Drugs in obstetrics

Drugs in obstetrics

1. PHARMACOTHERAPEUTICS IN OBSTETRICS Mrs. U SREEVIDYA, Msc . NURSING, Associate Professor, Apollo college of nursing, CHITTOOR

2. DRUGS USED IN PREGNANCY, LABOUR AND PUERPERIUM

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. 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. EFFECTS OF DRUGS IN PREGNANCY

6. DRUGS USED IN PREGNANCY List of drugs used in pregnancy are :- Folic acid Iron Calcium Anti -hypertensive drugs Diuretics Tocolytic agents

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. Indications Megaloblastic or macrocytic anemia during pregnancy to prevent fetal damage Prevent fetal neural tube defect during pregnancy Contraindications 1. untreated vitamin B12 deficiency.

9. Adverse effects Abdominal cramps Diarrhoea Rash Irritability nausea or bloating Dosage and route of administration 0.4mg or 400mcg OD orally 0.4-0.8mg IM Or subcutaneously daily .

10. Nursing consideration Patient with H/O fetal neural tube defect in pregnancy should increase folic acid intake 1 month before and 3 months after conception. Patient with intestinal malabsorption may need parentral administration.

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. Indications Iron deficiency As a supplement during pregnancy Contraindications Primary haemolytic anemia Peptic ulcer disease Ulcerative colitis Repeated blood transfusions

13. Adverse effects Metallic taste Temporary stained teeth Nausea or vomiting GI irritation 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. Nursing considerations Advised patient to avoid taking tablet with milk or along with antacids. Caution patient to crush tablet Caution patient not to substitute one iron salt for another because amount of elemental iron may vary. Advised patient to report for constipation or change in stool colour

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 s u p p l eme n t

16. containdications Cancer patients with bone metastasis Hypercalcemia 3 .H y p o ph o s p h at e mi a 4 .Renal calculi Adverse effects Headache Irritability 3 .H y p e rc a l c emi a 4 .Chalky taste 5. Nausea or vomitings Dosage and route of administration 500mg OD orally.

17. Nursing considerations 1. Advise patient to take oral calcium 1 or 1.5 hours after meals if GI upset occurs Monitor calcium level if the patient is having mild renal impairment. Advise patient to report for any kind of abdominal pain, vomiting or nausea occurs.

18. ANTIHYPERTENSIVE DRUGS Here are the choice of drugs given during pregnancy are:- Alpha and Beta blockers- Labetalol hydrochloride calcium channel blockers-Nifedipine 3. alpha blockers-Methyldopa 4. vasodilators-Hydralazine hydrochloride

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 ACE inhibitors Minoxidil Sodium Nitoprusside Diltiazem Atenolol 6 . P r o pra n o l o l

20. Labetalol Hydrochloride Preparation  Injection-5mg/ml in 2 ml vial  Tablets- 100mg,2 00 mg ,300mg Action Reduced peripheral vascular resistance as a result of alpha and beta blocka g e.

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. Adverse effects Dizziness Fatigue Nausea or vomiting Headache 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. Nursing considerations Advised patient to remain in supine position for 3hrs after infusion. Monitor BP frequently In diabetic patient monitor glucose level closely. Advised patient that dizziness can be minimized by rising slowly and avoiding sudden position change

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. Indications Hypertension Classic chronic stable angina pectoris . Contraindications Heart failure Hypotension Severe GI narrowing Adverse effects Dizziness Syncope Heart failure Muscle cramps Peripheral edema

26. Dosage and route of administrations  5-20mg OD orally . Nursing considerations Monitor BP & HR regularly Advise patient to avoid taking this drug with grapefruit juice. Watch for symptoms for heart failure. Advise patient if chest pain worsen immediately report to doctor .

