PRESCRIPTION WRITING IN OBSTETRICS BY DR SHASHWAT JANI

PRESCRIPTION WRITING IN OBSTETRICS BY DR SHASHWAT JANI

1. Prescription Writing In Obstetrics Dr. Shashwat Jani . M. S. ( Obs – Gyn ) Diploma in Advance Laparoscopy. Consultant Assistant Professor , Smt. N.H.L. Municipal Medical College. Sheth V. S. General Hospital , Ahmedabad. Mobile : [phone]. E-mail : [email protected]

2. Definition A prescription is a written, verbal, or electronic order from a practitioner or designated agent to a pharmacist for a particular medication for a specific patient. .

3. Contents of the Prescription Date of the order Patient Name and Address Name of the drug Strength of the drug Quantity of the drug Directions for use Practitioner Name, Address, Telephone number , Registration Number

4. Parts of prescription: Superscription: name, professional degree, contact no. address of ! prescriber, ! date when ! order is written. name, address & age of ! patient; & ! symbol Rx (an abbreviation for "recipe," ! Latin for "take thou." _ Inscription : ! body of ! Pres. containing ! name, strength of each drug, & dosage form of ! Tr. Subscription: quantity to be dispensed. ! directions to ! pharmacist, usually consisting of a short sentence: "make a solution," "mix & place into 10 capsules," or "dispense 10 tablets." Transcription : labeling of instruction to ! Patient, Prescriber's signature.

5. Contents of the Prescription Name of the drug Multiple drugs per prescription can add to confusion. KEEP IT SIMPLE. LEGIBLE Preferably in CAPITAL LETTERS.

6. Abbreviation Potential Problem Preferred Term U (unit) Mistaken as zero, four Write “unit” IU (international unit) Mistaken as IV or 10 Write “international unit” Q.D., Q.O.D. Mistaken for each other. Period after Q and O after Q can be mistaken for “I” Write “daily” and “every other day” MS, MSO4 , MgSO4 Confused for one another Write “morphine sulfate” or “magnesium sulfate” List of dangerous abbreviations, acronyms, and symbols

7. Contents of the Prescription Strength of the drug Decimal points Avoid trailing zeros. EX. 5 mg vs. 5.0 mg; can be mistaken for 50 mg Always use leading zeros. EX. 0.8 ml vs. .8 ml; can be mistaken for 8 ml

8. Principles for writing prescription : Prescribers should: ALWAYS write legibly in ink (clear writing) Use metric system (g, L) ALWAYS sign & date ! the prescription Precise Accurate Use precautions to remind patients about SE NEVER abbreviate drug names

9. “ Prescription writing is a Science and art conveying message from Prescriber to the Patient. “ One of the least-developed areas of clinical pharmacology and drug research is the use of medication during pregnancy and lactation . 12-Apr-16 Dr Shashwat Jani 9909944160 9

10. Requires special considerations Is challenging to provide effective Rx while avoiding harm to embryo,fetus or neonate. Centered on risk/benefit ratio. Effects of drugs not always known. 12-Apr-16 Dr Shashwat Jani 9909944160 10

11. Rational prescribing : Like any other process in health care, writing a prescription should be based on a series of rational steps: 1- Make a specific diagnosis 2- Consider ! pathophysiologic implications of ! diagnosis 3- Select a specific therapeutic objective 4- Select a drug of choice 5- Determine ! appropriate dosing regimen 6- Devise a plan for monitoring ! drug’s action & determine an end point for therapy 7- Plan a program of patient education.

12. The average woman takes between 3 to 5 medications during her pregnancy making reproductive toxicity a very important topic for healthcare professionals. Many years ago , the placenta was thought to be a complete barrier to the outside world.  As modern medicine is now aware, almost all substances can cross the placenta .  What differs is how much or to what degree those substances pass.  In addition to concern over the effects of these medications, the effect of the untreated disease state, which often has its own undesirable effects, must be considered. 12-Apr-16 Dr Shashwat Jani 9909944160 12

13. Any drug taken by the pregnant or breastfeeding patient has the potential to reach the fetus by way of maternal circulation or neonate by way of breastmilk …!!!

14. EFFECTS OF DRUGS ON THE EMBRYO, FETUS, OR NEONATE May vary--- No effect. Little Serious- fetal toxicity Spontaneous abortion Death Fetal malfunction Fetal malformations .

15. DRUG THERAPY DURING PREGNANCY Centered on risk/benefit ratio Effects of some medication are known Unknown- new medications, different combinations, deficiency in maternal metabolism No drug is absolutely safe.

16. RECENT STUDIES 75% of pregnant clients use 3-10 different drugs(prescription or otc’s ) other than vitamins/mineral supplements during their pregnancy. Otc’s were used 4 times that of prescription drugs.

