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Drugs in obstetrics

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Drugs in obstetrics

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Drugs in obstetrics

  1. 1. PHARMACOTHERAPEUTICS IN OBSTETRICS Mrs. U SREEVIDYA, Msc. NURSING, Associate Professor, Apollo college of nursing, CHITTOOR
  2. 2. DRUGS USED IN PREGNANCY, LABOUR AND PUERPERIUM
  3. 3. INTRODUCTION The midwife should have thorough knowledge of the indications, actions and side effects of drugs used in obstetrics as well as the nursing considerations related to each of them.
  4. 4. INTRODUCTION • Drugs used in obstetrics have a huge impact on the outcome of both mother and baby. • Drugs used during first trimester can produce congenital malformation and the period of greatest risk is from the third to eleven weeks of pregnancy • During second and third trimester drugs can affect the growth and functional development of the fetus or they can have toxic effect on fetus tissues.
  5. 5. EFFECTS OF DRUGS IN PREGNANCY
  6. 6. DRUGS USED IN PREGNANCY List of drugs used in pregnancy are:- • Folic acid • Iron • Calcium • Anti -hypertensive drugs •Diuretics •Tocolytic agents
  7. 7. FOLIC ACID Preparation •Injection- 10ml vial (5mg/ml with 1.5% benzyl alchoal) •Tablet- 0.4mg , o.8mg , 1mg Action Stimulates normal erythropoiesis and nucleoprotein synthesis.
  8. 8. Indications 1.Megaloblastic or macrocytic anemia during pregnancy to prevent fetal damage 2.Prevent fetal neural tube defect during pregnancy Contraindications 1. untreated vitamin B12 deficiency.
  9. 9. Adverse effects 1. Abdominal cramps 2. Diarrhoea 3. Rash 4. Irritability 5. nausea or bloating Dosage and route of administration 0.4mg or 400mcg OD orally 0.4-0.8mg IM Or subcutaneously daily.
  10. 10. Nursing consideration 1.Patient with H/O fetal neural tube defect in pregnancy should increase folic acid intake 1 month before and 3 months after conception. 2.Patient with intestinal malabsorption may need parentral administration.
  11. 11. IRON (ferrous fumarate) Preparation Each 100mg provides 33mg of elemental iron. Tablet- 90mg,200mg,300mg,325mg,350mg Action Provides elemental iron, an essential component in the formation of haemoglobin.
  12. 12. Indications 1. Iron deficiency 2. As a supplement during pregnancy Contraindications 1. Primary haemolytic anemia 2. Peptic ulcer disease 3. Ulcerative colitis 4. Repeated blood transfusions
  13. 13. Adverse effects 1. Metallic taste 2. Temporary stained teeth 3. Nausea or vomiting 4. GI irritation 5. Black stools Dosage and routes of administration 30mg OD orally Injection- 20mg elemental iron/ml in 5ml and 10ml single dose vial (iron sucrose ) Dose-15mg/kg body weight or max 1000mg in single Inj IM Or diluted with 100ml of NS for IV.
  14. 14. Nursing considerations 1.Advised patient to avoid taking tablet with milk or along with antacids. 2. Caution patient to crush tablet 3.Caution patient not to substitute one iron salt for another because amount of elemental iron may vary. 4.Advised patient to report for constipation or change in stool colour
  15. 15. Calcium (calcium citrate) Preparation each tablet contains 211mg or 10.6meq of elemental calcium tablet- 250mg, 500mg Action Replaces calcium and maintain calcium level Indication supplement
  16. 16. containdications 1. Cancer patients with bone metastasis 2.Hypercalcemia 3.Hypophosphatemia 4.Renal calculi Adverse effects 1. Headache 2.Irritability 3.Hypercalcemia 4.Chalky taste 5. Nausea or vomitings Dosage and route of administration 500mg OD orally.
  17. 17. Nursing considerations 1.Advise patient to take oral calcium 1 or 1.5 hours after meals if GI upset occurs 2.Monitor calcium level if the patient is having mild renal impairment. 3.Advise patient to report for any kind of abdominal pain, vomiting or nausea occurs.
  18. 18. ANTIHYPERTENSIVE DRUGS Here are the choice of drugs given during pregnancy are:- 1.Alpha and Beta blockers- Labetalol hydrochloride 2.calcium channel blockers-Nifedipine 3.alpha blockers-Methyldopa 4.vasodilators-Hydralazine hydrochloride
  19. 19. Anti hypertensive drugs contraindicated in pregnancy These drugs should be avoided because they may cause poor fetal renal function, malformation or can cause IUGR 1.ACE inhibitors 2. Minoxidil 3. Sodium Nitoprusside 4. Diltiazem 5.Atenolol 6.Propranolol
  20. 20. Labetalol Hydrochloride Preparation Injection-5mg/ml in 20ml vial Tablets- 100mg,200mg ,300mg Action Reduced peripheral vascular resistance as a result of alpha and beta blockage.
