OB PHARM Flashcards
spontaneous abortion treatment
misoprostol (cytotec)
what else is misoprostol used for? patti’s lecture
for induction of labor - given with prostaglandin E to soften the cervix
then oxytocin given to start contractions
PRODUCTS OF CONCEPTION ARE EVACUATED IN 3 WAYS
o Surgical = if pt is unstable, has significant bleeding, has an infection, or just wants immediate treatment
o Medical = those who don’t want to wait for spontaneous passage (expectant) = Misoprostol
o Expectant = will eventually pass naturally (takes days to weeks)
if pt is stable = give them the choice to do surgical, medical, or expectant. if unstable = surgical
surgical evacuation of abortion is done if
pt is unstable
has significant bleeding
has an infection
or just wants immediate treatment
medical evacuation of abortion is done in
pts who don’t want to wait for spontaneous evacuation (expectant
expectant evacuation of abortion
conception products will eventually pass naturally (takes days - weeks to do so)
MISOPROSTOL DOSING
- 400mcg per vagina q4h x 4
- vaginal administration = highly effective
- minimizes the risk of SE
- expulsion rate = 70-90% within 24 hours
- if during 2nd trimester = more likely to need hospitalization
PRETERM LABOR TREATMENT
TOCOLYTICS + CORTICOSTEROIDS
GOAL OF TOCOLYTICS
for preterm labor
- delay delivery by at least 48 hours - to allow the administration of corticosteroids for fetal lung maturity
- this allows time for transport of the mother to a higher level of care
- this stops labor to allow the underlying medical condition that stimulated labor to clear
tocolytics shouldn’t be used before _________ weeks, and shouldn’t be used after __________ weeks
22 weeks
or after 34 weeks
tocolytics are contraindicated when:
- contraindicated when the baby or mother are unstable
⦁ fetal demise, lethal fetal anomaly, nonreassuring fetal status, severe preeclampsia or eclampsia, maternal hemorrhage, intraamniotic infection, or maternal contraindication to tocolytic drug
**CI with preeclampsia/eclampsia because the only tx for those is delivery, so don’t want to delay delivery
tocolytic drugs
to stop preterm labor
o NSAIDS = indomethacin
o CCB = nifedipine
o beta adrenergic receptor agonists = terbutaline
o magnesium sulfate
TOCOLYTIC OF CHOICE AT 24-32 WEEKS GESTATION
INDOMETHACIN
2ND LINE TOCOLYTIC
NIFEDIPINE (CCB)
associated with fewer maternal SE than Magnesium sulfate
MOA OF INDOMETHACIN
to stop preterm labor
decreases prostaglandin production through inhibition of COX
MATERNAL SE OF INDOMETHACIN
to stop preterm labor
⦁ nausea ⦁ GE reflux ⦁ gastritis ⦁ emesis ⦁ platelet dysfunction
FETAL SE OF INDOMETHACIN
to stop preterm labor
⦁ Constriction of DA (if drug is given > 48 hrs; more likely to occur past 32 weeks)
- prostaglandins maintain PDA, Indomethacin closes DA
⦁ Oligohydramnios - drug decreases fetal urine output –> decreases amniotic fluid volume
⦁ Neonatal complications - bronchopulmonary dysplasia, necrotizing enterocolitis, PDA, periventricular leukomalacia, intraventricular hemorrhage
MATERNAL CI FOR INDOMETHACIN
to stop preterm labor
⦁ platelet dysfunction ⦁ bleeding disorders ⦁ hepatic dysfunction ⦁ GI ulcers ⦁ renal dysfunction ⦁ Asthma if also sensitive to ASA
think platelet dysfunction/bleeding, GI, renal, hepatic
monitoring for indomethacin
to stop preterm labor
o if given > 48 hrs = need fetal US to evaluate for oligohydramnios & narrowing of DA
MOA OF NIFEDIPINE
to stop preterm labor
CCB –> results in myometrial relaxation & peripheral vasodilation
DO NOT USE NIFEDIPINE WITH
to stop preterm labor
magnesium sulfate
can act synergistically to suppress muscle contraction and result in respiratory depression
MATERNAL SE OF INDOMETHACIN
to stop preterm labor
⦁ nausea ⦁ flushing ⦁ headache ⦁ dizziness ⦁ palpitations ⦁ can cause severe hypotension
CONTRAINDICATIONS FOR NIFEDIPINE
to stop preterm labor
⦁ hypotension
⦁ preload dependent cardiac lesion
⦁ use cautiously in LV dysfunction or CHF
