Prescribing and contraception Flashcards
**LABETALOL
Indication
effect /
when (perinatally) is it contraindicated
indication: hypertension in pregnancy - aim for 140/90
effect: beta blocker
contraindicated- 1st trimester / bresatfeding / Asthma
**Anti-D immunoglobulin
**
Indication
when is it given / dose
indication: mum is Rh neg blood group. Given to prevent mum developing isoimmunisation
When- Given prophylactically (28 + 34 wks) or within 72 hrs of isoimmunising event
dose:
>12wks: 625 IU IM (Standard) or more (if Kleihauer is positive >6)
<12wks- 250IU
Aspirin
Indication
effect /
dose
when:
Indication: Women at risk of PE/ GIH
effect : Vasodilation / reduce platelet aggregation
dose: 100mg
when: 12 -16wks - 36 wks
betamethasone
indication
effect
dose
when
indication: given to mum at risk of Preterm birth within 7 days (at 24-34+6 wk gestation)
effect: corticosteroid helps baby develop surfactant - reduce risk of RDS
Dose: 12mg IM x 2 (24hrs apart)
When: 24 - 34+6 weeks
Calcium
indication
effect
dose
when
indication- reduce risk of gestational hypertension / PIH
dose: 1g/ day
when: 12-16 wks - 36 wks
Folic acid
effect
dose
when
risk factors
effect: reduce risk of neural tube defect
dose: 800mcg (standard) / 5mg (higher risk )
when: from 1mth prenatally - 1st trimester
Risk factors
- previously had NTD affected pregnancy/ family hx of NTD
- taking medications that affect folate metabolism (insulin, anti-convulsants, infertility treatment)
Iodine
effect
dose
when
effect- brain development
dose- 150 mcg / day
when- pregnancy + breastfeeding
Magnesium sulphate
indication (x2)
side effects
monitoring
antidote
** indication:
** 1) given to mum for Neuroprotection for baby (reduce risk of cerebral palsy) born before 30wks signs of toxicity- hypoventilation, arrythmia, hypotonia
2) SEIZURES- Given to mum with unstable pre-eclampsia to prevent seizures / given to mum with eclampsia to prevent further seizures
**side effects-
** nausea / vomiting / headache / flushing/ drowsy
signs of toxicity- hypoventilation, arrythmia, hypotonia
monitoring
resps/ HR/ oxygen sats / reflexes / FHR monitoring
**antidote-
** calcium gluconate
calcium gluconate
effect
indication
dose
indication mag sulphate toxicity ( hypoventilation, arrythmia, hypotonia )
antidote to mag sulphate
neonatal adrenaline
indication
dose
indication- when HR <60bpm, 30sec after commencing chest compressions
dose: 1: 10k solution. (~5ml for term)
neonatal naloxone
indication
dose
effect: antidote to opioid
indication- reverse respiratory depression effect
dose- 0.1mg / kg
nifidipine
indication
effect
side effects
contraindications (to nifidipine specifically)
Effect- calcium channel blocker
indication- Tocolytic (preterm labour)
side effect- flushing, nausea, vomiting, hypotension
contraindications to nifidipine - cardiac issues / hypotension
Salbutamol
indication
indication- tocolytic (birth <34wks)
Less preferred option (after nifidipine)
Terbutaline
indication
dose
indication- acute tocolysis due to uterine hyperstimulation (tachysystole (>5:10)hypertonus (cx >2mins) + abnormal FHR
dose- 250mcg SC / IM
vitamin D
indication
effect
dose
indication - dark skin / lack of sunshine
effect- bone ( rickets)/ teeth/ muscle dev
dose- 10mcg drop / day
vitamin K
indication
dose
Indication- given to baby to reduce risk of vit K deficiency bleeding
dose: IM 1mg (0.1ml) / Oral 2mg (0.2ml) (24hrs/ 1wk/ 6wks)
Paracetamol
effect
dose
effect- antipyretic, analgesia, (NOT anti-inflammatory)
dose: 1g 4-6 times / day (no more than 4g daily)
iburoprofen
effect
dose
contraindicated
Effect- NSAID - Anti inflammatory / anti-pyrexic/ analgesia
risk of adverse reactions (renal impairment, cardiac myopathy)
Dose: 400mg PO 4-6hourly (no more than 1.6g daily)
Contraindicated-
- Post partum only (can cause congenital malformations in T1, Risk of premature closure of foramen ovale = pulmonary hypertension, stop platelet aggregation, delay labour and birth
- NSAID-induced asthma, rhinitis
Diclofenac
effect
dose (PO and PR)
Effect- NSAID
Dose- 75 mg (PO) 100MG (PR)
(no more than 150 mg daily)
methotrexate- indication
medical mgmt of ectopic pregnancy (stops embryo growing)
**Tramadol
**Effect
side effects
