Drugs used in obstetric

emergencies
RINJU JOY
BSC NURSING IV YEAR
KCON.

Drugs in Pregnancy
FIRST TRIMESTER :
congenital malformations
(teratogenesis)
SECOND & THIRD TRIMESTER :
affect growth & fetal
development or
toxic effects on fetal tissues
NEAR TERM :
adverse effects on Labour or
neonate after delivery

Drug categories
Category A
- practically Not harmful
during any trimester of pregnancy.
eg- antibiotics( penicillin, ampicillin,
amoxicillin, cloxacillin,
erythromycin
stearate,
cephalosporin)
vitamin and mineral in standard
doses
Thyroxin and humanized insulin

Conti.
Category B
- used in pregnancy
with out
adverse
effect
egmetronidazole,
tinidazole,
azithromycin,
nystatin, paracetamol,
ranitidine, ritodrine,

Conti..
Category C

- Shown adverse fetal effects

in the animal model, but no adequate studies

in pregnant women

- immediate benefits have

to be weighed against the potential risks of
drug used
Eg- trimethoprim, anti tuberculosis
norfloxacin, ciprofloxcin,lfloxacin ,

drugs,

aminophylline, quinine, acyclovir,

zidovudine,heparin,
hydralazine, Beta blockers, MAO- inhibitors,
lorazepam etc.

Conti..
Category D
- known to be potentially
harmful. Evidence of positive fetal risks.
Certain situation maternal benefits may outweigh
the potential fetal risks.

Eg

Tetracycline's, streptomycin, kanamycin,

phenytoin,phenobarbitone,
valproicacid,
alprazolam,chlordiazepoxide,
lithium, tricyclic depressants, ACE inhibitors,
spironolactone, propyl thiouracil, corticosteroids,
tobacco, iodine, warfarin, thiazides, alcohol,
etc.

Conti.
Category- X - proven to exert harmful
effects on the fetus in both animal and
humans.
Fetal risks outweigh any possible benefits to mother
Hence should be avoided.
Eg.
Aminoptterin.,androgens,clomphene,diethylstilboestrol,
oestrogens,antimalignancy drugs,
substance abuse, such as heroin,opium,lysergic acid
diethylamide,etc
used by drug addicts.

Definition of
Obstetric Emergencies:
An emergency is an occurrence
of serious and dangerous nature,
developing suddenly and
unexpectedly, demanding
immediate attention.

Obstetric emergencies related

directly to pregnancy include, for
instance
1. Pre-eclampsia
2. Eclampsia
3. Antepartum Haemorrhage
4. Postpartum Haemorrhage
5. Amniotic Fluid Embolism
6. Congenital Heart Disease
7. Epilepsy

Uterotonics and tocolytics

drugs
Uterotonics increase uterine
contractions (oxytocine,
prostaglandines, serotonine, kinines,
cathecholamines).
Tocolytics decrease uterine
contracions (spasmolytics, betareceptor-stimulating medications,
anti-oxytocin drugs).

Medications for Uterine Atony

I
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OXYTOCIN
The Champ

Cytotec
Inexpensive (?)

R
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Mechanism of myometrium
contractions
Myometrium has alpha and betaadrenoreceptors.
Stimulation of alpha-receptors by
catheholamines causes uterus
contraction
Stimulation of beta-receptors by
catheholamines causes uterus
relaxation

Mechanism of myometrium
contractions
Uterus body contains alpha and beta
catheholamines receptors
Lower segment contains choline and
serotonine receptors
Cervix contains chemo-, baro- and
mechanoreceptors

Severe Pre eclampsia / HTN

IV Labetolol ( blocker):
- Side effects: headache, nausea, vomiting, postural
hypotension & liver damage
- Contraindication: Asthma, marked bradycardia
IV hydralazine (vasodilator) :
- Side effects: headache,nausea, vomitting,
dizziness, flushing, tachycardia, palpitation &
hypotension
- Because of hypotension preload with gelofusin adv.
- Contraindication- SLE, severe tachycardia & MI

Nifedipine
Calcium Channel blocker

Clinical use:
Mild to moderate- 5-20 mg TDS/PO
Severe HTN- 10 mg Retard/PO
Tocolytic- Incremental doses every 20 min
until contraction stop, then 20 mg TDS/PO

Side effects: Headache,dizziness,palpitation,

tachycardia, hypotension,sweating &
syncope.

