Drugs used in pregnancy, labour and puerperium
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This document discusses various drugs used during pregnancy, labor, the postpartum period, and for newborns. It describes oxytocics like oxytocin, ergot derivatives, and prostaglandins that are used to induce and augment labor. It also discusses antihypertensive drugs like methyldopa, labetalol, and nifedipine that are used to treat high blood pressure during pregnancy. Finally, it provides details on indications, mechanisms of action, dosages, and side effects of these important obstetric medications.
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Drugs used in pregnancy, labour and puerperium
- 1. DRUGS USED IN PREGNANCY, LABOUR, PUERPERIUM & NEWBORN- There are various drugs in obstetrics which are used during pregnancy, labour, puerperium & for newborn. PREGNANCY- Oxytocin Ergot derivatives- Ergometrine, Methergin Prostaglandins- Misoprost, Carboprost, Dinoprostone Antihypertensive- Methyldopa, Sodium Nitroprusside, Labetalol, Nifedipine, Prazocin, Propranol, Diuretics (Frusemide, Hydralazine Hydrochloride, Spironolactone) Tocolytic agents- Betamimetics(Terbutaline, Ritodrine & Isoxsuprine), Nifedipine, Magnesium Sulphate, Indomethacin) Anticonvulsant- Magnesium Sulphate, Diazepam, Phenytoin. Anticoagulants- Heparin, Warfarin LABOUR Oxytocin Ergot derivatives- Ergometrine, Methergin Prostaglandins- Misoprost, Carboprost, Dinoprostone Anticonvulsant- Magnesium Sulphate, Diazepam, Phenytoin PUERPERIUM Oxytocin Ergot derivatives- Ergometrine, Methergin Prostaglandins- Misoprost, Carboprost, Dinoprostone DRUGS USED IN Pregnancy Labour Puerperium Newborn
- 2. Rhogam NEWBORN Betamethasone Vit. K OXYTOCICS Oxytocics are the drugs of varying chemical nature that can excite uterine contractions of the uterine muscles. There are a number of drugs but the important ones are Oxytocin Ergot derivatives Prostaglandins OXYTOCIN INTRODUCTION: It is synthesized in the paraventricular nuclei of the hypothalamus. It has a half life of 3-4 minutes.
- 3. MODE OF ACTION: During labour, increase in myometrial oxytocin receptor concentration Oxytocin acts through these oxytocin receptors & calcium channels & stimulate amniotic & decidual prostaglandin production & initiate myometrial contractions PREPARATIONS USED: Synthetic oxytocin (pitocin): is widely used. It has got oxytocic effect without any vasopressor action. It is available in ampoules containing 5I.U/ml Syntometrine(sandoz): combination of 5 units of syntocinon and 0.5 mg ergometrine Desamino oxytocin: It is more effective than oxytocin, used as buccal tablets containing 50I.U Oxytocin nasal solutions contain 40units/ml. ROUTES OF ADMINISTERATION: IV or IM Buccal tablets Nasal sprays
- 4. Calculationof dose delivered in miliunits (mU) & its correlation with drop rate per minute Units of oxytocin mixed in 500ml Ringer solution ( 1Unit = 1000 miliunits) Drops per minute 15 drops =1ml 15 30 60 In terms of mU / minute 2 4 8 4 8 16 16 32 64 INDICATIONS: It may be conveniently given in pregnancy, labour and puerperium. It is grouped as Therapeutic Diagnostic THERAPEUTIC Pregnancy Labour Puerperium PREGNANCY: 1 To accelerate abortion 2 To stop bleeding 3 To induce labour 4 To facilitate cervical ripening of labour LABOUR In active management of 3rd stage of labour Expulsion of placenta as an alternative to ergometrine