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. Indications Hypertension Hypertensive crisis Contraindications Hepatic disease or liver cirrhosis Lactating mother Adverse effects Decrease mental acuity Sedation Headache or depression Bradycardia Hepatic necrosis Hepatitis

29. Dosage and routes of administration  250mg BD or TDS max 2g daily titrated by BP Nursing considerations Monitor BP regularly. Monitor patient coomb’s test result. Report for involuntary movements. Tell patient to check weight daily and notify if s he gains 2 or more pounds in a week

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 Hypertension Severe essential hypertension

31. contraindications Coronary artery disease Rheumatic heart disease Stroke Severe renal impairment Adverse effects Neutropenia Leukopenia 3 . Th ro m b oc y t o pe n ia 4. Orthostatic hypotension

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 Monitor patient BP, pulse rate, body weight frequently. Monitor patient for muscle and joint pain, fever or throat pain. Advised patient to take drug after food to increase absorption

33. DIUR E T ICS a Diuretics are used in the following conditions during pregnancy: PIH with massive edema Eclampsia with pulmonary ede m Severe anemia in pregnancy with heart failure Prior to blood transfusion in severe anemia As an adjunct to certain antihypertensive drugs.

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 Acute pulmonary edema Edema Hypertension

35. Contraindications Anuria Hepatic cirrhosis Allergic to sulfonamides Adverse effects Maternal: Weakness, fatigue, muscle cramps, hypokalemia Fetal: May occur due to decreased leading to fetal compromise, hyponatremia . Dosage and routes of administration  40 mg tablet, daily following breakfast.  In acute conditions, the drug is administered parenterally in doses of 40-120 mg daily .

36. Nursing considerations Monitor weight, BP and pulse rate routinely for long term use. Monitor patient I/O chart. Watch the signs for hypokalemia such as muscle weakness and cramps. Monitor uric acid if patient is having gout. Advise the patient to take drug in the morning after food. Advised patient to avoid direct sunlight to prevent photosensitivity reactions.

37. T OCOL Y TI C AG E N T S 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:- Isoxsuprine Hydrochloride Ritodrine hydrochloride

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 Prevent Preterm labour Inhibit uterine contractions .

39. Contraindications Hypersensitivity Postpartum Adverse effects Hypotension Tachycardia Nausea or vomiting Pulmonary edema Cardiac arrhythmias Hyperglycemia or hypokalemia

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 Assess patient BP, pulse during treatment Take BP lying & standing as orthostatic hypotension is common Monitor for Intensity & length of uterine contractions and FHS. Advise patient to make position changes slowly as fainting may occur .

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 Hypersensitivity Eclampsia Hypertension Dysrhythmias

42. Adverse effects Hyperglycemia Headache Restlessness or sweating Chills and drowsiness Nausea or vomiting 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. Nursing considerations Assess Maternal & fetal heart tones during infusion and also Intensity & length of uterine contractions Monitor Fluid intake to prevent fluid overload, discontinue if this occurs. 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 Positioning of patient in left lateral recumbent position to decrease hypotension & increase renal blood flow. Advise patient to remain in bed during infusion .

44. Other drugs such as, Thyroid Drugs – Levothyroxine Proton Pump Inhibitors – Lansoprazole Oral Diabetic Drugs – Metformin Anti Coagulants – Warfarin Anti pyretics - Paracetamol

45. DRUGS USED IN LABOUR

46. DRUGS USED IN LABOR Here are the drugs used in labor are:- Oxytocics Analgesics Anticonvulsant s Anticoagulant s

47. O XY T O C ICS 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 :- Oxytocin Ergot derivatives Prostaglandins

48. O X Y T OCIN & 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. Indications Pregnancy To induce abortion, labour To expedite expulsion of hydatidiform mole For oxytocin challenge test To stop bleeding following evacuation . Labour To augment labour, in uterine inertia to prevent & treat postpartum hemorrhage Postpartum 1. To initiate milk let-down in breast engorgement .

