DRUGS USED IN GYNAECOLOGY BY COSS B.pptx

Drugs

1. DRUGS USED IN GYNAECOLOGY BY COSAM BANDA EN/EM/RN WITH BSCN CHN MAJOR

2. COMMON DRUGS Prostaglandins and Oxytocics Mifepristone Myometrial relaxants Opioid analgesics – Pethidine (Controlled drug) Magnesium Sulphate (MgSO 4 ) Calcium gluconate

3. PROSTAGLANDINS AND OXYTOCICS Prostaglandins and oxytocics are used to induce abortion , induce and augment labour and to minimise blood loss from the placental site. T

4. Oxytocin Ergometrine c.Prostaglandins

5. OXYTOCIN Oxytocin is a peptide hormone of the posterior pituitary gland. It stimulates the contractions of the pregnant uterus, which becomes much more sensitive to it at term. Oxytocin is reflexly released from the pituitary following suckling [and manual stimulation] and causes almost immediate contraction of the myoepithelium of the breast it can be used to enhance milk ejection.

6. The only other clinically important effect is on the blood pressure which may fall if an overdose is given. Synthetic oxytocin [ Syntometrine ®] is pure and is not contaminated with vasopressin as is the natural product, which is obsolete

7. INDICATIONS induction for medical reasons or stimulation of labour in hypotonic uterine inertia Prevention of post partum haemorrhage, after delivery of placenta. Treatment of post partum haemorrhage. Incomplete, inevitable or missed abortion

8. CONTRAINDICATIONS Hypertonic uterine contraction Mechanical obstruction to delivery Fetal distress Any condition where spontaneous labor or vaginal delivery is inadvisable ( e.g significant cephalopelvic disproportion, malpresentation , placenta preavia , vasa preavia placental abruption, cord presentation or prolapse, predisposition to uterine rupture as in multiple pregnancy, polyhydramnios , grand multiparity and presence of uterine scar from major sugery - including ceasarean section . Avoid prolonged administration in oxytocin-resistant uterine inertia, severe pre- eclamptic toxeamia or severe cardiovascular disease.

9. SIDE EFFECTS Uterine spasm (may occur at low doses) Uterine hyper stimulation (with excessive doses- may cause fetal distress, asphyxia and death, or may lead to hyper tonicity, titanic contractions, soft tissue damage or uterine rupture Water intoxication and hyponaetreamia associated with high doses with large infusion volumes of electrolyte- free fluid Nausea, vomiting, arrhythmias. Rashes and anaphylactic reactions( with dyspnoea, hypotension or shock) Placental abruption and amniotic fluid embolism also reported on overdose

10. DOSE Induction of labour for medical reasons or stimulation of labour in hypotonic Uterine inertia; By intravenous infusion, initially 0.001 – 002units/minute increased at intervals of at least 30 minutes until a maximum of 3 – 4 contractions occur every 10 minutes [0.012 units/minute is often adequate]

11. recommendations Oxytocin should be used in standard dilutions of 10 units/500ml [Infusion 3ml/hour delivers 0.001 unit/minute] for higher doses, 30 units/500ml [infusing 1ml/hour delivers 0.001 units/minute]

12. NURSING IMPLICATION careful monitoring of fetal heart rate and uterine motility essential for dose titration( never give intravenous bolus injection during labour); discontinue immediately in uterine hyperactivity or fetal distress.

13. DOSE PER CONDITION Prevention of post partum haemorrhage,after delivery of placenta; By slow I.V injection, 5 units(if infusion used for induction or enhancement of labour, increase rate during third stage and for the next few hours).

14. Treatment of post partum haemorrhage ; By slow IV injection, 5 – 10 units followed in severe cases by IV infusion of 5 – 30 units in 500ml infusion at a rate sufficient to control uterine atony Incomplete, inevitable, or missed abortion, by slow IV Infusion, 0.02 – 0.04 units/minute or faster. Ceasarean section, by slow iv injection immediately after delivery, 5units.

15. ERGOMETRINE Ergometrine and Oxytocin differ in their actions on the uterus. In moderate doses, oxytocin produces slow generalized contractions with full relaxation in between; Ergometrine produces faster contractions superimposed on tonic contractions. Thus, oxytocin is more suited in induction of labour and ergometrine to the prevention and treatment of post partum haemorrhage.