- 5. PUERPERIUM To minimize blood loss and to control PPH Out of many ergot derivatives two are used as oxytocics. DIAGNOSTIC: Contractions Stress test Oxytocin sensitivity test CONTRAINDICATIONS PREGNANCY Grand multipara Contracted pelvis History of caesarean section or hysterotomy Malpresentation LABOUR Grand multipara Contracted pelvis History of caesarean section or hysterotomy Malpresentation Obstructed labour Incoordinate uterine action Fetal distress OTHER Hypovolaemic state Cardiac disease DANGERS OF OXYTOCIN: MATERNAL 1. Uterine hyper stimulation 2. Uterine rupture 3. Water intoxication
- 6. FETAL 1. Fetal distress or fetal death ERGOT DERIVATIVES Out of many ergot derivatives two are used as oxytocics Ergometrine Methargin MODE OF ACTION: Ergometrine, Methargin acts directly on the myometrium & excites uterine contractions PREPARATIONS USED: Ergometrine- 0.25mg in ampoules 0.5 mg ampoules Methargin 0.2 mg in ampoules 0.5-1mg tablet
- 7. INDICATIONS: Therapeutic Prophylactic THERAPEUTIC To stop the atonic uterine bleeding Following delivery, abortion Expulsion of hydatidiform mole PROPHYLACTIC Excessive heamorrhage following delivery In active management of 3rd stage of labour CONTRAINDICATIONS: 1 Suspected plural pregnancy 2 Organic cardiac diseases 3Severe eclampsia and preeclampsia 4 Heart disease and HTN SIDE EFFECTS Nausea & vomiting Rise in blood pressure, stroke Rarely gangrene of the toe PROSTAGLANDINS INTRODUCTION: Prostaglandins are the derivatives of prostanoic acid they have the property of acting as local hormone
- 8. PROSTAGLANDINS MISOPROSTOL It is a methyl ester of PGE1 preprations of PROSTAGLANDINS Tablet Vaginal suppository Or Vaginal pessary Parentral Prostaglandins PGE1- Misoprostol PGE2- Dinoprostone PGE2α - Carboprost
- 9. MECHANISM OF ACTION PGE1 Act on the myometrium & causes the cervical ripening INDICATIONS 1 Induction of abortion 2 Induction of labour 3 Acceleration of labour 4 Management of atonic postpartum hemorrhage CONTRAINDICATIONS Hypersensitivity to drug Uterine scar Pelvic inflammatory disease Hepatic & renal disorder ADVERSE EFFECTS Tacysystole (Hyperstimulation) Meconium passage DINOPROSTONE It is a PGE2 Prostaglandin
- 10. MECHANISM OF ACTION Change in myometrial cell membrane permeability Or alteration of membrane bound calcium Then they sensitise myometrium to produce uterine contractions INDICATIONS 1 Induction of abortion 2 Induction of labour 3 Acceleration of labour 4 Management of atonic postpartum heamorrhage 5 Termination of molar pregnancy 6 Management of ectopic tubal pregnancy CONTRAINDICATIONS Hypersensitivity to drug Uterine scar Pelvic inflammatory disease Hepatic & renal disorder SIDE EFFECTS Reproductive system: uterine rupture VascularDisorders: Hypotension Pregnancy, Puerperium and Perinatal Conditions: Amniotic fluid embolism CARBOPROST It is a PGE2 Prostaglandin
- 11. MECHANISM OF ACTION Change in myometrial cell membrane permeability Or alteration of membrane bound calcium Then, it produces strong uterine contractions of smooth muscles of uterus INDICATIONS 1 Induction of abortion 2 Induction of labour 3 Acceleration of labour 4 Management of atonic postpartum heamorrhage 5 Termination of molar pregnancy 6 Management of ectopic tubal pregnancy CONTRAINDICATIONS Hypersensitivity to drug Uterine scar
- 12. SIDE EFFECT Vomiting and diarrhea Nausea Dysmenorrhea-like pain Breast tenderness Urinary tract infection Uterine rupture ADVANTAGES OF PROSTAGLANDINS OVER OXYTOCIN It has got powerful oxytocic effect. Ii is more effective than oxytocin DISADVANTAGES OF PROSTAGLANDINS It is costly Tachysystole Nausea Vomiting ANTIHYPERTENSIVES INTRODUCTION: Antihypertensive drugs are given when B.P. is 160/110mm of Hg to protect mother from cerebral haemorrhage, cardiac failure and placantal abruption. First line therapy is methyldopa and second line of therapy is nifedipine.
