Pharmacotherapy in obstetrics. Medical ethics and
deontology
Pharmacotherapy in obstetrics.Medical ethics and
deontology.Pharmacokinetics and pharmacodinamicsof drugs. By Korda
I. TREATMENT OF THE PREGNANT WOMAN MEANS THAT ONE IS CARING FOR TWO
PATIENTS, NOT ONE The use of drugs during pregnancy
graviora quadem sunt remediapersculis (some drugs worse than the
disease - Lat.) Drugs may be divided into three groups:
Do not cross the placenta, and therefore does not cause direct harm
to the fetus; cross the placenta, but no adverse effects on the
fetus; cross the placenta and accumulate in fetal tissues, also has
a damaging effect. Categories of Risk for Drugs During
Pregnancy
CATEGORY DESCRIPTION These drugs are the safest. Well-designed
studies in people show no risks to the fetus. Studies in animals
show no risk to the fetus, and no well-designed studies in people
have been done. OrStudies in animals show a risk to the fetus, but
well-designed studies in people do not. A B Categories of Risk for
Drugs During Pregnancy
CATEGORY DESCRIPTION C D X No adequate studies in animals or people
have been done. Or In animal studies, use of the drug resulted in
harm to the fetus, but no information about how the drug affects
the human fetus is available. Evidence shows a risk to the human
fetus, but benefits of the drug may outweigh risks in certain
situations. For example, the mother may have a life-threatening
disorder or a serious disorder that cannot be treated with safer
drugs. Risk to the fetus has been proved to outweigh any possible
benefit. 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 Ergometrine
Sustained myometrial contraction & vasoconstriction
Syntometrine IM: 5U syntocinon(rhythmic contraction in 2min) + 500g
ergometrine(sustained contraction in 7 min) Side effects Nausea,
vomiting, abdominal pain, chest pain, palpitation, severe HTN ,
Stroke & MI Contraindication- HTN, Cardiac disease Clinical
use: - Management of 3rd stage -Management of PPH -2nd dose give.
Alternatively IV ergometrine can be given (works with in 40 sec)
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)
Sustained myometrial contraction & vasoconstriction
Syntometrine IM: 5U syntocinon(rhythmic contraction in 2min) + 500g
ergometrine(sustained contraction in 7 min) Side effects Nausea,
vomiting, abdominal pain, chest pain, palpitation, severe HTN ,
Stroke & MI Contraindication- HTN, Cardiac disease Clinical
use: - Management of 3rd stage -Management of PPH -2nd dose give.
Alternatively IV ergometrine can be given (works with in 40 sec)
Atosiban(Tractocile)
Oxytocin receptor antagonist Inhibition of uncomplicated preterm
labour between 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 Nifedipine Calcium Channel blocker
Clinical use:
Mild to moderate 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 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 mg
BD/TDS PO max 2.4g/24hr ACE inhibitors are contraindicated in
pregnancy 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 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
Drugs in early pregnancy
Mifepristone- 200mg PO Mechanism: Antiprogestogenic steroid
Sensitizes myometrium to prostaglandin-inducedcontractions &
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 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: mgx
TDSD1-3 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
Progesterone is a hormone that naturally occurs in the human body.
Vaginally dosed progesterone is being investigated as potentially
beneficial in preventing preterm birth in women at risk for preterm
birth. ART Women with previous preterm labours -cyclogest pessary
200mg PV/PR daily till 36 weeks Following IVF/ICSI- Gestone inj +
cyclogest pessary periods of pregnancy, when the fetus is most
susceptible to the damaging effects of drugs:
1Up to 11 days from the moment of conception. 2. On the 11th day
prior to the third week, when the fetus begins the period of
organogenesis. 3. Between 4 and 9 weeks of when the danger of fetal
growth retardation, but teratogenic practically does not occur. 4.
The fetal period (9th week before birth). In this period, the
growth of structural defects usually do not occur, but may be in
breach of postnatal functions and various behavioral abnormalities.