16. INDICATION Prevention and treatment of haemorrhage

17. CONTRAINDICATION Induction of labour, first and second stage of labour Vascular disease Severe cardiac disease Impaired pulmonary function Severe hepatic and renal impairment, Sepsis Severe hypertension, eclampsia

18. SIDE EFFECTS Nausea, vomiting, headache, dizziness, tinnitus, chest pain, Palpitation, Dyspnoea, bradycardia Transient hypertension, vasoconstriction, stroke, myocardial infarction and pulmonary oedema also reported

19. DOSAGE Orally – 0.5 – 1mg, when action begins in about 8 minutes and last about 1 hour. Intravenously – 100 – 500 micrograms [µg]; onset of action about 1 minute used as treatment of established post partumhaemorrhage . Intramuscularly – 200 - 500µg; action begins in about 6 minutes; the onset is speeded by mixing the injection with hyaluronidase [1500], which enhances tissue permeation and so speeds absorption.

20. PROSTAGLANDINS Prostaglandins that soften the uterine cervix [by an action on collagen] and have a powerful oxytocic effect include; Carboprost Dinoprostone Gemeprost

21. DINOPROSTONE INDICATION They are used to induce labour and to terminate pregnancy, including missed or partial abortion and in the treatment of hydatiform mole;

22. CONTRAINDICATIONS Active cardiac, pulmonary, renal or hepatic disease Placenta praevia or unexplained vaginal bleeding during pregnancy, ruptured membranes Fetal malpresentation

23. History of caesarian section or major uterine surgery Untreated pelvic infection Fetal distress Grand multiparas and multiple pregnancy

24. SIDE EFFECTS Nausea, vomiting, diarrhea ; Uterine hypertonus Severe uterine contractions Pulmonary or amniotic fluid embolism Abruption placenta Fetal distress Maternal hypertension Bronchospasm, etc

25. DOSE By vagina, cervical ripening and induction of labour at term, 1 pessary inserted high into posterior fornix; if cervical ripening insufficient, remove pessary 8 - 12 hours later and replace with a second pessary [which should also be removed not more than 12 hours later]; max. 2 consecutive pessaries . By mouth, induction of labour, 500 micrograms, followed by 0.5 – 1mg [max. 1.5mg] at hourly intervals.

26. CARBOPROST Indications Postpartum haemorrhage due to uterine atony in patients unresponsive to ergometrine and oxytocin.

27. Contraindications Untreated pelvic infections Cardiac, renal, pulmonary, or hepatic disease. Side effects Nausea, vomiting and diarrhea Hyperthermia and flushing, Bronchospasm

28. Dose By deep intramuscular injection 250 micrograms repeated if necessary at intervals of 1 1 / 2 hours. Total dose should not exceed 2mg [8 doses]

29. Misoprostol [ Cytotec ®] – is given by mouth or by vaginal administration to induce medical abortion [unlicensed indication]; intravaginal use ripens the cervix before surgical abortion

30. Gemeprost – is used intravaginally to soften the cervix before operative procedures in the first trimester of pregnancy and for abortion alone and in combination with an anti progestogen [ Mifeprostone ]

31. ANTIPROGESTOGENS MIFEPROSTONE Mifepristone, an antiprogestogen steroid used for the termination of pregnancy. For medical termination it is given in combination with Gemeprost ; it is also used for softening and dilating the cervix before surgical termination. Although the licensed dose of mifepristone is 600mg, there is evidence that lower doses are effective for medical abortion in pregnancy of up to 20 weeks gestation

32. CONTRAINDICATION Suspected ectopic pregnancy Chronic adrenal failure Long term corticosteroid therapy Haemorrhagic disorders and anticoagulant therapy smoking

33. DOSE Medical termination of intra uterine pregnancy up to 63 days of gestation, by mouth, Mifepristone 600mg as a single dose in presence of doctor and observed for at least 2 hours followed 36 – 48 hours later [unless abortion already complete] by Gemeprost 1mg by vagina and observed for at least 6 hours with follow up visit 8 – 12 days later to verify complete expulsion

34. MYOMETRIAL RELAXANT Β 2 agonists relax uterine muscle and are used in selected cases to inhibit premature delivery. Β 2 agonists are indicated for the inhibition of uncomplicated premature labour between 24 and 33 weeks of gestation and they may permit a delay in delivery of at least 48 hours.