- 13. METHYLDOPA Drug of first choice during pregnancy, effective & safe for both mother & fetus. MODE OF ACTION Stimulates central α adrenergic receptors Resulting in decrease of arterial pressure Antihypertensi ves Methyldopa Labetalol Prazosin Nifedipine Propranol Sodium nitroprusside Diuretics
- 14. DOSE ORALLY-250mg-500mg I.V- 250-500mg INDICATIONS Hypertension Gestational hypertension (pregnancy-induced hypertension -PIH) Pre-eclampsia SIDE EFFECTS MATERNAL- Postural hypotension Haemolytic anaemia Sodium retention FETAL- Intestinal ileus CONTRAINDICATIONS Hepatic disorders Psychic patients CCF LABETALOL Efficacy & safety with short term use
- 15. MECHANISM OF ACTION Decrease in systemic arterial blood pressure and systemic vascular resistance Because of its combined α- and β-adrenergic blocking activity INDICATIONS Hypertension Severe hypertension, hypertensive emergencies DOSAGE Orally -100mg t.i.d I.V. Infusion- 1-2mg/min until desired effect SIDE EFFECTS MATERNAL- Postural hypotension Sodium retention FETAL- Intestinal ileus CONTRAINDICATIONS Hepatic disorders PROPRANOL Propranolol (INN) is a sympatholytic non-selective beta blocker.
- 16. MECHANISM OF ACTION A non selective beta blocker that reduces cardiac oxygen demand By blocking catecholamine –induced increases in heart rate, blood pressure & force of myocardial contraction DOSAGE Orally – 80-240mg INDICATIONS Hypertension SIDE EFFECTS MATERNAL Severe hypotension Sodium retension Bradicardia Bronchospasm Cardiac failure Hypoglycemia FETAL Bradycardia Impaired fetal response to hypoxia IUGR when began in first & second trimester Neonatal hypoglycemia Contraindications Bronchial asthma Renal insufficiency Diabetes
- 17. CONTRAINDICATIONS Bronchial asthma Cardiogenic shock PRAZOSIN It is a sympatholytic drug used to treat high blood pressure DOSAGE Orally -1mg b.i.d INDICATIONS Hypertension SIDE EFFECTS Hypotension Nasal congestion Fluid retention CONTRAINDICATIONS Hypotension Syncope
- 18. NIFEDIPINE It is a dihydropyridine calcium channel blocker MODE OF ACTION Calcium channel blockers ( Nifedipine) Block the entry of Calcium ions from ECF to ICF Reduces the contractility of muscles. DOSE ORALLY-5-10mg INDICATIONS Pre term labour Hypertension Chronic or stable angina
- 19. SIDE EFFECTS Flushing Hypotension Headache Tachycardia a Inhibition of labour Bradycardia Ankle edema Constipation Placental ischemia Heart block CONTRAINDICATIONS It could be hazardous due to its synergic effect Bradycardia Cardiogenic shock Systolic pressure < 90mmhg Sick sinus syndrome Left ventricle dysfunction SODIUM NITROPRUSSIDE Sodium nitroprusside is a potent vasodilator
