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Drugs in obstetrics

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Detailed description of drugs in obstetrics for the midwifery students and beginners. Easy reference in one powerpoint presentation. Key details of drugs are mentioned . All drugs discussed as per INC Nursing syllabus for BSc & MSc Students.

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Drugs in obstetrics

  1. 1. Drugs in Obstetrics By: Maj Saminder Malik
  2. 2. Drugs in Obstetrics 1. Oxytocics 2. Epidosin 3. Antihypertensives 4. Anticonvulsants 5. Analgesia & anesthesia
  3. 3. Oxytocic in Obstetrics Power to excite uterine muscle contractions 1. Oxytocin 2. Ergot Derivatives 3. Prostaglandins
  4. 4. Oxytocin It is synthesized in the supra-optic and para ventricular nuclei of the hypothalamus A half life of 3-4 min and duration of action of approx. 20 min Stimulates amniotic and decidual prostaglandin production Bound intracellular calcium (mobilize from the sarcoplasmic reticulum to activate the contractile protein) Stimulate myoepithelial cells of mammary glands for milk ejection Anti diuretic action
  5. 5. Oxytocin (preparations) Synthetic oxytocin (5IU/ml) Syntometrine (5+0.5mg) Desamino oxytocin ( buccal tablets; 50IU) Oxytocin nasal solution (40U/ml)
  6. 6. Indications Pregnancy, labor , puerperium To accelerate abortion, expedite H. Mole To stop bleeding following evacuation of the uterus Adjunct to induction of abortion along with other abortifacient agents To induce and augment labor Active management of third stage of labor To minimize & control blood loss & control PPH To facilitate cervical ripening for effective induction Diagnostic of Contraction Stress Test & Oxytocin Sensitivity Test
  7. 7. Contraindications Grand multipara Obstructed labor Fetal distress Cardiac patient Previous history of anaphylactic shock
  8. 8. Adverse effects Maternal Uterine hyper stimulation Uterine rupture Water intoxication Hypotension Anti diuresis Amniotic fluid embolism Fetal : fetal distress, fetal hypoxia, fetal death
  9. 9. 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
  10. 10. Nurse’s responsibilities Evaluate: length and duration of contractions Notify physician of contractions lasting over 1 min or absence of contractions Teach: To report increased blood loss, abdominal cramps or increased temperature
  11. 11. Ergot derivatives Preparation Ampoules Tablet Ergometrine (ergonovine) 0.25mg or 0.5mg 0.5mg Methergine(methylergonovi ne) 0.2mg 0.5-1mg Syntometrine (Sandoz) 0.5mg ergometrine 0.5-1mg +5 U syntometrine
  12. 12. Onset of action Routes Ergometrine methergine IV 45-60sec 5min IM 6-7min 7min Oral 10min 10min
  13. 13. Mode of action Acts directly on myometrium Excites powerful frequent uterine contractions with increasing intensity without any relaxation in between both upper & lower uterine segment
  14. 14. Indications Prophylaxis & treatment of atonic PPH First trimester MTP Following LSCS/ Hysterotomy
  15. 15. Contraindications Before birth of anterior shoulder Before second twin is born Heart disease in pregnancy PIH/ Chronic hypertension Rh negative patient Vascular diseases
  16. 16. Ergot derivatives Common side effects are nausea and vomiting Precipitate rise of BP, myocardial infarction, stroke and bronchospasm because of vaso-constrictive effect Prolonged use may result in gangrene formation of the toes Prolonged use in puerperium may interfere with lactation Caution: ergometrine should not be used during pregnancy, first stage of labor, second stage of labor, second stage prior to crowning of the head an din breech delivery prior to crowning
  17. 17. Ergot derivatives Nurse’s responsibilities: Assess : Blood pressure, pulse and respiration Watch for signs of hemorrhage 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, headache, sweating, nausea, vomiting or dyspnea
  18. 18. Prostaglandins Mechanism of action: increases intramyometrial calcium concentration & enhance uterine contraction. Act on G protein coupled receptors & activate calcium channels PGF2α promotes myometrial contractility PGE2α helps cervical maturation
  19. 19. Prostaglandins Routes Availability Preparation Dose Vaginal route Dinoprostone (prostin E2) Vaginal tablet 3mg in post. Fornix. Repeat dose after 6-8 hrs. Max dose 6mg Releasing dinoprostone Vaginal pessary 10mg over 24hrs. Removed when cervix is ripe Prostin E2 (cerviprime) Vaginal gel 0.5mg at/below internal os Parenteral PGE2 IV 1mg/ml PGF2a (dinoprost tromethamine) IM 5mg/ml Methyl analogue of PGF2a (carboprost) IM 250mcg/ml Methyl ester of PGE1 (misoprost) tablets
  20. 20. Contraindications Hypersenstivity to the compound Uterine scar Active cardiac, pulmonary, renal or hepatic disease, hypotension (PGE2) Bronchial asthama (PGF2a)
  21. 21. Side effects Nausea, vomiting Tachycardia Bronchospasm Cervical lacerations hyper stimulation
