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OB/Gyn > Labor & Delivery (Pharm) > Flashcards

Labor & Delivery (Pharm) Flashcards

1
Q

Significant uterine contractions prior to the completion of 37 weeks gestation?

A

Preterm Labor

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2
Q

What effects neonatal outcome?

A

Gestational Age.

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3
Q

What decreases uterine contractions to prolong time to delivery?

A

Tocolytic Agents; generally safe if used appropriately.

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4
Q

Used to delay delivery to decrease risks associated with premature delivery (2-7 days)?

A

Tocolytic Agents.

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5
Q

What gestational weeks are tocolytic agents most useful?

A

24-44 weeks gestation – benefits out-weight risks of tocolytics.

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6
Q

What gestational weeks is tocolytic therapy not recommended due to the lower risk of complications from premature delivery?

A

> 34 weeks gestation.

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7
Q

What situations do we avoid tocolytic therapy?

A

Intrauterine infection, fetal distress, maternal hemodynamic instability, vaginal bleeding.

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8
Q

Name the most commonly used Tocolytic Agents?

A
  1. Magnesium Sulfate.
  2. Beta 2-Agonists (Mimetics) – TERBUTALINE (Brethine).
  3. NSAIDs – INDOMETHACIN (Indocin).
  4. Calcium Channel Blockers (CCB) – Nifedipine (Adalat, Procardia); Dihydropyridine type.
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9
Q

Tocolytic MOA of Magnesium Sulfate?

A

Suppresses contraction of uterine smooth muscles by antagonizing intracellular Ca++

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10
Q

MOA of Magnesium Sulfate as a Seizure prophylaxis in Eclampsia/Pre-Eclampsia?

A

Decreases acetylcholine in motor nerve terminals.

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11
Q

Adverse effects of magnesium sulfate?

A
  1. Serious – maternal pulmonary edema, cardiac arrest.

2. COMMON – flushing, HA, nausea.

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12
Q

Serious toxicity from magnesium sulfate can be managed with?

A

Calcium Gluconate.

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13
Q

Contraindications/Cautions of magnesium sulfate?

A

Renal impairment, hepatitis, neuromuscular conditions.

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14
Q

What do we monitor with use of mag sulfate?

A

Mag levels, RR, DTRs, Renal function, Vital signs.

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15
Q

Dosing of mag sulfate?

A

IV loading dose (4-6g) with maintenance dosing titrated to maintain serum level of 4-8 mg/dL.

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16
Q

Stimulates Beta-2 receptors in uterine smooth muscle causing muscle relaxation?

A

Beta-2 Agonists – Terbutaline (Brethine).

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17
Q

How does Terbutaline (Brethine) cause muscle relaxation?

A

Decreases intracellular Ca and decreases contractile sensitivity to Ca.

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18
Q

Adverse Effects of Beta-2 Agonists?

A
  1. Increased incidence of maternal AEs compared to other tocolytics:
    - -Arrhythmias, Tachycardia, Lyte abnormalities, Increased glucose, pulmonary edema.
  2. Fetal/Natal AEs:
    - -Tachycardia, blood glucose abnormalities.
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19
Q

Monitoring parameters with Terbutaline (Brethine)?

A

Serum Lytes, BG, Vitals (HR, BP, RR), S/Sx of pulmonary edema.

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20
Q

How is pulmonary edema avoided with use of Beta-2 agonists?

A

Adjustment of fluid and sodium intake.

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21
Q

Some studies indicated that this medication has a better neonatal outcomes and less maternal AEs than other tocolytics?

A

CCB – Nifedipine.

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22
Q

The precise mechanisms is uncertain but probable Ca channel inhibition in uterine smooth muscle?

A

CCB – Nifedipine.

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23
Q

Dosage and DI of Nifedipine?

A
  1. PO 10-30 mg Q4-6 hrs.

2. CYP450.

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24
Q

Monitoring parameters with Nifedipine (Adalat, Procardia)?

A

HR, BP, S/Sx of CHF, Peripheral edema.

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25
Q

Adverse effects of Nifedipine (Adalat, Procardia)?

A

**Fewer AEs than mag or terbutaline.

  1. (-) effect on blood flow between placenta and uterus.
  2. CV: Hypotension, flushing, EDEMA, palpitations, CHF.
  3. CNS: dizziness, HA.
  4. GI Upset.
  5. Derm: dermatitis, urticaria.
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26
Q

MOA of Indomethacin?

A

Inhibition of prostaglandins, closure of PDA (Patent Ductus Arteriosus).

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27
Q

What is involved in the the onset of synchronous uterine contractions, cervical ripening and the increase in myometrial sensitivity to oxytocin – in other words, the transition into labor?

A

Prostaglandins – Indomethacin inhibits the transition into labor (decreases preterm labor) by inhibiting prostaglandins (PGs).

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28
Q

Adverse effects of Indomethacin?

A
  1. Maternal – N, dyspepsia, dizziness, bleeding.

2. RARE/Serious neonatal complications – necrotizing enterocolitis, hemorrhage.

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29
Q

Dosing of Indomethacin?

