UNIT XIII. Drugs Affecting the

Reproductive System

Drugs Related To Female

Reproductive Cycle

Drugs that decrease uterine muscle contractility

Preterm Labor labor that occurs between 20 wks and 37

wks of pregnancy fetus with estimated weight between 500-

2499 g regular contractions occur at < 10 min

intervals over 30 to 60 minutes

contractions strong enough to result in 2 cm cervical dilation and 80% effacement

occurs in 8 to 10 & of all pregnancies Risk Factors

◦ maternal age <18◦ maternal age >40

◦ low socioeconomic status◦ previous history of preterm

delivery◦ intrauterine infection◦ polyhydramnios◦ multiple gestation

uterine anomalies antepartum hemorrhage smoking drug use urinary tract infection incompetent cervix

Contraindications of Tocolysis

pregnancy of < 20 wks (confirmed by ultrasound)

bulging or premature rupture of membranes confirmed fetal death or anomalies

incompatible with life maternal hemorrhage and evidence of

severe fetal compromise chorioamnionitis

Tocolytic Therapy◦ drug therapy to decrease uterine muscle

contraction ◦ uses beta adrenergic receptor antagonist or the

calcium antagonist magnesium sulfate

GOAL:◦ to interrupt or inhibit uterine contraction to create

additional time for in utero fetal maturation◦ to delay delivery so antenatal corticosteroids can

be delivered to facilitate lung maturation◦ to allow safe transport of the mother to an

appropriate facility

Beta Sympathomimetic Drugs

Terbutaline (Brethine)

Mechanism of Action stimulating beta receptors on smooth

muscle frequency and intensity of uterine

contractions decrease as the muscle relaxes decrease uterine contraction

Therapeutic Uses PTL

Side Effects Maternal S/E tremors malaise weakness dyspnea tachycardia (maternal and fetal) increased systolic pressure and decreased

diastolic pressure chest pain

nausea vomiting diarrhea constipation erythema sweating hyperglycemia hypokalemia

Most Serious Adverse Reactions pulmonary edema dysrhythmias ketoacidosis anaphylactic shock

Fetal S/E Tachycardia potential hypoglycemia resulting from fetal

hyperinsulinemia caused by maternal hyperglycemia

Nursing Implications Monitor and assess uterine activity and

FHR Maintain client in left lateral position as

much as possible to facilitate uteroplacental perfusion.

Monitor V/S / unit protocol, specifically maternal pulse. Report maternal HR >110 beats/min.

Report auscultated cardiac dysrhythmias. An ECG may be ordered.

Auscultate breath sounds every 4 H. Notify health care provider if respirations are >30/min or if there is a change in quality. (wheezes, rales, coughing)

Monitor daily weight to assess fluid overload; strict I&O measurement.

Report baseline FHR that is >180 beats/min or any significant increase in uterine contractions from pretreatment baseline.

Report persistence of uterine contractions despite tocolytic therapy.

Report leaking of amniotic fluid, any vaginal bleeding or discharge or complains of rectal pressure.

Be alert to presence of hypoglycemia and hypoglycemia in the newborn delivered within 5 H of discontinued Beta-sympathomimetic drugs.

Assist clients on bed rest and home tocolytic therapy to plan for assistance with self-care and family responsibilities.

Corticosteroid Therapy Mechanism of Action Accelerates lung maturation Therapeutic Uses PTL to decrease the incidence of RD Betamethasone (Celestone) When PTL occurs before the 33rd AOG,

corticosteroid therapy with betamethasone may be prescribed , 12 mg IM every 24 H X 2 doses

Adverse Reactions

1. seizures 2. headache 3. vertigo 4. edema 5. hypertension 6. increased sweating 7. petechiae 8. ecchymoses 9. facial erythema

Nursing Interventions

Shake the suspension well. Avoid exposing to excessive heat or light.

Inject into large muscle, but not to deltoid, avoid local atrophy.

Monitor maternal V/S. Maintain accurate I & O. Check blood glucose if used for client with

diabetes.

