DRUG THERAPY WITH PREGNANCY

Drug Class: Uterine Stimulants

General uses: Four primary clinical indications:

1. Induction of labor: history of precipitous labor and delivery, postterm pregnancy, prolonged
pregnancy with placental insufficiency, prolonged rupture of membranes, PIH
2. Augmentation of labor: dysfunctional labor (prolonged latent phase or arrest of descent)
3. Control of postpartum atony and hemorrhage: Reduce risk of postpartum hemorrhage
4. Control of post surgical hemorrhage: Cesarean section
5. Induction of therapeutic abortion

Generic Name: dinoprostone

Brand Name: Prostin E, Prepidil, Cervidil

Actions:
• Prostaglandin E2
• Uterine and gastrointestinal smooth muscle stimulation
• Cervical softening and dilation
• Increases frequency and strength of uterine contractions

Uses:
• Expel uterine contents = intrauterine fetal death, hydatidiform mole, missed spontaneous
miscarriage, second trimester abortion
• Used together with oxytocin\

Therapeutic Outcomes:
• Cervical softening and dilatation before labor
• Evacuation of uterine contents

Dosage and Administration: Intravaginal administration

• Cervidil = Intracervical gel
• Prostin E2 = Intravaginal suppository

Side Effects:
• Nausea and vomiting; diarrhea
• Fever
• Orthostatic hypotension
• Arrhythmia

Generic Name: ergonovine maleate

Brand Name: Ergotrate Maleate

Generic Name: methylergonovine maleate

Brand Name: Methergine
Actions:
• Directly stimulate uterine contractions
• Small doses = with normal resting muscle tone
• Intermediate doses = more forceful and prolonged contractions with elevated resting
muscle tone
• Large doses = severe, prolonged contractions
• Not for induction of labor (intense uterine activity)

Uses: Postpartum patients to control bleeding and maintain uterine firmness

Therapeutic Outcomes: Reduced postpartum blood loss
Dosage and administration: PO = 0.2 mg q 6-8 H (max 1 week); IM = 0.2 mg q 2 – 4 H (max 5
doses)

Side Effects:
• Nausea, vomiting, abdominal cramping
• Hypertension

Drug Interactions:
• Inhibitions of Prolactin (breastfeeding) = ergonovine only
• Caudal or spinal anesthesia = hypertension and headcahes

Generic Name: oxytocin

Brand Name: Pitocin

Actions:
• Stimulates the smooth muscles of uterus, blood vessels and mammary glands
• Third trimester = active labor

Uses:
• Inducing labor at term and augmenting uterine contractions (first and second stages of labor)
• Postpartum to control uterine atony and postpartum hemorrhage
• Promote milk letdown (intranasally)
• Treat breast engorgement during lactation

Therapeutic Outcomes:
• Initiation of labor
• Support of uterine contractions (1st and 2nd stages of labor)
• Control of postpartum bleeding
• Milk letdown for nursing mothers

Dosage and Administration:

• IV infusion = added to a solution; with infusion pump
• Induction of labor = IV (initially 1 to 2 mU per minute; 2 to 10 mU per minute; if 32 to 36
weeks, 20 to 30 mU per minute)
• Augmentation of labor = IV (0.5 to 2 mU per minute)
• Postpartum hemorrhage = IM (10 U after placenta delivery); IV (10 – 40 U in 100 mL of fluid
 and electrolyte solution)
• Milk letdown = Intranasal spray (1 spray or 3 drops into one or both nostrils 2 – 3 minutes
before nursing)

Side Effects:
• Uterine contractions
• Nausea and vomiting
• Fetal distress
• Hypertension, hypotension
• Water intoxication
• Dehydration
• Postpartum hemorrhage

Drug Interactions:
• Anesthetics = blood pressure and pulse rate changes (if containing epinephrine, report
diaphoresis, fever, chest pain, palpitations, severe throbbing headache)

Drug Class: Uterine Relaxants

Uses: Primarily to delay or prevent preterm labor and delivery in selected patients

Generic Name: ritodrine hydrochloride

Brand Name: Yutopar

Generic Name: terbutaline sulfate

Brand Name: Bricanyl

Actions:
• Beta-adrenergic receptor stimulants (predominantly beta-2, plus beta-1 for higher doses)
• Beta-2 = relaxation of uterine, bronchial, and vascular smooth muscle
• Beta-1 = increased heart rate
• Regulate fate and carbohydrate metabolism

Uses: Premature labor = reduction of intensity and frequency of uterine contractions

Therapeutic Outcome: Arrest preterm labor

Dosage and Adminsitration:

• IVF dextrose 5%, Ringer's lactate, saline solution
• Ritodrine: Usual concentration: 3 ampules in 500 mL; initial dose: 50 to 100 mcg per minute;
effective dose:150 to 350 mcg/min
• Terbutaline: Add 20 mg to 1000 mL of destrose 5% loading dose of 250 mcg IV over 1 – 2
minutes; start infusion: 10 mcg (30 mL/hr); max: 26 mcg/min (80 mL/hr)

Side effects:
• Tachycardia, palpitations, hypertension, and hypotension
• Tremors
 • Nervousness, anxiety, restlessness, headache
• Nausea, vomiting
• Dizziness
• Hyperglycemia
• Electrolyte imbalance
• Neonatal adverse effects: hyperglycemia, followed by hypoglycemia, hypocalcemia,
hypotension, and paralytic ileus