35. Examples Atosiban [oxytocin receptor antagonist] Ritoride Hydrochloride TerbutalineSulphate Salbutamol

36. SALBUTAMOL INDICATION Uncomplicated premature labour Asthma  

37. CONTRAINDICATIONS Cardiac disease Eclampsia and severe pre-eclampsia Intra uterine fetal death Ante partum haemorrhage [requires immediate delivery] Placenta praevia Cord compression

38. SIDE EFFECTS Nausea, vomiting Tremor, hypokalemia , Tachycardia, Palpitations and hypotension Uterine bleeding Pulmonary oedema Chest pain or tightness Liver function abnormalities

39. DOSE By intravenous infusion 10µg/min, rate increased gradually according to response at 10 minute intervals until contractions diminish the increase rate slowly until contractions cease [Max rate 45µg/min; maintain rate for 1 hour after contractions have stopped, then gradually reduce by 50% every 6 hours, then by mouth 4mg every 6 – 8 hours.

40. OPIOID ANALGESICS PETHIDINE INDICATION Moderate to severe pain Obstetric analgesia Peri -operative analgesia

41. CONTRAINDICATIONS Avoid in acute respiratory depression, acute alcoholism and where risk of paralytic ileus; Also avoid in raised intracranial pressure or head injury Avoid injection in phaechromocytoma ( tumor of the kidney)

42. SIDE EFFECTS Nausea and vomiting Constipation Drowsiness Large doses produce respiratory depression and hypotension difficult with micturition, ureteric or billiary spasm Dry mouth, sweating, headache, facial flushing, vertigo Decreased libido or potency hallucinations Dependence etc

43. DOSE Obstetric analgesia , by subcutaneous or intramuscular injection, 50 – 100mg, repeated 1 – 3 hours later if necessary; max. 400mg in 24 hours.  Postoperative pain , by subcutaneous or intramuscular injection, 25 – 100mg, every 2-3 hours if necessary; CHILD, by intramuscular injection, 0.5-2mg/kg

44. ANTI MALARIAL Intermittent Presumptive Treatment (IPT) In pregnancy give 3 doses (three tablets per dose) of Sulphadoxine + Pyrimethamine ( Fansidar ®) during the 2 nd and 3 rd trimesters, at least one month apart. Fansidar should be avoided in the 1 st trimester. NB . Quinine can be give for the treatment of malaria in all the three trimesters

45. Pregnant Women and HIV HIV testing should be provided on an opt-out basis for all women presenting to their first antenatal clinic visit. Women who test negative at the first visit should be retested every 3 months at subsequent antenatal visits, when presenting in labour, and during the breastfeeding period (e.g., at the 6 week postnatal visit) Diagnosing and treating pregnant women with ARV therapy to prevent transmitting the virus to the foetus is a priority. Pregnant, HIV positive women will either be offered HAART to both prevent MTCT of HIV and treat maternal disease or short-term ARV therapy to prevent mother-to-child transmission only

46. HAART for PMTCT of HIV and Maternal Treatment of HIV HAART provides maternal treatment for pregnant women who are eligible HAART is also associated with the lowest rates of mother-to-child transmission (1-2%) What Do You Do If a Woman Becomes Pregnant While On HAART

47. CONTRACEPTION The process of contraception is achieved by preventing ovulation [oestrogens] and also by causing the thickening of cervical mucus [ progestogens ] which then impedes entry of the sperms into the uterus and interferes with implantation.

48. Contraceptives Combined oral contraceptives Progestogen -only contraceptives Spermicidal contraceptives Contraceptive devices

49. COMBINED ORAL CONTRACEPTIVES Oral contraceptives containing oestrogen and a progestogen are the most effective preparations for general use.

