OBSTETRIC PHARMACOLOGY

Drugs and the fetus

MECHANISMS

The placenta forms a barrier between the fetal and maternal circulations.
This barrier is not just a passive block or filter but is able to transfer substances
actively.It can select those substances which are essential for fetal growth and
transfer them to the fetus so that there is higher concentration on the fetal side.

One important aspect of the transfer of the drugsto the fetus is whether they are
chemical soluble in fat (or lipid), those drugs that are lipid soluble only pass when
they are in high concentration.Once the drug has passed to the fetus,it may persist
there for a long time.This is due to the poor developed mechanisms necessary to
excrete the drug

Effects
The possible bad effects of the drug on the growing fetus are expressed
as,’Teratogenic’ which means making of monsters or abnormal children
s
Drugs with such properties are most dangerous soon after implantation when the
majority of the fetal organs are forming (organogenesis)

Methods of action

Drugs crossing the placenta barrier may act:

- Directly on the placenta (impairing the function)

- On the fetus (reducing blood supply)
- On the maternal hormone balance

Specific dangers

EARLY PREGNANCY

This is the time characterizedby nausea, vomitingand occasionally

Drugs to stop this vomiting (antiemetics) are notoriously dangerous to the fetus
and should be avoided whenever possible
Thalidomide was the drug widely used for morning sickness of pregnancy from
1959-1961. A large number of children were born without long bones of the arms

i
and legs (hands and feet arising on or near the trunk) following the administration
of this drug and late1961; it was withdrawn from the market

NB. All drugs which are toxins(or mild poison) by nature, should be avoided in
early pregnancy:in particular, the following should be avoided
1. Ant parasitic agents
2. Strong antibiotics

LATE PREGNANCY
While drugs given in late pregnancy may not cause gross anatomical defects ,they
can affects the fetus in other ways;
 Androgens or progesterone can cause fetal masculinization
(to cause a female take on male characteristics )
 Iodine and ant thyroid drugs can cause goiter
 Tetracycline can interfere with bone and tooth development

JUST BEFORE LABOUR

 Drugs given at this time may accumulate in the fetal circulation, the fetal
liver is not mature enough to excrete them
 Anticoagulants will cause severe neonatal haemorrhage
 Sulphanomides will cause jaundice
 Chloramphenicol results into general collapse (thegrey baby syndrome)

DURING LABOUR

Any drug which acts to depress the respiration like pain relievers, which make the
new born
have difficult in starting respiration
Barbiturates and anesthetic agentsmay depress the new born’s respiration

Summery
ii
As a principle,all drugs should be avoided throughout pregnancy but especially in
the first trimester (first 12 weeks)
You should attempt to cope with the mother’s problems by giving reassurance and
moral support with minimum amount of drugs
If drugs are really required,their safety should be assured and they should be used
for a very short period of time

iii
SECTION ONE: INTRODUCTION TO PHARMACOLOGY

Introduction
In this section, we shall look at definition of terms, sources of drugs, drug
classification and storage, routes of drug administration and essential drugs among
others.
Let’s look at the section objectives

Objectives
At the end of the section you will be able to:-

1. Define the common terms used in Pharmacology

2. Outline the background and the importance of

pharmacology in midwifery
3. Describe drug administration

Definition of terms

Pharmacology
This is the study of the effect of drugs on the living system. The word
pharmacology comes from two Greek words that is to say Pharmakon- meaning
drugs or poison and cology the study of.

Pharmacology is divided into two parts namely pharmacokinetics and

pharmacodynamics.
i. Pharmacokinetics
This is the study of the movement of drugs throughout the body.
It involves drug absorption, distribution, metabolism and excretion.

4
Absorption: This is the process by which a drug is transferred from the site of
administration into the blood stream.
Drug absorption is determined by the following factors;
Route of administration (inject able drugs are absorbed faster than oral drugs).
Surface area (the greater the surface area the faster the absorption- that is why most
drugs are absorbed from the small intestines).
Blood flow to the site of application.Presence of food in the stomach (absorption of
some drugs given orally may be affected by presence of food in the stomach).

Distribution: This is the movement of a drug from the blood stream to its site of
action.
The degree of distribution depends on protein binding, lipid solubility and the rate
of blood circulation.

Bioavailability: This is the fraction of a dose of a drug which is absorbed from the
site of administration into the blood stream. Drugs given intravenously give 100%
of the dose that enters the blood stream.Bioavailability following oral
administration is reduced by incomplete absorption and first pass metabolism.
Metabolism:This is a process by which a drug is converted to a less active form.
Drug metabolism usually takes place in the liver.
Metabolism of drugs may be affected by age of the patient that’s neonates and
elderly patients have reduced capacity to metabolize some drugs, activity of drug
metabolizing enzymes (some drugs such as carbamazepine may increase the
metabolism of other drugs when given together.
Excretion: This is the process by which drugs or their metabolites are removed
from the body. Most drugs are excreted by the kidney in urine and others through
breast milk, faeces, sweat and breath.

