Reproductive and

Gender-Related Agents

Ma. Tosca Cybil A. Torres, RN, MAN

Therapeutic Drug Use in Pregnancy

• Iron – In pregnancy, approximately 2x the normal

amount of iron is need to meet fetal and maternal daily requirements–27mg daily –Needed during the 2nd trimester where the

fetus begins to store iron–GOAL: to prevent maternal deficiency, not

supply the fetus

• Iron – Ex:

• Ferrous sulfate 20% (300mg of ferrous sulfate is equivalent to 60mg elemental iron)

– Adverse effect: • Nausea, constipation, black or tarry stools, epigastric pain,

vomiting, and diarrhea– Nursing implications:

• Liquid for should be diluted and administered through a straw to prevent teeth discoloration

• May inhibit absorption of others medications, appropriate separation of doses should be followed

• Instruct to take between meals---1hour before meals is suggested

• Do not administer with milk or antacids • Advise client to swallow whole, not to crush

• Folic Acid– Needed to prevent spontaneous abortion or birth

defects, premature births, LBW, and premature separation of the placenta

– RDA: 400mcg to women of childbearing age– RDA: 600mcg for pregnant women – Recommended amount should be ingested from

folate-enriched foods and supplementation• Ex:

– Bread, rolls, flour, cornmeal, rice, pasta, and cereals

• Adverse reactions: – Allergic bronchospasm, rash, pruritus, erythema,

and general malaise– May turn urine in an intense yellow

• Multivitamins –Preparations generally supply vitamins

A,D,E,C,B complex, iron, calcium and other minerals–Helps prevent congenital defects –Most effective if taken with meals–Vitamin A in large doses can be teratogenic – Excessive ingestion of vitamins D,E, and K

can be toxic

Drugs for Minor

Discomforts of

Pregnancy

• Physiologically, minor discomforts in pregnancy are associated with increased level of human chorionic gonadotropin(HCG) levels

• Increased levels of progesterone relaxes smooth muscles which contributes to the discomforts of heart burn and constipation

• Elevated female sex hormones during pregnancy changes the motility of the GI tract and the enlarging fetus displaces the bowel

• Nausea and vomiting (morning sickness) are major complaints during early pregnancy and hyperemesis gravidarum which needs hospitalization for hydration and nutrition

• The FDA did not approve any drug for the treatment of morning sickness but the common drugs used are: – Prokinetic agents

• Metoclopramide (Reglan)

– Anticholinergic• Scopolamine (Scopace)

– Phenothiazine • Promethazine (Phenergan)

– Antihistamines• Meclizine(Antivert)

– SE: dizziness, drowsiness, dry mouth and nose, blurred vision, diplopia, urinary retention, palpitations and tachycardia

• Heartburn (pyrosis) –Burning sensation in the epigastric and

sternal regions that’s occurs with reflux of acidic stomach contents –Results from a normal increase in

progesterone----relaxing the cardiac sphincter

Pharmacological management • Antacids- first line of therapy if client did not respond to non

pharmacological management – Magnesium hydroxide and aluminum hydroxide with

Simethicone(Maalox plus)» For heartburn with antiflatulence action

– Aluminum hydroxide (Amphojel)» For heartburn secondary to reflux» Action: neutralization of gastric acidity » SE: constipation » AR: dehydration, GI obstruction » Nursing responsibility:

• Instruct to store liquid form in room temperature, not to let it freeze, and to shake bottle well before pouring

• Constipation – Frequent in pregnancy due to decreased GI

motility – Safest oahrmacological management is the use of

bulk-forming preparation with fiber• Metamucil • Docusate sodium –stool softener

Avoid use of castor oil----promotes uterine contractions Avoid intake of mineral oil----reduces absorption of

vitamin K

• Pain – Acetaminophen(Tylenol, Datril)• Pregnancy category B • With analgesic and antipyretic effects• A weak prostagladin inhibitor and does not have

significant anti-inflammatory effect • should be used cautiously in clients at risk for infection

because of the possibility of masking s/sx• SE: skin eruptions, urticaria, unusual bleeding,

erythema, hypoglycemia, jaundice, hemolytic anemia, thrombocytopenia

• Pain – Aspirin (ASA, Bayer, Ecotrin) • Classified as a mild analgesic• Pregnancy category C • Prostaglandin synthetase inhibitor that has antipyretic,

analgesic, and anti-inflammatory properties • No known teratogenic effect, risk for anomalies is small • Inhibits the initiation of labor and actually prolong

labor• May increase risk of anemia and antepartum

hemorrhage

Drugs that

Decrease

Uterine Muscle Contrac

tility

• Tocolytic Therapy – Drug therapy that decreases uterine muscle

contractility for clients who are experiencing true PTL (with cervical changes)

