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1

What should we treat spontaneous abortion with?

Misoprostol (Cytotec)

2

SPONTANEOUS ABORTION: Products of conception are evacuated in 3 ways?

1. Surgical
Unstable, significant bleeding, infection or want immediate treatment

2. Medical
Those who do not want to wait for spontaneous passage

3. Expectant
Will eventually pass naturally (days to weeks)

3

MISOPROSTOL IS THE MAIN DRUG FOR MEDICAL MANAGEMENT
1. MOA?
2. For which type of abortions? 2
3. Off label use? 2

1. Prostaglandin E1 analog and induces uterine contractions
2.
-For missed abortion
-For incomplete abortion

3. Unlabeled uses
-Cervical ripening (intravaginally)
-Treatment of post partum hemorrhage


4

PRETERM LABOR
What drugs should we use? 2

1. Tocolytics
2. Corticosteroids

5

GOALS OF TOCOLYTICS
3

1. Delay delivery by at least 48 hours to allow the administration of corticosteroids for fetal lung maturity

2. Provide time for transport of the mother to a higher level of care

3. Stop labor to allow the underlying medical condition that stimulated labor to clear

6

BENEFITS OF TOCOLYTICS NEED TO OUTWEIGH THE RISKS
1. Used on what timeline?
2. Contraindications? (main one?)
9

1. Generally not used past 34 weeks of gestation and controversial use any earlier than 22 weeks

2.
-Contraindicated when the baby or the mother are unstable**
Review of contraindications
-Fetal demise,
-lethal fetal anomaly,
-nonreassuring fetal status,
-severe preeclampsia or
-eclampsia,
-maternal hemorrhage,
-intraamniotic infection,
-maternal contraindication to the tocolytic drug

7

WHAT IS THE DOC AT 24-32 WEEKS GESTATION for preterm labor?

INDOMETHACIN

8

INDOMETHACIN
1. MOA?
2. Maternal SE? 5

1. Decreases prostaglandin production through inhibition of cyclooxygenase

Maternal side effects
1. Nausea,
2. GE reflux,
3. gastritis,
4. emesis
5. Platelet dysfunction

9

1. FETAL SIDE EFFECTS OF INDOMETHACIN

2. Neonatal complications associated with use? 5

1.
-Constriction of ductus arteriosus
-Oligohydramnios

2.
-Bronchopulmonary dysplasia,
-necrotizing enterocolitis,
-PDA,
-periventricular leukomalacia,
-intraventricular hemorrhage
Data is conflicting

10

INDOMETHACIN
1. Constriction of ductus arteriosus if drug is given when?
2. More likely to occur in what gestational week?

3. What is Oligohydramnios?

1. If drug given > 48 hrs
2. More likely to occur past 32 weeks

3. Drug decreases fetal urine output therefore decreasing amniotic fluid volume

11

INDOMETHACIN
1. Maternal contraindications? 6

2. Monitoring: If given > 48 hours then need what?

1. Maternal contraindications
-Platelet dysfunction
-Bleeding disorders
-Hepatic dysfunction
-GI ulcers
-Renal dysfunction
-Asthma if also sensitive to ASA


2. fetal US to evaluate for oligohydramnios and narrowing of the ductus arteriosus

12

What is second line therapy for preterm labor?

NIFEDIPINE FOR SECOND LINE THERAPY

13

1. NIFEDIPINE MOA?
2. Associated with what?
3. Maternal SE? 6

1. Calcium channel blocker which results in myometrial relaxation and peripheral vasodilation

2. Associated with fewer maternal side effects compared to magnesium sulfate

3. Maternal side effects
-Nausea,
-flushing,
-headache,
-dizziness,
-palpitations
-Can cause severe hypotension

14

NIFEDIPINE
1. Contraindications? 4

2. Precaution? 1

1. Contraindications
-Hypotension,
-preload dependent cardiac lesion,
-use cautiously in LV dysfunction -CHF

2. Precaution
Do not use in conjunction with magnesium sulfate as they can act synergistically to suppress muscle contraction and result in respiratory depression

15

NIFEDIPINE PHARMACOKINETICS
1. Half life?
2. Peak plasma concentration?
3. Metabolized and excreted through what?

1. Half life 2-3 hours

2. Peak plasma concentrations in 30-60 minutes

3. Metabolized through the liver and excreted by the kidneys

16

32-34 WEEKS GESTATION (preterm labor)
1. DOC?
2. Second line?