  21. 21. Indications 1.Hypertension 2.Hypertensive emergencies Contraindications 1.Hypersensitive to drug or its component. 2.Bronchial asthma 3.Hepatic or heart failure 4.Prolonged hypotension 5.Severe bradycardia
  22. 22. Adverse effects 1. Dizziness 2. Fatigue 3. Nausea or vomiting 4. Headache 5. Vertigo Dosage and route of administration 50mg or 100mg tablet OD orally 20mg/20ml Inj IV bolus wait for 10min if no response then give 40mg slow bolus.
  23. 23. Nursing considerations 1.Advised patient to remain in supine position for 3hrs after infusion. 2. Monitor BP frequently 3.In diabetic patient monitor glucose level closely. 4.Advised patient that dizziness can be minimized by rising slowly and avoiding sudden position change
  24. 24. NIFEDIPINE Preparations Capsule-10mg,20mg Tablet-20mg,30mg,60mg,90mg Action Thought to inhibit calcium ion reflex across cardiac and smooth muscle cells, decreasing contractility and oxygen demand and also dilates arteries and arterioles.
  25. 25. Indications 1. Hypertension 2. Classic chronic stable angina pectoris. Contraindications 1.Heart failure 2. Hypotension 3. Severe GI narrowing Adverse effects 1. Dizziness 2. Syncope 3. Heart failure 4. Muscle cramps 5. Peripheral edema
  26. 26. Dosage and route of administrations 5-20mg OD orally. Nursing considerations 1. Monitor BP & HR regularly 2.Advise patient to avoid taking this drug with grapefruit juice. 3. Watch for symptoms for heart failure. 4.Advise patient if chest pain worsen immediately report to doctor.
  27. 27. METHYLDOPA Preparations Tablet-250mg,500mg Inj-50mg/ml Action Inhibit the central vasomotor centre, decreasing sympathetic outflow to the heart, kidney and peripheral vasculature.
  28. 28. Indications 1. Hypertension 2. Hypertensive crisis Contraindications 1. Hepatic disease or liver cirrhosis 2. Lactating mother Adverse effects 1. Decrease mental acuity 2. Sedation 3. Headache or depression 4. Bradycardia 5. Hepatic necrosis 6. Hepatitis
  29. 29. Dosage and routes of administration 250mg BD or TDS max 2g daily titrated by BP Nursing considerations 1. Monitor BP regularly. 2. Monitor patient coomb’s test result. 3. Report for involuntary movements. 4.Tell patient to check weight daily and notify if she gains 2 or more pounds in a week
  30. 30. Hydralazine Hydrochloride Preparation Inj-20mg/ml in 1ml vial Tablet-10mg,25g,50mg,100mg Action Direct acting peripheral vasodilator that relexes arteriolar smooth muscle. Indications 1. Hypertension 2. Severe essential hypertension
  31. 31. contraindications 1. Coronary artery disease 2. Rheumatic heart disease 3. Stroke 4. Severe renal impairment Adverse effects 1. Neutropenia 2.Leukopenia 3.Thrombocytopenia 4. Orthostatic hypotension
  32. 32. Dosage and route of administration • 25mg tablet BD and if necessary may increase to 50mg BD • 5mg diluted in 10ml of NS slow IV at 15- 20minutes interval. Nursing considerations 1. Monitor patient BP, pulse rate, body weight frequently. 2.Monitor patient for muscle and joint pain, fever or throat pain. 3.Advised patient to take drug after food to increase absorption
  33. 33. DIURETICS a Diuretics are used in the following conditions during pregnancy: 1. PIH with massive edema 2. Eclampsia with pulmonary edem 3. Severe anemia in pregnancy with heart failure 4. Prior to blood transfusion in severe anemia 5.As an adjunct to certain antihypertensive drugs.
  34. 34. FUROSEMIDE (LASIX) Preparation Inj-10mg/ml Tablets-20mg,40mg,80mg,500mg Action Inhibits sodium and chloride reabsorption at proximal and distal tubules and loop of Henle. Indications 1. Acute pulmonary edema 2. Edema 3. Hypertension
  35. 35. Contraindications 1. Anuria 2. Hepatic cirrhosis 3. Allergic to sulfonamides Adverse effects 1. Maternal: Weakness, fatigue, muscle cramps, hypokalemia 2.Fetal: May occur due to decreased leading to fetal compromise, hyponatremia. Dosage and routes of administration 40 mg tablet, daily followingbreakfast.  In acute conditions, the drug is administered parenterally in doses of 40-120 mg daily.