tocolytic of choice at 32-34 weeks gestation
to stop preterm labor
nifedipine
2nd line tocolytic at 32-34 weeks gestation
Terbutaline (beta adrenergic receptor agonist)
MATERNAL SE OF TERBUTALINE
to stop preterm labor
⦁ tachycardia ⦁ palpitations ⦁ hypotension ⦁ tremor ⦁ SOB ⦁ chest discomfort ⦁ hypokalemia ⦁ hyperglycemia
CONTRAINDICATIONS TO TERBUTALINE
to stop preterm labor
⦁ tachycardic sensitive cardiac disease (tachycardia / palpitations)
⦁ uncontrolled hyperthyroidism or DM (hyperglycemia)
⦁ Use with caution in placenta previa or abruption - risk of hypovolemia & shock
TERBUTALINE MONITORING
to stop preterm labor
⦁ I&Os
⦁ Maternal symptoms of SOB, CP (chest pain), tachycardia
⦁ stop drug if maternal HR > 120
⦁ check blood glucose and K+ every 4-6 hours (hypokalemia, hyperglycemia)
3rd line therapy for prevention of preterm labor
MAGNESIUM SULFATE
corticosteroids reduces the incidence of ________ by 50%
⦁ respiratory distress syndrome ⦁ intraventricular hemorrhage ⦁ necrotizing enterocolitis ⦁ sepsis ⦁ neonatal mortality
antenatal corticosteroids given for preterm labor
- given at 23-34 weeks
o Betamethasone
o Dexamethasone
preferred antenatal corticosteroid
for preterm labor
o betamethasone
dexamethasone has to be ____________ containing, otherwise it can be _________ to the fetus
non-sulfite
neurotoxic
PREMATURE RUPTURE OF MEMBRANES TREATMENT
TREATMENT = ANTIBIOTIC PROPHYLAXIS (polymicrobial)
⦁ Azithromycin 1g on admission
⦁ Followed by Ampicillin IV x 48 hrs
⦁ Followed by Amoxicillin x 5 days
(AAA - azithro / amp / amox
- If PCN Allergy
⦁ Clindamycin IV x 48 hrs + Gentamicin x 48 hrs
⦁ Followed by Clindamycin PO x 5 days - Tocolytics are often given to delay delivery in the presence of uterine contractions
- Corticosteroids may be indicated
POSTPARTUM HEMORRHAGE = WANT TO USE _____________ DRUGS
UTEROTONIC = cause uterus to contract
uterotonic drug of choice for postpartum hemorrhage
oxytocin
drugs to treats postpartum hemorrhage
⦁ Oxytocin
⦁ Misoprostol
⦁ Carboprost Tromethamine
⦁ Methylergonovine Maleate
SE of Misoprostol (Cytotec)
- causes uterine contractions
- given to induce labor, abortion, & PP hemorrhage
GI symptoms = diarrhea, constipation, N/V, flatulence, abdominal pain, dyspepsia
CNS = headache
which uterotonic drugs = do NOT give IV
methylergonovine (methergate)
give IM or intramyometrial
AND
Hemabate (Carboprost tromethamine)
- give IM
CI TO METHYLERGONOVINE
- for PP hemorrhage
- HTN
- Raynaud’s
- Scleroderma
CI TO HEMABATE
- for PP hemorrhage
- HTN
- asthma
- renal failure
- reduced CO
TREATMENT FOR PREECLAMPSIA - severe HTN - DURING LABOR
⦁ IV Labetalol
⦁ IV Hydralazine
⦁ PO NIfedipine
All cases of preeclampsia should be treated with ______________ during labor to prevent seizures
magnesium sulfate
- adjust dose with renal insufficiency
continue magnesium sulfate x ____ hrs after delivery
24
MOA OF MAGNESIUM SULFATE
blocks neuromuscular transmission and decreases the amount of ________ at the end plate of the motor neuron impulse
acetylcholine
TREATMENT FOR TOXIC LEVELS OF MAGNESIUM
CALCIUM GLUCONATE
ADVERSE EFFECTS OF ELEVATED MAGNESIUM LEVELS
⦁ DTRs decrease (plasma level = 4)
⦁ DTRs absent (8-10)
⦁ Respiratory paralysis (10-15)
⦁ Cardiac arrest (20-25)
DO NOT USE MAGNESIUM SULFATE WITH
CCB (NIFEDIPINE)
therapeutic levels of Mag sulfate
4.8 - 8.4
CI to magnesium sulfate
heart block
myocardial damage
myasthenia gravis
SE OF MAGNESIUM SULFATE
flushing, diaphoresis, warmth, N/V, Headache, muscle weakness, visual disturbance, palpitations
induction of labor treatment
oxytocin (Pitocin)
maternal adverse reactions to oxytocin
⦁ CV – arrhythmias, HTN
⦁ GI – nausea, vomiting
⦁ GU – pelvic hematoma, postpartum hemorrhage, uterine hypertonicity, uterine rupture
⦁ Severe water intoxication with seizure, coma and death associated with a slow infusion over 24 hours
FETAL ADVERSE RXNS TO OXYTOCIN
⦁ CV – arrhythmia, bradycardia ⦁ CNS – brain damage, seizures ⦁ Hepatic - jaundice ⦁ Ocular – retinal hemorrhage ⦁ Other – death, low Apgar score