Magnesium Sulphate
Clinical use: Prevention & treatment of seizure
in eclampsia / severe pre eclampsia
Dose: 4g IV stat then 1g/hr to be continued
24hr after last seizure
Side effects: nausea,vomiting,flushing,
drowsiness,confusion,loss of tendon reflexes,
hypotension, decrease U/O, respiratory
depression, arrhythmias,cardiac arrest
Because of toxicity, Mg levels monitored

Magnesium Sulfate

Mech of action is unclear

Impedes acetylcholine release?
Decr sens of the motor end plate?
Central anticonvulsant effect?
4 g iv bolus(20 cc of 20% soln) over
1015min
Maintenance is 13 g/h(alt 10 g im)

MgSo4
First line treatment of eclampsia
Recommended as prophylaxis
against
eclampsia in severe pre eclampsia

MgSo4
Cochrane reviews: MgSo4 safer and
more
effective than diazepam or phenytoin for
prevention of recurrent seizures
SE: Mg toxicity
Loss of DTRs @ 810 mEq/L
Respiratory paralysis @1015 mEq/L
Cardiac arrest @ 2025 mEq/L

MgSo4
Monitor:
RR hourly
Patellar reflexes hourly
U/O <20cc/hrdecrease dose
Serum Mg levels q 4 hrs 948mEq/L)
Crosses the placenta freelyrarely NN
depression
Calcium gluconate1g iv over 35 min(10cc
of
10% soln) antidote!

Post partum hemorrhage

Postpartum Haemorrhageuterotonics- oxcyticin
0.2 mg IM/IV q2-4hr PRN; not to exceed 5
doses, THEN 0.2-0.4 mg PO q6-8hr PRN for
2-7 days
Administer IV only in emergency because of
potential for Hypertension & CVA
Administer over >1 minute and monitor BP
Refractory Cluster Headache (Off-label)
0.2 mg PO q6-8hr, not to exceed 6 months

OXYTOCIN
OXYTOCIN
The Champ

The common medication

used to achieve uterine
contraction
First-line agent to
prevent and treat PPH

Oxytocin

Mechanism of action:
Acts through oxytocin receptors
present in smooth muscles of
myometrium.
Stimulates the amniotic and decidual
prostaglandin production.
Mobilization of bound intracellular calcium
from sarcoplasmic reticulum to activate
the contractile protein.
There is increase in frequency and force
of uterine contractions, similar to
physiological uterine contractions

Oxytocin
Duration of action: approximately 20 minutes. In non
pregnant women, half life (t1/2) is 10-15 minutes and
the removal from circulation is due mainly to kidneys
and liver, but t1/2 in pregnant women is only 3
minutes, because of presence of enzyme oxytocinase in
placenta, uterine tissue and plasma which inactivates it.
Given orally it is ineffective as it is inactivated rapidly in
the Gastro-intestinal tract by enzyme, trypsin, needs to
be administered by parenteral, nasal or buccal
routes.
Unitage and Preparation: 1 international unit (i.u.) of
oxytocin is equivalent to 2 microgram of pure hormone.
Commercially available preparation is produced
synthetically. Oxytocin injections are available in
concentration of 5 i.u. / ml (Syntocinon) , 5 i.u/ 0.5ml.
(pitocin) or 2 i.u./ 2ml. (oxytocin).
Oxytocin nasal spray contains 40 units/ ml.

