Drugs In Obstetrics

PRESENTERS: KAMBUGU CAR TREVOR & KATULEGE

TUTOR: DR. KIGGUNDU
OUTLINE
Oxytocics
Anti-hypertension therapy
Diuretics
Tocolytics
Maternal drug intake and breastfeeding
Fetal hazards on maternal medicine during pregnancy
Analgesia and anesthesia
 OXYTOCICS

Definition: Oxytocics are the drugs of varying chemical nature that have the
power to excite contractions of the uterine muscles.

Among a large number of drugs belonging to this group, the following are the
important ones and are extensively used in clinical practice.
◦ Oxytocin
◦ Ergot derivatives
◦ Prostaglandins
OXYTOCICS ---- Oxytocin
Oxytocin is a nonapeptide
It is synthesized in the supraoptic and paraventricular nuclei of the
hypothalamus. By nerve axons it is transported from the
hypothalamus to the posterior pituitary where it is
stored and eventually released.
T ½ = 3-4 mins DOA is aprox. 20mins.
MODE OF ACTION: Myometrial oxytocin receptor concentration increases
maximum (100-200 fold) during labor. Oxytocin acts through receptor and
voltage mediated calcium channels to initiate myometrial contractions
OXYTOCICS ---- Oxytocin
It stimulates amniotic and decidual prostaglandin production. Bound intracellular
calcium is eventually mobilized from the sarcoplasmic reticulum to activate the
contractile protein.
Preparations:
1) Synthetic oxytocin
2) Syntometrine
3) Desamino oxytocin
4) Oxytocin nasal solution
Effectiveness: 3rd trimester>>>>2nd > 1st trimester.
Why?
OXYTOCICS ---- Oxytocin
Indications:
May be safely used in pregnancy, labor or puerperium.
A. Therapeutic
 Pregnancy
 Labor
 peurperium
B. Diagnostic
OXYTOCICS ---- Oxytocin
In early pregnancy:
To accelerate abortion
To stop beeding following evacuation of the uterus
Used as an adjunct to induction of labor along with other abortifacts
In late pregnancy
To induce labor
Cervical ripening before induction
Augmentation of labor
Uterine inertia
Active manegment of 3rd stage of labor
OXYTOCICS ---- Oxytocin
In puerperium:
To minimize blood loss and control PPH

Diagnostic
Contraction Stress test (CST)
Oxytocin sensitivity test (OST)
Dangers of oxytocin
1) Uterine hyperstimulation
2) Uterine rapture
3) Water intoxication
4) Hypotension Routes of administration
5) Antidiuresis Controlled IV infusion
6) Fetal distress Bolus IM or IV (5-10IU) after birth of baby
Buccal or nasal spray…(In trials)
OXYTOCICS ---- Ergots
The ergot derivatives most extensively used as oxytocics are:
Ergometrine (ergonovine)
Methergin (methyl ergonovine)
Ergometrine is an alkaloid isolated from Ergot, a fungus Claviceps purpurea that develop
commonly in cereals like rye, wheat, etc

Methergin is a semisynthetic product derived from lysergic acid

MODE OF ACTION: Ergometrine acts directly on the myometrium. It excites uterine

contractions which come so frequently one after the other with increasing intensity that
the uterus passes into a state of spasm without any relaxation in between.
OXYTOCICS ---- Ergots
Mode of Administration: Parenteral and Oral
should only be used either in the late second stage of labor (after the delivery of the anterior shoulder) or
following delivery of the baby. Syntometrine should always be administered intramuscularly.

Hazards:
1) Common side effects: N&V
2) Precipitation of HTN, MI, stroke and bronchospasm
3) gangrene of the toes (prolonged use)
4) Prolonged use in puerperium may interfere with lactation by lowering prolactin level
CAUTIONS: Ergometrine should not be used during pregnancy, first stage of labor, second stage prior to
crowning of the head and in breech delivery prior to crowning
OXYTOCICS ---- Prostaglandins (PGs)
Prostaglandins are derivatives of prostanoic acid
They are synthesized from one of the essential fatty acids,
arachidonic acid, which is widely distribute throughout the body.
In the female, these are identified in menstrual fluid, endometrium,
decidua and amniotic membrane.

Increased biosynthesis of PGs of E and F series in the uterus is a prerequiste for

labor both term and preterm.
OXYTOCICS ---- Prostaglandins (PGs)
Decidua is the main source of PGF2a
Fetal membranes (amnion) produce PGE2
The myometrium mainly produce PGI2

In vivo, PGF2a promotes myometrial contractility, PGE2 helps cervical ripening.