– Goal: • to inhibit or interrupt uterine contractions to

create additional time for in utero fetal maturation• delay delivery so antenatal corticosteroids can be

delivered to facilitate fetal lung maturation• to allow safe transport of mother to an

appropriate facility

• Tocolytic therapy– Beta-Sympathomimetic Drugs • Act by stimulating beta2 receptors of smooth muscles.

The frequency and intensity of uterine contractions decrease as the muscle relaxes• Prototype:

– Terbutaline (Brethine)-most commonly used

• AR: – maternal side effects include tremors, malaise, weakness,

dyspnea, tachycardia (maternal and fetal), chest pain, vomiting, diarrhea, constipation, pulmonary edema, dysrrhythmias, anaphylactic shock.

– Fetal side effects include tachycardia and potential hypoglycemia

• Drug interactions: – general anesthetics--- can produce additive hypotension– Corticosteroids--- pulmonary edema

• Nursing considerations: – Monitor and assess uterine activity and FHT – Maintain client in left lateral position as much as

possible to facilitate uteroplacental perfusion– Monitor maternal V/S– monitor daily weight to assess fluid overload; strict

I & O monitoring – Report significant increase and persistence in

uterine contractions despite tocolytic therapy – Report any leaking of amniotic fluid, any vaginal

bleeding, or discharge, or complains of rectal pressure

– Monitor for side effects such as palpitations and dizziness

• Tocolytic therapy– Magnesium Sulfate • Calcium antagonist and CNS depressant----relaxes

smooth muscles of the uterus through calcium displacement • Increases uterine perfusion---beneficial for the

fetus• Less expensive with lesser adverse effects than

beta-sympathomimetics• Excreted by the kidneys and crosses the placenta• Maintenance dose be titrated to keep uterine

contractions under control • Contraindicated for clients with MG, impaired

kidney function and recent MI

Magnesium sulfate • Adverse Reactions: – Mother: flush, feelings of increased warmth,

perspiration, dizziness, nausea, headache, lethargy, slurred speech, sluggishness, nasal congestion, decreased GI action, increased pulse rate, and hypotension.

– Fetus: decreased heart rate and slight hypotonia with diminished reflexes and lethargy for 24 to 48 hours

– Toxicity: respiratory depression and arrest, circulatory collapse, cardiac arrest

– Antidote for toxicity: calcium gluconate (10mg IV push over 3 minutes)

Corticosteroid Therapy in preterm

labor

• Corticosteroid Therapy in preterm labor –Accelerates lung maturation with

resultant surfactant development in the fetus in utero-----decreasing the incidence and severity of respiratory distress syndrome (RDS) with increased survival of preterm infants

– Prototype: • Betamethasone(Celestone)

– Given to prevent RDS to preterm infants by injecting the mother before delivery to stimulate surfactant production in the fetal lung

– Not effective in treating preterm infants after delivery – More effective if given at least 24hrs but less than 7days before

delivery in week 33 and before – less effective with multifetal birth – AR: rare but includes seizures, headache, vertigo, edema,

hypertension, increased sweating, petechiae, ecchymoses, and facial erythema

– Nursing responsibilities: » Shake suspension well. Avoid exposing to excessive heat or light » Inject to large muscle » Monitor maternal V/S» Maintain accurate I & O

• Dexamethasone– Has a rapid onset of action and a shorter duration

of action – AR: insomnia, nervousness, increased appetite,

headache, hypersensitivity reactions

Drugs for Pregnancy Induced

Hypertension (PIH)

• PIH– Most common serious complication of pregnancy– Most often observed after 20 weeks gestation

intrapartum and during the first 72 hours post partum

– Believed to be related to decreased levels of vasodilating prostaglandins with resulting vasospasm

