Tocolytics Flashcards
Define Tocolytic Drug :
Any drug use to suppress premature labor
Most Common tocolytics
1) Beta agonist (Ritrodrine or Terbutaline ) but use has declined due to maternal side effects
2) Magnesium
Maternal (6)side effects of tocolytics: ( TRHAMM)
- Tachycardia
- Rarely Pulmonary edema
- Hyperglycemia + Hypokalemia
- Arrhythmia
- Myocardial Ischemia
- Mild hypotension
Why use caution when using ephedrine and /or Ketamine ?
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Premature labor is inhibited until ___________and ___________. What medication is given , and a minimum of _________hours is required.
Until lung mature And Sufficient surfactant is produced . Give steroids to induce production of surfactant A minimum of 24- 48 hrs is required
When Tocolytic therapy fails , what becomes necessary
Anesthesia ( for delivery )
Terbutaline : routes, rapid route, duration of effects and MOA of that duration .
Routes: PO, SQ, Inhalation
Rapidly effective by SQ and Inhalation.
Effects persists 3-6 hrs partly bc its structure w/ a RESORCINOL ring preventing COMT action.
Bc of this ring , terbutaline cannot be methylated by COMT
When are the tocolytics Terbutaline and Ritodrine used and how is Ritodrine administered ?
used to manage premature labor contractions through relaxation of myometrium via their B2 effect .
Ritodrine started IV and continued PO if tocolysis is achieved
How is ritodrone metabolized
Liver
To inactive conjugated
1/2 is excreted unchanged on the urine
Continuous use of beta agonist prayer has been associated with:
hypokalemia and tachyphylaxis
What is the mechanism of hypokalemia in beta 2 agonists ?
Insulin mediated increase in uptake of extra cellular K+
or
Increased Na+/K+/ATPase activity .
Pulmonary edema with normal PCWP have been attributed to what medications?
Terbutaline and Ritodrine
All beta adrenergic Tocolytic drugs only have B2 receptor effects . True or False ?
False .
Both B1 and B2 receptor effects
Where are B2 receptors found ? ( PALSSS)
Pancreas Adipose Tissue Liver Smooth muscle : Uterus, blood vessels , bronchi , intestine , detrusor , spleen Skeletal muscle Salivary glands
B2 Smooth muscles : name organs/locations
Uterus Blood vessels Bronchi Intestine Detrusor Spleen
Ritrodrine and Terbutaline are relatively selective B2 and stimulation of B2 in the myometrium =
Relaxation of the uterine smooth muscle
Other B2 effects such as vasodilation occur as well ( can be undesired ) + some B1 effects
Where are Beta 1 receptors located ?
Predominantly: Heart and adipose tissue .
This results in increased maternal HR and CO ( can be undesired )
MOA Beta Adrenergic Tocolytic Drugs
Agonist» Beta 2 site on outer membrane of uterine myometrail cells»_space;activate the enzyme adenyl Cyclase»_space; adenyl cyclase catalyzes conversion of ATP to cAMP» rise in intracellular concentration of cAMP = high cAMP concentration»_space;decrease in available intracellular concentration of calcium + inhibits myosin light chain kinase (MLCK)»_space; inhibition of MLCK= decrease interaction between actin and myosin = myometrial relaxation
A delay of ____minutes often results in slowing of maternal HR after administration of Tocolytic drug . However ,______, ______and ________ often require anesthesia
15 minutes ;
Advanced labor , non reassuring FH status, and abnormal presentation often require anesthesia
Theoretically, what are the effects of epidural analgesia/anesthesia after beta adrenergic agonist when compared to spinal anesthesia ? And why ?
May cause less hemodynamic compromise than spinal anesthesia
Because of slowe onset of sympathetic blockade .
However this theory remains UNPROVEN
Aggressive hydration in patients on Tocolytic therapy . Any thought ?
Avoid aggressive hydration before and during induction of anesthesia in these patients
Due to :
Risk of pulmonary edema
GA is required in a patient who has recently received beta-adrenergic tocolysis , what agents will you avoid in order to prevent exacerbation of maternal tachycardia
Atropine
Glycopyrrolate
Pancuronium
- Maternal tachycardia may make it difficult to asses volume status and depth of anesthesia
Why is it a bad idea to use Halothane on patients on tocolysis ?
Because halothane sensitizes the myocardium to catecholamine-induced-arrhythmias
It should not be used
Why should hyperventilation avoided ?
It will exacerbate the hypokalemia = hyperpolarization of the cell membrane will be potentiated
A study found what effects of terbutaline pretreatment in non-pregnant patients on Succs neuromuscular blockage ?
The terbutaline pretreatment shortened BOTH onset time and recovery time of succs- induced-NMB. Therefore :
May be pro dent to use a nerve stimulator during GA
What are the MOA of Magnesium :
- Extra cellular Mag = competitive antagonist of calcium either at the motor end plate or cell membrane» reducing calcium influx into the myocyte .
- Competes with Ca++ for low affinity calcium-binding sites on outside of the sarcoplasmic reticulum and prevents the rise in free intracellular calcium concentration.
To sum it up : - Reduce calcium influx into the myocyte
- Prevent rise in free intracellular calcium concentration
Hypermagnesemia result in
1) Abnormal neuromuscular function
2) Decrease the release of acetylcholine at the NMJ + decrease the sensitivity of the end plate to acetylcholine
True or False . Per studies , Mag Sulfate results more frequent and more severe CV side effects than beta adrenergic tocolytic agents
No !
Mag Sulfate = less severe and less frequent CV side effects than Tocolytic
Magnesium can have similar effects of beta adrenergic tocolytic agents .what side effects have been reported ?
- Chest Pain And Tightness
- Palpitations
- Nausea
- Transient hypotension
- Blurred vision
- Sedation
- Pulmonary edema
- May lessen normal compensatory responses to hemorrhage in the mother AND fetus
How is Magnesium is eliminated
Almost entirely by renal excretion
Do you give Mag in patients with abnormal renal function ?
Monitor carefully if they receive Mag sulfate
Should you D/C magnesium before administering an epidural ? Why or why not ?
Yes, D/C it because Mag will increased the likehood of hypotension through its generalized vasodilation properties
This electrolyte potentiates the action of both depolarizing and non-depolarizing muscle relaxants
Magnesium
In hypermagnesemic women, what should not be given prior to administration of Succinylcholine?
A defasiculating dose of NDMB
-a standard dose of muscle relaxant (ie Succ 1mg/kg) should be used b/c the extent of potentiation by mag sulfate is variable
During the maintenance of anesthesia, in a hypermagnesemic woman, how would you adjust muscle relaxant?
Lower doses
Parturients receiving mag sulfate often appear
Sedated
It is recommended that severely pre-eclampsia woman undergoing c/s should receive mag sulfate on what scheduling?
- at least 2 hours BEFORE procedure
- during surgery
- 12 hours postpartum
Treatment for mag toxicity
- immediate d/c of infusion
- IV admin of calcium gluconate 1gm over 10mins
Primary anesthetic considerations for women receiving magnesium sulfate are: (3)
- Interaction with NDMDs
- Effects on uterine tone
- Interaction with calcium entry -blocking agents
Magnesium sulfate increases the potency and duration of:
Mevacurium
Rocuronium
Vecuronium
Why do many practitioners avoid use of depolarizing drugs in parturient?
Concern for residual post op NMB — which can lead to respiratory complications
Why is NMB rarely required to facilitate surgical closure after c/s?
Abdominal wall distention in the term parturient