- 20. PREPARATIONS Nipride Nitropress MECHANISM OF ACTION Directly relaxes arteriolar venous smooth muscle Resulting in reduction of cardiac preload &after load INDICATIONS Hypertensive crisis To decrease bleeding by creating hypotension during pregnancy CONTRAINDICATIONS MATERNAL Nausea Vomiting Severe hypotension Restlessness Decreased reflexes Loss of consciousness FETAL Toxicity due to metabolites-cyanide & thiocyanate DIURETICS COMMON PREPARATIONS USED: FRUSEMIDE – It is a loop diuretic
- 21. ACTION Acts on loop of Henle Prevents reabsorption of sodium and potassium DOSE Oral solution – 10mg/ml, 40mg/5ml Injection-10mg/ml Tablets-20mg, 40mg, 80mg, 500mg INDICATIONS Pregnancy induced HTN In eclampsia with pulmonary edema CONTRAINDICATIONS Patient with anuria Hypersensitive to drug SIDE EFFECTS MATERNAL- Weakness Fatigue
- 22. Muscle cramps Postural hypotension Hypokalemia Hyponatremia FETAL- Fetal compromise HYDROCHLOROTHIAZIDE It is a thiazide diuretic. PREPARATIONS Esidrex, hydrodiuril , hydroozide ACTION Acts on distal tubule Increasing excretion of water, sodium, chloride and potassium INDICATIONS Edema Hypertension DOSAGE AND ROUTE P.O.-25-100mg/day
- 23. SIDE EFFECT Polyuria, glycosuria, frequency Nausea, vomiting, anorexia Rash, urticaria, fever Increased creatinine CONTRAINDICATIONS Hypersensitivity to thiazides SPIRONOLACTONE It is a potassium sparing diuretic MODE OF ACTION The drug antagonizes aldosterone by competitive inhibition in the distal tubules Thereby preventing the potassium excertion and decreasing the sodium reabsorpition. DOSE Tablets- 25mg, 50mg, 100mg
- 24. INDICATIONS Edema Hypertension CONTRAINDICATIONS Hypersensitive to drug Acute or progressive renal insufficiency SIDE EFFECTS Hyperkalemia Weakness Fatigue Muscle cramps Postural hypotension TOCOLYTIC AGENTS Preterm delivery can be delayed by drugs in order to improve the perinatal outcome. Tocolytic agents Betamimetics Indomethacin Magnesium Sulphate Nifedipine
- 25. BETAMIMETICS(TERBUTALINE, RITODRINE & ISOXSUPRINE) ISOXSUPRINE It is a betamimetic to halt premature labour ACTION Acts directly on vascular smooth muscle Causes cardiac stimulation and uterine relaxation DOSE IV drip 100 mg in 5 percent dextrose Rate 0.2 u.g. per minute MAINTENANCE I.M. 10 mg six hourly for 24 hours, Tab 10 mg 6-8 hourly INDICATIONS Delaying preterm birth Management of preterm labour SIDE EFFECTS Hypotension Tachycardia
- 26. Nausea Vomiting Pulmonary edema Cardiac arrhythmias Adult respiratory distress syndrome Hyperglycemia Hypocalcaemia Lactic acidosis RITODRINE HYDROCHLORIDE It is a tocolytic drug, was used to treat premature labour ACTION Uterine relaxant –acts directly on vascular smooth muscle Causes cardiac stimulation and uterine relaxation DOSAGE AND ROUTES IV drip 100 mg in 5 percent dextrose Rate 0.1 mg per minute gradually increased by 0.05 mg per minute q 10 min until desired response. To continue for at least 2 hours after the contractions cease.
