OB Drugs: Clomiphene (Clomid)

OB Drugs: Clomiphene (Clomid)

• Primarily used to treat infertility as a hazardous drug.
• It blocks estrogen receptors in the hypothalamus and pituitary gland.
• This causes an increase in the release of LH and FSH.
• LH and FSH act on the ovaries to promote follicular maturation.
• Clomiphene increases the menstrual cycle to increase ovulation.
• Promotes follicular maturation and ovulation in infertile patients who have functional pituitary glands and ovaries.
• It exclusively works if the pituitary gland produces FSH and LH and if the ovaries respond to them.
• Adverse effects include hot flashes, abdominal discomfort, breast enlargement, and visual disturbances.
• Visual disturbances include blurred vision/visual flashes that usually stop once the medication is discontinued.
• There is a risk of multiple gestation and ovarian overstimulation.
• Ovarian overstimulation can lead to lower abdominal pain, weight gain, bloating, and pressure.
• Monitor via serial ultrasound to show follicular enlargement.
• Monitor for signs of ovarian overstimulation such as low abdominal pain, bloating, pressure, and weight gain.
• There is an education about the education about the risk of multiple gestation, which is about 8-10% of the pregnancies.
• Administer orally.
• Start five days after the first day of the menstrual period.
• Conduct a serial ultrasound while on the medication.
• Treatment typically lasts for 3-6 months.

Terbutaline

• Suppresses preterm labor, but it is not for prevention.
• It is classified as a beta 2 adrenergic antagonist.
• It reduces the activity of uterine muscles by activating beta 2 receptors in the uterus.
• Suppresses uterine muscle activity which decreases the intensity and frequency of contractions.
• Terbutaline increases the production of AMP, which mediates the suppression of myosin LC kinase.
• It is used to slow preterm labor and cervical changes between 20-37 weeks of pregnancy.
• It is also used for asthma.
• Maternal adverse effects include pulmonary edema, tachycardia, palpitations, chest pain/myocardial ischemia, hypotension/tremors, and hyperkalemia/hyperglycemia.
• Fetal adverse effects include tachycardia/hypotension, ileus, hyperinsulinemia with hypoglycemia, and hyperbilirubinemia.
• Monitor the heart rate and BP.
• Watch for pulmonary edema.
• Hold for maternal heart rate greater than 120.
• Keep a close watch on the maternal monitor.
• Administer subcutaneously every 20 minutes for 3 hours.
• It can be administered IV.
• Use no more than 4 doses.

Nifedipine (Procardia)

• Supresses preterm labor, but not for prevention.
• Class: calcium channel blocker.
• Blocks calcium, which inhibits entry of calcium into myometrium (muscular wall of uterus) cells.
• Decreases the release of calcium from SR as a result.
• The activity of myosin LC kinase deceases as well.
• Suppresses preterm labor for at least 48 hours.
• Cervical changes occur between 20-37 weeks.
• Maternal adverse effects include tachycardia, hypotension in hypovolemic pt, nephrotoxicity, facial flushing, headache, dizziness, and nausea.
• Fetal adverse effect: hypotension
• Do not use longer than 48 hours.
• Safer than terbutaline.
• Assess BP and HR prior to administration.
• Monitor the maternal monitor.
• Also monitor liver functions.
• Metabolized in the liver (cyp450).

Indomethacin (Indocin, Tivorbex)

• Suppresses preterm labor but not for prevention.
• Class: glycooxygenase inhibitor (cox).
• Inhibits the synthesis of prostaglandins, by increasing the release of calcium from SR (sarcoplasmic reticulum).
• Used for very preterm labor; cervical changes before 37 weeks.
• Maternal adverse effects include nausea, gastric irritation, interstitial nephritis, and prolonged postpartum bleeding (rare).
• Fetal adverse effect: prolonged renal insufficiency.
• Other fetal effects include bronchopulmonary dysplasia, necrotizing enterocolitis, periventricular leukomalacia, and closure of ductus arteriosus if given high doses.
• Administer orally with food to decrease GI upset.
• Administer orally or rectally.