5
 ii. Pharmacodynamics
This is the study of the process by which the drugs influence the body physiology.
Pharmacodynamics usually results into clinical response of the patient.
A dose: A dose is the amount of the drug given at a particular time. The adult dose
of amoxicillin is 500mg.
Side effect: Side effects refer to unavoidable secondary effect of the drug
produced when the drug is given at the recommended doses.
For example ampicillin produces diarrhoea or skin rash as a side effect when given
to treat bacterial infections such as pneumonia.
Toxicity: These are adverse drug reactions produced by a drug when the dose
given is higher than normal (excessive dosing).
Adverse drug reaction: These are untended response to a drug. They may be mild
or life threatening
Teratogenic effect:These are birth defects induced by use of the drug.
Tetracycline is teratogenic because it causes staining of the teeth of the born child
when given during pregnancy.
Drug interaction: This is a process in which one drug changes the effect of
another when used at the same time. Drug interaction may be an advantage to the
patient since it may result in better clinical response or a disadvantage when
therapeutic response is compromised.
Indications:These are conditions or diseases where the drug is recommended.
Contraindications
These are cases where the use of a particular drug will cause harm.

Drug
A drug is any chemical substance that changes the physiological function of the
body.
Drugs may be used to treat, control, prevent or diagnose diseases.
Sources of drugs
Drugs used to treat different conditions may be obtained from different sources as
outlined in the table below.

6
Let’s look at table I1 illustrating the sources of drugs
Table 1: Sources of drugs

Source Example
Plants Quinine
Animals Insulin

Microorganisms Antibiotics such as some penicillin

Minerals Iron
Chemical substance Ampicillin

Classification of drugs
Drugs may be classified as follows:
Class A drugs: Class A drugs are controlled drugs which must be dispensed
against a valid prescription from a registered doctor. Examples morphine,
pethidineand tramadol.
These drugs are kept under lock and key cup board because they are commonly
abused.
Class B drugs: These drugs include antibiotics, ant diabetics, antihypertensive
among others.
These drugs also need a valid prescription from a registered medical doctor or any
other authorized prescriber. Class B drugs can only be obtained from a registered
pharmacy.
Class C drugs: These drugs can be given without a prescription because they are
considered safe and their uses are known to patients. Examples include
paracetamol, Aspirin. Class C drugs can either be obtained from a drug shop or a
pharmacy.
Drug nomenclature: These are ways how drugs are named.
Generally one drug may have 3 different names at ago which include chemical
name, generic names and brand (trade) name..

7
Generic name: Generic nameis a name given to the drug by an approved
competent body for example world health organization. It is the recommended
name to be used in writing a prescription but because of the availability of many
drugs and heavy promotion by drug companies, some prescriptions come with
brand names.

Brand name: Brand name (Trade names) is the name given to the drug by a drug
manufacturing company. These names are usually shorter and easier to write and
remember. All brand names begin with a capital letter and have a symbol to
indicate a trade name.
Brand name (Trade names) is the name given to the drug by a drug manufacturing
company. These names are usually shorter and easier to write and remember. All
brand names begin with a capital letter and have a symbol to indicate a trade name.

Generic and brand names

Generic name Brand names

Paracetamol Panadol, Kamadol, Cetamol.
Amoxicillin Amoxil,Amoxapen,Penamox
Diclofenac Olfen,Voltaren,Diclomol,Dicloran
Ciprofloxacin Ladnini,Ciprobid,Bactiflax
Ergometrine Ergomin
Metformin Glucophage,Glyformin

Omeprazole –
Cefixime –
Metronidazole
Cefriaxone –
Acyclovir –

8
 Clotrimazole-
Drug storage
When drugs are not stored well, they lose their effectiveness. Therefore, a
midwife must understand how drugs are stored to avoid giving his or her
patients drugs that do not work.
Essential Drugs
Essential drugs, currently known as Essential medicines according to WHO
recommendations are those which satisfy the health needs of the majority of the
population. Examples of essential medicine include Amoxicillin, Benzathine
penicillin, Gentamycin, ceftriazone, quinine, Artemether/Lumefantrin, Artemether
among others.