A

1st dose – rectal suppository 50-100 mg followed by 25-50 mg PO Q6hrs.

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30
Q

Name some Antenatal Glucocorticoids?

A
  1. BETAMETHASONE – 12 mg IM Q24 hr x2 doses.

2. Dexamethasone.

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31
Q

What does Antenatal mean?

A

Before birth, prenatal.

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32
Q

Used to promote fetal lung maturation?

A

Antenatal Glucocorticoids.

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33
Q

MOA of Antenatal Glucocorticoids?

A

Act directly to upregulate PG production in fetal membranes at term.

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34
Q

What are some complications associated with prematurity? What is used to decrease these?

A
  1. RDS – Respiratory Distress Syndrome.
  2. Intraventricular Hemorrhage.
  3. Death.

**Antenatal Glucocorticoids such as Betamethasone.

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35
Q

Who is Betamethasone indicated for?

A

Pregnant women 24-34 weeks gestation who are at risk for preterm delivery within the next 7 days.

36
Q

What increases the risk of premature delivery and risk of neonatal infection?

A

Women colonized with Group B Strep during pregnancy.

37
Q

What is associated with invasive neonatal disease?

A

Infection with Group B Strep.

38
Q

When is screening of Group B Strep in pregnancy completed?

A
  1. Vaginal and Rectal culture at 35-37 weeks gestation.
39
Q

When do we treat a pregnant mother with Intrapartum antibiotics?

A
  1. (+) cultures.
  2. Previous infant with invasive Group B strep disease.
  3. Pt. w/unknown Group B status presents for delivery, and any of the following occur:
    - -Temp >100.4.
    - -ROM >18 hrs previous; ROM – rupture of membranes.
    - - < 37 weeks gestation.
40
Q

When do we start treatment for Group B Strep infection?

A

When ROM (Rupture of membranes) occurs and continue until delivery.

41
Q

1st line treatment for Group B Strep?

A

Penicillin G – Pen G.

-5 million units IV followed by 2.5 million units Q4hrs until delivery.

42
Q

Alternatives to Pen G?

A

AMPICILLIN, Cefazolin, Clindamycin, Erythromycin.

43
Q

What to use if pt has a PCN allergy?

A

“PEC” – PCN, Erythromycin, Clindamycin, Vancomycin (best choice for GBS).

44
Q

What Abx if Group B Strep is resistant to PCN (not an alternate)?

A

Vancomycin.

45
Q

Name some Labor Induction Prostaglandin Analogs? What is another description of these meds?

A
  1. DINOPROSTONE (Cervidil) – Vaginal PG E2 (PGE2).
  2. Misoprostol.

*Cervical Ripening Agents.

46
Q

When can we begin to use a labor induction PG analog?

A

When the cervix is favorable for labor.

47
Q

Why is Dinoprostone favored over Misoprostol?

A

Misoprostol has a higher efficacy but a higher rate of AEs.

48
Q

What do cervical ripening agents induce?

A

Contractions.

49
Q

If contractions do not occur in the appropriate time frame after cervical ripening agents are administered, what is the next step?

A

Oxytocin is administered.

  • Dinoprostone, contractions occur w/in 6-12 hrs.
  • Misoprostol, contractions occur w/in 3 hrs.
50
Q

MOA of Dinoprostone (Cervidil)?

A

Prostaglandin Analog

-PGs are involved in the onset of synchronous uterine contractions, cervical ripening and the increase in myometrial sensitivity to oxytocin use.

51
Q

Indications for Dinoprostone?

A
  1. Labor induction/cervical ripening – pt’s near term w/indication for labor induction (Vaginal gel/insert).
  2. Termination of pregnancy from 12-20th week to evacuate the uterus in cases of missed abortion or intrauterine fetal death up to 28 weeks gestations (Vaginal suppositories).
52
Q

What is the black box warning for Dinoprostone (Cervidil)?

A

It is ONLY to be used by medical providers in a medical facility.

53
Q

Adverse effects of Dinoprostone (Cervidil)?

A

Fever, GI upset, back pain, abnormal uterine contractions.

54
Q

Drug Interactions of Dinoprostone?

A

Oxytocin – incr. effects, wait 6-12 hrs after Dinoprostone gel or 30 mins after removal of insert.

55
Q

Produces the rhythmic uterine contractions characteristic to delivery?

A

MOA of Oxytocin (Pitocin).

56
Q

Indications for Oxytocin?

A
  1. Induction of labor at term.

2. Control of postpartum bleeding.

57
Q

Drug Interactions of Oxytocin?

A
  1. Dinoprostone – wait 6-12 hrs.

2. Misoprostol – wait 3 hrs.

58
Q

Maternal AEs of Oxytocin?

A
  1. CV – Arrhythmias, HTN.
  2. GI – N/V.
  3. GU – pelvic hematoma, uterine hypertonicity, uterine rupture.
59
Q

Fetal AEs of Oxytocin?