- 27. MAINTENANCE Tab 10 mg 6-8 hourly P.O 10 mg given half hour before termination of IV, then 10 mg q2h × 24 hrs, then 10- 20 mg q4h, not to exceed 120 mg/day. INDICATIONS Delaying preterm birth Management of preterm labour SIDE EFFECTS Hyperglycemia, headache, restlessness, sweating, chills, and drowsiness. Nausea, vomiting, anorexia and malaise Altered maternal and fetal heart tone and palpitations CONTRAINDICATIONS Hypersensitivity, eclampsia, hypertension and dysrhythmias TERBUTALINE It is a tocolytic drug, was used to stop premature labour
- 28. MODE OFACTION Activation of intracellular enzymes Causes smooth muscle relaxation DOSE I.V-50mg/ml INDICATIONS Delaying preterm birth Management of preterm labour SIDE EFFECTS MATERNAL- Headache Palpitations Oedema Hyperglycemia FETAL- Tachycardia Heart failure INDOMETHACIN It is a cyclo–oxygenase inhibitor appropriate first-line tocolytic for the pregnant patient
- 29. MODE OF ACTION Reduces synthesis of PGs Thereby reduces intracellular free Ca++ Activation of MLCK & uterine contractions DOSE Loading dose25-50mg INDICATIONS In early preterm labor (< 30 wk) Preterm labor associated with polyhydramnios SIDE EFFECTS MATERNAL- Heart burn G.I bleeding Asthma Thrombocytopenia Renal injury
- 30. MAGNESIUM SULPHATE Magnesium sulfate is widely used as the primary tocolytic agent because it has similar efficacy to terbutaline with far better tolerance. MECHANISM OF ACTION Competitive inhibition to calcium ion either at motor end plate or at the cell membrane Reduces calcium influx Decreases acetylcholine release & its sensitivity at the motor end plate Direct depressant action on uterine muscles INDICATIONS Premature rupture of membranes Active labor Planned delivery within 24 hours LOADING AND MAINTENANCE DOSES It should not normally exceed 6 g, 1-2 g/h, and 24 hours SIDE EFFECTS MATERNAL Flushing
- 31. Nausea Headache Drowsiness Blurred vision FETAL Respiratory Depression Motor Depression CONTRAINDICATIONS Patients with Myasthenia gravis & impaired renal function NIFEDIPINE Nifedipine, a calcium channel blocker, nifedipine has emerged as an effective and safe alternative tocolytic agent for the management of preterm labor. MECHANISM OF ACTION Inhibit contractility in smooth muscle cells By reducing calcium influx into cells MAINTAINCE DOSE A recommended initial dosageof nifedipine is 20 mg orally, followed by 20 mg orally after 30 minutes. If contractions persist, therapy can be continued with 20 mg orally every 3-8 hours for 48-72 hours with a maximum doseof 160 mg/d. After 72 hours, if maintenance is still required, long-acting nifedipine 30-60 mg daily can be used. CONTRAINDICATIONS Allergy to nifedipine Hypotension Hepatic dysfunction Concurrent use of beta-mimetics or mgso4 or other antihypertensive medication.
- 33. MODE OF ACTION It decreases the ACH release from the nerve endings Reduces the motor and plate sensitivity DOSE IM-4gm-10gm I.V-4-6gm Regimen Loading dose Maintaince dose Intramuscular 4gm I.V over 3-5 min followed by 10gm deep I.M 5gm I.M 4 hrly in alternate buttocks Intravenous 4-6 gm I.V over 15-20 min 1-2gm /hr I.V infusion INDICATIONS Prevention or control of seizures in pre-eclampsia & eclampsia Hypomagnesia SIDE EFFECTS MATERNAL Muscular paresis Respiratory failure FETAL Respiratory Depression Motor Depression
- 34. CONTRAINDICATIONS Patients with Myasthenia gravis & impaired renal function Magnesium sulfate (magnesium sulfate injection should not be administered parenterally in patients with heart block or myocardial damage DIAZEPAM ACTION Depresses sulbcortical levels of CNS, antianxiety. DOSAGE AND ROUTE OF ADMINISTRATION PO-2 to 10 mg t.i.d – q.i.d IV-5 to 20 mg (bolus), 2 mg/min, may repeat q5-10 min, not to exceed 60 mg may repeat in 30 minute if seizures reappear SIDE EFFECTS MOTHER: Hypotension Dizziness Drowsiness Headache FETUS:
- 35. Respiratory depression Birth hypotonea Thermoregulatory problems in newborn PHENYTOIN It is a centrally acting anticonvulsant MECHANISM OFACTION Prolongs inactivation state of Na + channels Reducing likelihood of repetitive discharge INDICATIONS Prevention or controlof seizures in pre-eclampsia & eclampsia Gen. tonic-clonic, partial [status epilepticus] SIDE EFFECTS MATERNAL Occular Ataxia [sedation] Gingival hyperplasia
- 36. Hirsuitism FETAL Dysmorphogenic-cleft palate ANTICOAGULANTS HEPARIN SODIUM Prevents conversion of fibrinogen to fibrin INDICATIONS Deep vein thrombosis Thrombo-embolism Disseminated intravasculation coagulation Patients with prosthetic valves in the heart ACTION Interferes with blood clotting by indirect mean depresses hepatic synthesis of vitamin K-dependent coagulation factors (II,7,9,10) DOSAGE AND ROUTES Administered parenterally; only 5,000-7,000 IU to be administered initially as IV push, followed by 2,500 units subcutaneously every 24 hours
- 37. INDICATIONS Deep vein thrombosis Pulmonary embolism DOSAGE AND ROUTE 10-15mg orally daily for 2 days, followed by 2-10 mg at the same time each day depending upon the prothrombin time SIDE EFFECTS MATERNAL Haemorrhage FETAL Skeletal & facial deformities Optic atrophy Microcephaly RHOGAM INTRODUCTION- Prevention of anti Rh(d) antibody formation is most successful if the medication is administered twice at 28 weeks of gestation and again within 72 hrs after delivery.