1.5 Drug administration

This is the process of giving a drug to the patient in order to have a therapeutic
effect. Drugs can be administered to a patient in a variety of ways namely:-
i. Enteral route (oral)
ii. Parenteral route

i. Enteral route
Enteral route also called oral route means that the drug reaches the site of action
through the mouth. Drugs are administered using this route in form of capsules,
tablets, suspension, syrups or powders.
Absorption of oral drugs takes place in the stomach and small intestines
Advantages and disadvantages of oral route
Table 2: Advantages and disadvantages of oral route

Advantages Disadvantages
Most convenient and safe route of drug Oral drugs have a slow onset of action.
administration
Oral route doesn’t require skilled person Drug absorption is not predictable i.e.
can be delayed or affected by presence
of food in the GIT

9
 Some drugs can only be given by oral It is not suitable for patient in coma, or
route for example penicillin V those who are in vomiting.
In case of any mistake, the drug can be Some drugs such as insulin can be
retrieved by inducing vomiting destroyed by stomach acid therefore
cannot be given orally
Some drugs given orally have
unpleasant taste and cause irritation
Some medicines given orally in form of
syrups may harm children’s teeth

ii. Parenteral route

Parenteral medicines are administered into the body by use of a needle and a
syringe. It is the most commonly used route when fast onset of action is desired
and for those patients who are vomiting. Parenteral route is further divided into 3
namely:-
a. Intramuscular
b. Intravenous
c. Subcutaneous

a. Intramuscular injection
The drug is injected into the muscle especially of the thigh or buttocks. Absorption
of the drug may be rapid or slow depending on the blood supply to the site of
injection or water solubility of the drug.
Drugs commonly given by this route include Benzathine penicillin, procaine
penicillin or streptomycin. Intramuscular route is the preferred route for depot
injections.
Drug absorption from IM site may be increased by rubbing the site of injection.
Advantages and disadvantages of IM route
Table 3: Advantages and disadvantages of IM route

10
Advantages Disadvantages
Poorly soluble drugs may be given I M injection is painful
by this route
Drugs with depot effect can only be Care has to be taken not to inject IV
given by IM route only.
IM Injection is technically easier Introduction of infection to the site
than IV injection of injection is possible causing
abscess.

b. Intravenous injection
With IV Injection, the drug is injected directly into the blood stream via a vein.
Drugs commonly given by IV route include normal saline, quinine IV etc. It is the
preferred route when large volume of fluids are to be administered and for cases
where rapid onset of the drug is needed.

Advantages and disadvantages of IV injection

Advantages Disadvantages
IV injection may be used in It is expensive since it requires a lot
emergencies where rapid onset of of things for example giving set,
drug is needed. cannula before it is given
Large volumes of drugs may be Fluid overload may occur if the drug
given by this route. is given in large volumes.
Irritant drugs can be given by this Repeated injections may damage the
route. vein.
The amount of drug given IV route It requires a skilled person to give
can be controlled. drugs by IV route
There is no barrier to absorption
since the drug is introduced directly
into the blood stream

11
 c. Subcutaneous injection or route
Drugs are injected just beneath the skin especially around the thigh; abdomen and
upper aim drugs given by subcutaneous route include vaccines insulin etc.
Abbreviations used in drug administration
These abbreviations are categorized as follows
Abbreviations related to frequency of drug administration
OD Once daily
BID Twice daily
TDS 3Times daily
QID 4Times daily
PRN When necessary
Stat Immediately
Ac Before meals
Pc After meals

1) Abbreviations related o dosage form

Caps Capsules
Tabs Tablets
Syr Syrup
Gut Eye drops
Inf. Infusion
Pess. Pessaries
Mist Mixture
Iv Intravenous

12
Assessment question

1. Pharmacokinetics involves the following processes except.

A). Absorption B.) Metabolism C). Excretion D) side effects

2. Most of the drugs taken orally are metabolized in

A.) Liver B.) Kidney C) Lungs D) Intestines
3. The following drops belong to class except
A) Morphine B) Codéine C) Pethidine. D) Amoxicillin.
4. One of the advantages of intramuscular route is that
A) It is painless
B) It is not recommended for vomiting patients.
C.) Drugs with depot effect can be given by im Route.
D) Large amount of drug can be given by this route.
5 .The abbreviation TDS means
A) Four times daily B) Three times daily
C) Two times daily D) Once daily

6. Which one of the following names is a brands name?

A. Gentamycin B. Quinine C. Amoxil D. Diclofenac
7. Which one of the following is not a common source of drugs used in Uganda?
A. Plants C. Minerals
B.Animals D. Urine
8. Pharmacology is the study of
A. Drugs and their interaction with the living system

13
 B. Drugs and how they are stored.
C. Pharmacokinetics and teratogenicicity.
D. Pharmacokinetics and teratogenicity.
ESSENTIAL DRUG LIST FOR MIDWIVES IN A MATENITY CENTRE

Anaesthetics

Oxygen cylinder 2 cylinders

Lignocaine 2 % 2 X 30ml or
Analgesics

Tabs acetylsalicylic acid (ASA) 300mg 1000 tabs

Tabs ibuprofen 200 tabs
Tabs paracetamol 1000 tabs
Tabs Diclofenac 200 tabs
Narcotics