Magnesium Sulfate

• Drugs that protect the preterm fetus.
• The mechanism of action inhibits the release of acetylcholine at the neuromuscular junction.
• Used as a seizure precaution in mothers with preeclampsia.
• Maternal adverse effects include flushing, hypotension, headache, dizziness, lethargy, and feeling warm initially.
• Later adverse effects are decreased respiration, sleepiness, and pulmonary edema (from hyper magnesium).
• Fetal adverse effects: muscle weakness, hypotonia, and poor feeding.
• Contraindicated in myasthenia gravis and kidney impairment.
• Magnesium checks includes assessing vital signs, intake and output, deep tendon reflexes, fetal heart tones and contractions pattern.
• Also check serum magnesium and kidney function. Administer IV.

Antibiotics

• Any infection of the lower genital tract increases the risk of preterm labor.
• Group B strep positive: IV Penicillin or Ampicillin.

Glucocorticoid

• Promotes lung maturation.
• Betamethasone: IM. First drug is most common.
• Dexamethasone: IM.

Hydroxyprogesterone Caproate (Makena)

• Prevents preterm labor.
• Very expensive.
• It does not have a MOA.
• For singleton pregnancies with a history of at least one preterm labor birth.
• Weekly, active progesterone derivative.
• Effective for some women but not all.
• Adverse effects include injection site reactions.
• Rarely, thromboembolic events may occur.
• It may promote glucose intolerance, depression, and fluid retention.
• Monitor patients with a history of diabetes, depression, or any condition that could worsen fluid retention.
• Contraindications include uncontrolled hypertension, liver cancer/disease, history of thromboembolic events, cholestatic jaundice of pregnancy, undiagnosed vaginal bleeding, and breast cancer due to a decrease in progesterone.
• Route: 16-20 weeks, IM/SubQ weekly until 37 weeks.
• Metabolism: CYP3A4.

Dinoprostone (Prepidil (gel), Cervidil (pouch))

• Class: synthetic prostaglandin E2.
• Breaks down collagen chains in the cervix and stimulates contractions.
• Used for cervical ripening and softening of the cervix.
• Adverse effects include nausea/vomiting, diarrhea, and fever.
• Nursing actions include monitoring the mother.
• After administration of Prepidil, instruct client to stay supine for 30 minutes.
• After administration of Cervidil, instruct client to stay supine for 2 hours.
• Use continuous uterine and fetal monitoring before insertion.
• Uterine tachysystole can result in fetal distress.
• Cervidil can be removed if tachysystole occurs, but Prepidil cannot.
• Oxytocin may be given 6-12 hours after Prepidil, and 30 minutes after Cervidil pouch removal.
• Terbutaline may be given if tachysystole occurs with Prepidil.

Misoprostol (Cytotec)

• A synthetic prostaglandin used as a first-step induction and is very powerful.
• Promotes cervical ripening and uterine contraction.
• Adverse effects include an increased risk of uterine tachysystole, shivering, and increased temperature.
• Do not administer to patients with the history of uterine surgery.
• Oxytocin may be administered 4-6 hours after Cytotec.
• Monitor the fetal heart rate and uterine activity; It's also used in post-partum hemorrhage.
• Administer as a tablet in the vagina.

Oxytocin

• A second-line drug for post-partum hemorrhage that induces labor.
• Class: synthetic form of a posterior pituitary hormone, peptide hormone.
• Mechanism of action stimulates the frequency, duration, and force of uterine contractions.
• Induces labor and promotes contraction in post-partum hemorrhage.
• Adverse effects include water retention, uterine tachysystole, uterine rupture, fetal distress, and hypoxia, which increases pain with labor.
• Before administration, monitor; lung maturity should be established, and cervical ripening has happened.
• Provide pain control with mom, very dangerous drug.
• Administer IM after birth; IV is diluted.

First-Line Post-Partum Hemorrhage

• What happens? The Uterus doesn't contract, doesn't ligate where the placenta was attached.
• Treatments include Oxytocin and Misoprostol.

Second-Line Post-Partum Hemorrhage

• Drugs: carboprost tromethamine (hemabate) and Methylergonovine (methegine).
• Class: hemabate: prostaglandin F2 alpha & methergine: ergonovine derivative.
• Action: both cause contraction and vasoconstriction.
• Hemabate's adverse effects include nausea, vomiting, diarrhea, fever, possible hypertension, and impaired respiration.
• Methergine's adverse effects includes hypertension from vasoconstriction, headache, and nausea & vomiting.
• Contraindications for hemabate include pelvic inflammatory disease and disease of the heart, lungs, kidneys, and liver.
• Caution with hypertension, diabetes, and uterine scarring.
• Contraindications for methergine include pre-existing hypertension, caution with liver, kidney, or hepatic disorders.

