Unit XII

Pharmaco- therapeutics in Obstetrics – 6hrs

 Indication, dosage, action, contra indication and side effects of drugs

 Effect of drugs on pregnancy, labour &puerperium,
 Nursing responsibilities in the administration of drug in Obstetrics ::oxytocics, anti
hypertensives, diuretics, corticosteroids, tocolytic agents, anti convulsants,
anticoagulants.
 Analgesics and Anaesthetics in Obstetrics
 Effects of maternal medication on foetus and neonate
 Role of obstetric nurse
Short notes

1. Oxytocin
2. Ergot Derivatives
3. Prostaglandin
4. Anti hypertensive drug
5. Diuretics
6. Corticosteroids
7. Tocolytic agents
8. Anti convulsants
9. Anticoagulants.
10. Analgesics
11. Anaesthetics in Obstetrics
12. Effects of maternal medication on foetus and neonate

Answers

1. Oxytocin
It is synthesised in the supra-optic and para ventricular nuclei of the hypothalamus

Mode of Action

 receptor and voltage mediated calcium channels

 amniotic and prostaglandin decidual production

Preparations used

 Synthetic oxytocin

 Syntometrine

 Desamino oxytocin

 Oxytocin nasal solution

INDICATIONS

 Pregnancy:
 Early:

 to accelerate abortion.

 To stop bleeding following evacuation of the uterus.

  Used as an adjunct of abortion along with other abortifacient
agents.

— Late:

• To induce labour.

• To facilitate cervical ripening for effective induction.

• Augmentation of labour.

• Uterine intertia

— Labour:

 In active management of third stage of labour.

 Following expulsion of placenta.

Pueperium:

 To minimize the blood loss and to control the PPH.

Contraindications

 Grand multipara
 Contracted pelvis
 History of caesarean
 Malpresentation
 Obstrected labour
 Incoordinate uterine action
 Cardiac disease

Adverse effect

MATERNAL

 Uterine hyperstimulation
 Uterine rupture
 Water intoxication
 Hypotension
 Anti-diuresis

FETAL

 Fetal distress,
 fetal hypoxia
 fetal death
Dose

 10 units of oxytocin in 1lt of RL or 5%dextrose

Nurses Role

 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.

2. Ergot Derivatives
Mode of action:

 Ergometrine acts directly on the myometrium

Effectiveness

 It is highly effective in hemostasis

Indications:

 Therapeutic:
 To stop the atonic uterine bleeding following delivery, abortion or expulsion of
hydatidiform mole.
 Prophylactic:
 Against excessive haemorrhage following delivery.

CONTRAINDICATIONS:

Prophylactic:
  Suspected plural pregnancy.

 Organic cardiac diseases.

 Severe pre-eclampsia and eclampsia

 Rh- negative mother.

Therapeutic:

 Heart disease or severe hypertensive disorders

Preparations

 Ergometrine .25mg IV, .5-1mg Tablets

 Methergine .2mg injection
 Syntometrine .5mg injection

side effects

 nausea and vomiting.

 Precipitate rise of blood pressure, myocardial infarction,

 Prolonged use may result in gangrene formation of the toes.

 Prolonged use in puerperium may interfere with lactation

Nurses Role

Nurse’s responsibilities:

 Assess

 Blood pressure, pulse and respiration.

 Watch for signs of haemorrhage.

 Administer

 Orally or IM in deep muscle mass.

 Have emergency cart readily available.

 Evaluate

 Therapeutic effect: decreased blood loss.

 Teach
  To report increased blood loss, abdominal cramps,

3. Prostaglandin
It is prepare from thearachidonic acid

Mechanism of action

 PGF2α promotes myometrial contractility

 PGE2 helps cervical maturation

Indications

 Induction of abortion.

 Termination of molar pregnancy.

 Induction of labour.

 Cervical ripening prior to the induction of abortion or labour.

 Acceleration of labour.

 Management of atonic PPH.

 Medical management of tubal ectopic pregnancy

Contraindications

Contraindications:

 Hypersensitivity to the compound.

 Uterine scar.

Preparations

 Tablet.
 Vaginal suppository
 Vaginal pessry
 Prostin E2.
 Parentral

Nurses Role

 Assess
 Respiratory rate,rhythem
 Vaginal discharge
 Administer
 Antiemitics or antidiarrheal prior to the drug
 Evaluate
 Length and duration of contraction
 Fever or chills
 Teach
 Remain supine for 10-15 after vaginal insertion
4. Antihypertensive drugs

a. METHYLDOPA
Action
 Drug of first choice. Central and peripheral antiadrenergic action
 Effective and safe for both the mother and the fetus
Dose
 Orally – 250 mg bid – may be increased to 1