Oxytocin
Indications for stopping the infusion
Abnormal uterine contractions
occurring too frequently ( less than every 2
minutes),
lasting more than 60 seconds ( hyper stimulation)
and increased tonus in between the contraction
Evidence of Foetal distress
Appearance of untoward maternal signs and
symptoms

Oxytocin
Dangers of Oxytocin
Maternal
Uterine hyper stimulation; increased frequency
and duration of uterine contractions & / or increased
tonus, is often associated with abnormal foetal heart
rate pattern
Urine rupture; high risk in grand multipara,
malpresentation, contracted pelvis, prior uterine scar
and excessive dosages.
Water intoxication; due to its ADH like antidiuretic
action, when used in high dosages i.e. 30 40 i.u. /
min., manifested by hyponatremia, confusion,
convulsions, coma, CHF and even death. Can be
prevented by strict intake output record, use of salt
solutions, and by avoiding high doses oxytocin for a
longer time.

 Hypotension; it is seen with bolus i.v.

injection especially when the patient is
hypovolemic or in patients with heart disease.
Occasionally may produce anginal pain.
Anti- diuresis; especially with higher dosages
Foetal
Foetal distress, foetal hypoxia or even foetal
death may occur due to reduced placental
blood flow due to uterine hyper stimulation.

Oxytocin (Syntocinon)
Octapeptide
Strong rhythmical contraction of myometrium
Large doses- sustained contraction( placental
blood flow & fetal hypoxia/death)
Clinical use:
- IOL (IVI 3U syntocinon+50 ml of saline)
- Augment slow labour (IVI same as above)
-3rd stage of labour- 5 U IM for HTN ,cardiac disease
- IVI 40 U in 500ml saline
( PPH)
-Surgical termination of preg./ERPC- 5U slow IV

uterotonicsmethylergonovin
Postpartum Haemorrhage
0.2 mg IM/IV q2-4hr PRN; not to exceed 5
doses, THEN 0.2-0.4 mg PO q6-8hr PRN for
2-7 days
Administer IV only in emergency because of
potential for Hypertension & CVA
Administer over >1 minute and monitor BP
Refractory Cluster Headache (Off-label)
0.2 mg PO q6-8hr, not to exceed 6 months

 carboprost tromethamine(Rx)Hemabate
Refractory Postpartum Uterine
Bleeding
Initial 250 mcg IM, repeat PRN q1590min
No more than 2000 mcg or 8 doses

 misoprostol(Rx)- Cytotec
Postpartum Hemorrhage (Off-label)
Prophylaxis: 600 mcg PO within 1 minute
of delivery
Treatment: 800 mcg PO once; use
caution if prophylactic dose already
given and adverse effects present or
observed
Use only in settings where oxytocin not
available

 ergonovine(Discontinued)- ergometrine,
Ergotrate
Pospartum or Postabortion Hemorrhage
0.2 mg IM; may repeat in 2-4hr; not to exceed
5 doses total
Give IV only in emergency because of
potential for HTN & CVA
Alternatively, 0.2-0.4 mg PO q6-12hr PRN for
48 hr or until danger of uterine atony has
passed; no more than 1 week
Give over >1 minute & monitor BP

Dinoprostone ( prostin E2)

Vaginal pessary/gel
Clinical use: IOL 3mg 6hrs apart ( no more
than 2 pessaries in 24hrs and max. 3 doses)
Side effect: Nausea ,vomiting, diarrhoea, fever,
Uterine hyperstimulation , HTN,
bronchospasm
Advantages :
- Mobile patient
-Reduce need for syntocinon

Carboprost ( Hemabate)
Dose ; 250g deep IM repeated every
15 min max 8 doses.
(OR Intra-myometrial use at C/S)
Side effects: Nausea ,vomiting,
diarrhoea, fever, bronchospasm,
dyspnoea, pulmonary oedema,
HTN, cardiovascular collapse
Clinical use: Postpartum haemorrhage

Atosiban(Tractocile)

Oxytocin receptor antagonist

Inhibition of uncomplicated preterm labour
between 24-33 weeks ( Tocolytic)
Contraindication: severe PET, eclampsia,
IUGR, IUD, placenta previa, placental
abruption, abnormal CTG, SROM after
30/40
Side effects: Nausea,vomiting,headache,
hot flushes, tachycardia, hypotension &
hyperglycemia
Dose- Stat IVI then continue infusion until
no contraction for 6 hrs.

