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 COMMON Drugs used in obstetric emergencies
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COMMON Drugs used in obstetric emergencies

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     COMMON Drugs used in obstetric emergencies COMMON Drugs used in obstetric emergencies Presentation Transcript

    • Drugs used in obstetric emergencies Vasanthakumari,Msc (N) Lecturer(pediatrics) Sri manakula vinayagar nursing clg,pudhucherry.
    • Drugs in Pregnancy FIRST TRIMESTER : congenital malformations (teratogenesis) SECOND & THIRD TRIMESTER : affect growth & fetal development or toxic effects on fetal tissues NEAR TERM : adverse effects on Labour or neonate after delivery
    • Drug categories Category –A - practically Not harmful during any trimester of pregnancy. eg- antibiotics( penicillin, ampicillin, amoxicillin, cloxacillin, erythromycin stearate, cephalosporin) vitamin and mineral in standard doses Thyroxin and humanized insulin
    • Conti…. Category B eg- - used in pregnancy with out adverse effect metronidazole, tinidazole, azithromycin, nystatin, paracetamol, ranitidine, ritodrine,
    • Conti….. • Category – C - Shown adverse fetal effects in the animal model, but no adequate studies in pregnant women • - immediate benefits have to be weighed against the potential risks of drug used • Eg- trimethoprim, anti tuberculosis drugs, norfloxacin, ciprofloxcin,lfloxacin, – aminophylline, quinine, acyclovir, zidovudine,heparin, – hydralazine, Beta blockers, MAO- inhibitors, lorazepam etc.
    • Conti.. • Category –D - known to be potentially harmful. Evidence of positive fetal risks. Certain situation maternal benefits may outweigh the potential fetal risks. • Eg – Tetracycline's, streptomycin, kanamycin, phenytoin,phenobarbitone, valproicacid, alprazolam,chlordiazepoxide, lithium, tricyclic depressants, ACE inhibitors, spironolactone, propyl thiouracil, corticosteroids, tobacco, iodine, warfarin, thiazides, alcohol, etc.
    • Conti……. • Category- X - proven to exert harmful effects on the fetus in both animal and humans. • Fetal risks outweigh any possible benefits to mother • Hence should be avoided. Eg. Aminoptterin.,androgens,clomphene,diethylstilboestrol, oestrogens,antimalignancy drugs, substance abuse, such as heroin,opium,lysergic acid diethylamide,etc used by drug addicts.
    • Definition of Obstetric Emergencies: • An emergency is an occurrence of serious and dangerous nature, developing suddenly and unexpectedly, demanding immediate attention.
    • Obstetric emergencies related directly to pregnancy include, for instance 1. Pre-eclampsia 2. Eclampsia 3. Antepartum Haemorrhage 4. Postpartum Haemorrhage 5. Amniotic Fluid Embolism 6. Congenital Heart Disease 7. Epilepsy
    • Uterotonics and tocolytics drugs • Uterotonics increase uterine contractions (oxytocine, prostaglandines, serotonine, kinines, cathecholamines). • Tocolytics decrease uterine contracions (spasmolytics, beta-receptor-stimulating medications, anti-oxytocin drugs).
    • Medications for Uterine Atony NE I OXYTOCIN “The Champ” Cytotec Inexpensive (?) Effective RG H E y” ET e d M pe “S
    • Mechanism of myometrium contractions • Myometrium has alpha and betaadrenoreceptors. • Stimulation of alpha-receptors by catheholamines causes uterus contraction • Stimulation of beta-receptors by catheholamines causes uterus relaxation
    • Mechanism of myometrium contractions • Uterus body contains alpha and beta catheholamines receptors • Lower segment contains choline and serotonine receptors • Cervix contains chemo-, baro- and mechanoreceptors
    • Severe Pre eclampsia / HTN • IV Labetolol (ß blocker): - Side effects: headache, nausea, vomiting, postural hypotension & liver damage - Contraindication: Asthma, marked bradycardia • IV hydralazine (vasodilator) : - Side effects: headache,nausea, vomitting, dizziness, flushing, tachycardia, palpitation & hypotension - Because of hypotension preload with gelofusin adv. - Contraindication- SLE, severe tachycardia & MI
    • Nifedipine • Calcium Channel blocker • • • • Clinical use: Mild to moderate- 5-20 mg TDS/PO Severe HTN- 10 mg Retard/PO Tocolytic- Incremental doses every 20 min until contraction stop, then 20 mg TDS/PO • Side effects: Headache,dizziness,palpitation, tachycardia, hypotension,sweating & syncope.