Contraindications

 Hepatic disorders
 CCF
Side effect
• Maternal –
 Postural hypotension,
 hemolytic anemia,
 sodium retention,
 excessive sedation.
 Coombs’ test may be positive
• Fetal
 Intestinal ileus
 Hepatic disorders,
 psychic patients, c
 ongestive cardiac
b. HYDRALAZINE
Acts by peripheral vasodilatation as it relaxes the arterial smooth muscle.
Dose
 Orally – 100 mg/day in four divided
Side effect
 Maternal hypotension,
 tachycardia, arrhythmia,
 palpitation,
 lupus like syndrome,
 fluid retention
• Fetal –
thrombocytopenia
 c. LABETALOL
Combined α and β adrenergic blocking agent
Dose
 Orally – 100 mg tid
 2040 mg IV

Contraindications

 Brochial asthma
 Hepatic disorders
Side effects
 Tremors,
 headache,
 asthma, congestive
 cardiac failure

d. NIFEDIPINE
Direct arteriolar vasodilatation by inhibition of slow inward calcium channels in
vascular smooth muscle
Dose
 Orally 510 mg tid maximum dose 60120 mg/day
Side effect
 Flushing,
 hypotension,
 headache,
 tachycardia,
 inhibition of labor
e, SODIUM NITROPRUSSIDE
Direct vasodilator
Dose
 IV infusion 0.258 mg/ kg/min

Contraindication

 Hypertension

Side effect

 Maternal
 Nausea,
 vomiting,
 severe hypotension

• Fetal
  toxicity

Nurses Role

 Assess
 Vital signs
 Daily weight
 Biood studies
 Evaluate
 Therapeutic effect
 Hydration status
 Edema in feet, leg daily
 Renal function
5. Diuretics
Indications
 Pregnancy induced hypertension with massive edema.
 Eclampsia with pulmonary edema.
 Severe anemia in pregnancy with heart failure.
 Prior to blood transfusions in severe anemia.
 As as adjunct to certain antihypertensive drugs, such as hydralazine or dioxide

a.FUROSEMIDE

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

Contraindications:

 Hypersensitivity

Side effect

Maternal

 Weakness
 Fatigue
 muscle cramps
 hypokalemia
 hyponatremia
 hypokalemia
  hypochloremic
 alkalosis
 postural hypotension

fetal

 fetal compromise due to decreased placental perfusion.

 Thrombocytopenia
 Hyponatremia

b. 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.

 Nausea, vomiting, anorexia.

 Rash, urticarial, fever.

 Increased creatinine, decreased electrolytes

6.Corticosteroids
Most commonly used corticosteroids in pregnancy are

 Prednisolone
 dexamethasone
 betamethasone

Indication

 pregnancy is less than 34 weeks

 Lung machuration
 RDS
 Intraventricular haemorrhage

Contraindication
  Premature rupture of the membranes
 Insulin dependent diabetes mellitus
 Transient reduction of fetal breathing and body movements.

Side effect

 Flushing of the mother's face and chest

 Hyperglycemia
 Oesteoporosis
 Glycosuria

Nurses Role

 Check vital signs

 Conduct MSE
 FHR monitoring
 Monitoring the condition of mother

7. TOCOLYTIC AGENTS
Commonly used drugs are

a.Betamimetics

Commonly used drugs:

 Terbutaline
 Ritodrine
 Isoxurpine
Mechanism of action:
Activation of the intracellular enzymes reduces intracellular free calcium

Dose

 Ritodrine is given by IV infusion, 50µg/min

 Terbutaline 0.25 mg every 3-4 hours is given.

Side effects:

Maternal:

 Headache
 Palpitation
 Tachycardia
  Pulmonary edema
 Hypotension
 Cardiac failure

Neonatal:

 Hypoglycaemia
 Intraventricular haemorrhage

b.prostaglandin synthetase inhibitors

Mechanism of action:

 Reduces synthesis of PGs thereby reduces intracellularfree Ca++

 activation of uterine contractions.

Dose:

Loading dose , 50 mg P.O.

Side effects:

Maternal

 Heart burn
 G.I. bleeding
 Asthma
 Thrombocytopenia
 Renal injury

c. 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

Side effects:

Maternal
  Hypotension
 Headache
 Flushing
 Nausea

d.oxytocin receptor 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

Nurses Role

Assess

 Maternal and fetal heart tones during infusion

 Intensity and length of uterine contraction
 Fluid intaketo prevent overload

Evaluate

 Therapeutic response
 Length of contraction
 Condition of the mother

8. Anti convulsants
a.MAGNESIUM SULPHATE:

Mode of action:

 It decreases the acetylcholine release from thenerve endings.

Dose:

 IM – loading dose: 4 gm
  IV- loading dose: 4-6 gm

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.

b.DIAZEPAM

mode of action:

 central muscle relaxant and anticonvulsant.

Dose:

 20-40 mg IV

Side effects:

Maternal

 Hypotension

Fetal

 Respiratory depression
 Hypotonia
 Thermoregulatory problem

C. PHENYTOIN

Mode of action:

 Centrally acting anticonvulsant

Dose:

 10 mg/ kg IV at the rate not more than 50 mg/ min

Side effects:

Maternal
  Hypotension
 Cardiac arrhythmias
 Phlebitis at injection site

Fetal

 Fetal hydantoin syndrome

Nurses Role

 Blood studies
 Hepatic studies
 Assess the blood pressure
 Assess the reflex

9.Anticoagulant
a. Heparin

Mechanism of action:

 It inhibits action of thrombin

Dose:

 5000-10000 I.U. to be administered parenterally [SC or IV].