  36. 36. Nursing considerations 1.Monitor weight, BP and pulse rate routinely for long term use. 2. Monitor patient I/O chart. 3.Watch the signs for hypokalemia such as muscle weakness and cramps. 4. Monitor uric acid if patient is having gout. 5.Advise the patient to take drug in the morning after food. 6.Advised patient to avoid direct sunlight to prevent photosensitivity reactions.
  37. 37. TOCOLYTIC AGENTS These drugs can inhibit uterine contractions & used to prolonged the pregnancy. In women who develop premature uterine contractions, in addition to putting them to absolute bed rest & sedating, Tocolytic drugs are administered in an attempt to inhibit uterine contraction. Here are the drugs used are:- 1. Isoxsuprine Hydrochloride 2. Ritodrine hydrochloride
  38. 38. Isoxsuprine hydrochloride (Duvadilan) Preparation Tablet -10mg Inj-10mg/ml Action Acts directly on vascular smooth muscle, causes cardiac stimulation & uterine relaxation And thus causing relaxing the veins and arteries and making them wider to increase the blood flow to certain parts of the body. Indication 1. Prevent Preterm labour 2. Inhibit uterine contractions.
  39. 39. Contraindications 1. Hypersensitivity 2. Postpartum Adverse effects 1. Hypotension 2. Tachycardia 3. Nausea or vomiting 4. Pulmonary edema 5. Cardiac arrhythmias 6. Hyperglycemia or hypokalemia
  40. 40. Dosage & routes of administration Initial: IV drip 100 mg in 5% dextrose @Rate0.2ug/minute. To continue at least 2 hours after the contractions cease Maintenance: IM 10mg 6 hourly for 24 hrs or tab 10mg 6- 8hrly. Nursing considerations 1. Assess patient BP, pulse during treatment 2.Take BP lying & standing as orthostatic hypotension is common 3.Monitor for Intensity & length of uterine contractions and FHS. 4.Advise patient to make position changes slowly as fainting may occur.
  41. 41. Ritodrine hydrochloride (yutopar) Preparation Inj-5ml amp-10mg/ml=50mg per amp. Tablet-10mg Action Acts directly on vascular smooth muscle, causes cardiac stimulation & uterine relaxant. Indications Prevent preterm labour Contraindications 1. Hypersensitivity 2. Eclampsia 3. Hypertension 4. Dysrhythmias
  42. 42. Adverse effects 1.Hyperglycemia 2. Headache 3. Restlessness or sweating 4. Chills and drowsiness 5. Nausea or vomiting 6. Altered maternal & fetal heart tone & palpitations. Dosage and routes of administration Initial: IV drip 100 mg in 5% dextrose @ 0.1 mg/minute gradually increased by 0.05mg/min ,To continue for at least 2 hrs after contractions cease. Maintenance -Tab 10mg 6-8 hourly PO 10 mg given half hour before termination of iv, then 10 mg q2 hr x 24 hrs, then 10-20 mg q4th, not to exceed 120 mg/day
  43. 43. Nursing considerations 1.Assess Maternal & fetal heart tones during infusion and also Intensity & length of uterine contractions 2.Monitor Fluid intake to prevent fluid overload, discontinue if this occurs. 3.Administer only clear solutions after dilution 150 mg in 500 ml D5W or NS, give at 0.3 mg/ml By Using infusion pumps/monitor carefully 4.Positioning of patient in left lateral recumbent position to decrease hypotension & increase renal blood flow. 5. Advise patient to remain in bed during infusion.
  44. 44. Other drugs such as, Thyroid Drugs – Levothyroxine Proton Pump Inhibitors – Lansoprazole Oral Diabetic Drugs – Metformin Anti Coagulants – Warfarin Anti pyretics - Paracetamol
  45. 45. DRUGS USED IN LABOUR
  46. 46. DRUGS USED IN LABOR Here are the drugs used in labor are:- 1.Oxytocics 2. Analgesics 3. Anticonvulsants 4. Anticoagulants
  47. 47. OXYTOCICS Oxytocics are the drugs that have the power to excite contractions of the uterine muscles. Among a large number of drugs belonging to this group the ones that are important and extensively used are :- 1. Oxytocin 2. Ergot derivatives 3. Prostaglandins
  48. 48. OXYTOCIN & Oxytocin is an octapeptide synthesized in the hypothalamus and stored in the posterior pituitary. Preparations Synthetic oxytocin available for parenteral use includes:- •Syntocinon : 5units/ml in ampoules of 1 ml •Pitocin 10 units/ml in ampoule of 0.5 ml •Syntometrine : A combination of syntocinon on 5 units & ergometrine 0.5mg •Oxytocin nasal solution 40 unit/ml Actions Acts directly on myofibrils producing uterine contractions stimulates milk ejection by the breasts.