PGs promote myometrial contraction irrespective of the duration of gestation,

whereas oxytocin acts predominantly on the uterus at term or in labor
>>>> the use of PGs in first trimester and at term
OXYTOCICS ---- Prostaglandins (PGs)
MOA:
Both PGE2 and PGF2a have got an oxytocic effect on the pregnant uterus when used in
appropriate dose
The probable mechanism of action is change in myometrial cell membrane
permeability and/or alteration of membrane-bound Ca++

PGs also sensitise the myometrium to oxytocin.

PGF2a acts predominantly on the myometrium, while PGE2 acts mainly on the cervix
due to its collagenolytic property
OXYTOCICS ---- Prostaglandins (PGs)
Use in obstetrics Contraindications
1) Induction of abortion 1) Hypersensitivity to the compound
2) Termination of molar pregnacy 2) Uterine scar
3) Induction of labor 3) Active cardiac, pulmonary, renal or hepatic
4) Cervical ripening disease
5) Augmentation of labor 4) Hypotension (PGE2)
6) Mgt of atonic PPH 5) Bronchial asthma (PGF2a)
7) Medical mgt of tubal ectopic pregnancy
ANTIHYPERTENSIVE DRUGS
are essential when the BP is 160/110 mm of Hg to protect the mother from
1.Eclampsia
2.Cerebral hemorrhage
3.Cardiac failure
4.Placenta abruption

Aim is to reduce BP to a mean < 125 mm Hg

If there is any risk of target 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

ACE inhibitors are avoided in pregnancy
 ANTIHYPERTENSIVE DRUGS
A- methyldopa
Indications:
- reserpine
Pre-eclampsia and eclampsia
Chronic hypertension B- labetalol

Gestational hypertension - propranolol

C- Hydralazine

The commonly used classes include: - Nitroglycerin

A. Sympatholytics - Sodium nitroprusside

B. Adrenergic receptor blockers D- Nifeipine
C. Vasodilators - Nicardipine
D. Calcium channel blockers E- Captopril
E. ACEIs - Lisinopril
DIURETICS
Indications:
1) Pregnancy induced hypertension with pathological edema
2) As an adjunct to certain antihypertensive drugs such as hydralazine or diazoxide
3) Severe anemia in pregnancy with heart failure
4) Eclampsia with pulmonary edema
5) Prior to blood transfusion in severe anemia
DIURETICS
Loop diuretics:
Furosemide>>40 mg tab daily following breakfast for 5 days a week.
In acute conditions, the drug is administered parenterally in doses of 40-120 mg daily.
Mode of action—It directly prevents reabsorption of sodium and potassium mainly from the
loop of Henle.
Hazards:
1. Maternal: weakness, fatigue, muscle cramps, hypokalemia and postural hypotension.
(=/= potassium supplementation)
2. Fetal: in pre-eclampsia, use with caution>>hypoperfusion of the fetus. Others include
thrombocytopenia, hyponatremia
DIURETICS
Thiazides
often used in conjunction with other antihypertensives. It is safe in pregnancy.
Dose: 12.5 mg twice daily maximum up to 50 mg daily may be used.
Side effects are: Maternal and fetal hyponatremia, acute pancreatitis, rise
in uric acid levels, and neonatal thrombocytopenia. In a diabetic patient, it may
cause hyperglycemia.

Spironolactone: a sulfonamide, k+ sparing diuretic. potentiates thiazide or loop

diuretics by antagonising aldosterone
TOCOLYTICS
These are drugs used to arrest uterine Drugs commonly used include:
contractions
1) Betamimetics
Preterm labor and delivery can be delayed by
drugs in order to improve the perinatal 2) Prostaglangin synthetase inhibitors
outcome. Short 3) Magnesium sulphate
term delay of 48 hours allows the use of
corticosteroids that can reduce the perinatal 4) Nitric oxide donors
mortality and serious
morbidity significantly. 5) Progesterone
ANTICONVULSANTS
Convulsion in pregnancy is largely due to eclampsia.
Other causes are:
1. Epilepsy
2. Meningitis
3. Cerebral malaria
4. Tumors
Eclampsia should be considered first unless proved otherwise by
history, examination and investigations
Drugs used are: MgSO4, Diazepam and Phenytoin
Refer to Mulago protocols
ANTICOAGULANTS
Not commonly used in pregnancy

Cardiac disease, venous thrombosis, antiphospholipid syndrome are some of

the indications

Drugs include:
 Heparin (Fractionated and LMWH)
 Warfarin
References
DC Dutta’s Textbook of Obstetrics, 7th edition reprited