– Prototype: • Methyldopa(aldomet) and hydralazine (Apresoline)

– First line therapy for pre-eclampsia

• Methyldopa(Aldomet)– MOA: stimulates the central alpha-adrenergic

receptors that results in a decreased sympathetic outflow to the heart, kidneys, and peripheral vasculature

– AR: peripheral edema, anxiety, drowsiness, headache, dry mouth, mental depression

– Nursing responsibilities: • Assist client to left lateral recumbent position • Teach about s/sx of progressive PIH• Advise diet rich in protein, normal sodium diet, and

increase OFI • Monitor BP and report persistent and progressive

elevation in readings

• Magnesium Sulfate – Prevention and treatment of seizure r/t PIH. – Acts as CNS depressant. Decreases acetylcholine

from motor nerves, which blocks neuromuscular transmission and decreases incidence of seizures. Secondary effect is reduction of BP as the smooth muscles relaxes

– Increases uterine blood flow– S/E: lethargy, flush, feelings of increased warmth,

perspiration, thirst, sedation, slurred speech, hypotension, decreased muscle tone

–Nursing interventions: (Magnesium sulfate)• Continuous fetal monitoring • Monitor for maternal toxicity----weakness and

lethargy from the blocking of the neuromuscular transmission. • Have calcium gluconate available-----as antidote

for toxicity • Maintain client in left lateral position in low

stimulation environment • Monitor for S/E

• Hydralazine – Antihypertensive agent. Acts by causing arterial

vasodilation. – Objective of treatment is to maintain diastolic BP

between 90 mmHg and 110 mmHg– AR: headache, N and V, nasal congestion,

dizziness, tachycardia, palpitations, and angina – Nursing interventions: • Take pulse and BP every 5 minutes until stabilized • Observe for change in LOC and headache • Monitor FHT • Monitor I and O

Drugs that Enhance Uterine

Muscle Contractility

• Uterotropic drugs enhance uterine contractility by stimulating the smooth muscle of the uterus.

• Prototype: – Oxytocin(Pitocin)• indicated for the initiation or improvement of uterine

contractions, where this is desirable and considered suitable for reasons of fetal or maternal concern, in order to achieve vaginal delivery.• Indicated for:

– induction of labor in patients with a medical indication for the initiation of labor

– stimulation or reinforcement of labor, as in selected cases of uterine inertia

– adjunctive therapy in the management of incomplete or inevitable abortion

• Oxytocin (Pitocin, Syntocinon)– MOA: promotes uterine contractions by increasing

intracellular concentrations of calcium in uterine myometrial tissue

– S/E: hypotension, dysrrhythmias, uterine hyperstimulation

– AR: seizures, asphyxia, cardiac dysrrhythmias – Nursing interventions:

• Have oxygen readily available • Monitor maternal pulse and BP, uterine activity, and FHT• Maintain in left lateral position to maintain placental

perfusion • Monitor for signs of placental rupture---FHT decelerations,

sudden increased pain, loss of uterine contractions, hemorrhage, and rapidly developing hypovolemic shock

• Ergot alkaloids – Act by direct smooth-muscle-cell receptor

stimulation– Not used during labor because they can cause

sustained uterine contractions (tetanic contractions)------fetal hypoxia and possibly rupture of the uterus

– Effective in control of postpartum hemorrhage and promotion of uterine involution

– Prototype: • Ergonovine maleate (Ergotrate)• Methylergonovine maleate (Methergine)

• Ergot alkaloids – S/E: uterine cramping, nausea and vomiting, dizziness,

hypertension, sweating, tinnitus, chest pain, dyspnea, sudden severe headache. Ergot toxicity(ergotism)----pain in arms, legs, and lower back, numbness, cold hands and feet, muscular weakness, diarrhea, hallucinations, seizures, and blood hypercoagulability

– Nursing responsibilities: • Assess lochia and uterine tone before administration • Monitor clients BP----notify AP if systolic BP increases by 25

mmHg or diastolic BP by 20 mmhg over baseline • Protect drugs from exposure to light• Monitor for side effects or symptoms of ergot toxicity (ergotism)• Inform client that she will feel intense uterine cramps after

receiving the drug• Instruct not to smoke----increases vasoconstricting effect