Dexamethasone

Has a rapid onset of action and shorter duration of action

Must be prescribed in a shorter frequency 6 mg IM every 12 H X 4 doses

Adverse Reaction insomnia nervousness increased appetite headache hypersensitivity reaction arthralgia

Drugs that Enhance Uterine Muscle Contractility

Before labor induction begins, risks and benefits and the status of the mother and the fetus must be assessed:

gestational age of fetus size of the fetus in relation to the client’s

pelvis cervical ripening

Oxytoxin

Mechanism of Action facilitates smooth muscle contraction in the

uterus Therapeutic Uses to reduce or augment labor contractions; to

treat uterine atony; milk letdown (intranasal spray)

Side Effects Maternal effects with undiluted IV use only hypotension dysrhythmias tachysystole oterine hyperstimulation

Adverse Reactions

Seizure Water intoxication if given in electrolyte

free-solution or at a rate greater than 20 mU/min (nausea, vomiting, hypotension, tachycardia and cardiac arrhythmias)

Nursing Interventions

◦ Have tocolytic agenrs and oxygen readily available.

◦ Monitor I & O.◦ Monitor maternal pulse and BP, uterine activity

and FHR during oxytocin infusion.◦ Maintain client in sitting or lateral recumbent

position to promote placental infusion.

Monitor for signs of uterine rupture which include FHR decelerations, sudden increased pain, loss of uterine contraction, hemorrhage and rapidly developing hypovolemic shock.

Ergot Alkaloids

Mechanism of Actions Act by direct smooth-muscle-cell receptor

stimulation Therapeutic Uses prevention and treatment of post-partum

hemorrhage

Side Effects and Adverse Reactions

uterine clamping nausea and vomiting dizziness hypertension with IV administration sweating tinnitus chest pain dyspnea itching

Nursing Interventions

Monitor client’s BP per agency protocol. Protect drugs from exposure to light. Monitor for side-effects or symptoms of

ergot toxicity (ergotism). Notify physician if systolic BP increases by 25 mmHg or diastolic BP by 20 mmHg over baseline

Drugs for Pregnancy induced Hypertension

Magnesium Sulfate◦ calcium antagonist◦ central nervous system depressant

Mechanism of Action relaxes the smooth muscle of the uterus

through calcium displacement direct depressant effect on uterine muscle

contractility increases uterine perfusion

Therapeutic Uses PTL Adverse Reactions Maternal S/E flush feelings of increased warmth perspiration

dizziness nausea headache lethargy slurred speech sluggishness

nasal congestion heavy eyelids blurred vision decreased GI action increased pulse rate hypotension

Increased severity of adverse reaction is evidenced by

depressed reflexes convulsion magnesium toxicity (respiratory depression

and arrest, circulatory collapse, cardiac arrest)

Fetal S/E decreased fetal heart rate variability

Neonatal S/E slight hypotonia with diminished reflexes lethargy for 24 to 48

Nursing Implications Monitor V/S, FHR and uterine activity as

ordered. Report respirations <12/min, which may indicate magnesium sulfate toxicity.

Monitor I&O. Report urinary output <30 ml/H.

Assess breath and bowel sounds as ordered or at least every 4 H.

Assess DTR and clonus before initiation of therapy and as ordered. Notify health care provider of changes in DTR.

Weight daily.

Monitor serum magnesium level as ordered (therapeutic level is 4 to 7 mg/dl).

Have calcium gluconate (1 g given over 3 minutes) available as an antidote.

Observe newborn for 24 to 48 H for magnesium effects if drug was given to mother before the delivery.

Drugs Used During the Postpartum Period Purposes to prevent uterine atony and postpartum

hemorrhage to relieve pain from uterine contractions,

perineal wounds and hemorrhoids1 to enhance or suppress lactation to promote bowel function to enhance immunity

Pain Relief for Uterine Contractions

Commonly Used Postpartum Systemic Analgesics Acetaminophen (Tylenol) Acetaminophen/codeine (Tylenol #3) Acetaminophen/propoxyphene (Darvocet

N50/Darvocet N-100) Ibuprofen (Motrin)

Codeine sulfate Ketololac tromethamine (Toradol) Meperidine (Demerol) Morphine sulfate Nalbuphine (Nubain) Oxycodone acetaminophen (Percocet)

Pain Relief for Perineal Wounds 1. benzocaine (Americaine, Dermoplast

OTC) 2. witch hazel pads (Tucks [50% witch

hazel with glycerine water and methylparaben])

Side Effects burning stinging tenderness edema rash tissue irritation sloughing tissue necrosis

Pain Relief for Hemorrhoids Burning pruritus irritation dryness folliculitis allergic contact dermatitis secondary infection

Nursing Implications Incorporate client’s cultural framework of

help in nursing plan of care. Do not use benzocaine spray when perineal

infection is present. Shake benzocaine pay can. Administer 6 to

12 inches from perineum with client lying on her

side with top leg up and forward to provide maximum exposure. This can also be done with one foot on the toilet seat after voiding.