  49. 49. Indications Pregnancy 1.To induce abortion, labour 2.To expedite expulsion of hydatidiform mole 3. For oxytocin challenge test 4.To stop bleeding following evacuation. Labour 1.To augment labour, in uterine inertia 2. to prevent & treat postpartum hemorrhage Postpartum 1.To initiate milk let-down in breast engorgement.
  50. 50. Contraindications In late pregnancy 1. Grand multipara 2. Contracted pelvis 3. History of LSCS or hysterotomy 4. Malpresentations During labour 1. All contraindications mentioned in pregnancy 2. Obstructed labour 3. Incoordinate uterine action Anytime 1. Hypovolemic state, cardiac disease
  51. 51. Adverse effects 1. Hypertonic uterine activity 2. Fetal distress & fetal death 3. Uterine rupture 4. Hypotension 5. Neonatal jaundice 6. Water retention & water intoxication Dosage & routes of administration Controlled IV infusion ( 10 units of oxytocin in 1 L of RL/5% Dextrose in water) Nasal spray for milk let- down
  52. 52. Nursing considerations 1.Assess Patient I/O Ratio, Uterine contractions, BP, pulse & respiration 2.Administer By IV infusion with appropriate drop rate. 3.Evaluate patient Length & duration of contractions and Notify physician of contractions lasting over one minute or absence of contractions.
  53. 53. ERGOT DERIVATIVES Ergot alkaloids are either natural or semi synthetic Preparations Ergometrine- 0.25mg/ 0.5mg ampoules & 0.5-1mg tablets Methergine - 0.2 mg ampoules & 0.5-1mg tablets Syntometrine Ergometrine - 0.5 mg+ syntocinon 5.0 units ampoules.
  54. 54. NOTE • Ergometrine & Methergine can be used parenterally or orally. As the drug produces titanic uterine contractions, it should only be used after delivery of the anterior shoulder or following delivery of baby. • It should not be used in induction of labor or abortion. • Syntometrine should always be administered IM Mode of Action Ergometrine acts directly on the myometrium. It stimulates uterine contractions & decreases bleeding.
  55. 55. Indications Therapeutic 1.To stop the atonic uterine bleeding following delivery, abortion/ expulsion of hydatidiform mole Prophylactic 1. As a prophylaxis against excessive hemorrhage , it may be administered after the delivery of the anterior shoulder with crowing / following delivery of baby. Contraindications 1. Suspected plural pregnancy 2. Organic cardiac disease 3. Severe Pre-eclampsia & Eclampsia
  56. 56. Adverse effects 1. Rise of BP due to vasoconstriction action 2.Prolonged use in puerperium may interfere by decrease concentration of prolactin & gangrene of toes due to vasoconstriction. Dosage and routes of administration • For active management of 3rdstage oflabour -0.2mg(1 amp) to be given IM. • For control of atonic PPH -1 amp slowly over 60 seconds, may be repeated after 2hrs. • For excessive lochia and subinvolution- 1 Tablet(0.125mg)TDS for 3 days.
  57. 57. Nursing considerations 1.Assess patient BP, pulse, respiration, signs of hemorrhage 2.Administer Orally/IM deep, assess for any emergencies. 3. Evaluate for decreased blood loss. 4.Advise patient to report for increased blood loss, abdominal cramps, headache, sweating, nausea, vomiting/ dyspnea
  58. 58. PROSTAGLANDINS Prostaglandins are synthesized from one of the essential fatty acids, which is widely distributed throughout the body. In the female, these are identified in the menstrual fluid, endometrium, decidua & amniotic membrane.
  59. 59. Preparations Tablet- 0.5mg 1. PG E2 – Prostin E2 ( Dinoprostone) Gel-0.5mg E2 in 2.5ml gel-comes in pre loaded syringe. 2.PG F2 alpha- Prostin F2 alpha ( Dinoprostodine) Inj- 125 and 250mcg 3. PGE1 – Misoprostol Tablet-100mcg,200mcg,600mcg Action Both PGE2 & PGF2 alpha have an oxytocic effect on the pregnant uterus. They also sensitize the myometrium to oxytocin. PGF2 alpha acts predominantly on the myometrium, while PGE2 acts mainly on the cervix.