- 38. MECHANISM OFACTION Blocks Rh antigen of fetal cells Antigen coated red cells are removed through maternal circulation. Central inhibition-interfere the production of Ig G from B cells. DOSE:- <13 wk gestation: 50 mcg IM >13 wk gestation: 300 mcg IM UTERINE BLEEDING Give 300 ug per 30 ml fetal whole blood or 15 ml pRBC NO UTERINE BLEEDING Gestation under 13 weeks: Rhogam 50 ug IM Gestation over 13 weeks: Rhogam 300 ug IM ADMINISTRATION: First shot around 28 week. Second within 72 hours following delivery or abortion. May be given upto 14-28 days after delivery to avoid sensitisation. INDICATION To prevent Iso-immunisation in Rh negative clients exposed to Rh positive, MTP, abdominal trauma or bleeding during pregnancy ADVERSE REACTIONS- Elevated temperature Tenderness CONTRAINDICATIONS- Rh positive woman Patients with allergic reactions
- 39. BETAMETHASONE It is a glucocorticosteroid, It is similar as dexamethasone probably a little more potent MODE OF ACTION It leads to improvement in neonatal lung function via two mechanisms by enhancing maturational changes in lung architecture and by inducing lung enzymes that play a role in biochemical maturation OR Alveoli are lined with two types of cells, the type 1 and type 2 pneumocytes The type 1 pneumocyte is responsible for gas exchange in the alveoli, while the type 2 pneumocyte is responsible for the production and secretion of surfactant It accelerates morphologic development of both types of alveolar cells.
- 40. INDICATIONS- Lactating mothers, to mature the lungs of premature babies Betamethasone is also used to stimulate fetal lung maturation (prevention of IRDS), and to decrease the incidence and mortality from intracranial hemorrhage in premature infants. DOSE Dosage-4-20mg IV or IM CONTRAINDICATIONS- Hypersensitivity and systemic infections SIDE EFFECTS- Cataract Osteoporosis Peptic ulcers Hypertension VIT. K(PHYTONADIONE)
- 41. ACTION An ant hemorrhagic factor that promotes Hepatic formation of active coagulation PREPRATIONS Inj.-2mg/ml, 10mg/ml Tablets-5mg DOSE 0.5mg – 1mg vitamin K IM at birth INDICATIONS Coagulation disorders due to decreased formation of phyton-dependent factors II, VII, IX, and X Anticoagulant induced hypoprothrombinemia Prophylaxis & treatment of hemorrhagic disease of newborns Reversal of warfarin anticoagulant effects CONTRAINDICATIONS Hypersensitivity Avoid IM if bleeding, 3rd trimester pregnancy SIDE EFFECTS IV or IM use: Severe reactions, including fatalities, have occurred during and immediately after IV administration, even when precautions have been taken with proper dilution and avoiding rapid infusion Severe reactions, including fatalities, also have been reported following IM administration; typically, these severe reactions are hypersensitivity or anaphylaxis in nature and include shock and cardiac or respiratory arrest These reactions may occur with the first dose
- 42. DRUGS USED IN PREGNANCY, LABOUR, PUERPERIUM & NEWBORN-