Use witch hazel compresses (Tucks or witch hazel solution) with an ice pack and a peri-pad to apply cold to the affected area in addition to the active agent.

Store Anusol HC suppositories below 86F (30C) but protect from freezing. Use gloves for administration. If client is breastfeeding, assess to determine whether client is ready to switch to nonhydrocortisone preparation (goal is to discontinue use of suppositories as quickly as possible).

Check lot numbers and expiration date.

Use of Proctofoam-HC needs to be explained carefully to client because directions instruct the client to place the agent inside the anus, which is not generally done with obstetric clients because they may have perineal wounds that extend into the anus.

Do not use rectal suppositories in client with 4th degree perineal laceration.

Lactation Suppression Chlorotrianisene Deladumone OB Bromocriptine mesylate Promotion of Bowel Function stool softeners laxative stimulant antiflatulence

Side Effects and Adverse Reactions

Docusate sodium (Colace)- Bitter taste, throat irritation, rash

Casanthranol and docusate sodium (Peri-colace)- nausea, abdominal cramping, diarrhea, rash

Bisacodyl suppositories (Dulcolax)- proctitis, inflammation

Magnesium hydroxide (Milk of Magnesia)- abdominal cramps, nausea

Senna (Senakot)- Nausea, vomiting, diarrhea, abdominal cramps; can also create diarrhea in breastfeed infants.

Mineral oil- nausea, vomiting, diarrhea, abdominal cramps; if aspirated, lipid pneumonitis may occur

Nursing Implications Docusate Sodium (Colace) and

Casanthranol with Docusate Sodium (Peri-colace); Casanthranol with Docusate Potassium (Dialose Plus)

Store at room temperature. If a liquid preparation is ordered, give with

milk or fruit juice to mask bitter taste.

Take with a full glass of water. Assess client for any history of laxative

dependence. Drug interaction may occur with mineral oil,

phenolphthalein or aspirin.

Bisacodyl USP (Dulcolax)◦ Store tablets and suppositories below 77F (25F)

and avoid excess humidity.◦ Do not crush tablets.◦ Do not administer within 1 to 2 H of milk or

antacid because enteric coating may dissolve resulting in abdominal cramping and vomiting.

◦ Take with a full glass of water.

Mineral Oil Do not give with or immediately after

meals. Give with fruit juice or carbonated drinks

to disguise taste. Magnesium Hydroxide (Milk of

Magnesia) Shake container well. Do not give 1 to 2 H before or after oral

drugs because of effects on absorption.

Take with a full glass of water. Note that milk of magnesia concentrate is

3X as potent as regular-strength product. Give laxative 1 H before or 1 H after any

oral antibiotic. Senna (Senokot) Protect from light and heat.

Simethicone (Mylicon) 1. Administer after meals and at bedtime. 2. If chewable tablets ordered instruct

client to chew tablets thoroughly before swallowing.

Immunizations Rh (D) Immune Globulin Document Rh work-up and eligibility of

client to receive drugs in client record. Check lot no. on vial and laboratory slip for

agreement before administration; check expiration date.

Administer Rho (D) immune globulin, dose according to gestational weeks and exposure and route according to provider orders and agency.

Administer intramuscularly, in the deltoid within 72 H following delivery. If after 72 H, administer as soon as possible up to 28 days.

Rho (D) immune globulin administration is possible though infrequent. Check provider orders and dose. If IV administration then reconstitute with normal saline.

Store at 36 F to 46 F . Have epinephrine available to treat

anaphylaxis

Rubella Vaccine

Nursing Interventions 1. Protect vaccine from light and store at

35.6 F to 46.4 F before reconstitution. 2. Reconstitute with dilutent provided

and administer within 8 H. 3. Administer 0.5 ml vaccine subQ in

upper outer arm. Do not administer IV. 4. If tuberculin skin test is to be done,

administer it before or simultaneously with rubella vaccine.

Contraceptives

Oral Contraceptive Products 2 Main Types of Oral Contraceptive estrogen-progestin combination products

“the pill” progestin-only products “the minipill”

Estrogen-Progestin Products

Mechanism of Action suppress pituitary release of follicle

stimulating hormone (FSH) and luteinizing hormone (LH), which are needed to mature a graafian follicle in the ovary thereby inhibiting ovulation

Mechanism of Action changes in the endometrium that make it

less favorable for implantation of a fertilized ovum

the quantity and viscosity of the cervical mucus is changed by progestins, making it hostile to sperm

3 Types of Combination Product 1. monophasic- fixed ratio of estrogen to

progestin throughout the menstrual cycle 2. biphasic- amount of estrogen is fixed

throughout the cycle, but the amount of progesterone varies.