  22. 22. Prostaglandins - uses Powerful oxytocic effect irrespective of period of pregnancy. In later months it can be used for acceleration of labor It has got no anti diuretic effect Termination of molar pregnancy Induction of abortion, labor & augmentation Cervical ripening prior to the induction of abortion or labor Management of atonic PPH Medical managemnt of tubal ectopic pregnancy
  23. 23. Nurses' responsibility Monitor for hypersensitivity reaction Maintain asepsis After instillation of cerviprime gel patient should lie in bed for half an hour. Max. 3 instillations can be done at the interval of 6-8hrs
  24. 24. Epidosin (valethamate bromide) Used in active management of labor Facilitate dilataion and effacement of cervix Anticholinergic, spasmolytic action on smooth muscles
  25. 25. Indications Acceleration of first stage of labor Dilataion of cervix in labor Spasmodic dysmenorrhea
  26. 26. Route of administration & dose SC/IM/ IV/Orally Dose: >3-4cm dilated cervix in labor 1ampoule = 8mg IM/IV 3doses every 20min Side effects mild tachycardia
  27. 27. Anti-hypertensive therapy Sympathom imetics Adrenergic receptor blocking agent Vasodilators Calcium channel blockers Methyldopa Labetalol Hydralazine Nifedipine
  28. 28. Methyldopa Drug of first choice Central and peripheral anti-adrenergic action Effective and safe for both mother and fetus Dose: Orally 25omg BD may be increased o 1gm tds depending upon the response IV infusion 250 – 500 mg
  29. 29. Methyldopa Contraindications: hepatic disorders Psychic patients CCF Side effects: Maternal hypotension Hemolytic anemia Sodium retention Excessive sedation Fetal intestinal ileus
  30. 30. Labetalol Mechanism of action: combined alpha and beta adrenergic blocking agents Contraindication: hepatic disorders Dose: orally 100mg tds. May be increased upto 800mg daily IV infusion (hypertensive crisis) 1-2 mg/ ml until desired effect Side effects: experience is less compared to methyldopa. Efficacy and safety with short term use. Appear equal to methyl dopa
  31. 31. Hydralazine 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 25mg in 200 ml NS at a rate of 2.5 mg/hr to be doubled every 30 min Side effects: maternal : hypotension, tachycardia, arrhythmia, palpitation, lupus like syndronme Neonatal : thrombocytopenia
  32. 32. Nifedipine Mode of action: direct arteriolar vasodilator Dose: orally 5-10 mg td Contraindications: simultaneous use of magnesium sulphate could be hazardous due to synergic effect Side effects: flushing, headache, hypotension, tachycardia, inhibition of labor
  33. 33. Tocolytic agents Prevention of preterm labor Delays labor by 48-72 hrs Give time to administer steroids, treat infection 1. Beta 2 adrenergic receptor agonists 2. Prostaglandin synthetase inhibitors 3. Calcium channel blockers 4. Antagonists (atosiban)
  34. 34. Betamimetics Commonly used: Terbutaline Ritodrine Isoxuprine Mechanism of action: Activation of the intracellular enzymes( acetylate cyclase, cAMP, protein kinase) reduces intracellular free calcium and inhibits the activation of MLCK
  35. 35. Betamimetics Dose: ritodrine is given by infusion 50mcg/min and increased by 50 mcg every 10min until contractions cease. Maximum dose of 200mcg /min till 12-48 hrs may be given. Infusion is continued for about 12 hours after contraction ceases. DO NOT USE SALINE TO MAKE INFUSION Terbutaline: has longer life and has fewer side effects subcutaneous injection of 0.025mg every 3-4 hours is given
  36. 36. Betamimetics Isoxuprine: is given a IV drip 100mg in 5%D. Rate 0.2 mcg/minute. To continue for at least 2 hours after contraction ceases. Maintenance Is by IM 10mg six hourly for 24 hours, tab 10mg 6-8hourly Side effects: maternal headache, palpitation, tachycardia, pulmonary edema, hypotension, cardiac failure, hyperglycemia, ARDS, Hyper-insulinemia, lactic academia, hypokalemia, even death Neonatal hypoglycemia, IVH
  37. 37. PG synthetase inhibitor - Indomethacine Reduces synthesis of PGs thereby reduces intracellular free ca, activation of MLCK and uterine contractions Dose: loading dose 50mg PO or PR followed by 25mg evry 6 hours for 48 hrs Side effects: Maternal heart burn , GI bleeding, asthma, thrombocytopenia, renal injury
  38. 38. Calcium Channel blockers Nifedipine MgSo4 Mechanism: nifedipine blocks the entry of calcium inside the cell. Compared to beta-mimetics, effects are less. It is equally effective to Mg SO4 Dose: oral: 10 -20 mg every 6-8hrs Side effects: maternal hypotension, headache, flushing, nausea
  39. 39. Magnesium Sulphate Inhibition to calcium ion Contraindication: myasthenia gravis, impaired renal function Side effects: Maternal: flushing, perspiration, headache, muscle weakness, pulmonary edema rarely Neonatal Lethargy hypotonia respiratory depression rerely
  40. 40. Oxytocin antagonists - Atosibvan It blocks myometrial oxytocin receptors Dose: IV infusion 300mcg/min, initial bolus may be needed Side effcts: nausea, vomiting, platelet dysfunction Fetal oligohydramnios, IVH, NEC