Other tocolytics
Salbutamol inhaler- 100 mcg x 2 puffs stat
Terbutaline- 250 mcg subcutaneous
Clinical use: both drugs are used for short term.
(i) relaxing uterus at C/S
(ii) ECV procedure
Side effects: Headache, palpitation,
tachycardia, MI ,arrhythmias, hypotension &
collapse

Mild /Moderate HTN/PET

Methyldopa:
-Dose: 250mg BD/TDS , PO max dose 3g /day
-Side effects: Headache,dizziness,dry mouth ,
postural hypotension,nightmares, mild
psychosis, depression,hepatitis & jaundice
- Important to stop drug in postnatal period
Labetolol 100-200mg BD/TDS PO max
2.4g/24hr
ACE inhibitors are contraindicated in pregnancy

Dont forget
analgesia & anaesthesia
for labour & delivery!!

Commonly used drugs that should be

avoided in pregnancy and safer alternatives
Drug class

Drugs to
avoid in
pregnancy

Associated
problems

Drugs
considered
safer
alternatives

analgesics

Non steroidal
anti
inflammatory

Increased risk
of spontaneous
abortion

Paracetamol,
opiates

antibiotics

trimethoprim

Causes
structural
defects-cleft
palate

Penicillin and
cephalosporin

CNS defects,
hemorrhage,
stillbirth,
spontaneous
abortion,
prematurity.

Low molecular
weight heparin

anticoagulants

Warfarin(1st
&3rd trimester)

anticonvulsants' phenytoin

Congenital

carbamazepine

Antibiotics categorized according to

their safety profile
Name of the drugs
Ampicillin,
cephalexin,
amoxycillin,
erythromycin,
chloramphenicol,
clindamycin.

category

remarks
A

May be prescribed
safely

Tinidazole,
trimethoprim +
sulphonamides

Preferably avoided

Tetracycline,
aminoglycosides,
doxycycline

Should always be
avoided

Drugs in early pregnancy

Mifepristone- 200mg PO
Mechanism:
Antiprogestogenic steroid
Sensitizes myometrium to prostaglandininduced contractions & ripens the cervix
Clinical use:
Medical termination of pregnancy
Medical management of miscarriage/IUD
Side effects: Gastro intestinal cramps, rash,
urticaria, headache,dizziness,
Contraindication: severe asthma

Misoprostol
Synthetic prostaglandin
PO/PV route
Clinical use:
- Medical TOP
- Medical management of miscarriage/ IUD
( For 1st trimester single dose of 400mcg
From 12- 34 weeks 400mcg 3hrly ,max 5 doses)
- Postpartum hemorrhage- 800mcg PR/PV
Side effects: nausea,vomiting, diarrhoea,
abdominal pain

Methotrexate
Cinical use: Medical management of
ectopic pregnancy
Dose 50mg per kg/m2
Criteria- adenexal mass, non viable
pregnancy hCG< 3000U,
haemoperitonuem < 150ml
Side effects:
Disadvantage : repeated hCG levels,
emergency surgery
Advantage: Avoid surgery, tube preserved

Menorrhagia /
dysmenorrhea
Mefenamic acid:
- NSAID, reduces bleeding by 25%
- Dose: 250-500mgx TDS D1-3 of cycle or PRN
- Side effects: Gastro-intestinal discomfort
nausea, diarrhoea, bleeding/ulceration
Tranexamic acid:
- Antifibrinolytic,reduces bleeding by 50%
- Dose: 1g TDS/QDS D1-4 of cycle
- Contraindication: thromboembolic disease
- Side effects: nausea,vomiting,diarrhoea,
thrombo embolic event