17. Other Obstetricians…. Others who spoil your Prescription … Relatives ( Mother in law & Mother ) Friends Distant relatives Dai Sometimes Nursing Staff Neighbors

18. PHARMACOKENETICS OF DRUGS DURING PREGNANCY Absorption - decreased gi motility causes increased drug absorption. Distribution - protein binding is decreased causes increased free drug to be available. Metabolism -increased hepatic metabolism occurs for some drugs

19. PHARMACOKINETICS Excretion- in the 3rd trimester increased renal blood flow & GFR causes some drugs to clear the body faster .

20. Major congenital anomalies Functional & minor anomalies Embryo Death Highly sensitive period Less sensitive period 1 2 3 4 5 6 7 8 9 16 32 38 TA, ASD, and VSD A melia/Meromelia C left lip CNS TEETH EARS PALATE GENITALIA Early development Main embryonic period (weeks) Fetal period (weeks) EYES Masculinsation Neural tube defects Mental retardation HEART LIMBS UPPER LIP Low-set malformed ears and deafness Microphthalmia, cataracts,glaucoma Enamel hypoplasia Cleft palate Common site(s) of action

21. 12-Apr-16 Dr Shashwat Jani 9909944160 21

22. A challenge … Prescribing drugs in pregnancy is an unusual risk-benefit situation. Drugs that may be of benefit or even life-saving to the mother can deform or kill the fetus . However, the risk to the fetus should not be exaggerated. 12-Apr-16 Dr Shashwat Jani 9909944160 22

23. The FDA Categorization of Drugs in Pregnancy Category A- Controlled studies in women fail to demonstrate a risk to the fetus in the any trimester and the possibility of fetal harm appears remote Category B- Animal studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, 12-Apr-16 Dr Shashwat Jani 9909944160 23

24. Category – C : Drugs should be given only if the potential benefit justifies the potential risk to the fetus. Category – D : If the drug is needed in a life-threatening situation for which safer drugs cannot be used or are ineffective. Category – X : The drug is contraindicated in women who are or may become pregnant 12-Apr-16 Dr Shashwat Jani 9909944160 24

25. Controversy Determining the risk of use of a particular medication in pregnancy is extremely difficult .  First, pregnant women are almost always excluded from clinical trials of new medications.   Studies are typically conducted in pregnant animals; however teratogenicity is often species specific meaning that animal data is not predictive of human risk.  The risk remains unknown for approximately 90% of the medications on the market today. To further complicate this issue, the baseline rate of congenital malformations has been reported to be in the range of 1-4%.   Due to this confounder, a single malformation that occurs following the use of a medication cannot automatically be linked to the medication.  12-Apr-16 Dr Shashwat Jani 9909944160 25

26. The classic example of a teratogen is thalidomide.  Although thalidomide, a medication widely prescribed in the 1960s as a treatment for morning sickness, is associated with a high incidence of a very specific severe limb deformity, it took three years to make the connection between the defect and the drug and to stop using it in pregnant women.

27. Very high doses of vitamin A, D and E in pregnancy have been linked to birth defects. Professor Owens said doctors should not underestimate the dosage of vitamin supplements that some pregnant women consumed, particularly if they used high-potency multivitamins . Professor Julie Owens, from Adelaide University's school of pediatrics and reproductive health,

28. Some prescription meds can harm fetus : November 17, 2009 . More than six percent of expectant mothers in Quebec consume prescription drugs that are known to be harmful to their fetuses, according to a Université de Montréal investigation published in the British Journal of Obstetrics and Gynaecology .

29. Asthmatic children: Did mom use her pump during pregnancy? October 5, 2009 Expectant mothers who eschew asthma treatment during pregnancy heighten the risk transmitting the condition to their offspring, according to one of the largest studies of its kind published in the European Respiratory Journal . A research team from the Université de Montréal, the Hôpital du Sacré-Cœur de Montréal and Sainte-Justine University Hospitl Research Center f ound that 32.6 percent of children born to mothers who neglected to treat their asthma during pregnancy developed the respiratory illness themselves.

30. Sexually transmitted disease, Urinary tract infections may be bad combination for birth defect June 20, 2008 [ B]Chances of gastroschisis increase fourfold in babies whose moms have both infections[/B] University of Utah researchers report in the online British Medical Journal .