A
  1. CV – Arrhythmias.
  2. CNS – brain damage, seizures.
  3. Other – jaundice, low APGAR score, retinal hemorrhage.
60
Q

Contraindications for Oxytocin?

A
  1. Significant cephalopelvic disproportion.
  2. Unfavorable fetal positions.
  3. Fetal Distress.
  4. Hypertonic or Hyperactive uterus.
61
Q

What conditions contraindicate a vaginal delivery?

A
  1. Active genital herpes.
  2. Prolapse of cord.
  3. Total placenta previa.
62
Q

What class of medications are used in Postpartum Hemorrhage? Name the med?

A
  1. Ergot Derivatives.

2. Methylergonovine (Methergine).

63
Q

MOA: affects primarily uterine smooth muscle producing sustained contractions and thereby shortens the 3rd stage of labor?

A

Methylergonovine (Methergine) – Ergot Derivative.

64
Q

Indications for Methylergonovine (Methergine)?

A
  1. Prevention and treatment of postpartum and post-abortion hemorrhage caused by uterine atony or subinvolution.
65
Q

What is Uterine Atony?

A

When the uterus fails to contract after the delivery of the baby, which can lead to a potentially life-threatening condition known as postpartum hemorrhage.

66
Q

What is Subinvolution?

A

When the uterus does not return to normal size after delivery.

67
Q

Adverse effects of Methylergonovine (Methergine)?

A
  1. CV – MI, HTN, Palpitations.
  2. Ergotism.
  3. Metabolic/GI – N/V/D, Water intoxication.
68
Q

What is the condition of early symptoms of poisoning include nausea, vomiting, muscle pain and weakness, numbness, itching, and rapid or slow heartbeat; it can progress to gangrene, vision problems, confusion, spasms, convulsions, unconsciousness, and death?

A

Ergotism.

69
Q

What do we monitor with the use of Methylergonovine (Methergine)?

A

BP, HR, Uterine Response.

70
Q

Drug interactions with Methylergonovine (Methergine)?

A

CYP450, Azoles, many Abx, Serotonin agonists.

71
Q

What narcotics can we use as analgesia in labor?

A

Meperidine (Demerol), Morphine, Fentanyl – IV or IM.

72
Q

What medications can be used as augmentation of pain relief?

A

Antihistamines – Promethazine or Hydroxyzine.

73
Q

What are some concerns with Epidural Analgesics?

A
  1. Greater risk of need for Oxytocin.
  2. Longer stages of labor.
  3. Greater risk of intervention.
74
Q

What is the 1st line medication for HTN in pregnancy? Alternatives?

A

**1st line: Methyldopa.

Alternatives: Nifedipine (CCB) or BBs.

75
Q

What is the risk of using Beta Blockers for HTN in pregnancy?

A

Possibly associated with reduced growth of fetus, but could be due to underlying maternal medical condition.

76
Q

Hypertension + Proteinuria after the 20th week of pregnancy?

A

Pre-Eclampsia/Eclampsia.

*Proteinuria results from hepatic or renal dysfunction.

77
Q

Signs and Symptoms of Pre-Eclampsia/Eclampsia?

A
  1. Headache.
  2. Edema of hands and face.
  3. Weight gain >2 lbs/wk or sudden weight gain over 1-2 days.
78
Q

What is the cure for Pre-Eclampsia/Eclampsia?

A

ONLY cure/Tx is Delivery.

79
Q

What are the indications for delivery in pre-eclampsia/eclampsia?

A
  1. Fetal: severe IUGR, fetal compromise, oligohydramnios (amniotic fluid < expected).
  2. Maternal: > 37 wks, low platelets, worsening hepatic and renal function, eclampsia.
80
Q

What does IUGR stand for?

A

Intrauterine Growth Restriction (Fetal growth restriction).

81
Q

What is Eclampsia?

A

The severe form of pre-eclampsia characterized by HTN in pregnancy that leads to seizures.

82
Q

What is the medical management of Pre-eclampsia/Eclampsia?

A
  1. Bed rest and minimal activity.
  2. Seizure Prophylaxis – mag sulfate.
  3. Control of BP – Hydralazine or Labetalol.
83
Q

Infection of the uterus most common after cesarean delivery?

A

Metritis.

84
Q

What is the cause of Metritis and what do we treat with?

A
  1. Polymicrobial with anaerobic organisms.
  2. Tx with Broad-Spectrum Abx:
    - -Cefotetan, Cefoxitin.
    - -Ampicillin + Aminoglycoside (Gentamicin, Streptomycin).
    - -Clindamycin + Gentamicin.

**Provide additional Abx coverage if no response in 48-72 hrs.

85
Q

Define Mastitis?

A

Breast infection most commonly occurs in lactating women several weeks after delivery.

86
Q

Clinical presentation of significant fever, chills, malaise and vague breast symptoms?

A

Mastitis.

87
Q

What is the cause of Mastitis and what do we treat with it?

A
  1. MCC is Staph Aureus.

2. Treat with Dicloxacillin.

OB/Gyn (14 decks)

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