3. Maternal SE? 8

1. Nifedipine is the DOC

2. Second line therapy is a Beta-adrenergic receptor agonist
-Terbutaline is the most commonly used in the US

3. Maternal side effects
-Tachycardia,
-palpitations,
-hypotension,
-tremor,
-shortness of breath,
-chest discomfort,
-hypokalemia,
-hyperglycemia

17

BETA ADRENERGIC RECEPTOR AGONISTS
-Contraindications? 3
-Do not use longer than what?

Contraindications
1. Tachycardia sensitive cardiac disease
2. Uncontrolled hyperthyroidism or DM
3. Use with caution in placenta previa or abruption due to risk of hypovolemia and shock

1. Do not use longer then 48-72 hours

18

MONITORING in preterm labor?
4

1. I/O’s
2. Maternal symptoms of shortness of breath, CP, tachycardia
3. Stop drug if maternal HR > 120
4. Check blood glucose and K+ every 4-6 hours

19

OTHER TOCOLYTICS
Third line treatment?

Magnesium sulfate

20

CORTICOSTEROIDS
Reduces the incidence of the following by 50%?
5

1. respiratory distress syndrome
2. intraventricular hemorrhage
3. necrotizing enterocolitis
4. sepsis
5. neonatal mortality

21

ANTENATAL CORTICOSTEROIDS
1. Used in which weeks?
2. Whats preferred?
3. Other option?

1. 23-34 weeks

2. Betamethasone (preferred)
12 mg IM q 24 hrs X 2

3. Dexamethasone (use non-sulfite containing suspension otherwise neurotoxicity of fetus)
6 mg IM q 12 hrs X 4

22

INDICATIONS FOR ABX PROPHYLAXIS for Group B strep
4

1. Positive rectovaginal culture

2. Positive history of birth of an infant with early onset GBS disease

3. GBS bacteriuria during current pregnancy

4. Unknown culture status AND
-Maternal fever ≥ 100.4 OR
-Preterm labor less than 37 weeks OR
-Prolonged rupture of the membranes ≥ 18 hours

23

GROUP B STREP
Don’t give abx prophylaxis for GBS positive patient undergoing what?

planned c-section unless their membranes rupture

24

ANTIBIOTIC REGIMEN
Group B Strep? 2

1. Penicillin G
5 million U IV then 2.3-3 million U q 4 hours until delivery

2. OR Ampicillin
2 g IV followed by 1g q 4 hours until delivery

25

ANTIBIOTIC REGIMEN
Group B Strep for PCN allergic pts:

1. Low risk for anaphylaxis?

2. High risk for anaphylaxis to PCN then use? 2

PCN allergic patients

1. Cephazolin (Ancef) 2g IV then 1g q 8 hours until delivery

2.
-Clindamycin (if known to be susceptible)
-OR Vancomycin 1g IV q 12 hours until delivery

26

PREMATURE RUPTURE OF THE MEMBRANES: ANTIBIOTIC PROPHYLAXIS
1. What may be the cause of the premature rupture? 2

2. Tx? 3

3. If PCN allergy? 3

1.
-Infection may be the cause of the premature labor or may be a
-consequence of premature rupture of the membranes

2.
-1g azithromycin on admission
-Followed by ampicillin 2 g IV q 6 hr X 48 hrs
-Followed by amoxicillin 875mg BID X 5 days

3. If PCN allergy
-Clindamycin 900 mg IV q 8 h X 48 h
-+ gentamycin 7 mg/kg IBW q 24 h X 2
-Followed by Clindamycin 300 mg q 8 h X 5 days

27

ADDITIONAL MEDICAL THERAPY: for premature membrane rupture?
2

1. Tocolytics are often given to delay delivery in the presence of uterine contractions

2. Corticosteroids may be indicated

28

POSTPARTUM HEMORRHAGE
Which drugs to use?
4

1. Oxytocin
2. Misoprostol
3. Carboprost tromethamine
4. Methylergonovine maleate

29

POST PARTUM HEMORRHAGE UTEROTONIC DRUGS
1. DOC?
2. Then add? 3

1. Oxytocin is the uterotonic DOC
2.
-Add Misoprostol
-Add Methylergonovine
-Add Carboprost tromethamine (Hemabate

30

POST PARTUM HEMORRHAGE UTEROTONIC DRUGS

OXYTOCIN
1. Administered how?
2. If already on an infusion do what?

3. If no IV access do what?

1. 40 U in 1 L saline infuse at 10-40 ml/min
2. increase the dose
3. give 10 U IM