50. Contraindication s In late pregnancy Grand multipara Contracted pelvis History of LSCS or hyster o tomy Malpresentation s During labour All contraindications mentioned in pregnancy Obstructed labour Incoordinate uterine action Anytime 1. Hypovolemic state, cardiac disease

51. Adverse effects Hypertonic uterine activity Fetal distress & fetal death Uterine rupture Hypotension Neonatal jaundice 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. Nursing considerations Assess Patient I/O Ratio, Uterine contraction s , BP, pulse & respiration Administer By IV infusion with appropriate drop rate. Evaluate patient Length & duration of contractions and Notify physician of contractions lasting over one minute or absence of contractions.

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. 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. 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 Suspected plural pregnancy Organic cardiac disease Severe Pre-eclampsia & Eclampsia

56. Adverse effects Rise of BP due to vasoconstriction action 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 3 rd stage of labour -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. Nursing considerations Assess patient BP, pulse, respiration, signs of hemorrhage Administer Orally/IM deep, assess for any emergenc ies . Evaluate for decrease d blood loss . Advise patient to report for increased blood loss, abdominal cramps, headache, sweating, nausea, vomiting/ dyspnea

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. Preparations Tablet- 0.5mg PG E2 – Prostin E2 ( Dinoprostone) Gel-0.5mg E2 in 2.5ml gel-comes in pre loaded syringe. PG F2 alpha - Prostin F2 alpha ( Dinoprostodine) Inj- 125 and 250mcg PGE1 – Misoprostol T a b let-1 00 m c g , 2 m cg , 6 m cg 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. I n d i ca t i o ns For induction of abortion during 2 nd trimester & expulsion of hydatidiform mole For induction of labor in IUD of fetus In augmentation/ acceleration of labor To stop bleeding from the open uterine sinuses as in refractory cases of atonic PPH Cervical ripening Contraindications Hypersensitivity Uterine fibroids Cervical stenosis PID

61. Side effects Headache Dizziness Hypertension leg cramps 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 F2 alpha 5mg/ml Misoprostol 50mg given 4 hourly by oral, vaginal/ rectal route for induction of labour

62. Nursing considerations Assess patient RR, rhythm & depth, vaginal discharge, itching/ irritation Administer Antiemetic/ antidiarrheal preparations prior to giv e this drug, high in vagina, after warming the suppository by running warm water over package Evaluate patient for length & duration of contractions, notify physician of contractions lasting over 1 minute or absence of contractions, fever & chills Advise patient to remain supine for 10-15 minutes after vaginal insertion.

63. ANTICONVULSANTS MAGNESIUM SULPHATE Preparation Inj - 1amp=2ml contains 1gm Mgso4. T a b - 6 4 m g 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. Indications . It is a valuable drug lowering seizure threshold in women with pregnancy- induced hypertension. Used in preterm labor to decrease uterine activity . Contraindications Heart block Impaired renal function Pregnant women actively progressing labor Adverse effects Maternal Severe CNS depression Evidence of muscular paresis Fetal 1 . T a c h y c a rd ia 2. Hypoglycemia

65. Dosage & routes of administration For control of seizures, 8 ml , (4gm) IV slowly in 3-4 mins, to be followed immediately by 10 gm 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 4gm IV slowly over 10 min, followed by 2 gm/hr and then 1gm/ hr in drip of 5% dextrose for tocolytic effect

66. Nursing considerations Assess patients Vital signs 15 min after IV dose . Monitor magnesium level If using during labour, time of contractions, determine intensity Urine output should remain 30 ml/hr or more if less notify physician Examine patient Reflexes-knee jerk, patellar reflex. Administer Only after calcium gluconate is available for treating magnesium toxicity

67. Provide Seizure precautions: place client in single room with decreased stimuli, padded side rails Positioning of client in left lateral recumbent position to decrease hypotension & increased renal blood flow Evaluate patient Mental status , sensorium, memory , Respiratory status & Reflexes. 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. ANA L G E S ICS 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 Cervical dilatation in the first stage of labor. Symptomatic relief of GI tract and ureteric colic.