Morphine 10mg/ml IM 10 ampoules

Morphine oral solution 10mg/5ml 100mls
Pethidine/pethilorfan 50mh/ml IM 20 ampoules
Anti Allergy Medicine

Chlopheniramine tablet 4mg 1000 tabs

Epinephrine inj.1mg/ml 5 vials
Promethazine tablet 25mg 100 tabs
promethazine inj. 25mg/ml/IM 5 ampoules
Hydrocortisone inj.100mg/IV/IM 5 vials
Antidotes

Activated charcoal table 250mg 100 tabs

Calcium gluconate inj.10 % 5 ampoules
Anti-convulsants

Magnesium sulphate inj.500mg/ml 5 ampoules

14
50% IM(each ampoule-20ml )
Diazepam rectal tube 2mg/ml paed 5 tubes
cases only
Diazepam 5mg/ml IM/IV 10 ampoules
Carbamezapine tablet 200mg 500 tablets
Carbamezapine tablet 200 tabs
(chewable)100mg
Phenobarbitone tablet 30mg 200 tabs
Phenytoin tablet 50mg 200 tabs
Phenytoin tablet 100mg 200 tabs
Intestinal antihelmiths

Mebendazole tablet 500mg 1000 tabs

Mebendazole tablet 100mg 1000 tabs
Albendazole tablet 400mg 1000 tabs
Anti-bacterial medicine

Chloramphenicol inj.1G IM 5 vials

Chloramphenicol capsule 250mg 200 tabs
Ciprofloxacilin tablet 250mg 100 tabs
Cotrimoxazole tablet 480mg 200 tabs
Cotrimoxazole paed 120mg 100 tabs
Doxycycline tablet/capsule 100mg 100 tabs
Metronidazole tablet 200mg 200 tabs
Nitrofuradantoin tablet 100mg 200 tabs
Amoxyl tablet/capsule 250mg 200 tabs
Benzyl penicillin inj. IM 1,000,000 IU 50 vials
Benzathine penicillin inj.IM 2.4 MU 5 vials
Procainebenzylpenicilin fortified inj.IM 10 vials
4 MU
Ampicillin Inj 500mg 5 vials
Gentamicin Inj 40mg/ml 5 vials
Anti-fungal medicine

Nystatin pessary 100,000 IU 200 pessaries

Nystatin oral suspension 100,000 IU/ml 5 bottles

15
Nystatin oral tablet 500,000IU 1000tabs
Clotrimazole pessaries 500mg 50 pessaries
Clotrimazole cream 1% 10 cubes
Griseofulvin tab500 mg 200 tabs
Benzoic acid+ salicylic acid ointment 6 1 tin or 5 tubes
%+ 3 %
Anti- amoebic medicine

Metronidazole tab 200 mg 200 tabs

Anti-malarial medicine
Artemether inj. 80mg/ml 5 ampoules
Artemether+lumefantrine tablet 50 doses
20mg+120mg
Atesunate inj. 60mg/ml 5 vials
Artesunate supposity 200 suppositories
Sulfadoxin+pyrimethamine table 100 tabs
500mg+25mg
Quinine ionj. 300mg/ml IM 5 vials
Quinine table 300mg 200 tabs
Anti-anaemia medicine

Ferrous sulphate tablet 60mg 1000 tabs

Ferrous sulphate +folic acid tablet 1000 tabs
60mg+400ug
Folic acid tablet 5mg 1000 tabs
Ferrous solution 25mg/ml 10 bottles
Medicine used for bleeding disorders

Phytomenadione inj.10mg/ml IM (vit k) 5 ampoules

Phytomenadione inj. 1mg/ml IM (vit k) 10 ampoules
Anti-hypertensive medicine

Methylodopa tab 250mg 200 tabs

Nifedipine tablet 20mg 200 tabs
Other topical anti infective
Methylesanilium chloride (gentian 5 bottles each 10 mls
violate )
16
Aqueous paint 1 %
Potassium pamanganent solution 1 tin
Aqueous 0.01%
Benzyl benzoate lotion 25 % 5 bottles
Silver nitrate pencil 40% 1 stick
Clohexidine cream 5% 5 tubes
Clohexidine cutanous solution 2% 5 bottles
Silver sulfadiazine cream 10% 5 tubes
Anti-septic and disinfectants
Cetrimide+chlorexidine(hibitane ) 5 lit
solution
0.15%+0.015%
Hydrogen peroxide solution 6% ½ lit
Providone iodone solution ½ lit
Calcium or sodium hypochloride 5 lit
solution 5%(jik)
Anti-acids