    • Magnesium Sulphate • Clinical use: Prevention & treatment of seizure in eclampsia / severe pre eclampsia • Dose: 4g IV stat then 1g/hr to be continued 24hr after last seizure • Side effects: nausea,vomiting,flushing, drowsiness,confusion,loss of tendon reflexes, hypotension, decrease U/O, respiratory depression, arrhythmias,cardiac arrest • Because of toxicity, Mg levels monitored
    • Magnesium Sulfate • • • • • • Mech of action is unclear – Impedes acetylcholine release? – Decr sens of the motor end plate? – Central anticonvulsant effect? • 4 g iv bolus(20 cc of 20% soln) over 1015min • • Maintenance is 1-3 g/h(alt 10 g im)
    • MgSo4 • First line treatment of eclampsia • • Recommended as prophylaxis against • eclampsia in severe pre eclampsia
    • MgSo4 • • • • • • • • Cochrane reviews: MgSo4 safer and more effective than diazepam or phenytoin for prevention of recurrent seizures • SE: Mg toxicity – Loss of DTRs @ 8-10 mEq/L – Respiratory paralysis @10-15 mEq/L – Cardiac arrest @ 20-25 mEq/L
    • MgSo4 •• Monitor: •– RR hourly •– Patellar reflexes hourly •– U/O <20cc/hr--decrease dose •– Serum Mg levels q 4 hrs 94-8mEq/L) •• Crosses the placenta freely--rarely NN •depression • Calcium gluconate--1g iv over 3-5 min(10cc of 10% soln) antidote!
    • Post partum hemorrhage • Postpartum Haemorrhage- uterotonicsoxcyticin • 0.2 mg IM/IV q2-4hr PRN; not to exceed 5 doses, THEN 0.2-0.4 mg PO q6-8hr PRN for 2-7 days • Administer IV only in emergency because of potential for Hypertension & CVA • Administer over >1 minute and monitor BP • Refractory Cluster Headache (Off-label) • 0.2 mg PO q6-8hr, not to exceed 6 months
    • OXYTOCIN OXYTOCIN “The Champ” • The common medication used to achieve uterine contraction • First-line agent to prevent and treat PPH
    • Oxytocin • • • • Mechanism of action: Acts through oxytocin receptors present in smooth muscles of myometrium. Stimulates the amniotic and decidual prostaglandin production. Mobilization of bound intracellular calcium from sarcoplasmic reticulum to activate the contractile protein. There is increase in frequency and force of uterine contractions, similar to physiological uterine contractions
    • Oxytocin Duration of action: approximately 20 minutes. In non pregnant women, half life (t1/2) is 10-15 minutes and the removal from circulation is due mainly to kidneys and liver, but t1/2 in pregnant women is only 3 minutes, because of presence of enzyme oxytocinase in placenta, uterine tissue and plasma which inactivates it. • Given orally it is ineffective as it is inactivated rapidly in the Gastro-intestinal tract by enzyme, trypsin, needs to be administered by parenteral, nasal or buccal routes. Unitage and Preparation: 1 international unit (i.u.) of oxytocin is equivalent to 2 microgram of pure hormone. • Commercially available preparation is produced synthetically. Oxytocin injections are available in concentration of 5 i.u. / ml (Syntocinon) , 5 i.u/ 0.5ml. (pitocin) or 2 i.u./ 2ml. (oxytocin). • Oxytocin nasal spray contains 40 units/ ml.