Progestogens
Dysfunctional uterine bleeding/menorrhagiaNorethisterone 5mg TDS D5-25 (3ks on/1wk off)
Endometriosis- same dose contin. 9 months
Menorrhagia- Depoprovera, Mirena
Contraception- Mini pill, Mirena
Induce withdrawal bleeding eg. PCOS ( 10 days Rx)
Endometrial hyperplasia ( except atypical variety)Depo provera, Mirena
HRT
Women with previous preterm labours -cyclogest
pessary 200mg PV/PR daily till 36 weeks
Following IVF/ICSI- Gestone inj + cyclogest pessary

Progesterone
Increases membrane potential of myocyte and
particularly blocks impulses between myocytes
Myometrium becomes insensitive to irritatons

myometrium

Estrogen

Contraceptive - COC
DUB/menorrhagia-COC
Endometriosis- COC continued for 9 months
PCOS/Hirsutism - Dianette
PMS- E2 patches + Mirena
HRT
Hypogonadism- cyclical therapy initially
oestogen then combined oestrogen &
progesterone

Gonadorelin analogue
Mechanism- Initial stimulation then down
regulation of GnRH receptors reducing the
release of gonadotrophins and in-turn release
of estrogen & androgen production
Side effects:menopausal symptoms,
headache, hypersensitivity( rash,asthma,
anaphylaxis), palpitation,hypertension,breast
tenderness & GI symptoms, irritation of nasal
mucosa (spray)
E.g Prostap, Zoladex & Buserelin spray
S/C /IM inj. Monthly or nasal spray TDS for 6/12
Maximum treatment no more than 6 months

Gonadorelin analogue- clinical

use

Endometriosis
Chronic pelvic pain
Prior to myomectomy- size & bleeding
Prior to hysterectomy for fibroids
Infertility- pituitary desensitisation before
induction of ovulation by gonadotrophin
for IVF
Menorrhagia in perimenopausal women
Precocious puberty

Danazol
Mechanism: Inhibits pituitary gonadotrophin
-antioestrogenic & antiprogestogenic
- androgenic activity
Dose : 200-800mg 4 divided dose for 3-6 month
Clinical use:
- Endometriosis
- Benign fibrocystic disease(breast tenderness)
Side effects: Nausea, headache,dizziness, weight gain, libido
changes, androgenic side effects ( acne, oily skin, hair
loss,voice changes)

HRT
Benefits:
- Systemic therapy- improves vasomotor symp.
- prevents osteoporosis
- Vaginal cream/ pessary - atrophic vaginitis/ urinary
symptoms
Risk of HRT:
- Breast Ca(6 additional cases in 50-59 old , 5 yr use)
- Ovarian Ca (1)
- Endometrial Ca(unopposed E2)
- VTE (7)
- Stroke (1)
- Coronary heart disease(15 ,70-79yr)

HRT
Route-Tab,gel,patches,implant,vaginal
pessary/cream
Conventional HRT prep: E2 +12 days P
: Combined E+P
Sequential HRT:
- Indication: Perimenopausal women with uterus
- Regular withdrawal bleeding
Continuous combined:
- Indication: Postmenopausal (>1yr) with uterus
- Bleed free

Other HRT
Raloxifene: SERMs
- Post menopausal women>1 yr
- Prevents osteoporosis
- less risk of breast Ca
- Not effective for vasomotor symptoms
- Same risk of VTE as other HRT
Tibolone
- Synthetic prep with oestogenic,progestogenic
& androgenic effect
- Same benefits & risks as HRT
- Improves libido

Management of vasomotor
symptoms of menopause

Systemic HRT
Tibolone
Clonidine
Venlafaxine
Fluoxetine
Not recommendedginseng,Kosh,Soya prep( ?safety)

Anticholenergics for Urge

incontinence
Preparations:
- Tolterodine (Detrusitol XL) 4mg/OD
- Solifenacin(Vesicare) 5-10mg OD
- Trospium chloride(Regurin) 20mgBd
- Oxybutynin- tab 2.5 mg OD
- patches 36mg twice weekly
Side effects: dry mouth,constipation,blurred
vision,dry eyes,drowsiness,dizziness &
palpitation

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