69. Contraindications Paralytic ileus Myasthe n ia Gravis Hypertension Ulcerative colitis Closed angle glaucoma CVS disorders Adverse effects Dryness of mouth Thirst Dilatation of pupil Palpitations Giddiness

70. Dosage and routes of administration Inj-8mg deep IM. It may be repeated after 4 hours if necessary . Nursing considerations Advise patient to report for any blurred vision, giddiness ,dry mouth immediately. Advise patient to get up from the bed carefully and slowly .

71. Tramadol hydrochloride Preparation Inj-1amp=50mg Tablet-50mg,100mg,200mg Action Bind to opioid receptor and inhibit reuptake of norepinephrine and serotonin Indications Moderate to moderately severe pain Safe given during labor as it does not cause depression to fetal respiratory centre and hence safe for baby.

72. Contraindications Breast feeding mothers Hypersensitiviy Hepatic impairment Increased ICP Adverse effects Dizziness Headache Malaise Hypertonia Nausea or vomiting

73. Dosage and routes of administration 50 to 100mg IM 6hrly or as required. Nursing considerations Monitor patient CV and respiratory status. Monitor patient at risk for seizure. Monitor patient bowel and bladder function.

74. C O A G U L A N T S 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. Action It promotes the hepatic formation of the clotting factors II,VII,IX and X. Indications It is used to treat or prevent certain bleeding problems. It helps liver to produce blood clotting factors C o ntr a in d i c ati o ns Hypersensitivity Adverse effects Pain and edema may occur at injection site. Allergic reaction such as rash and urticaria may occur. Hyperbilirubinemia

76. t o Dosage and routes of administration 0.5mg IM within 1 hour of birth. Nursing considerations Document the giv en medication to the newborn to prevent an accidental doubling. Observe for bleeding from cord usually occurs on 2 nd and 3 rd day. Observe for jaundice Observe for local inflammation.

77. DRUGS USED IN PUERPERIUM

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. Acetaminophen (paracetamol) e p t o r s . Preparation Tablet-80mg,160mg,500mg Suppository-80mg,120mg Oral solution-16m g /ml, 80mg/ml Action Produce analgesia by inhibiting prostaglandins and other substances that sensitizes pain receptors. Indications Mild to moderate pain Fever

80. Contraindications Liver disease Hypersensitivity Adverse effects Neutropenia Hemolytic anemia Hypoglycemia Urticaria

81. Dosage and routes of administration 500mg tablet thrice a day for 5 days Nursing considerations Advise the patient not to exceed the prescribed dose. Advise the patient t hat drug is only for short term use and avoid taking without prescription. Advise patient to take tablet after meal to prevent GI symptoms .

82. Lactation suppressants (Bromocriptine mesylate) Preparation Tablet-0.8mg, 2.5mg Action It blocks the release of a prolactin from the pituitary gland. Indications Suppression of lactation Pregnancy with prolactinoma Infertility 4 . A m e n o r r h oe a

83. Adverse effects Dizziness or lightheadedness especially when getting up from lying position. Confusion Hallucinations Hypertension Seizures Myocardial infarction Dosage and routes of administration 2.5mg tablet orally once in a day.

84. Nursing considerations Monitor patient for adverse reactions Drug may lead to early post partum conception . A fter menses resumes, test for pregnancy every 4 weeks or as soon as period is missed . Assess orthostatic vital signs before initiation of the therapy. Instruct the patient to take drug with meal.

85. EFFECTS OF MATERNAL MEDICATIONS ON FETUS & BREAST FEEDING INFANTS During early embryogenesis , the drugs taken by the mother reach the conceptus through the tubal/ uterine secretions by diffusion. The harmful effect on the blastocyst is usually death, in case of survival there is chance of congenital anomalies From 2 nd -12 th week (period of organogenesis) drugs can cause serious damages Gross congenital malformations & even death of the fetus may result, depending on route, length of time & dose of exposure

86. From 2 nd trimester transfer of drugs takes place through the utero-placental circulation due to lowered serum albumin concentration which results from haemodilution As the albumin binding capacity of the drugs is decreased , more free drug is available for placental transfer

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. Maternal medications with established teratogenic properties & their effects Cytotoxic drugs : multiple fetal malformations & abortion Androgenic steroids, hydroxy progesterone : masculinization of the female offspring Lithium: increased congenital malformations when used in the 1 st trimester, neonatal goitre, hypotonia & cynosis Diethyl stillbestrol : vaginal stenosis, cervical hoods uterine hypoplasia in female foetuses.

