Prescribing and contraception Flashcards by mariko carding

**LABETALOL

Indication
effect /
when (perinatally) is it contraindicated

indication: hypertension in pregnancy - aim for 140/90
effect: beta blocker
contraindicated- 1st trimester / bresatfeding / Asthma

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**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

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Aspirin

Indication
effect /
dose
when:

Indication: Women at risk of PE/ GIH
effect : Vasodilation / reduce platelet aggregation
dose: 100mg
when: 12 -16wks - 36 wks

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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

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Calcium

indication
effect
dose
when

indication- reduce risk of gestational hypertension / PIH
dose: 1g/ day
when: 12-16 wks - 36 wks

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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)

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Iodine

effect
dose
when

effect- brain development
dose- 150 mcg / day
when- pregnancy + breastfeeding

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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

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calcium gluconate
effect
indication
dose

indication mag sulphate toxicity ( hypoventilation, arrythmia, hypotonia )

antidote to mag sulphate

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neonatal adrenaline

indication
dose

indication- when HR <60bpm, 30sec after commencing chest compressions

dose: 1: 10k solution. (~5ml for term)

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neonatal naloxone
indication
dose

effect: antidote to opioid
indication- reverse respiratory depression effect
dose- 0.1mg / kg

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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

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Salbutamol

indication

indication- tocolytic (birth <34wks)
Less preferred option (after nifidipine)

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Terbutaline
indication
dose

indication- acute tocolysis due to uterine hyperstimulation (tachysystole (>5:10)hypertonus (cx >2mins) + abnormal FHR

dose- 250mg SC / IM

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vitamin D
indication
effect
dose

indication - dark skin / lack of sunshine
effect- bone ( rickets)/ teeth/ muscle dev
dose- 10mcg drop / day

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vitamin K
indication
dose

Indication- given to baby to reduce risk of vit K deficiency bleeding
dose: IM 0.1ml / 0.2ml Oral (24hrs/ 1wk/ 6wks)

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Paracetamol
effect
dose

effect- antipyretic, analgesia, (NOT anti-inflammatory)
dose: 1g 4-6 times / day (no more than 4g daily)

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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

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Diclofenac
effect
dose (PO and PR)

Effect- NSAID
Dose- 75 mg (PO) 100MG (PR)
(no more than 150 mg daily)

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methotrexate- indication

medical mgmt of ectopic pregnancy (stops embryo growing)

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**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)

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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

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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, entonox, SSRI

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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)

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Entonox

what is it, Contraindications

50% nitrous oxide, 50% oxygen
passes though placenta

contraindiction- morphine / haemolytic disease

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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)

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Epidural
what is in it
effect
where is epidural placed
contraindications

what is in it: fentanyl (opioid) + anaesthetic

effect - anaesthetic + analgesia
side effect- hypotension, headache, respiratory depression, nausea + vomiting, pruititis, pyrexia, urinary retention

WHERE: Before Spinal cord - into “lumbar epidural space” (between dura mater and ligamentum (lumber)

contraindications
clotting disorder, abnormal anatomy or skin infection / sepsis, CV issues

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Spinal
effect
comparison to epidural

effect- analgesia + hypotension

comparsion- faster / shorter acting. goes directly into CSF.

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How do we treat Iron deficiency / IDA

what about post partum

what are recommendations for absorption

what to do if iron supplements are not tolerated

**Iron deficiency
**Normal Hb (>110)/ Low Ferritin ( </= 29 )
*low dose iron supplements ** 65mg (Ferrotab)

**
iron deficiency anaemia**
low Hb (<100) / low ferritin (</=29)
*therapeutic dose (100-200mg)

postpartum
- assess anaemia based on CBC (ferrtin is unreliable due to inflammation)
- if EBL>500 + known IDA- 100mg recommended

absorption
- best absorbed taken separately (not with multi)
- calcium inhibits iron absorption (don’t take with antacids)
-vit c

improve tolerance
- intermittant dosing
- don’t take with vit c (may increase GI side effects)
- lower dose
- take with food + at bedtime

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what is low molecular weight heparin

effect
indication
dose
signs of overdose
antagoist

effect- anti-coagulant - prevents DVT/ pulmonary embolism
indication- post partum, women are increased risk of hypercoagulation, if they are not mobile (e.g. Post surgery)
dose 40 mg

hematuria, ecchymosis (bruise), epistaxis (nose bleed)
antagonist- protamine sulphate

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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

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omeprazole
indication
effect

indication- reflux
effect- reduces amount of acid stomach makes

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what do we prescribe for post partum perineal analgesia

paracetamol 1g PR
diclofenac 100mg

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cyclazine
indication
effect

AKA Nausicalm

indication- anti-emetic

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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

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metoclopramide
indication
effects

indication - antiemetic

effect- safe for baby / risk of maternal dystonic reaction (abnormal movements)

safe during pregnancy- but only for short period (5 days)

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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)
**
indication
dose
Cautions

indication uterotonic to reduce risk of PPH
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 in labour

indication
who prescribes
dose / start rate
time to effect
side effects
risks
contraindicated
mgmt / monitoring
antagonist

indication- Augmentation

prescribed
by obstetric team.

dose: 10 IU in 500ml NaCl 0.9% + 1L NaCL 0.9%
start on 6ml/hr

Time to effect
immediate onset and rapidly inactivated
half life 1-6mins

side effects
anti diuretic–> water intoxication
hyponatraemia (low sodium in blood)
headache/ nasusea / vomiting / tachycardia or bradycardia
fetal bradycardia, dysrhythmias/ neonatal jaundice

Risks
Fluid retention
placental abruption
amniotic fluid embolism

Contraindicated
Hypertonus / fetal distress / any reason why vaginal birth contraindicated
NOT- within 6hrs after prostaglandin gel

management
maternal obs 4hrly
monitor effect on cx / FHR
Fluid chart
anti-emetic
active management

antagonist
terbutaline

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

symptoms
nipple- burning / itching / stinging, can be mild or severe, nipples can be tender
bresat- stabbing / shooting pain, deep ache / burning
pain experienced immediately after and during feeds

assessment
nipple may appear pink / shiny, areola dry / flaky
nipple damage (crack)
thick white coating / spots on baby’s tongue / inside cheeks

prescribe
nipples- topical Antifungal (micronazole 2%) - bid after breastfeeding. wipe off prior to BF. 10-14days
neonatal- 1ml nystatin liquid qid after B

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

tramadol
indication / effect / contraindications

indication
analgesia during pregnancy and for analgesia postpartum (Caesarean section)

effects
* breastfeeding- passes into breatmilk- efect is not known.
* neonatal Respiratory depression - bradyapnoea / shallow breathing / difficulty or noisy breathing, more sleepy, trouble breastfeeding
* constipation
*
contraindications
* 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

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
opioid substitution treatment ( 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

what is

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