Magnesium trisilcate co-tablet 370mg 1000 tab

Magnesium trisilcate suspension (60- 5 bottles
100ml)
Anti-emetics

Pro-chloperrazine tab 5mg 100 tab

Promethazine inj.25mg/ml 5 ampoules
Promethazine tablets 25mg 200 tabs
Laxatives

Bisacodyl tab 5mg 100 tabs

Medicines foe oral rehydration

ORS 50 pkts
Contraceptives

Ethinylestradiol 30ug+50ug 100 cycles

levonorgesterol

17
Ethinylestradiol 30ug+300ug 100 cycles
levonorgesterol
Ethinylestradiol 50ug+250ug 100 cycles
levonorgesterol
Ethinylestradiol 50ug+1mg 100 cycles
norethisterone
Levonorgestrel tablets 750ug 100 cycles
Jadelle(implants) 5 doses
Medroxyprogesterone acetate 10 vials
inj.150mg/ml
Copper T 380A 6
Condoms 1000 pcs
Vaccines

BGC vaccine inj.intradermal 20 dose 5 ampoules

vial
DPT-hepb +haemophilus influenza (20 50 vials
dose vial)
Measles vaccine (10 dose vial) 5 vials
Poliomyelitis vaccine(20 dose vial) 5 vials
TT vaccine (20 dose vial) 5 vials
Ophthalmological preparations

T.E.O 10 tubes
Oxytosics

Ergometrine meleate inj.500ug /ml 50 ampoules

Oxytocin inj.10IU/ML 50 ampoules
Misoprostal tablets 200ug 500 tablets
Psychotherapeutic medicine

Chlorpromazine inj.25mg 10 ampoules

Amitryptyline tablet 200 tabs
Diazepam tablets 5mg 200 tabs
Promethazine tablets 25mg 200 tabs
Promethazine inj.25mg/ml 5 ampoules
Anti-asthmatic drugs

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Adrenaline inj. 1mg/ml 5 ampoules
Aminophiline tablet 100mg 5 ampoules
Salbutamol tablet 4mg 50 tabs
Hydrocortisone succinate 100mg 5 ampoules
Cough soothing preparations

Simple linctus syrup (BNF formula) 5 bottles

Parenterals

Darrow’s solution infusion ½ strength in 5 bottles

5% glucose
Glucose infusion 5% () 10 bottle
Glucose infusion 50% 1 bottle
Sodium chloride infusion 0.9% (normal 10 bottles
saline)
Ringers lactate 10 bottles
Miscellaneous

water for inj. 2 ml 50ml

Water for inj. 5 ml 50ml
Water for inj.10 ml 10ml
Vitamins and minerals

Calcium lactate 300mg 100 tab

Retinol (vit A) capsule (drops) 50,000IU 500caps
Retinol (vit A) capsule (drops) 500 caps
100,000IU
Retinal (vit A) capsule (drops) 500caps
200,000IU
Multivitamin tablet BPC 73 1000 tabs
Pyridoxine (vit B) tablet 50 mg 200 tabs

DRUGS USED IN TREATMENT OF OBSTETRIC AND

19
 GYNAECOLOGICAL DISORDERS

Drugs used in the treatment of menstrual disorders

Menstruation is vaginal bleeding that occurs monthly in adolescent girls and pre-
menopausal women. Most menstrual periods last between 3-5 days though up to 7
days would also be considered normal.
Menstrual disorders include Dysmenorrhea, abnormal uterine bleeding, menorrhea
and menorrhohagia.
Dysmenorrhoea
Dysemenorrhoea is pain that occur during menstruation. Patients with
dysmenorrhoea usually complain of cramping abdominal pain, headache, nausea
and vomiting, diarrhea, lower back pain, loss of appetite.
It may be classified as either primary or secondary dysemenorrhoea.
Primary dysemenorrhoea
Primary dysmenorrhoea is painful menstruations that occur when a girl has just
started menstruating at the age of 11-12 years.
The pain occurs as a result of contractions of the uterine muscles due to over
production of prostaglandins (a substance responsible for pain and inflammation).
There is no direct cause of this type of dysmenorrhoea.
Secondary dysemenorrhoea
These are painful menstruations that develop later in life as a result of medical or
physical conditions such as endometriosis, pelvic inflammatory disease or uterine
fibroids.
Management of dysmenorrhoea
Drugs used in the treatment of dysmenorrhoae include

1. non steroid anti inflammatory drugs (NSAIDS) e.g.