  60. 60. Indications 1.For induction of abortion during 2ndtrimester & expulsion of hydatidiform mole 2. For induction of labor in IUD of fetus 3. In augmentation/ acceleration of labor 4.To stop bleeding from the open uterine sinuses as in refractory cases of atonic PPH 5. Cervical ripening Contraindications 1. Hypersensitivity 2. Uterine fibroids 3. Cervical stenosis 4. PID
  61. 61. Side effects 1. Headache 2. Dizziness 3. Hypertension 4. leg cramps 5. Joint swelling Dosage & routes of administration • Tablets: containing o.5 mg prostin E2 • Vaginal suppository: containing 20 mg PGE2 or 50 mg PGF2 alpha • Vaginal pessary: 3mg PGE2 • Injectable ampoules/vials of prostinE2 1 mg/ml prostin F2alpha 5mg/ml Misoprostol 50mg given 4 hourly by oral, vaginal/ rectal route for induction of labour
  62. 62. Nursing considerations 1.Assess patient RR, rhythm & depth, vaginal discharge, itching/ irritation 2.Administer Antiemetic/ antidiarrheal preparations prior to give this drug, high in vagina, after warming the suppository by running warm water over package 3.Evaluate patient for length & duration of contractions, notify physician of contractions lasting over 1 minute or absence of contractions, fever & chills 4.Advise patient to remain supine for 10-15 minutes after vaginal insertion.
  63. 63. ANTICONVULSANTS MAGNESIUM SULPHATE Preparation • Inj- 1amp=2ml contains 1gm Mgso4. • Tab-64mg Action Decreased acetylcholine in motor nerve terminals, which is responsible for anticonvulsant properties, thereby reduces neuromuscular irritability. It also decreases intracranial edema & helps in diuresis. Its peripheral vasodilatation effect improves the uterine blood supply. Has depressant action on the uterine muscles & CNS
  64. 64. Indications . 1.It is a valuable drug lowering seizure threshold in women with pregnancy- induced hypertension. 2. Used in preterm labor to decrease uterine activity. Contraindications 1. Heart block 2. Impaired renal function 3. Pregnant women actively progressing labor Adverse effects •Maternal 1. Severe CNS depression 2. Evidence of muscular paresis •Fetal 1.Tachycardia 2. Hypoglycemia
  65. 65. Dosage & routes of administration 1.For control of seizures, 8 ml, (4gm) IV slowly in 3-4 mins, to be followed immediately by 10gm of 50% solution IM & continued 4 hourly till 24 hours postpartum. Repeat injections are given only if knee jerks are present, urine output exceeds 100 ml in 4 hours & respiration are more than 10/ minute. The therapeutic level of serum magnesium is 4-7 mEq/L 2.4gm IV slowly over 10 min, followed by 2 gm/hr and then 1gm/ hr in drip of 5% dextrose for tocolytic effect
  66. 66. Nursing considerations 1.Assess patients Vital signs 15 min after IV dose. 2.Monitor magnesium level If using during labour, time of contractions, determine intensity 3.Urine output should remain 30 ml/hr or more if less notify physician 4. Examine patient Reflexes-knee jerk, patellar reflex. 5.Administer Only after calcium gluconate is available for treating magnesium toxicity
  67. 67. 6.Provide Seizure precautions: place client in single room with decreased stimuli, padded side rails 7.Positioning of client in left lateral recumbent position to decrease hypotension & increased renal blood flow 8.Evaluate patient Mental status , sensorium, memory , Respiratory status & Reflexes. 9.Discontinue infusion if respirations are below 12/min, reflexes severely hypotonic, urine output below 30ml/hr or in the event of mental confusion/ lethargy/ fetal distress.
  68. 68. ANALGESICS valethamate bromide (epidosin) Cervical spasmolytic (to treat pain associated with smooth muscle spasm) Preparation Inj-1amp-8mg/ml Action Relieves smooth muscle pain, stiffness or spasm, thereby improving muscle movement. It helps relieve pain due to periods (menstrual pain), pain in labour which enables cervical dilatation. Indication 1. Cervical dilatation in the first stage of labor. 2. Symptomatic relief of GI tract and ureteric colic.
  69. 69. Contraindications 1. Paralytic ileus 2. Myasthenia Gravis 3. Hypertension 4. Ulcerative colitis 5. Closed angle glaucoma 6. CVS disorders Adverse effects 1. Dryness of mouth 2. Thirst 3. Dilatation of pupil 4. Palpitations 5. Giddiness
  70. 70. Dosage and routes of administration Inj-8mg deep IM. It may be repeated after 4 hours if necessary. Nursing considerations 1.Advise patient to report for any blurred vision, giddiness ,dry mouth immediately. 2.Advise patient to get up from the bed carefully and slowly.