Contraindications
dose
Classification of drug
MCNZ restrictions
Effect- opioid
side effects- less likely to cause respiratory depression. nausea, vomiting
**Contraindications- Concurrent use of SSRI (serotonin toxicity)
**
dose - 50-100mg / dose QID (max 400mg day )
Classification
C2 Controlled Drug (“misuse of drugs order) - so doesn’t need to be stored in controlled drugs safe. Max supply is 1mth/ script must be presented within 4 days writing
MCNZ
MW can prescribe (anytime perinatally)
Opioid prescribing
Effects
side effects
MW responsibilities
contraindications
Effect- Analgesia
side effects- Respiratory depression, sedation, FHR reduced variability / Decels, reduce BF success, vomiting + nausea
MW responsibilities-
- can prescribe Pethidine, Morphine + Fentanyl + tramadol
- require education to prescribe morphine / fentanyl
-Can prescribe morphine + pethidine at BU ( 1 dose, and should consider transfer/ Hospital)
-only prescribe fentanyl at hospital (protocols permitting)
- - consider consult if prescribing >1 dose / analgesia not controlled after administration
- don’t mix opiates
- have naloxone ready
- ensure maternal / fetal wellbeing before/ afterwards
- Avoid opioids too close to birth (3-4hrs) and early labour (opioid become metabolites that can cross placenta )
contraindications-
Severe asthma, SSRI ( serotonin toxicity)
At home
3-4hrs before birth
Morphine
dose
route
Contraindications
8-10mg IM (15-30min time to peak effect)
2mg IV (15min peak effect)- consult/ requires prescription
MW responsibilities- can prescribe at BU/ hospital (NOT Home)
CI- asthma
small risk of serotonin toxicity (not as bad as codeine / tramadol)
Fentanyl
Side effects
time to peak effect
MW scope
side effects- maternal apnoea
route- IV
5mins peak effect
IV route requires extra monitoring
scope -
* MW can prescribe if they have completed education
* prescribe for intrapartum only (but they have to follow hospital protocols, which vary)
* Only in secondary / tertiary setting with medical backup available (NOT Primary BU / if woman requires transfer)
Entonox
what is it, Contraindications
50% nitrous oxide, 50% oxygen
passes though placenta
contraindiction- fentanyl / haemolytic disease
lignocaine
Effect
dose
Rapid acting local anaesthetic
dose- 1% 20ml (200mg) - 2-5MINS EFFECT
Administer- SC, slowly with aspiration to prevent intravascular injection (can cause systemic toxic effect)
Epidural
where is it placed
WHERE: Before Spinal cord - into “lumbar epidural space” (between dura mater and ligamentum (lumber)
Spinal
effect
comparison to epidural
effect- analgesia + hypotension
comparsion- faster / shorter acting. goes directly into CSF.
what is agonist for mgso4
calcium gluconate
what is low molecular weight heparin
indication
dose
what is contraindicated
signs of overdose
agonist
effect- anti-coagulant - prevents DVT/ pulmonary embolism
indication- risk of VTE
dose 40 mg
contraindicated- Ibuprofen
hematuria, ecchymosis (bruise), epistaxis (nose bleed)
antagonist- protamine sulphate
Antacids
indication
what type to use
interactions
Indication - heart burn (only if diet changes haven’t worked)
use combination calcium / magnesium based antacids (these neuralise stomach acid)
avoid aluminium containing antacids (these can cause constipation / diarrhoea)
- CAUTION
- Consider PE
- interactions- can bind with other medications so take >1hr away from iron + other meds
omeprazole
indication
effect
indication- reflux
effect- reduces amount of acid stomach makes
what do we prescribe for post partum perineal analgesia
paracetamol 1g PR
diclofenac 100mg
cyclazine
indication
effect
AKA Nausicalm
indication- anti-emetic
Pyridoxine
indication
effect
dose
AKA B6
indication - anti-emetic
Effect- nausea prophylactic
dose 25mg TID
safe throughout pregnancy. can be taken with other anti-emetics
metoclopramide
indication
effects
indication - antiemetic
- antenatal- <5 days (risk of abnormal movements)
- intrapartum- use with opioids (instead of ondansetron, which may cause SST)
ondansetron
indication
contraindication
indication - anti-emetic
NOT first line treatment
avoid 1st trimester (cleft palate)
what is prescribed for Raynauds
nifidipine
pyridoxine (b6)
magnesium