3. triphasic- deliver low doses of both hormones with minimal side effects

Progestin-only Products Mechanism of Action 1. altering the cervical mucus 2. altering the endometrium to inhibit

implantation 3. ovulation is also inhibited

Side Effects and Adverse Reactions Estrogen Excess 1. nausea 2. vomiting 3. dizziness 4. fluid retention 5. edema 6. bloating 7. breast tenderness

8. chloasma 9. leg cramps 10. decreased tearing 11. corneal curvature alteration 12. visual changes 13. vascular headache 14. hypertension

Estrogen Deficiency vaginal bleeding oligomenorrhea nervousness dyspareunia

Progesterone Excess 1. increased appetite 2. weight gain 3. oily skin and scalp 4. acne 5. depression 6. vaginitis 7. excess hair growth 8. decreased breast size 9. amenorrhea after cessation of use

Progestin Deficiency 1. dysmenorrhea 2. bleeding late in the cycle (days 15 to

21) 3. heavy menstrual flow with clots 4. amenorrhea

Nursing Implications Separate personal views from those of

client regarding contraception and use of specific products.

Recognize that many clients on oral contraceptives abandon the method within a year; therefore plan to provide client with alternatives.

Non nursing mothers can begin combination oral contraceptives 3 to 4 wks postpartum, regardless of whether menstruation has spontaneously occurred.

Alternative Methods of Contraception

1.Norplant2.Implanon3. Depo-Provera4. Lunelle5. NuvaRing

6. Today Sponge 7. IUD 8. Patch9. Medical Abortion

Emergency Contraception postcoital contraception

Drugs Related to Reproductive Health:

Male Reproductive Disorders

Substances Related to Male Reproductive Disorders

Androgen (Testosterone) Mechanism of Action Development and maintenance of male

sex organs and secondary sex characteristics.

Therapeutic Indications for Androgen Therapy

1.hypogonadism 2.constitutional growth delay

Side-effects 1. abdominal pain 2. nausea 3. insomnia 4. diarrhea/ constipation 5. hives/ redness at the injection site 6. increased salivation

7. mouth soreness 8. increased/ decreased sexual desire Adverse Reaction 1. virilizing effect (development of 2nd

male sexual characteristics) 2. acne, skin oiliness 3. growth of facial hair 4. vocal huskiness

5. menstrual irregularity/ amenorrhea 6. suppressed ovulation/ lactation 7. baldness or increased hair growth 8. hypertrophy of clitoris

MEN 1. priapism 2. gynecomastia 3. urinary urgency 4. oligospermia

Nursing Implications Instruct client and family on proper

administration of the medications, their reactions for use and potential side- effect.

2. Teach client that an intermittent approach to treatment allows for monitoring of endocrine status between courses of androgen therapy.

3. Instruct families pursuing treatment for a client with delayed puberty about the range of normal development.

4. Urge individuals being treated for tissue wasting to reduce environmental stressors and promote rest and relaxation, because stress hormones are catabolic. Muscle strength will be monitored during treatment.

Anabolic Steroids

Mechanism of Action Maximize the anabolic effects of androgens

and to minimize their androgenic effects Therapeutic Indications “sport supplements” “teen formulas”

Side-effects◦ water retention- overloads the kidneys◦ cardiac damage

Other steroids (athletes) hCG, Pregnyl, Novarel, Ovidrel- a hormone

used to treat infertility, which also stimulates testosterone production

tetrahydrogestrinone (THG)- potent androgen developed to escape urine detection

Antiandrogen

Mechanism of Action block the synthesis or actions of androgen

Therapeutic Indications◦ benign prostatic hypertrophy◦ carcinoma of the prostate◦ male pattern baldness

◦ acne◦ hirsutism◦ virilization syndrome in women◦ precocious puberty

GnRH or an analogue Eg. Lueprolide- most effective inhibitor of testosterone synthesis (LH and testosterone levels fall)

Ketoconazole- an antimycotic, used for the treatment of prostatic carcinoma because of its inhibition of adrenal and gonadal steroid synthesis

Androgen receptor antagonist Cyproterone acetate- suppresses LH and

FSH secretion Flutamide- competes with androgen at

androgen receptor site

Spironolactone- competes with dihydrotestosterone at the receptor sites. Treats hirsutism in women.

Finasteride- steroids, inhibits conversion of testosterone to dihydrotestosterone. Used to treat BPH.