  71. 71. Tramadol hydrochloride Preparation • Inj-1amp=50mg • Tablet-50mg,100mg,200mg Action Bind to opioid receptor and inhibit reuptake of norepinephrine and serotonin Indications 1. Moderate to moderately severe pain 2.Safe given during labor as it does not cause depression to fetal respiratory centre and hence safe for baby.
  72. 72. Contraindications 1. Breast feeding mothers 2. Hypersensitiviy 3. Hepatic impairment 4.Increased ICP Adverse effects 5. Dizziness 6. Headache 7. Malaise 8. Hypertonia 9. Nausea or vomiting
  73. 73. Dosage and routes of administration 50 to 100mg IM 6hrly or asrequired. Nursing considerations 1. Monitor patient CV and respiratory status. 2. Monitor patient at risk for seizure. 3. Monitor patient bowel and bladder function.
  74. 74. COAGULANTS Vitamin K 1 (phytonadione) At birth, the newborn does not have bacteria in the colon that necessary for synthesizing fat soluble vitamin k. Therefore newborns have decreased level of Prothrombin during the first 5 to 8 days of life. Preparation INJ- 2ml vial=2mg/ml
  75. 75. Action It promotes the hepatic formation of the clotting factors II,VII,IX and X. Indications 1. It is used to treat or prevent certain bleeding problems. 2. It helps liver to produce blood clotting factors Contraindications Hypersensitivity Adverse effects 1. Pain and edema may occur at injection site. 2.Allergic reaction such as rash and urticaria may occur. 3. Hyperbilirubinemia
  76. 76. t o Dosage and routes of administration 0.5mg IM within 1 hour of birth. Nursing considerations 1.Document the given medication to the newborn to prevent an accidental doubling. 2.Observe for bleeding from cord usually occurs on 2ndand 3rdday. 3. Observe for jaundice 4. Observe for local inflammation.
  77. 77. DRUGS USED IN PUERPERIUM
  78. 78. DRUGS GIVEN DURING PUERPERIUM Here are the drugs given during puperium are:- 1.Iron 2.Folic acid 3.Calcium 4.Acetaminophen(paracetamol) 5.Lactation suppressant (in case of stillbirth, neonatal death, breast abscess or severe psychiatric illness.
  79. 79. Acetaminophen (paracetamol) eptors. Preparation • Tablet-80mg,160mg,500mg • Suppository-80mg,120mg • Oral solution-16mg/ml, 80mg/ml Action Produce analgesia by inhibiting prostaglandins and other substances that sensitizes pain receptors. Indications 1. Mild to moderate pain 2. Fever
  80. 80. Contraindications 1. Liver disease 2. Hypersensitivity Adverse effects 1. Neutropenia 2. Hemolytic anemia 3. Hypoglycemia 4. Urticaria
  81. 81. Dosage and routes of administration 500mg tablet thrice a day for 5 days Nursing considerations 1.Advise the patient not to exceed the prescribed dose. 2.Advise the patient that drug is only for short term use and avoid taking without prescription. 3.Advise patient to take tablet after meal to prevent GI symptoms.
  82. 82. Lactation suppressants (Bromocriptine mesylate) Preparation • Tablet-0.8mg, 2.5mg Action It blocks the release of a prolactin from the pituitary gland. Indications 1. Suppression of lactation 2. Pregnancy with prolactinoma 3.Infertility 4.Amenorrhoea
  83. 83. Adverse effects 1.Dizziness or lightheadedness especially when getting up from lying position. 2. Confusion 3. Hallucinations 4. Hypertension 5. Seizures 6. Myocardial infarction Dosage and routes of administration • 2.5mg tablet orally once in a day.
  84. 84. Nursing considerations 1. Monitor patient for adverse reactions 2.Drug may lead to early post partum conception . After menses resumes, test for pregnancy every 4 weeks or as soon as period is missed. 3.Assess orthostatic vital signs before initiation of the therapy. 4.Instruct the patient to take drug with meal.
  85. 85. EFFECTS OF MATERNAL MEDICATIONS ON FETUS & BREAST FEEDING INFANTS 1.During early embryogenesis, the drugs taken by the mother reach the conceptus through the tubal/ uterine secretions by diffusion. 2.The harmful effect on the blastocyst is usually death, in case of survival there is chance of congenital anomalies 3.From 2nd-12th week (period of organogenesis) drugs can cause serious damages 4.Gross congenital malformations & even death of the fetus may result, depending on route, length of time & dose of exposure
  86. 86. 5.From 2ndtrimester transfer of drugs takes place through the utero-placental circulation due to lowered serum albumin concentration which results from haemodilution 6.As the albumin binding capacity of the drugs is decreased, more free drug is available for placental transfer
  87. 87. 7. The metabolism of the drug may be hampered by the increase in plasma steroids, increased utero-placental blood flow, increased placental surface area & decreased thickness of placental membrane. These are the additional causes for increased drug transfer. 8. Fetotoxic/ teratogenic drugs are prescribed only when the benefits out weigh the potential risks. 9. Prior councelling is mandatory & minimum therapeutic dosage is used for shortest possible duration.