+ keep nipples warm
what is prescribed for mastitis
flucloxacillin 500mg
what is prescribed for UTI
Nitrofuratoin -
NOT after 36wks (risk of haemolytic anaemia / lactating mothers >1mth postpartum)
not for parent/baby with G6PD
Don’t take urine alkaliniser (drug is more effective in acidic environment)
Trimethoprim - NOT 1st trimester (interferes with folate metabolism)
indication / when do we prescribe progesterone
indication- risk of PTL
effect- uterine quiescence
Take up to 34 wks
What AB for Post partum wound infection
Flucloxacillin 500mg
What AB for GBS infection
Asymptomatic (benzylpenicillin IV 1.2g, then 0.6g q4h)
Symptomatic (amoxicillin
Thrush (PV)
what is it / physiolmedication
what is it
- yeast infection (lactobacilli)- may be caused by various Candida species (usually candida albicans)
physiology
develops when there is change in vaginal flora
risk factors- 2nd half pregnancy, antibiotics, diabetes, UTI’s, anaemia, HIV
NOT A STI
symptoms
vaginal irritation (itching / irritation/ redness), burning or stinging with PU, PV dx (thick / white/ thin / watery)
swelling / splits in skin
risks in pregnancy
may be associated with PTL so best to get treated
management
treat only if symptomatic
send swab for culture before commencing treatment (confirm which type of candida)
Clotrimazole !% (36g)- 6-7 day course
what is syntometrine
dose (TOTAL / 24HRS
onset / duration
side effects
contraindications
dose 5IU oxytocin +0.5mg ( 500mcg) ergometrine (1ml IM)
Can repeat after 2hrs (max 3ml in 24hrs)
onset - acts within 2-3mins
lasts- 2-4hrs
side effects- nausea / vomiting/ headache
contraindications- hypertensive disorders (incl PE), cardiac disease, asthma (ergometrine can result in vasospasm)
what is oxytocin Iv bolus:
dose
onset / duration
side effects
Cautions
dose- 5IU (1ml) IV
onset- 1min, lasts 15-30mins
side effect- nausea / vomiting
cautions- oversaturation of oxygen receptors / max 100 IU / 24hrs
what is oxytocin IM bolus:
indication
dose
onset / duration
side effects
Cautions
uterotonic
dose: 10 IU (1ml) IV
onset- 2-3mins, lasts 30-60mins
side effects nausea + vomiting
caution- oversaturation of oxytocin receptors
max in 1hr- 100IU
**oxytocin infusion (for PPH/ Risk of PPH)
**
when do you give it?
dose
Cautions
dose- 40 IU / 500ml (4hrs)
ONLY AFTER BIRTH OF PLACENTA!!
**TXA (tranexamic acid)
**
effect
dose
contraindication
effect-“antifibrinolytic”- reduces bleeding by stopping breakdown of fibrogen / fibrin
dose- 1g IV (slow push to avoid hypotension)
contraindicatd- if woman has coagulopathy
**Carboprost
effect
indication
side effect
contraindication
effect- uterotonic
indication- PPH - use after oxytocin, ergometrine
side effect- nausea, vomiting, diarrhea, fever
Contraindication- asthma, cardiac/ pulmonary/ renal / PID
copper IUD
what is mechanism of action
when can you start?
hormonal side effects / BF safe?
Primary- toxic to sperm / stops transports
secondary- inflmmatory effect on endometrium
when- <48hrs postpartum, or after 4-6 wks postpartum (risk of expusion >48wks-<4wks)
no hormonal side effects
likely to cause heavier / painful bleeding
hormonal IUD (Mirena)
what is mechanism of action
when can you start?
hormonal side effects / BF safe?
mechanism of action
progesteogen released into uterine cavity- causes cervical mucous thickening and alters composition of endometrial fluid
Does not interfere with breastfeeding
when can you start?-
if not breastfeeding, can be inserted within first 48hrs or after 4wks (high risk of expusion >48hrs- 4wks)
if breastfeeding- wait 4 wks (avoid interfering wtih breastfeeding)
side effects
lighter bleeding
Tocolytics
what are they
preferred choice
contraindications
Drugs that delay birth
preferred- Nifipine (calcium channel blocker)
contraindications -
- >34wks gestation
-risk to mum / baby to delay birth ( significant bleeding / infection / abnormal HR/ fetus not compatible with life)
maternal refusal
Pethidine- dose / route/ setting
dose- IM ~80-100mg qid (max 300mg / day) (maternal Weight dependent)
Route- IM
time to peak effect 15-30mins
Setting- primary unit (1 only/ consider transfer) + tertiary
Contraceptive Implant
what is it
what is mechanism of action
when can you start?