  41. 41. Anticonvulsants – MgSo4 Mode of action: it decreases the acetylcholine release from the nerve endings Dose: IM loading dose 4gm IV ( 20% solution) over 3-5min to follow 10gm deep IM, 5gm in each buttock. Maintenance dose: 5gm deep IM on alternate buttocks every 4 hours (pritchard’s regimen) IV loading dose: 4-6 gm. IV over 15-20min. Maintenance dose: 1- 2gm/hr IV infusion (Zuspan regimen) Maintenance dose to be continued for 24hrs after the last seizure Side effects: relatively safe and is drug of choice. Muscular paresis (diminished knee jerks), respiratory failure. Renal function to be monitored. Antidote: injection of calcium gluconate 10% 10ml IV
  42. 42. MgSo4 – Toxic levels Normal = 0.8 – 1mmol/L Therapeutic levels = 1.7 – 3.5 mmol/L Prolonged PR interval & wide QRS = 3.5-5mmol/L Loss of tendon reflexes = 5-7.49mmol/L Respiratory paralysis = 7.5 – 11.9mmol/L Cardiac arrest = >12mmol/L
  43. 43. MgSo4 - side effects Flushing & lethargy Generalized muscle weakness Pulmonary oedema Cardiac arrest & death Newborn respiratory depression hyporeflexia
  44. 44. Diazepam Central muscle relaxant & anticonvulsant Dose: 20-40mg IV Side effects: Maternal – Hypotension Fetal - Respiratory Distress, hypotonia, thermoregulatory problem
  45. 45. Analgesia & anesthesia in obstetrics Sedatives and analgesics Opioid analgesics
  46. 46. Pethidine Dose: injectable preparations contains 50 mg/ml can be administered SC, IM, IV .its dose is 50-100mg IM combined with promethazine. Contradictions: should not be used IV within 2hrs and IM within 3 hrs. of expected time of delivery of the baby, for fear of birth asphyxia. It should not be used in cases of preterm labor and when respiratory reserve of the mother is reduced Side effects: M: drowsiness, dizziness, confusion, headache, sedation, nausea, vomiting
  47. 47. Fentanyl Inhibits ascending pathways in CNS. Increases pain threshold and alters pain perception. Indications: moderate to severe pain in labor, postoperative pain , and adjunct to GA Dose: 0.5-1mg IM per1-2hrs available in injectable form 0.05mg/ml Side effects: dizziness, delirium, euphoria, nausea, vomiting, muscle rigidity, blurred vision
  48. 48. Pentazocin Dose: 30-40mg Naloxone is an efficient & reliable antagonist Adverse effects: neonate respiratory depression secondary to the medication crossing to the placenta and affecting the fetus. Unsteady ambulation of the client Inhibition of the mother’s ability to cope with the pain of labor
  49. 49. Tranquilizers Diazepam – usual dose is 5-10mg Midazolam – dose of 0.05mg/kg is given IV Combination of narcotics & tranquilzers Butorphanol and nalbuphine
  50. 50. Inhalational methods Nitrous Oxide and air Premixed nitrous oxide and oxygen Trichloroethylene Methoxyflurane, isoflurane , enflurane
  51. 51. Epidural and spinal regional analgesia Adverse effects: Nausea & vomiting Inhibition of bladder & bladder elimination sensations Bradycardia or tachycardia Hypotension Respiratory depression Allergic reaction and pruritis
  52. 52. Pudendal block It consists of a local anesthetic such as lidocaine (xylocaine) or bupivacaine (Marcaine) being administered transvaginally into the space in front of the pudendal nerve
  53. 53. Epidural anaesthesia Epidural block consists of a local anesthetic bupivacaine (Marcaine) along with an analgesic morphine (duramorph) or fentanyl (sublimaze) injected into the epidural space at the level of 4th or 5th vertebrae Adverse effects : maternal hypotension, fetal bradycardia, inability to feel the urge to void, loss of bearing down refl;ex
  54. 54. Spinal block Spinal block consist of a local anesthetic injected into the subarachnoid space into the spinal fluid at 3rd, 4th, 5th lumbar interspace, alone or in combination with an analgesic such as fentanyl Adverse effects: maternal hypotension, fetal bradycardia, loss of bearing fown reflex
  55. 55. Para-cervical block It consists of lidocaine (xylocaine) being injected into the cervical mucosa early in labor during the 1st stage to block the pain of uterine contractions Adverse effects include fetal bradycardia. Improper technique can result in serious toxicity
  56. 56. General Anesthesia 100% oxygen is administered by tight mask fit for more than 3 min. Induction of anaesthesia is done with the injection of thiopentone sodium 200 – 250mg as a 2.5% solution IV followed by refrigerated suxamethonium 100mg. 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 4mg or Atracurium 25mg)
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Detailed description of drugs in obstetrics for the midwifery students and beginners. Easy reference in one powerpoint presentation. Key details of drugs are mentioned . All drugs discussed as per INC Nursing syllabus for BSc & MSc Students.

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