 Mefenamic acid
 Ibuprofen
 Piroxicam
 Diclofenac
 Indomethacin

20
  Naproxen e.t.c

IBUPRO
FN

Non-steroidal anti-inflammatory drug

(NSAID) used to reduce fever and relieve pain

Dosage forms
Enteric coated tablet: 200 mg

Indications

 Mild to moderate pain

 Painful menstruation
 Headache
 Acute migraine attack
 Pain due to rheumatic disease
 Muscle and joint pain
 Fever

Dose and duration

All uses

Adult: 200–400 mg every 6–8 hours

Child 8–12 years: 200 mg every 6–8 hours
Child 3–7 years: 100 mg every 6–8 hours
Child 1–2 years: 50 mg every 6–8 hours
Child 3 months–1 year: 20–40 mg/kg daily in
divided doses
Taken when necessary. Avoid prolonged use

Contra-indications

 Allergy to NSAIDs
 Asthma
 Rhinitis
 Angioedema
21
  Blood coagulation disorders
 Severe liver disease
 Severe kidney disease
 Heart failure
 Severe malnutrition
 Uncorrected dehydration
 Shock
 Severe infection

Side effects
 Stomach upset, peptic ulcer
 Allergic reactions
 Dizziness

INDOMETHACIN

Non-steroidal anti-inflammatory drug

Dosage forms
Capsule: 25 mg

INDICATIONS
 Pyogenic (septic) arthritis
 Rheumatoid arthritis
 Gout arthritis
 Osteoarthritis
 Osteomyelitis
 Nociceptive or somatic pain
 Dysmenorrhoea

Dose and duration

 All uses

Adult: 50–200 mg daily in 2–3 divided doses (maxi-mum

dose in dysmenorrhoea, 75 mg in 2–3 divided doses a day)
Child 1 month–18 years: 0.5–1 mg/kg every 12 hours

22
Contra-indications
 Hypersensitivity to aspirin or other NSAIDs
 History of or active peptic ulcer disease
 Nasal polyps associated with angioneurotic oedema
 Coagulation defects
 Severe heart failure

Side effects
 Headache,
 dizziness,
 depression,
 vertigo, fatigue
 Nausea,
 anorexia,
 vomiting,
 epigastric distress,
 abdominal pain,
 constipation,

NB. NSAIDS should be taken preferably 2 days before the

anticipated date of menstruation since they work by
preventing formation of prostaglandin which is responsible
for pain

2. Oral contraceptives:
Patients who fail to respond to NSAIDS may be given progesterone
(norethisterone)

23
9.4 Drugs used in the treatment of infertility
Infertility is defined as the failure to conceive after one year of frequent
unprotected sexual intercourse.
Infertility may be as a result of either partner i.e. husband or wife.
The causes of infertility include:
 Failure of ovulation in female
 Low sperm count /quality in men
 Tubal damage
 Endometriosis
 Unknown cause

Treatment of infertility
Drugs used in the treatment of infertility include

 Clomiphene
 Bromocriptine in case of hyperprolactinaemia
 Tamoxifen

Drugs used in treatment of infertility, clinical uses and contraindications

CLOMIFENE

Anti-oestrogen ovulation inducer which

induces gonodotrophin release by occupying
oestrogen receptors in the hypo-thalamus

Dosage forms : Tablet: 50 mg

INDICATIONS
Female infertility due to disturbances in
ovulation

Dose and duration

Female infertility due to disturbances in
ovulation

Adult: 50 mg once daily for 5 days starting

within 5 days of onset of menstruation
24
preferably on the 2nd day. May be started at
any time if menstruation cycles have ceased
In the absence of ovulation, a second course of
100 mg

Contra-indications
 Hepatic disease or history of hepatic dysfunction
 Ovarian cysts
 Hormone dependent tumours
 Uterine bleeding of undetermined cause
Side effects
 Visual disturbances
 Ovarian hyper stimulation, hot flushes,
breast tenderness, menstrual spotting,
 menorrhagia, endometriosis
 Abdominal discomfort, nausea and
vomiting
 Depression, insomnia, dizziness,
headache, convulsions
 Weight gain
 Rash
 Hair loss

BROMOCRIPTINE
Ergot derived dopamine receptor agonist which
also inhibits release of prolactin and growth
hormone by the pituitary

Dosage forms :Tablet: 2.5 mg

INDICATIONS
 Parkinson’s disease
 Galactorrhoea
 Prolactinoma
 Acromegaly
 Hypogonadism
 Menstrual cycle disorders and female
infertility
 Suppression or prevention of lactation

25
 Dose and duration
Parkinson’s disease

Adult: 1–1.25 mg at night in the 1st week, 2–

2.5 mg at night in the 2nd week, 2.5 mg every
12 hours for the 3rd week, 2.5 mg every 8
hours for the 4th week, then in-creasing by
2.5mg every 3–14 days according to response
to a usual range of 10–30 mg daily

Prevention or suppression of lactation

Adult: 2.5 mg on the day of delivery

(prevention)or 2.5 mg once a day for 2–3 days
(suppression);
Then 2.5 mg every 12 hours for 14 days

Drugs used in the treatment of disorders during pregnancy

There several disorders during pregnancy however in this sub section, we shall
look at the following.
 Hypertension
 Preterm labor

Hypertension in pregnancy
Hypertension is defined as persistent elevation of blood pressure above
140/90mmHg.
Hypertension in pregnancy may be classified as follows:
 Gestation hypertension
 Chronic hypertension
 Pre – eclampsia

Gestation hypertension
It is defined as blood pressure elevation that occurs during pregnancy without
proteinuria.