 Low molecular weight heparin is 2500 IU

Side effects:

Maternal

 Haemorrhage
 Urticarial
 Thrombocytopenia
 Osteopenia.

Fetal

 It does not cross the placenta

b. Warfarin

Mechanism of action:

 Interferes with synthesis of vit K dependent factors.

Dose:
  10 mg orally

Side effects:

Maternal

 Haemorrhage

Fetal

 Contradi’s syndrome
 Optic atropy
 Microcephaly
 Chondrodisplasia punctate.

Nurses Role

 Blood studies
 Vital signs
 Partial prothrombin time
 Bleeding
 Therapeutic effect

10.Analgesics
. SEDATIVES AND ANALGESICS

 OPIOID ANALGESICS:
 PETHIDINE

Mechanism of action:

 Inhibits ascending pain pathways in CNS ,

 increase pain threshold and alters pain perception.

Indications:

 Moderate to severe pain in labour,

 postoperative pain,
 abruption placentae,
 pulmonary edema.

Dose:

 Injectable preparations contains 50mg/ml can be administered SC, IM,IV

Contraindication
  Should not be used 3 hrs of expected time of delivery of the baby
 preterm labour

side effect

Maternal

 Drowsiness
 Dizziness
 Confusion
 Headache
 Sedation
 Nausea
 Vomiting

Fetal

 Respiratory depression
 Asphyxia

Nurses role

Assess

 Vital signs
 Muscle rigid
 Urinary output
 Fetus respiratory status
 Therapeuticeffect

11.Anaesthetics in Obstetrics

EPIDURAL AND SPINAL REGIONAL ANALGESIA

Adverse effects

 nausea and vomiting.

 Inhibition of bowel and bladder elimination sensations.
 Bradycardia or tachycardia.
 Hypotension.
 Respiratory depression.
 Allergic reaction
 pruritus.

PUDENDAL BLOCK
  It consists of a local anesthetic such as lidocaine or bupivacaine being
administered transvaginally into the space infront of the pudendal nerve

EPIDURAL ANAESTHESIA

 Epidural block consists of a local anesthetic bupivacaine along with an analgesic

morphine or fentanyl injected into the epidural space at the level of the fourth
of fifth vertebrae.

Adverse effects

 Maternal hypotension.
 Fetal bradycardia.
 Inability to feel the urge to void.
 Loss of the bearing down reflex.

SPINAL BLOCK

 Spinal block consists of a local anaesthetic injected into the subarachnoid space
into the spinal fluid at the third, fourth, or fifth lumbar interspace, alone or in
combination with an analgesic such as fentanyl .

Adverse effects

 Maternal hypotension.

 Fetal bradycardia.

 Loss of the bearing down reflex.

PARACERVICAL BLOCK

 It consists of lidocaine (Xylocaine) being injected into the cervical mucosa

early in labor during the first stage to block the pain of uterine contractions.

Adverse effects

 fetal bradycardia.
 toxicity.

GENERAL ANAESTHESIA

 100% oxygen is administered by tight mask fit for more than 3 minutes.
 Induction of anaesthesia is done with the injection of thiopentone sodium 200- 250
mg as a 2.5 % solution IVsuxamethonium 100 mg.
 The patient is intubated with cuffed ET tube.
 Anaesthesia is maintained with 50% NO2 , 50% oxygen and a trace of halothane
  Relaxation is maintained with non- depolarizing muscle relaxant [ vecuronium 4 mg
or atracurium 25 mg].

12.Effects of maternal medication on foetus and neonate

Mechanism of teratogenicity

 Folic acid deficiency.

 Epoxides or arena oxides
 Environmental and genesabnormalities.
 Maternal disease and drugs
 Homebox genes

PLACENTAL TRANSFER OF DRUGS

The factors responsible for transfer are:

 Molecular weight
 Concentration of free drug.
 Lipid solubility.
 Utero-placental blood flow.
 Placental solubility.

Guidelines

 If the benefit outweighs the potential risks, only then can the particular drugs be
used with prior counselling.
 Only, well tested and reputed drugs are to be prescribed and that too using the
minimum therapeutic dosage for the shortest possible duration.

MATERNAL DRUG INTAKE AND BREASTFEEDING

Transfer of drugs through breast milk depends on

following factors:

 Chemical properties
 Molecular weight
 Degree of protein binding
 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
 Anticoagulants: Haemorrhagic tendency.
 Isoniazid: Anti-DNA activity and hepatotoxicity.
 Anti-thyroid drugs and radioactive iodine: Hypothyroidism
 Diazepam, opiates, phenobarbitone: Sedation effect with poor sucking reflex