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

remedia persculis

(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

A-------------------------------

B------------------------------

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.

Or Studies in animals show a risk to the fetus, but well-designed studies in people do not.

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)OctapeptideStrong rhythmical contraction of

myometriumLarge 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

ErgometrineSustained myometrial contraction &

vasoconstrictionSyntometrine IM: 5U syntocinon(rhythmic contraction in

2min) + 500µg ergometrine(sustained

contraction in 7 min)Side effects – Nausea, vomiting,

abdominal pain, chest pain, palpitation, severe HTN , Stroke & MI

Contraindication- HTN, Cardiac diseaseClinical 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/gelClinical 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, bronchospasmAdvantages : - Mobile patient -Reduce need for syntocinon

Carboprost ( Hemabate)Sustained myometrial contraction &

vasoconstrictionSyntometrine IM: 5U syntocinon(rhythmic contraction in

2min) + 500µg ergometrine(sustained contraction in

7 min)Side effects – Nausea, vomiting, abdominal

pain, chest pain, palpitation, severe HTN , Stroke & MI

Contraindication- HTN, Cardiac diseaseClinical 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 antagonistInhibition 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 tocolyticsSalbutamol inhaler- 100 mcg x 2 puffs statTerbutaline- 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

NifedipineCalcium Channel blocker

Clinical use: Mild to moderate- 5-20 mg TDS/POSevere 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/PETMethyldopa: -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

Severe Pre eclampsia / HTN

IV Labetolol (ß blocker): - Side effects: headache, nausea, vomiting, postural hypotension & liver damage - Contraindication: Asthma, marked bradycardiaIV 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 SulphateClinical 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 pregnancyMifepristone- 200mg POMechanism: Antiprogestogenic steroid Sensitizes myometrium to prostaglandin-induced contractions & ripens the cervixClinical use: Medical termination of pregnancy Medical management of miscarriage/IUDSide effects: Gastro intestinal cramps, rash, urticaria,

headache,dizziness,Contraindication: severe asthma

MisoprostolSynthetic prostaglandinPO/PV routeClinical 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/PVSide effects: nausea,vomiting,

diarrhoea, abdominal pain

MethotrexateCinical use: Medical management

of ectopic pregnancyDose 50mg per kg/m2Criteria- adenexal mass, non viable

pregnancy hCG< 3000U, haemoperitonuem < 150ml

Side effects: Disadvantage : repeated hCG

levels, emergency surgeryAdvantage: Avoid surgery, tube

preserved

Menorrhagia / dysmenorrheaMefenamic acid: - NSAID, reduces bleeding by 25% - Dose: 250-500mgx TDS D1-3 of cycle or PRN - Side effects: Gastro-intestinal discomfort

nausea, diarrhoea, bleeding/ulcerationTranexamic 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

ProgestogensProgesterone 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 pregnancy

involves 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 22-24 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 deontologyMedical 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?

«Многих воителей стоит один врачеватель искусный»

Гомер

"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

1. 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?

2. 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

1. Artificial insemination is an unmarried woman2. Artificial insemination is a married woman without her

husband3. Artificial insemination with the husband's consent and

with the use of donor genetic material4. Homogenous conception (fertilization with sperm of her

husband).5. Method of artificial fertilization in vitro with the

destruction of the "extra" embryos6. Modification fertilization using a single egg or with all the

resulting embryo in the womb. “7. Egg Donation and fertilized embryos8. All varieties of

surrogacy.

Problems of surrogate motherhood

1. и т.д.

4. Instills fear psychological adaptation of the child when he learns of his birth, in communication with the surrogate mother

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.

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

52-year-old Sebir living in Côte 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 as close to the bedside bedside

as possible.as possible.

THANK YOU