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Chronic hypertension
This type of hypertension presents before pregnancy or diagnosed before 20 th week
of gestation.
Pre-eclampsia
It refers to an increase in blood pressure associated with proteinuria occurring
usually after 20 weeks gestation in a previously normotensive woman.
Drugs commonly used in the treatment of hypertension during pregnancy are listed
in the table below.
MAGNESIUM SULPHATE

Anticonvulsant
Dosage forms

Solution for injection: 500 mg/ml (50%)

INDICATION
 Eclampsia in pregnancy
 Prevention of eclampsia (severe pre-
eclampsia)
 Hypomagnesaemia

Preparation
Dilute 4 g (8 ml) to make up to a total
volume of 20 ml with water for injection
Dilute solution with normal saline or
dextrose 5% to 20% w/v for IM injection or
to 20% or less for IV administration

Adult: by IM injection, 1 g every 6 hours for

4 doses in mild hypomagnesaemia (In severe
cases, 5 g by IV infu
Contra-indications
Severe kidney disease
Side effects

 Pain at injection site

 Warm flushes

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  Nausea, vomiting
 Thirst
 High blood
magnesium levels

9.6 Drugs used in management of pre-term labor

Pre-term labor is the presence of contractions of sufficient strength and frequency
to effect dilation of the cervix before 37 completed weeks of gestation.
Risk factors associated with pre-term labor include:
 Incompetent cervix
 Uterine abnormalities
 Bacterial vaginosis
 Maternal diseases
 Over distended uterus
 Fetal death
.
Drugs used in the management of pre -term labor include tocolytics,
corticosteroids and antibiotics in case of infections.
Tocolytics
Tocoytics also known as uterine relaxants are used to delay or prevent pre-term
labor. They are used to delay labor for at least 2 days in order to transfer the
mother to the hospital with neonatal special care unit or to administer
corticosteroids in order to mature fetal lungs. These drugs include Salbutamol,
Nifedipine and magnesium sulphate.
Nifedipine is currently the preferred tocolytic due to fewer side effects compared
to magnesium sulphate and sulbutamol.

Corticosteroids
Corticosteroids are used in pre-term labor to mature the lungs of the fetus and
decrease respiratory distress syndrome. The most commonly used corticosteroids
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include dexamethasone injection given 6mg twice daily for 2 days or
betamethasone injection.
Drugs used during labor
Labor is a natural process which involves the contraction of the uterus and the
opening of the cervix. Drugs used during labor can either induce labor or augment
ongoing labor contractions.
Oxytocics
These are drugs which stimulate contractions of the uterine muscles. They include
oxytocin, Ergometrine, misoprostol and dinoprostone.
Oxytocin (pitocin, syntocinon)
Oxytocin is a natural hormone that promotes uterine contraction during parturition.
The sensitivity of oxytocin on the uterus increases towards the end of gestation. It
stimulates both the frequency and strength of uterine contractions.
Clinical uses
 induction and argumentation of labor
 post partum uterine haemorrhage

Dose and duration

Induction of labour

− Initially, dissolve 2.5 IU in 500 ml of normal saline and infuse at 10 drops per
minute
− Then, increase infusion rate by 10 drops per minute every 30 minutes until a
good contraction pattern is reached (3–4 contractions every 10 minutes, each last-
ing >40 seconds). Maintain this rate until delivery is completed
− Maximum infusion rate is 60 drops per minute

If good contraction pattern is not established at a rate of 60 drops per minute:

− Increase oxytocin concentration to 5 IU in 500 ml of normal saline and adjust
infusion rate to 30 drops per minute
− Then, increase infusion rate by 10 drops per minute every 30 minutes until a
good contraction pattern is reached; maximum 60 drops per minute

Contraindications
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Oxytocin is not recommended in the following cases.
 Fetal malpresentation
 Previous uterine surgery
 Fetal distress
 Hypertonic uterine contractions
 Mechanical obstruction to delivery
 Foetal distress
 Conditions where spontaneous labour or vaginal delivery is not
recommended
 Severe eclampsia
 Severe heart disease
 Foetus with big head

Side effects
Oxytocin is associated with the following side effects.
 Hypotension
 Hypertension
 Nausea and vomiting
 Reflex tachycardia
 Fetal distress

Ergometrine (ergonovine)

Available in injection 0.2mg/mL and tablet form of 0.2mg.