    • Oxytocin Indications for stopping the infusion  • • •   Abnormal uterine contractions occurring too frequently ( less than every 2 minutes), lasting more than 60 seconds ( hyper stimulation) and increased tonus in between the contraction Evidence of Foetal distress Appearance of untoward maternal signs and symptoms
    • Oxytocin Dangers of Oxytocin Maternal • Uterine hyper stimulation; increased frequency and duration of uterine contractions & / or increased tonus, is often associated with abnormal foetal heart rate pattern • Urine rupture; high risk in grand multipara, malpresentation, contracted pelvis, prior uterine scar and excessive dosages. • Water intoxication; due to its ADH like antidiuretic action, when used in high dosages i.e. 30 – 40 i.u. / min., manifested by hyponatremia, confusion, convulsions, coma, CHF and even death. Can be prevented by strict intake output record, use of salt solutions, and by avoiding high doses oxytocin for a longer time.
    • • Hypotension; it is seen with bolus i.v. injection especially when the patient is hypovolemic or in patients with heart disease. Occasionally may produce anginal pain. • Anti- diuresis; especially with higher dosages Foetal • Foetal distress, foetal hypoxia or even foetal death may occur due to reduced placental blood flow due to uterine hyper stimulation.
    • Oxytocin (Syntocinon) • Octapeptide • Strong rhythmical contraction of myometrium • Large doses- sustained contraction(↓ placental blood flow & fetal hypoxia/death) • Clinical use: - IOL (IVI 3U syntocinon+50 ml of saline) - Augment slow labour (IVI same as above) -3rd stage of labour- 5 U IM for HTN ,cardiac disease - IVI 40 U in 500ml saline ( PPH) -Surgical termination of preg./ERPC- 5U slow IV
    • uterotonics- methylergonovin • Postpartum Haemorrhage • 0.2 mg IM/IV q2-4hr PRN; not to exceed 5 doses, THEN 0.2-0.4 mg PO q6-8hr PRN for 2-7 days • Administer IV only in emergency because of potential for Hypertension & CVA • Administer over >1 minute and monitor BP • Refractory Cluster Headache (Off-label) • 0.2 mg PO q6-8hr, not to exceed 6 months
    • • • • • carboprost tromethamine (Rx) - Hemabate Refractory Postpartum Uterine Bleeding Initial 250 mcg IM, repeat PRN q15-90min No more than 2000 mcg or 8 doses
    • • misoprostol (Rx) - Cytotec • Postpartum Hemorrhage (Off-label) • Prophylaxis: 600 mcg PO within 1 minute of delivery • Treatment: 800 mcg PO once; use caution if prophylactic dose already given and adverse effects present or observed • Use only in settings where oxytocin not available
    • • ergonovine (Discontinued) - ergometrine, Ergotrate • Pospartum or Postabortion Hemorrhage • 0.2 mg IM; may repeat in 2-4hr; not to exceed 5 doses total • Give IV only in emergency because of potential for HTN & CVA • Alternatively, 0.2-0.4 mg PO q6-12hr PRN for 48 hr or until danger of uterine atony has passed; no more than 1 week • Give over >1 minute & monitor BP
    • Dinoprostone ( prostin E2) • Vaginal pessary/gel • Clinical use: IOL – 3mg 6hrs apart ( no more than 2 pessaries in 24hrs and max. 3 doses) • Side effect: Nausea ,vomiting, diarrhoea, fever, Uterine hyperstimulation , HTN, bronchospasm • Advantages : - Mobile patient -Reduce need for syntocinon
    • Carboprost ( Hemabate) • Dose ; 250µg deep IM repeated every 15 min max 8 doses. (OR Intra-myometrial use at C/S) • Side effects: Nausea ,vomiting, diarrhoea, fever, bronchospasm, dyspnoea, pulmonary oedema, HTN, cardiovascular collapse • Clinical use: Postpartum haemorrhage
    • Atosiban(Tractocile) • Oxytocin receptor antagonist • Inhibition of uncomplicated preterm labour between 24-33 weeks ( Tocolytic) • Contraindication: severe PET, eclampsia, IUGR, IUD, placenta previa, placental abruption, abnormal CTG, SROM after 30/40 • Side effects: Nausea,vomiting,headache, hot flushes, tachycardia, hypotension & hyperglycemia • Dose- Stat IVI then continue infusion until no contraction for 6 hrs.