Drug interactions:
• Enhance toxic effects: tricyclic antidepressant, sympathomimetic agents
• Reduce therapeutic effects: beta-adrenergic blocking agents
• Corticosteroids: pulmonary edema
• Antihypertensive agents: reduce therapeutic effects of antihypertensive agents
• General anesthesia: additional hypotensive effects

Other Agents

Generic Name: clomiphene citrate

Brand Name: Clomid

Actions:
• Structurally similar to natural estrogen
• Binds to estrogen receptors = reduce receptors available to circulating estrogen = receptors send
signal to hypothalamus and pituitary gland indicating lack of circulating estrogen = LH and
FSH = release of ova

Uses: Induce ovulation

Therapeutic Outcomes: Ovulation followed by fertilization and pregnancy
Dosage and Administration: PO = 50 mg daily for 5 days

Side Effects:
• Nausea and vomiting, diarrhea, constipation, hot flashes, abdominal cramps
• Severe abdominal cramps, visual disturbances, dizziness

Generic Name: magnesium sulfate

Actions:
• Normal = 1.8 to 3 mEq/L
• 4 mEq/L = depress central nervous system and blocks peripheral nerve transmission =
anticonvulsant effects and smooth muscle relaxation

Uses:
• Control of seizure activity
• Inhibit premature labor in patients who could not tolerate ritodrine
 • 3 – 5 mEq/L = side effects rare from hypermagnesemia
• 5 – 8 mEq/L = increasing signs of toxicity
• Early signs of maternal toxicity = complaints of “feeling hot all over”, “being thirsty all the
time”, flushed skin color, and diaphoresis
• May become hypotensive, have depressed patellar, radial and biceps reflexes, have flaccid
muscles
• Later signs of hypermagnesemia = CNS depression (first by anxiety, followed by confusion,
lethargy, and drowsiness
• If continue to increase = cardiac depression and respiratory paralysis
• For patients with impaired renal function and urine output less than 100 mL for the past 4 hours
= use with extreme caution

Therapeutic Outcomes:
• Elimination of seizure activity
• Arrest of preterm labor

Dosage and Administration:

• Anticonvulsant:
• IM = loading dose (10 g of 50% solution [20 mL] divided into 2 doses); maintenance
dose (4 – 5 g of 50% solution [10 mL] q4H deep IM; alternate buttocks
• IV = loading does (4 g MgSO4 in 250 mL of D5W infuse at 10 mL per minute;
maintenance dose (1 – 2 g per hour by continuous infusion)
• Preterm labor: IV = loading dose (4 g of MgSO4 over 15 – 30 minutes; maintenance dose (1 – 3
g per hour by continuous infusion)

Side effects:
• Deep tendon reflexes = absent
• Decreased urine output
• Decreases respiratory rate, blood pressure, fetal heart rate (fetal distress)
• Confusion
• Neonates = hypotension, hyporeflexia, respiratory depression

Drug Interactions:
• CNS depressants = potentiate CNS depressant effects of MgSO4 (barbiturates, analgesics,
general anesthetics, tranquilizers, and alcohol
• Neuromuscular blocking agents = concurrent use with MgSO4 will further depress muscular
activity

Generic Name: Rho(D) immune globulin (human)

Brand Name: RhoGam, Hypo-Rho-D, Gamulin Rh, MICRhoGam, Mini-Gamulin Rh

Actions:
• Suppresses stimulation of active immunity by Rh positive foreign red blood cells
• Prevent Rh hemolytic disease of the newborn

Uses: Prevent Rh immunization of Rh negative patient exposed to Rh positive blood

Therapeutic Outcomes: Prevention of Rh hemolytic disease

Dosage and Administration:

• Before administration:
1. Never administer intravenously
2. Never administer to a neonate
3. Never administer to an Rh negative patient who has been previously sensitized to the Rh
antigen
4. Confirm that the mother is Rh negative
• Postpartum prophylaxis = 1 standard dose vial IM
• Antepartum prophylaxis = 1 standard dose vial IM at about 28 weeks gestational age (within 72
hours after delivery)
• Transfusion accident = 1 standard dose vial IM for each 15 mL of transfused packed red cells

Side Effects:
• Localized tenderness
• Feve, arthralgia, generalized aches, pains
• Urticaria, tachycardia, hypotension

Drug Class: Neonatal ophthalmic solutions

Generic Name: erythromycin ophthalmic ointment

Brand Name: Ilotycin

Actions and Uses:

• Macrolide antibiotic used prophylactically against ophthalmia neonatorum (Neisseria gonorrhea
& Chlamydia trachomatis)

Therapeutic Outcomes:
• Prevention of postpartum gonorrhea or Chlamydia eye infection

Dosage and Administration:

• Ointment: Instill a ¼ inch narrow ribbon along the lower conjunctival surfaceof both eyes
(within 2 hours after birth); do not irrigate the eyes after

Side Effects:
• Mild conjunctivitis

Generic Name: phytonadione

Brand Name: Aquamephyton

Actions:
• Vitamin K (fat-soluble vitamin) = production of blood clotting factors: prothrombin (factor II),
proconvertin (factor VII), plasma thromboplastin componet (factor IX), and Stuart factor (factor
X)

Uses:
 • Administered prophylactically against hemorrhagic disease of the newborn

Dosage and Administration:

• 2 mg/mL concentrationn (0.5 mL) or 10 mg/mL concentration (0.1 mL)
• IM = 0.5 to 2 mg in the lateral aspect of the thigh

Side Effects:
• Bruising, hemorrhage (petechiae, generalized ecchymosis or bleeding from umbilical stump,
circumcision site, nose or GIT