Transcript Pharmacotherapy in obstetrics. Medical ethics and deontology

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
A------------------------------B------------------------------
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 welldesigned 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
 C
DESCRIPTION
 No adequate studies in animals or people have been done.
 Or In animal studies, use of the drug resulted in harm to the

 D


 X

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)
+
500µg 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) +
500µg 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
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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 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- 5-20 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 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 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-induced contractions
& 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 12- 34 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: 250-500mgx TDS D1-3 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
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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 lifethreatening 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 logosTeaching) examines moral
 Medical ethics is the
content of the actions and
theoretical basis of ethics.
behavior of medical
The latter is the practical
personnel in a particular
application of medical
situation.Deontology is
ethics in the daily practice
closely related to medical
of medical staff.
ethics, as well as issues of
health law, professional rules.
BIOETHICS
 Are there limits to medical care,
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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
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?
1.
3. What is the genetic risk of
using donor sperm for artificial
insemination?
Ethical issues of
artificial insemination
1.
2.
3.
4.
5.
6.
7.
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. 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 firstborn 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),
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 analgesicsв.
(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;
Also, in this group should
include a conscious awareness
hopelessly sick lethal dose of the
drug they received.
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 bedside
as possible.
THANK YOU