31. One wrong or illegible prescribed drug & …….

32. Commonly prescribed teratogenic Drugs…

33. Frequently used drugs in pregnancy : Vitamins, anti-emetics, analgesics, antipyretics, sedatives, antibiotics, laxatives, antacids, diuretics, antihistamines

34. Medications used to manage serious medical complications / pregnancy complications: Hypertension, PIH, diabetes, cardiac disease, bronchial asthma, thyroid disease, cancers, poly- hydramnios , pre-term labor, general and local anesthetics,coagulation disorders, auto-immune disorders, epilepsy etc…

35. Some Medications Considered Safe for Use During Pregnancy : Condition Medication Asthma · Budesonide inhaled or nasal spray (Pulmicort®, Rhinocort ®) Bladder infection (UTI) · Nitrofurantoin (Macrobid®)    - Avoid in patients with possible G6PD deficiency Cough · Dextromethrophan ( Robitussin DM sugar free ®) Constipation · Metamucil® , Citrucel®, · Docusate ( Colace ®, Ducolax ®) · Milk of magnesia. · Polyethyelene glycol ( Miralax ®)

36. Diabetes · Insulin · Glyburide (Micronase®) · Metformin (Glucophage®) Diarrhea · Loperamide (Imodium A-D ®) Gas · Simethicone (Gas-X ®, Mylicon ®, Phazyme ®) Gastroesophageal reflux disease (GERD), · Ranitidine (Zantac®) · Cimetidine ( Tagamet ®) Hayfever, sneezing, runny nose, itchy watery eyes · Chlorpheniramine ( Chlor-Trimeton ®, Efidac ®,      Teldrin ®) · Diphenhydramine  (Benadryl ®) Clemastine ( Tavist   Allergy ®) Headache or fever: · Acetaminophen ( APAP,Paracetamol,Panadol , Tylenol®)

37. High blood pressure · Methyldopa (Aldomet®) Hyperprolactinemia · Bromocriptine (Parlodel®) · Carbergoline (Dostinex®) Hypothyroidism · Thyroid hormone · Levothyroxine (Synthroid ®, Levoxyl ®) Infection · Acyclovir (Zovirax ®) · Azithromycin (Zithromax ®) · Cepaholosporins     examples: Cephalexin (Keflex®),     Cefazolin (Ancef ®), cefaclor (Ceclor®) · Clindamycin (Cleocin®) · Erythromycin · Penicillins     example Amoxicillin (Amoxil®),     Amoxicillin Clavulanate (Augmentin®),     methicillin, carbenicillin · Metronidazole (Flagyl®)

38. Motion sickness · Dimenhydrinate (Dramamine ®) Nasal congestion · Pseudoephedrine (Sudafed ®)     -Avoid in first trimester. Nasal congestion, sneezing, runny nose, itchy watery eyes · Actifed Cold and Allergy ®     Ingredients: Triprolidine, Pseudoephedrine     -Avoid in first trimester. Nasal congestion, sneezing, runny nose, itchy watery eyes, fever, and headache · Actifed Cold and Sinus ®     Ingredients: Acetaminophen, Chlorpheniramine,     Pseudoephedrine- Avoid in first trimester. Nausea · Ginger · Pyridoxine 25 mg PO TID WITH        Unisom Sleep Tabs ( Doxylamine Succinate 25 mg) 1/2 tablet TID · Metoclopramide ( Reglan ® )

39. Preeclampsia Magnesium sulfate Vaginal yeast infection · Clotrimazole cream (Gyne-Lotrimin®)

40. Process of writing a rational prescription : 1. Define the patient’s problem. 2. Specify the therapeutic objective i.e. what do you want to achieve with the treatment. 3. Verify the suitability of your treatment i.e. check effectiveness and safety.

41. Process of writing a rational prescription : 4. Start the treatment. 5. Give information instructions and warning, ask the patient to paraphrase. 6. Monitor the therapy and stop if required.

42. Factors Influencing Prescribing

43. Some influences are positive ones Policies, guidelines Research evidence Cost and clinical effectiveness Clinical Experience

44. Other influences are not so positive? Or are they? The prescribers personal selection list (known as P drugs) Custom and practice Influence of opinion leaders, colleagues and peers, Pharmas .

45. Prescription Writing is Obstetrician’s Burden

46. Take Home Message… Consider non drug options Avoid drugs if possible during weeks 6-10 Do not start any medication unless clearly indicated Do not discontinue medicines that successfully maintain the maternal condition unless there are clear indications to do so 12-Apr-16 Dr Shashwat Jani 9909944160 46

47. Ask about and document non-prescription medicines Have a pregnancy medication reference available Favor older medicines with longer record of use Keep doses low before delivery if possible 12-Apr-16 Dr Shashwat Jani 9909944160 47

48. Consult with pediatrician. Educate your patient Report adverse outcomes Always consider the effect of not treating Remember that few drugs are absolutely contraindicated 12-Apr-16 Dr Shashwat Jani 9909944160 48

49. Avoid Polypharmacy Optimize non-pharmacologic alternatives Determine whether each medication: Is necessary Is effective Is at lowest effective dose Does not adversely alter other medication effect 49

50. Simple Use generics Use least frequent dosing needed Tie to scheduled daily activities, meals, sleep/wake Provide legible written instructions 12-Apr-16 Dr Shashwat Jani 9909944160 50

51. Remember Pregnancy is a physiological condition…!!!

52. Length of prescription is inversely proportional to Knowledge of the Physician…!!!

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