    • Other tocolytics • Salbutamol inhaler- 100 mcg x 2 puffs stat • Terbutaline- 250 mcg subcutaneous • Clinical use: both drugs are used for short term. (i) relaxing uterus at C/S (ii) ECV procedure • Side effects: Headache, palpitation, tachycardia, MI ,arrhythmias, hypotension & collapse
    • Mild /Moderate HTN/PET • Methyldopa: -Dose: 250mg BD/TDS , PO max dose 3g /day -Side effects: Headache,dizziness,dry mouth , postural hypotension,nightmares, mild psychosis, depression,hepatitis & jaundice - Important to stop drug in postnatal period • Labetolol 100-200mg BD/TDS PO max 2.4g/24hr • ACE inhibitors are contraindicated in pregnancy
    • Don’t forget analgesia & anaesthesia for labour & delivery!!
    • Commonly used drugs that should be avoided in pregnancy and safer alternatives Drug class Drugs to avoid in pregnancy Associated problems Drugs considered safer alternatives analgesics Non steroidal anti inflammatory Increased risk of spontaneous abortion Paracetamol, opiates antibiotics trimethoprim Causes structural defects-cleft palate Penicillin and cephalosporin anticoagulants Warfarin(1st &3rd trimester) Low molecular weight heparin anticonvulsants' phenytoin CNS defects, hemorrhage, stillbirth, spontaneous abortion, prematurity. Congenital facial anomalies Cardio vascular drugs amiodarone carbamazepine Cardiac arrhythmias digoxin and growth restriction
    • Antibiotics categorized according to their safety profile Name of the drugs category remarks Ampicillin, cephalexin, amoxycillin, erythromycin, chloramphenicol, clindamycin. A May be prescribed safely Tinidazole, trimethoprim + sulphonamides C Preferably avoided Tetracycline, aminoglycosides, doxycycline D Should always be avoided
    • Drugs in early pregnancy • Mifepristone- 200mg PO • Mechanism: Antiprogestogenic steroid Sensitizes myometrium to prostaglandin-induced contractions & ripens the cervix • Clinical use: Medical termination of pregnancy Medical management of miscarriage/IUD • Side effects: Gastro intestinal cramps, rash, urticaria, headache,dizziness, • Contraindication: severe asthma
    • Misoprostol • Synthetic prostaglandin • PO/PV route • Clinical use: - Medical TOP - Medical management of miscarriage/ IUD ( For 1st trimester single dose of 400mcg From 12- 34 weeks 400mcg 3hrly ,max 5 doses) - Postpartum hemorrhage- 800mcg PR/PV • Side effects: nausea,vomiting, diarrhoea, abdominal pain
    • Methotrexate • Cinical use: Medical management of ectopic pregnancy • Dose 50mg per kg/m2 • Criteria- adenexal mass, non viable pregnancy hCG< 3000U, haemoperitonuem < 150ml • Side effects: • Disadvantage : repeated hCG levels, emergency surgery • Advantage: Avoid surgery, tube preserved
    • Menorrhagia / dysmenorrhea • Mefenamic acid: - NSAID, reduces bleeding by 25% - Dose: 250-500mgx TDS D1-3 of cycle or PRN - Side effects: Gastro-intestinal discomfort nausea, diarrhoea, bleeding/ulceration • Tranexamic acid: - Antifibrinolytic,reduces bleeding by 50% - Dose: 1g TDS/QDS D1-4 of cycle - Contraindication: thromboembolic disease - Side effects: nausea,vomiting,diarrhoea, thrombo embolic event