  88. 88. Maternal medications with established teratogenic properties & their effects 1.Cytotoxic drugs: multiple fetal malformations & abortion 2.Androgenic steroids, hydroxy progesterone: masculinization of the female offspring 3.Lithium: increased congenital malformations when used in the 1st trimester, neonatal goitre, hypotonia & cynosis 4.Diethyl stillbestrol: vaginal stenosis, cervical hoods uterine hypoplasia in female foetuses.
  89. 89. drug Teratogenic effect Cytotoxic drugs -Diethyl stilbestrol -androgenic steroids -lithium -anticonvulsants Phenytoin Valproate -aspirin multiple fetal malformations and abortion. vaginal adenosis, cervical hoods, uterine hypoplasia of the female offspring. masculinization of the female offspring. cardiovascular anomalies, neonatal goitre, hypotonia and cyanosis. benefits of treatment outweigh the risks to the fetus. Polytherapy should be avoided. Increase risk of neural tube defects, neonatal bleeding. high doses in the last few weeks cause premature closure of ductus arteriosus. Persistent pulmonary hypertension and kernicterus in newborn.
  90. 90. drug Tertogenic effect antimalarials -corticosteroids -aminoglycosides -chloramphenicol -tetracycline -quinolones -long acting sulphonamides -nitrofurantoin chloroquine, quinine- no evidence of fetal toxicity in therapeutic doses; benefits outweighs the risk. high doses[ >10 mg prednisolone daily] may produce fetal and neonatal adrenal suppression. Auditory or vestibular damage. Gray baby syndrome [peripheral vascular collapse]. Dental discolouration [yellowish] and deformity. Inhibition of bony growth- should be avoided. Arthropathy in animal studies Neonatal hemolysis, jaundice and kernicterus. Hemolysis in newborn, if used at term
  91. 91. drugs -metronidazole -ACE inhibitors -vitamin K[large dose] -all live viral vaccines -narcotics -anaesthetic agents antidepressants [imipramine] -benzodiazapines Teratogenic effect o No evidence of fetal or neonatal toxicity, high doses regimens should not be used. o IUGR, fetal and neonatal renal failure. o Hyperbilirubinemia and kernicterus. o Potentially dangerous to the fetus. o Depression of CNS-apnoea, bradycardia and hypothermia. acidosis,o Convulsion, bradycardia, hypoxia, and hypertonia. o cardiovascular abnormalities. o Growth restriction, CNS dysfunction.
  92. 92. Maternal drug intake & breastfeeding Maternal drug intake of nursing mothers have adverse effects on lactation & also on the baby as it may be present on the breast milk. Transfer of drugs through breast milk depends on the following factors: •Chemical properties •Molecular weight •Degree of protein binding •Ionic dissociation •Lipid solubility •Tissue pH •Drug concentration •Exposure time
  93. 93. Drugs identified as having effects on lactation & the neonates are listed below: •Bromides: rash, drowsiness, poor feeding •Iodides: neonatal hypothyroidism •Chloramphenicol: bone marrow toxicity •Oral pill: suppression of lactation •Bromocriptine: suppression of lactation •Ergot: suppression of lactation •Metronidazol: anorexia, blood dyscrasias, weakness, neurotoxic disorders
  94. 94. • Anticoagulants: hemorrhagic tendency • Isoniazid: anti-DNA activity & hepatotoxicity • Antithyroid drugs & radioactive iodine: hypothyroidism & goiter • Diazepam, opiates, phenobarbitone: sedation effect with poor sucking reflex.
  95. 95. USE OF SELECTED LIFE SAVING DRUGS IN OBSTETRICAL EMERGENCIES APPROVED BY THE MOHFW, INDIA PRINCIPLES:  The principle of safe medication management is essential for all nurses, midwives and health agencies involved in the care of patient, antenatal mothers, and clients.  Before administering any drug and before implementing any therapy, including those includes in standing orders, must use sound judgment in determining whether the interventions are correct and appropriate.  Based on these, in the non-availability of doctor, the nurse and midwives can provide treatment to patient at home, hospital or in the community.
  96. 96. Objectives • To maintain the continuity of the treatment of the patient. • To protect the life of the patient. • To create feeling of responsibility in the members of health team.