89. drug Teratogenic effect Cytotoxic drugs -Diethyl stilbestrol -androgenic steroids - l i t h i um -anticonvulsants Phenytoin V a l pr o ate -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. drug Tertogenic effect a n tima l ar i a l s -corticosteroids - am i n o g l y cos i d e s - ch l or a mp h e n ic o l -tetrac y cl i ne - q u i n o l o n es -long acting su l p h o n am i d e s -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. dru g s - m e tron i d az o l e -ACE inhibitors -vitamin K[large dose] -all live viral vaccines -n a r c o t i c s -anaesthetic agents a n t id e pr e ssan t s [imipramine] -benzodiazapines Teratogenic effect No evidence of fetal or neonatal toxicity, high doses regimens should not be used. IUGR, fetal and neonatal renal failure. Hyperbilirubinemia and kernicterus. Potentially dangerous to the fetus. Depression of CNS-apnoea, bradycardia and hypothermia. a c idosis, Convulsion, bradycardia, hypoxia, and hypertonia. o cardiovascular abnormalities. o Growth restriction, CNS dysfunction.

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. 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. Anticoagulants : hemorrhagic tendency Isoniazid: anti-DNA activity & hepatotoxicity Antithyroid drugs & radioactive iodine : hypothyroidism & goiter Diazepam, opiates, phenobarbitone : sedation effect with poor sucking reflex.

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. 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. 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. 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. 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 Ampicillin 1 gm – 6 hourly, oral / Ampicillin 1 gm – 6 hourly, IV Metronidazole 400mg – 8 hourly, oral / Metronidazole 500mg – IV, 8 hourly Gentamycin 80mg, BD, IM

100. DRUGS PERMITTED TO BE USED BY NURSE MIDWIVES BY GOVT. OF INDIA IN NEWBORN CARE   Inj. Vitamin-K Immunization – Vaccines Antibiotics for sepsis – Inj. Gentamycin – 5mg/Kg/dose, OD Inj. Amoxicillin – 25mg/kg/dose, TDS Anti-Retroviral prophylaxis – Neviripine syrup for 6 weeks

101. S.No 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. 4 Tab. Misoprostol Prophylaxis: 600 mcg Per oral within 1 minute of delivery   As an alternate to oxytocin in third stage of labour for uterine tonicity Post-partum hemorrhage to control bleeding - Contraindications include pelvic infection or sepsis, hemodynamic instability or shock, allergy to misoprostol, known bleeding disorder, 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. CONCLUSION No drug should be administered to a woman durin g pregnancy, labor and birth, unless the woman is fu lly informed of the known risks . U uncertainty regarding the effects of the drug on th e physiologic and neurologic development of the woman or her baby leads to dangers. The drugs that are used daily in obstetric ca re 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. BIBLIOGRAPHY D.C.Dutta’s “Textbooks of Obstetrics” 7 th edition. New Central Book Agency (P) Ltd page no.666. A.K Debdas “Drug handbook in Obstetrics”,3 rd edition.Jaypee brothers and medical publishers private limited, New Delhi. wolter Kluwer “Drug handbook”32 edition.lippincot William &Wilkinson publisher ,London . 1. Annamma Jacob “ A Comprehensive Textbook of Midwifery & Gynecological Nursing” 3 rd edition. Jaypee Brothers Medical Publishers (P) Ltd , page no. 604-619 www.medicine.tcd.ie/pharmacology_therapeutics/....Obs&Gyn.pd