    • Progestogens • Dysfunctional uterine bleeding/menorrhagiaNorethisterone 5mg TDS D5-25 (3ks on/1wk off) • Endometriosis- same dose contin. 9 months • Menorrhagia- Depoprovera, Mirena • Contraception- Mini pill, Mirena • Induce withdrawal bleeding eg. PCOS ( 10 days Rx) • Endometrial hyperplasia ( except atypical variety)- Depo provera, Mirena • HRT • Women with previous preterm labours -cyclogest pessary 200mg PV/PR daily till 36 weeks • Following IVF/ICSI- Gestone inj + cyclogest pessary
    • Progesterone • Increases membrane potential of myocyte and particularly blocks impulses between myocytes • Myometrium becomes insensitive to irritatons myometrium
    • Estrogen • • • • • • • Contraceptive - COC DUB/menorrhagia-COC Endometriosis- COC continued for 9 months PCOS/Hirsutism - Dianette PMS- E2 patches + Mirena HRT Hypogonadism- cyclical therapy initially oestogen then combined oestrogen & progesterone
    • Gonadorelin analogue • Mechanism- Initial stimulation then down regulation of GnRH receptors reducing the release of gonadotrophins and in-turn release of estrogen & androgen production • Side effects:menopausal symptoms, headache, hypersensitivity( rash,asthma, anaphylaxis), palpitation,hypertension,breast tenderness & GI symptoms, irritation of nasal mucosa (spray) • E.g Prostap, Zoladex & Buserelin spray • S/C /IM inj. Monthly or nasal spray TDS for 6/12 • Maximum treatment no more than 6 months
    • Gonadorelin analogue- clinical use • • • • • Endometriosis Chronic pelvic pain Prior to myomectomy- size & bleeding Prior to hysterectomy for fibroids Infertility- pituitary desensitisation before induction of ovulation by gonadotrophin for IVF • Menorrhagia in perimenopausal women • Precocious puberty
    • Danazol • Mechanism: Inhibits pituitary gonadotrophin -antioestrogenic & antiprogestogenic - androgenic activity • Dose : 200-800mg 4 divided dose for 3-6 month • Clinical use: - Endometriosis - Benign fibrocystic disease(breast tenderness) • Side effects: Nausea, headache,dizziness, weight gain, libido changes, androgenic side effects ( acne, oily skin, hair loss,voice changes)
    • HRT • Benefits: - Systemic therapy- improves vasomotor symp. - prevents osteoporosis - Vaginal cream/ pessary - atrophic vaginitis/ urinary symptoms • Risk of HRT: - Breast Ca(6 additional cases in 50-59 old , 5 yr use) - Ovarian Ca (1) - Endometrial Ca(unopposed E2) - VTE (7) - Stroke (1) - Coronary heart disease(15 ,70-79yr)
    • HRT • Route-Tab,gel,patches,implant,vaginal pessary/cream • Conventional HRT prep: E2 +12 days P : Combined E+P • Sequential HRT: - Indication: Perimenopausal women with uterus - Regular withdrawal bleeding • Continuous combined: - Indication: Postmenopausal (>1yr) with uterus - Bleed free
    • Other HRT • Raloxifene: SERMs - Post menopausal women>1 yr - Prevents osteoporosis - less risk of breast Ca - Not effective for vasomotor symptoms - Same risk of VTE as other HRT • Tibolone - Synthetic prep with oestogenic,progestogenic & androgenic effect - Same benefits & risks as HRT - Improves libido
    • Management of vasomotor symptoms of menopause • • • • • • Systemic HRT Tibolone Clonidine Venlafaxine Fluoxetine Not recommended- ginseng,Kosh,Soya prep( ? safety)
    • Anticholenergics for Urge incontinence • Preparations: - Tolterodine (Detrusitol XL) 4mg/OD - Solifenacin(Vesicare) 5-10mg OD - Trospium chloride(Regurin) 20mgBd - Oxybutynin- tab 2.5 mg OD - patches 36mg twice weekly • Side effects: dry mouth,constipation,blurred vision,dry eyes,drowsiness,dizziness & palpitation
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