  97. 97. DRUGS PERMITTED TO BE USED BY NURSE MIDWIVES BY GOVT. OF INDIA IN ANTENATAL PERIOD Iron and folic acid tablets Calcium tablets Inj. TD Inj. Magnesium Sulphate Antenatal corticosteroids (DEXAMETHOSONE) IV fluids for stabilization of the woman
  98. 98. DRUGS PERMITTED TO BE USED BY NURSE MIDWIVES BY GOVT. OF INDIA IN INTRANATAL PERIOD Inj. Magnesium Sulphate Inj. Oxytocin – 10 IU, IM Tab. Misoprostol Inj. Oxytocin – 20 IU in 500 ml RL, IV for PPH IV administration of fluids for stabilization of the woman
  99. 99. DRUGS PERMITTED TO BE USED BY NURSE MIDWIVES BY GOVT. OF INDIA IN POSTNATAL PERIOD Inj. Oxytocin – 10 IU, IM Inj. Oxytocin – 20 IU in 500 ml RL, IV for PPH Antibiotics for Puerperal sepsis o Ampicillin 1 gm – 6 hourly, oral / Ampicillin 1 gm – 6 hourly, IV o Metronidazole 400mg – 8 hourly, oral / Metronidazole 500mg – IV, 8 hourly o Gentamycin 80mg, BD, IM
  100. 100. DRUGS PERMITTED TO BE USED BY NURSE MIDWIVES BY GOVT. OF INDIA IN NEWBORN CARE Inj. Vitamin-K Immunization – Vaccines Antibiotics for sepsis – o Inj. Gentamycin – 5mg/Kg/dose, OD o Inj. Amoxicillin – 25mg/kg/dose, TDS Anti-Retroviral prophylaxis – Neviripine syrup for 6 weeks
  101. 101. S.N o Name of Drug Dosage Indication Contraindication Special considerations and precautions 1 Inj. Dexamethasone 6mg, IM, 12 hourly (4 Doses) Preterm labour between 24- 34 weeks gestation to the mother for fetal lung maturity 1. True preterm labour 2. Following conditions that lead to imminent delivery: • Antepartum hemorrhage • Preterm premature rupture of membranes • Severe pre-eclampsia Frank chorioamnionitis is an absolute contraindication for using antenatal corticosteroids. Following signs and symptoms in the mother suggests Frank amnionitis: 1. History of fever and lower abdominal pain 2. On examination: Foul smelling vaginal discharge, tachycardia, and uterine tenderness 3. Fetal tachycardia Should NOT be used if: • Previous corticosteroid course for fetal lung maturity in current pregnancy • Maternal diabetes (i.e., gestational diabetes, preexisting diabetes) • Expected to deliver in < 12 hours (e.g., cervical dilation ≥ 8 cm) • Chorioamnionitis • Multiple gestation • Maternal chronic steroid use during pregnancy
  102. 102. 4 Tab. Misoprostol Prophylaxis: 600 mcg Per oral within 1 minute of delivery o As an alternate to oxytocin in third stage of labour for uterine tonicity o Post-partum hemorrhage to control bleeding - Contraindications include pelvic infection or sepsis, hemodynamic instability or shock, allergy to misoprostol, known bleeding disord er, and confirmed or suspected ectopic or molar pregnancy. - Not to be used in patients with previous cesarean delivery or major uterine surgery - Use caution if prophylactic dose already given and adverse effects present or observed - Use only in settings where oxytocin not available
  103. 103. CONCLUSION • No drug should be administered to a woman during pregnancy, labor and birth, unless the woman is fully informed of the known risks. • Uuncertainty regarding the effects of the drug on the physiologic and neurologic development of the woman or her baby leads to dangers. • The drugs that are used daily in obstetric care have a huge impact on the outcome of both mother and child. Therefore, obstetric providers need to have a very clear understanding of the mechanism of action, doses and side-effects of the most commonly used drugs.
  104. 104. BIBLIOGRAPHY 2.D.C.Dutta’s “Textbooks of Obstetrics” 7th edition. New Central Book Agency (P) Ltd page no.666. 3.A.K Debdas “Drug handbook in Obstetrics”,3rd edition.Jaypee brothers and medical publishers private limited, New Delhi. 4.wolter Kluwer “Drug handbook”32 edition.lippincot William &Wilkinson publisher ,London. 1. Annamma Jacob “ A Comprehensive Textbook of Midwifery & Gynecological Nursing” 3rd edition. Jaypee Brothers Medical Publishers (P) Ltd, page no. 604-619 www.medicine.tcd.ie/pharmacology_therapeutics/....Obs& Gyn.pd
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Drugs in obstetrics

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