hormonal side effects / BF safe?
contraindications
what is it-
“Jadelle”
2 Rods SC Implanted into upper arm
lasts for 1-5 years
what is mechanism of action-
rod releases progestogen
primary - thins endometrium / affects cervical mucous
secondary - inhibit ovulation through suppressing LH surge
when can you start?
immediately postpartum
side effects
variable/ unpredictable bleeding
headache, acne, weight gain, mood changes
rapidly reversible
BF
minute amounts ingested via breastmilk
contraindications-
anti-epileptic meds, St johns wart, Antivirals for TB + HIV
Combined contraceptive
what is it
what is mechanism of action
side effects
when can you start?
Contraindications
what is it
oestrogen + progesterone pill
take within 24hrs of each other
what is mechanism of action
inhibits LH/ FSH
inhibit endometrium dev
side effects
oestrogen- Increased risk of VTE
disrupts lactogenesis III
Weight gain / acne /mood
increases risk of stroke
when can you start?
not breastfeeding -3 wks post partum ( avoid risk of VTE)
Breastfeeding- 6wks post partum but ideally wait for 6mths
impact on breastmilk
minute amount of hormone in breastmilk- but viewed as safe overall
Contraindications
breast cancer (family hx of certain genetic mutations that increase risk of breast cancer)
known genetic mutations
family hx of VTE
risk factors for stroke (BMI>30, >35 years, >smoking /
>diabetes / Hypertension
>taking medications that induce CYP3A4 liver system (reduce efficacy of contraceptive)
when do you need to start using contraception
21days postpartum
what is lactational amenorrhoea?
how effective? what are requirements for this
contraception via breastfeeding
prolactin inhibits GnRH –> FSH/LH
98% effective
3 Criteria must be met
<6mths
exclusively/ near fully BF (no long intervals (<4hrs during day, <6hrs night)
no period
effectiveness reduced with expressing
progestogen only pill
what is it
what is mechanism of action
when can you start?
Contraindications
what is it
Progesterone only
everyday -take within 3hr window (no inactive day)- if you miss a 3hr window, wait 48hrs
what is mechanism of action
* primary- block passage of sperm through thickening mucous + decreasing endometrial rceptivity
* varying effect on ovulation
when can you start?- anytime post partum
effect on Breastfeeding
doesn’t seem to reduce volume
minute amounts pass through breastmilk
Contraindications
current breast cancer (but ok if you are old / smoking/ clotting risk)
if mum is taking medication that affects CYP3A4 liver system
medical assessment req if hypertensive, cancers, previous ectopic pregnancy, cysts,)
Injectable contraction
what is it
what is mechanism of action
side effects
when can you start?
Contraindications
what is it
aka depo provera
3mth injection
medroxyprogesterone (doesn’t contain oestrogen)
what is mechanism of action
primary- suppress ovulation (suppress FSH/ LH)
Secondary- thickens mucous / thins endometrium
side effects
can take 1 year to return of fertilty
reduced bone density
variable effect on bleeding
when can you start?
Anytime post partum- but bleeding may be heavier in first 6wks
no evidence it affects breast milk
**Oxytocin infusion for augmentation
dose
10 IU in 500ml NacL
(With 1000ml Nacl)
metranidazole
indication/ considerations
indication- BV / trichomonal infection
pregnancy- recommended to treat BV/ trichomonas in all trimesters
breastfeeding -metranidazole crosses placenta + is excreted in breast milk- ideally avoid during breastfeeding / at least wait 12-24hrs after single dose regimen
Magnesium sulphate
indication - for PE
antidote- calcium gluconate
Indication-
prophylaxis of seziures for women with severe pre-eclampsia
treatment of eclamptic convulsions
side effect
nausea, vomiting, diarrhoea, thirst, flushing, hypotension, respiratory depression, loss of reflexes
cyclizine
indication/ effect
indication- anti-emetic
antihistamine
what are ACE inhibitors - when are they contraindicated
Anti hyperintensives
contraindicated in pregnancy
Thrush - nipples /neonatal
mum- micronazole
baby- nystatin
pharmacokinetics
how drugs are absorbed / distributed / metabolised / eliminated
pharmacodynamics
how drugs act on the body
anaphylactic shock
what is it/ signs + symptoms/ treatment
what is it
acute + severe systemic reaction after exposure to antigen
mast cells / basophils cause immune response
usually occurs seconds-minutes to exposure
range from mild-very severe
signs / symptoms
* tachycardia, sweating, dizzy, fainting, unconscious, wheezing, chest tightness, difficulty breathing, swelling lips / tongues/ eyes
* nausea / vomiting/ diarrhoea
* throat swelling
treatment
*stop any IV treatment
* call for Emergency help
* Commence Resus
* Adrenaline
aciclovir
Antiviral
increase healing rate + decrease pain of herpes lesions
codeine
Contraindicated for breatfeeding women- neonatal toxicity
as some women quickly metabolise codeine which creates risk of opioid toxicity
what are 2 key CI’s for tramadol
-breastfeeding
* concurrent use of SSRI antidepressants (Serotonin toxicity)
Haemorrhoids
what are options - what do they contain/ what is the effect
any contraindications during pregnancy?
