unknown.
C Animal studies have shown an adverse effect on the fetus, but there are no Docusate-sodium
adequate studies on humans, or there are no adequate studies in animals or
humans. Pregnancy risk is unknown.
D There is evidence of risk to the human fetus, but potential benefits of use in Lithium acetate
pregnant woman may be acceptable despite potential risks.
Molecular weight
Ionic dissociation
Lipid solubility
Tissue pH.
Drug concentration.
Exposure time.
DRUGS IDENTIFIED AS HAVING EFFECT ON
LACTATION AND THE NEONATE
Bromide: Rash. Drowsiness, and poor feeding.
Iodides: Neonatal hypothyroidism
Chloramohenicol: Bone marrow toxicity
Oral pill: Suppression of lactation.
Bromocriptine: Suppression of lactation.
Ergot: Suppression of lactation.
Metronidazole: Anorexia, blood dyscrasias, irritability, weakness,
neurotoxic disorders.
Anticoagulants: Haemorrhagic tendency.
Isoniazid: Anti-DNA activity and hepatotoxicity.
Anti-thyroid drugs and radioactive iodine: Hypothyroidism and
goitre, agranulocytosis.
Diazepam, opiates, phenobarbitone: Sedation effect with poor
sucking reflex.
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