Efficient, effective and safe use of drugs during pregnancyinvolves
the following conditions:
prescribe only established the security of their applications, with
well-known pathways of metabolism in order to avoid possible side
effects; due to the impossibility of determining the period of
final completion of embryogenesis (in the absence of urgent and
uncontested evidence) it is appropriate to postpone the use of
drugs to weeks of pregnancy; in the course of treatment requires
careful monitoring of the mother and the fetus. Drugs, the use of
which is contraindicated in any period of pregnancy
Antibacterials: tetracycline antibiotics - violate the bone
formation in the fetus and have hepatotoxicity; chloramphenicol
(chloramphenicol) - because of the risk of suppression of bone
marrow function and the possibility of life-threatening so-called
"gray baby syndrome"; fluoroquinolones - have a damaging effect on
the cartilage between interarticular growth of the fetus and
newborn; co-trimoxazole (biseptol and its analogues) -
significantly increase the risk of congenital anomalies of the
fetus; rifampicin, lincomycin, ethionamide, chloroquine (delagil),
griseofulvin, levorin Drugs, the use of which is contraindicated in
any period of pregnancy
Other drugs: All statins (lovastatin, simvastatin, Mevacor, Zocor);
indirect anticoagulants (fenilin, pelentan); Many antihistamines
(diphenhydramine, pipolfen, suprastin); oral hypoglycemic agents;
antigonadotropnym drugs (danazol, Clomid); androgens; Many
antidepressants, barbiturates, antipsychotics (haloperidol,
teralen, tizertsin); benzodiazepines; antiparkinsonian agents
(parkopan, cyclodol, NAC); Non-steroidal anti-inflammatory drugs
(meloxicam, phenylbutazone). Based on the above, the physician of
any specialty, choosing drug therapy of women of reproductive age,
must first make sure there is no pregnancy, the patient!!! Medical
ethics and deontology
Ethics - a philosophical discipline that studies the moral,
morality. Medical ethics - the study of moral principles in the
work of medical staff. The subject of her research is the
psycho-emotional aspect of the doctor, nurse, technician, junior
staff. In addition, the range of issues of medical ethics and the
problems are, the successful solution of which the life and health
of not only the living, but also future generations. Feature in the
development of medical ethics is the fact that it, unlike the right
to form and exist as a set of unwritten rules. Medical ethics and
deontology
Medical deontology together should consider the ethical norms and
regulations for health care providers in a professional activity in
the hospital and beyond.Deontology (from Greek deon - duty and
logos-Teaching) examines moral content of the actions and behavior
of medical personnel in a particular situation.Deontology is
closely related to medical ethics, as well as issues of health law,
professional rules. Medical ethics is the theoretical basis of
ethics. The latter is the practical application of medical ethics
in the daily practice of medical staff. BIOETHICS Are there limits
to medical care, and what they have in sustaining life terminally
ill person? Whether euthanasia is acceptable? At what point should
count of death? When does the fetus can be considered a living
person? Permissible at abortion? . , . , , ( - , ..) , , , ,
.
"When the embryo is considered a person?for performing the abortion
destruction of "spare" embryos without violating the commandment Do
not kill." Medicine is truly the most prudent of all the arts.
Hippocrates
The extent to which pregnancy occurred in infertile women,
contributeincrease the genetic load in the population due to the
birth of children with congenital disorders? What is the influence
of drugs, long used to treat infertility (especially hormones) on
the fetus? 3. What is the genetic risk of using donor sperm for
artificial insemination? Ethical issues of artificial
insemination
Artificial insemination is an unmarried woman Artificial
insemination is a married woman without her husband Artificial
insemination with the husband's consent and with the use of donor
genetic material Homogenous conception (fertilization with sperm of
her husband). Method of artificial fertilization in vitro with the
destruction of the "extra" embryos Modification fertilization using
a single egg or with all the resulting embryo in the womb. Egg
Donation and fertilized embryos8. All varieties of surrogacy.
Problems of surrogate motherhood
1. Children transformed into a commodity, and motherhood - in
contract work, paid secured childless couples. Health security of
the child and the surrogate mother are secondary to the material
gain. 2. Surrogate mother mentally traumatized need to "give" her
unborn child. 3 A child may inherit genetic defects of a surrogate
mother, some of which can not be detected by modern methods. 1. ..
4. Instills fear psychological adaptation of the child when he
learns of his birth, in communication with the surrogate mother The
desire to have grandchildren prompted 42-year-old Miss Evans to
seek permission for preservation of sperm of her dead son. Nikolas
Colton Evans was killed while trying to stop a fight in a bar.
Despite the fact that the mission has another son - 22-year-old
Ryan, who could easily make happy mother of his grandchildren, a
woman seeking a surrogate mother for gestation of her first-born
son. Euthanasia. The term "euthanasia" comes from the Greek words
"evos" - good" and thanatos-Death", literally meaning "good" death.
the act or practice of killing or permitting the death of
hopelessly sick or injured individuals (as persons or domestic
animals) in a relatively painless way for reasons of mercy
Classification of euthanasia.
Medical decision concerning end of life (MDEL), (Phisician assisted
sucide - PAS), when the doctor prepares a deadly drug that enters
the patient himself. Actually euthanasia - cases of active
participation of a physician in the patient's death. in fact,
produced the doctor killing the patient with the informed consent
of the latter; Cases where the physician's role is reduced to a
consistent rejection of the patient appointments, allowing to
extend the life of the patient, or to the implementation of the
actions and / or increase the dose to relieve the suffering
medications (such as pain medication or sleeping pills), resulting
in the patient's life is reduced. Basically - is welcome opioid
analgesics. Also, in this group should include a conscious
awareness hopelessly sick lethal dose of the drug they received.
52-year-old Sebir living in Cte d'Or in central France for eight
years has suffered from an incurable tumor nasal cavity, which is
strongly deformed her face and caused unbearable suffering, and
requested euthanasia. Chantal Sebir did not wait euthanasia. French
woman was found dead at his home. Story of a woman caused a great
resonance in France, resumed debate on the resolution of
euthanasia. The principle of informed consent.
Key elements of this process: the provision of information
obtaining consent Doctor s are obliged to inform the patient: the
nature and purpose of the proposed treatment of him; of the
associated significant risk; on possible alternatives to this kind
of treatment . Resolve conflicts . . . as close to the bedside as
possible. THANK YOU