50. Microgynon-30® [ Levornogestrel 150µg/ Ethinylestradiol 30 µg]

51. Advantages Reliable and reversible Reduced dysmenorrhoea and menorrhagia Reduced incidence of premenstrual tension Less symptomatic fibroids and functional ovaries cysts Less benign breast disease Reduced risk of ovarian and endometrial cancer Reduced risk of pelvic inflammatory disease which may be a risk with intra uterine device

52. INDICATION Contraception Menstrual symptoms   CONTRAINDICATIONS Pregnancy Personal history of venous of arterial thrombosis Heart disease associated with pulmonary hypertension or risk of embolus Migraine Liver disease Undiagnosed vaginal bleeding Breast feeding

53. SIDE EFFECTS Nausea, vomiting, headache Breast tenderness Changes in body weight Fluid retention Thrombosis Changes in libido Skin reactions Hypertension Impairment of liver function Reduced menstrual loss, ‘spotting’ in early cycles; Absence of withdrawal bleeding

54. DOSE Each tablet should be taken approximately same time each day; if delayed by longer than 12 hours contraceptive protection may be lost. 1 tab od

55. PROGESTOGEN-ONLY CONTRACEPTIVES Oral progestogen -only contraceptives Parenteral Intra uterine Progestogen -only contraceptive

56. ORAL PROGESTOGEN-ONLY CONTRACEPTIVES Oral progestogen -only preparations may offer a suitable alternative when oestrogens are contraindicated, but have a higher failure rate than combined preparations.  They are suitable for older women, for heavy smokers and for those with hypertension, valvular heart disease, diabetes mellitus and migraine. Menstrual irregularities [ Oligomenorrhoea , menorrhagia] are more common but tend to resolve on long term treatment

57. examples Norethisterone 350µg; Levornogestrel 30µg

58. INDICATIONS Contraception  CONTRAINDICATION Pregnancy Undiagnosed vaginal bleeding Severe arterial disease Liver adenoma Porphyria After evacuation of hydatiform mole

59. SIDE EFFECTS Menstrual irregularities Nausea, vomiting Headache Dizziness Breast discomfort Depression Skin disorders Disturbance of appetite Weight changes Changes in libido

60. PARENTERAL PROGESTERON-ONLY CONTRACEPTIVES Medroxyprogesterone acetate [ Depoprovera ®] is a long acting progestogen given by intramuscular injection; it is as effective as the combined oral preparations but because of its prolonged action it should never be given without full counseling backed by the manufacturers approval leaflet.

61. INTRA UTERINE PROGESTOGEN ONLY DEVICE The progestogen -only intra uterine system, releases levornogestrel directly into the uterine cavity. It is licensed for use as a contraceptive and for the treatment of primary menorrhagia

62. EMERGENCE CONTRACEPTIVES Hormonal methods Hormonal methods for contraception involve the use of either Levornogestrel or the combined preparation containing ethinyloestradiol with Levornogestrel . Both are effective if the first dose is taken within 72 hours [3 days] of unprotected sex; taking the first dose as soon as possible increases efficacy.

63. Levornogestrel is taken as 1 tablet of 750 micrograms followed 12 hours later [and no later than 16 hours] by a further tablet

64. Advantages The levornogestrel -only emergence contraceptive is more effective than the combined hormonal emergence contraceptive. It has fewer side effects than the combined hormonal emergence contraceptive

65. The combined hormonal [ Yuzpe ] method involves taking 2 tablets, each containing ethinylestradiol 50 micrograms and levornogestrel 250 micrograms, followed 12 hours later by a further 2 tablets. The combined method is not suitable for women with a history of thrombosis Active porphyria, or For those with focal migraine at the time of presentation

66. SIDE EFFECTS Nausea, vomiting Headache Dizziness Breast discomfort, and Menstrual irregularities

67. ANTIBIOTICS Ampicillin Gentamycin Metronidazole BenzathinePenicillins Cloxacillin Amoxicillin Cefaloxycine Cotrimazole vaginal pessary Erythromycin Ciprofloxacin Tetracycline or doxicycline Tetracycline 1% eye ointment

68. MISCELLANEOUS Lignocaine Adrenaline 1:1000 Vitamin K Vitamin A Diazepam Ringers lactate Paracetamol Gentian violet

69. Iron/Folic acid Mebendazole SulphadoxinePyrimethamine Niverapine Zidovudine Lamivudine Tetanus toxoid Normal saline Glucose Water for injection

70. HE WHO BELIEVES CAN DO IT,HE DOES IT ALREADY IN HIS MIND…SO YOU CAN DO IT!!!!!!!