ultraproct
contains steroids that have anti-inflammatory vasoconstrictor effect
+ local anaesthetic
Don’t use extensively (large amounts/ long duration) in pregnancy
contraindications- ultraproct in Trimester 1
lactulose
indication / time to effect / how does it work/ use in pregnancy
treatment of constipation (often used prophylactically for women with haemarroids /perineal tear/ operative birth)
time to effect
24-72hrs after oral administration
how it works
* shortens transit time of intestinal contents (by increasing fluid in intestine which increases peristalsis)
* promotes natural bowel flora
safe + effective in pregnancy / breastfeeding
promethazine
effect
indication- anti-emetic
effect- sedating anti-histamine
Vitamin D- Maternal
indication / dose
indication:
Vit d insufficiency (<50) / deficiency (<25)
Risks
maternal- risk of GDM / PE
neonatal- bone health / birth weight/ teeth / acute respiratory infection
Risk factors
- dark skin tone
-live south of nelson (winter/ spring)
-spend limited time outdoors
Prescribe
maternal - 400-800 IU colecalciferol 188mcg /ml (1-2drops) - anyone with > 1 risk factor
Testing
not routinely recommended
Can test if people have known hx of vit d deficiency, or all 3 risk factors
Vitamin D- neonatal
indication
indication- partially / exclusively breastfed
prescribe
400 IU 188mcg /ml (1 drop ) / day- from 1mth - 1year
don’t go into sun
tetracycline
indication
AB - contraindicated in pregnancy (rare maternal acute fatty liver necrosis)
BCG vaccine
Indication: for baby at high risk of Turburculosis
Country : >40casees / 100k population
Risk factors
- live with someone who has been In country with tb risk for last 5 years, for over 6mths
- baby going to high risk country for 3mths
Administration
-MW refer for vaccine
-Burwood contact- give before 5yrs
what antimicrobial for BV or trichomonas
metronidazole
crosses placenta + is excreted in breastmilk- NZF says avoid high single dose when breastfeeding
what are risks of excess iron supplementation
placental insufficiency (Excess iron poisons organs)
should always recheck bloods after starting iron supplements 2-4wks later
what prescribing codes do we use
A
4
What are options for emergency contraception and cautions
hormonal- safe to take postpartum, doesn’t effect lactation but mum should not breastfeed for 1wk
copper iud (no effect on BF)
which antidepressant should be avoided with breastfeeding
fluoxetine (slower clearance)- avoid unless used in pregnancy
generally benefit of BF outweighs risk
what are risks of antidepressants (i.e. SSRI’s)
possible risk of congenital cardiac malformation
PPH (active mgmt)
small but increased risk of persistent pulmonary hypertension of NB- look for cyanosis
poor neonatal adaption -investigate other possible causes
which psychotic medication requires AN obstetric consult + NICU review (PN)
what are risks in BF
Lithium
Lithum toxicity -if mum BF’s, requires lose monitoring
what are benzodiazepines for?
what are risks
Indication- treat anxiety / PTSD
risks
- neonatal breathing difficulty + neonatal abstinance (symptoms may not present for several day after birth) –> consider tapering/ stopping close to term
- caution with breastfeeding, as associated with adverse afefts (sedation, jaundice, apnoea)
what are risks of illicit opioid use?
how do we manage
risks- miscarriage, PTL, FGR, placental abruption, oligohydramnios
neonatal abstinance syndrome
DON’T suddenly withdrawal–> Risk of stillbrith
mgmt
minimise stimulation (swaddling / sucking/ skin to skin/ dark / quiet)
opioid substitution treatment ( morphine / methadone)
what is tested in 6 wk vaccinations
Rotavirus
pertussis (whooping cough, diphtheria, tetanus)
polio, hep B, Hib
pneumococcal
what is def of ‘high risk’ country for TB
> 40/ 100k people
