methergin and clomiphene citrate

clinical teaching

1. CLINICAL TEACHING ERGOT DERIVATIVES - METHERGIN CLOMIPHENE CITRATE

2. WHAT IS METHERGIN Methergine ( methylergonovine ) is an ergot alkaloid  that affects the  smooth muscle  of a woman's  uterus , improving the muscle tone as well as the strength and timing of uterine contractions. Methergine is administered in the  postpartum  period to help deliver the placenta and to help control bleeding and other uterine problems after childbirth.

3. CHEmical and physical data Formula : C 20 H 25 N 3 O 2 Molar mass 339.432g/mol/g.mol -1

4. action Ergot alkaloid that induces rapid, sustained tetanic uterine contraction that shortens third stage of labor and reduces blood loss . Therapeutic Effects Administered after delivery of the placenta. It minimizes the risk of postpartal hemorrhage.

5. composition Ergometrine :- Ampoule 0.25-0.5 mg Tablet 0.5-1 mg Methergin :- Ampoule 0.125-0.250 mg Tablet 0.125-0.5 mg Syntometrine :- Ampoule 0.5mg ergometrine + 5 unit syntocinon

6. pharmacokinetics Absorption:  Readily absorbed from GI tract.  Onset :  5–15 min PO; 2–5 min IM; immediate IV.  Duration :  3 or more h PO; 3 h IM; 45 min IV.  Distribution :  Distributed into breast milk .   Metabolism:  Slowly metabolized in liver.  Elimination :  Excreted mainly in feces, small amount in urine .   Half-Life:  0.5–2 h.

7. uses Routine management after delivery of placenta and for postpartum atony , subinvolution , and hemorrhage. With full obstetric supervision, may be used during second stage of labor . Active management of third stage of labour as prophylaxis to excess bleeding following delivery.

8. Contraindications- prophylactic Suspected pleural pregnancy Organic cardiac diseases Severe pre eclampsia and eclampsia Rh - negative mother

9. Contraindication- therapeutic Hypersensitivity to ergot preparations to induce labor use prior to delivery of placenta threatened spontaneous abortion uterine sepsis Hypertension Toxemia lactation.

10. SIDE EFFECT Nausea, Vomiting, Stomach pain, Diarrhea, Leg cramps, Increased sweating, Skin rash, Headache, Dizziness, Ringing in your ears, Stuffy nose Unpleasant taste in your mouth.

11. Nursing implications Assessment & Drug Effects Monitor vital signs (particularly BP) and uterine response during and after parenteral administration of methylergonovine until partum period is stabilized (about 1–2 h). Notify physician if BP suddenly increases or if there are frequent periods of uterine relaxation.

12. Patient & Family Education Report severe cramping for increased bleeding. Report any of the following: Cold or numb fingers or toes, nausea or vomiting, chest or muscle pain. Do not breast feed while taking this drug.

13. Clomiphene citrate Clomid , Milophene , Serophene Classifications:   Hormones and synthetic Substitutes; ovulation stimulant;  antiestrogenic

14. action Oral nonsteroidal estrogen agonist or antagonist. Induces ovulation in selected anovulatory women. Lacks androgenic, antiandrogenic , or progestational effects and does not appear to effect pituitary-adrenal or pituitary-thyroid functions. May act by binding to hypothalamic estrogen receptors, decreasing their numbers, and by inhibiting receptor replenishment.

15. Therapeutic effects Inhibition of receptor replenishment results in a false hypoestrogenic state which stimulates pituitary release of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and gonadotropins , leading to ovarian stimulation. Normal ovulatory function does not usually resume after treatment or after pregnancy.

16. Uses Infertility in appropriately selected women desiring pregnancy whose partners are fertile and potent . Ovulation induction

17. Unlabeled uses Male infertility Menstrual abnormalities Gynecomastia Fibrocystic breast disease Regulation of cycles in patients using rhythm method of contraception Endometrial hyperplasia Persistent lactation.

18. Contraindication Pregnancy (category X) Lactation Neoplastic lesions Ovarian cyst Hepatic disease or dysfunction Abnormal uterine bleeding Visual abnormalities Mental depression Thrombophlebitis .

19. Cautious use Polycystic ovarian enlargement Pelvic discomfort Sensitivity to pituitary gonadotropins

20. Route and dosage Infertility   PO First course:  50 mg/d for 5 d; start on 5th day of cycle following start of spontaneous or induced bleeding (with progestin) or at any time in the patient who has had no recent uterine bleeding  Second course if ovulation:  repeat first course until conception or for 3 cycles   Second course if no ovulation:  100 mg/d for 5 d as above (max: 100 mg/d)

21. administration Pretreatment with estrogen is indicated for the patient who has been hypoestrogenic for a long time. Estrogen therapy is stopped immediately before clomiphene therapy begins. Each course of therapy should start on or about the 5th cycle day once ovulation has been established. Store at 15°–30° C (59°–86° F) in tightly capped, light-resistant container.

22. Adverse effect Body as a Whole:   Vasomotor flushes,  breast discomfort, abdominal pain, heavy menses, exacerbation of endometriosis; mental depression, headache, fatigue, insomnia, dizziness, vertigo .   GI:  Nausea, vomiting, increased appetite with weight gain, constipation, bloating.

23. Endocrine:  Spontaneous abortion, multiple ovulations, ovarian failure, ovarian hyperstimulation syndrome, enlarged ovaries with multiple follicular cysts .   Special Senses:  Transient blurring, diplopia , scotomas , photophobia, floaters, prolonged after-images .   Urogenital :  Urinary frequency, polyuria .

24. Diagnostic test interference Clomiphene may increase BSP retention; plasma transcortin ,  thyroxine  and sex hormone binding globulin levels. Also increases follicle-stimulating and luteinizing hormone secretion in most patients.

25. pharmacokinetics Absorption:  Readily absorbed from GI tract.  Metabolism :  Metabolized in liver.  Elimination :  Excreted primarily in feces in 5 d; the remainder is excreted slowly from enterohepatic pool or is stored in body fat for later release.  Half-Life :  5 d.

26. Nursing implications Assessment & Drug Effects Monitor for abnormal bleeding. If it occurs, full diagnostic measures are crucial. Report it immediately. Monitor for visual disturbances. Their occurrence indicates the need for a complete ophthalmologic evaluation. Drug will be stopped until symptoms subside. If clomiphene is continued more than 1 y, patient should have an ophthalmologic examination at regular intervals. Pelvic pain indicates the need for immediate pelvic examination for diagnostic purposes.

27. Patient &family education Take the medicine at same time every day to maintain drug levels and prevent forgetting a dose. Missed dose: Take drug as soon as possible. If not remembered until time for next dose, double the dose, then resume regular dosing schedule. If more than one dose is missed, check with physician. Incidence of multiple births during clomiphene use is reportedly increased to 6 times normal and appears to increase with dose increases. Patient who is going to respond usually ovulates 4–10 d after last day of treatment.

28. Report these symptoms: hot flushes resembling those associated with menopause; nausea, vomiting, headache. Appropriate drug therapy may be prescribed. Symptoms disappear after clomiphene is discontinued. Reported promptly yellowing of eyes, light-colored stools, yellow, itchy skin, and fever symptomatic of jaundice. Stop taking clomiphene if pregnancy is suspected. Contact physician for a confirmatory examination.

29. Because of the possibility of light-headedness, dizziness, and visual disturbances, do not perform hazardous tasks requiring skill and coordination in an environment with variable lighting. Report promptly excessive weight gain, signs of edema, bloating, decreased urinary output. Do not breast feed while taking this drug.

30. Thank you……