Ergometrine directly stimulates uterine contractions but in high doses, it produces
severe contractions which make it unsuitable for induction of labor
Clinical uses of ergometrine
 Post partum haemorrhage
 Uterine firmness

Contraindications

 Hypertension (severe)
 Pregnancy
 Known hypersensivity to Ergometrine
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  Induction of labor
 Severe kidney diseases
 Severe deep vein thrombosis
 First and second stage of labor

Side effects
 Nausea and vomiting
 Diarrhoea
 Hypertension

Misoprostol (Cytotec)
Available in tablet form of 100mcg.
Misoprostol is a synthetic prostaglandin derivative which was initially used for
prevention of peptic ulcer due to chronic use of NSAIDS use.
Clinical uses
 Induction of active labor
 Cervical softening and dilation before labor
 Evacuation of uterine contents
 Postpartum haemorrhage

Dose and duration

Incomplete abortion
600mcg swallowed orally or 400mcg sublingually
Excessive bleeding after childbirth
800mcg (4 tablets) sublingually or 1000 mcg (5 tablets) rectally
Induction of labour
25 mcg inserted vaginally every 6 hours. If no response after 2 doses of 25 mcg,
insert 50mcg every 6 hours. Do not use more than 200mc mcg in 24 hours

Side effects
 Nausea and vomiting
 Abdominal pain
 Diarrhoea
 Fever
 Low blood pleasure

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  Fetal distress

Contraindications
Misoprostol is not recommended in the following cases;
 Acute pelvic inflammatory disease,
 Active heart disease,
 Active liver disease, fetal distress
 Mechanical obstruction of delivery.

Dinoprostone (E2)
Available as a vaginal suppository 20mg,3mg
Dinoprostone is a prostaglandin derivative that stimulates uterine contraction and
has a role in cervical softening and dilation (cervical ripening)
Clinical uses
 Induction of labor
 Cervical softening before labor.
 Evacuation of uterine contents

Contraindications
Dinoprostone is not recommended in’;
 mechanical obstruction of delivery,
 active liver and heart disease
 Fetal distress.
 Hepatic diseases
 Pulmonary diseases
 Multiple pregnancies
 Ruptured membranes
Dose
Induction of labor: 3mg inserted high into posterior fonix following after 6-8
hrs by 3mg if labor is not established.
Max. 6mg

Side effects
The use of dinoprostone is associated with;
 nausea and vomiting,

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  abdominal pain
 Diarrhoea.
 Shivering
 Flushing
 Fetal distress
 Bronchospasms

Drugs used to delay premature labor

Premature labour is the one that starts before the expected date resulting into
delivery of an immature infant
Risk factors for premature labor include
 Infections
 Premature rapture of membranes
 Cervical incompetence
 Multiple pregnancy long distances traveling while pregnant
 Polyhydramnious

Ways of preventing premature labor

 Cervical cerclage (for cervical incompetence)
 Treatment of infection
 Postpone delivery by use of drugs (tocolysis)

Uterine stimulants
These are drugs that inhibit uterine motility by decreasing the frequency and
strength of contraction
These include;

 Salbutamol
 Nifedipine
 Magnesium sulphate
Note:
Delay in premature labor is likely to succeed if only the cervical dilatation is less
than 4 cm
Tocolysis is rarely necessary after 34 weeks of gestation

Delay in premature labor should not be performed in the following cases

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  Toxemia of pregnancy
 Fetal death
 Intra uterine infection
 When the membranes have ruptured
 Antepartum hhemorrhage

SALBUTAMOL
Available preparation: Tablet 4mg
Solution for injection 50mcg/ml
Available brands: ventolin

Indications
 Uncomplicated premature labor between 24-34 weeksgestation
 Asthma
Contraindication
 Cardiac disease
 APH
 Intrauterine infection
 IUFD
 Cord compression
 Eclampsia and pre-eclampsia
 First and second trimester of pregnancy
 Rapture of membrane
Dose:
Premature labor
By intravenous infusion:initially 10mcg/minute gradually decreased according to
the response at 10 minute intervals until contractions diminish,then increase rate
until contractions have ceased,max 45mcg/min
Maintain rate for 1 hr then gradually reduce
NB. Don’t use for more than 48 hrs
Side effects
 Hypokalemia
 Vomiting sweating
 Hypotension
 Tremors
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  palpitation
 Headache
 nausea
 Flushing
 Uticaria

NIFEDIPINE
Available preparation: Tablet 10mg, 20mg

Indications
Threatened or establish pre-term labor (less than 34 weeks of gestation)
Contraindication
 Maternal conditions: hypotension, cardiac disease
 Any condition that would make prolongation of pregnancy hazardous
 Fetal death
 Intrauterine infection
Dose:
Initiallyconventiontablet 20mg, repeatthe dose after 30min if uterine contractions
persist
Crush or chew the first 2 doses to increase the rate of absorption
If contractions continue after 3 hrs, give 20mg every 2-3 hrs until contractions
cease,max 160mg per day
Side effects
 Dizziness
 Headache
 Flushing
 Odem of the ankle
 Fatigue

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