Anti-Coags, Antiplatelets, And Thrombolytics

• Hemostasis the process where the body stops bleeding.
• Stage one is the formation of platelet plug (temporary fix).
• Antiplatelets work in this stage.
• Platelet aggression happens after platelets adhere to the vessel injury site.
• Stage two is coagulation (thrombin turns fibrogen-fibrin).
• Anticoagulants work in this stage.
• Instrinsic pathway turns on due to collagen contact and extrinsic pathway turns on due to skin damage.
• Psychologic Clot Removal: Plasminogen - Plasmin.
• Antithrombin inactivates clotting factors to maintain homeostasis.
• Factor Xa helps turn prothrombin to thrombin, which turns the fibrogen to fibrin, making clots

Thrombosis

• Blood clot formation.
• Arterial thrombosis usually due to heart injury which forms a clot in the artery and localized harmful effects.
• Antiplatelet for treatment.
• Venous thrombosis causes sluggish blood flow.
• Forming a clot in the veins and causing Emboli.
• Anticoagulation is the treatment.
• Anticoagulation drugs work on venous thrombosis.
• Action: reduce formation of fibrin.
  • Warfarin inhibits the SYNTHESIS of clotting factors, targeting factor X and thrombin.
  • Other drugs-inhibit the ACTIVITY of clotting factors, targeting Xa, thrombin, or both.
• Heparin and Warfarin are both Anticoagulation medications.
• Antiplatelet medications work on arterial thrombosis.
• Aspirin and Clopidogrel are Antiplatelet medications.
• They inhibit platelet aggression.
• Thombolytics (TPA & Fibrolytic Drugs ) control homeosis, and dissolve any clots.

Heparin

• Unfractionated long chain molecule that doesn't cross membranes.
• Considered safe for pregnancy.
• Antidote is Protamine Sulfate (okay for preg)
• Action enhances activity of antithrombin, which leads to inactivation of factor Xa and Thrombin equally.
• Suppresses production of fibrin (step 2).
• Used for pulmonary embolism, evolving stroke, massive deep vein thrombosis, and open heart surgery.
• Adverse effects include hemorrhage, decreased blood pressure and heart rate, bruises, petechiae, hematomas, red/black stool, cloudy/discolored urine, pelvic pain, headache, and confusion.
• Monitor for spinal/epidural hematoma.
• Heparin-induced thrombocytopenia (because of the use of animal products).
• Platelet counts done 2-3times a week.
• Hypersensitive reactions include chills, fever, and urticaria (hives).
• Contraindications include thrombocytopenia, uncontrolled bleeding, and use during or immediately after brain, eye, or spinal surgery, or with other anticoagulation drugs with caution.
• Protamine Sulfate: has an immediate effect after IV inject and lasts 2 hours. A slow IV inject (20mg/min or 50mg in 10min) and 1mg of protamine is equal to 100 units of heparin.
• Lab monitoring: don't stop and titrate APTT every 4-6 hours (therapeutic range is 60-80 sec) & anti factor Xa every 4-6 hours (therapeutic range is .3-.7) expensive test.
• Route is IV/ deep sub-Q(prophylaxis) continuously using weight-based bolus followed by continuous. Titrate to aPTT or antifactory Xa values. Check the infusion pump every 30 minutes, requiring 2 RN check.
• Low dose therapy is prophylaxis and no APTT test is required. Sources: animal product (lungs of cattle, and intestines from pigs).

Enoxaparin (lovenox)

• Molecular weight heparin (short chain).
• Antidote: protamine sulfate.
• Classifications: anticoagulant that suppresses production of thrombin, enhances activity of antithrombin, has a longer half life, inactivates factor Xa.
• Uses include prevention of DVT, for abdominal surgery, prevents ischemia complication.
• Route is SubQ with a dose that can give at home. No monitoring is required
• Fixed dose OR weight based for a heavier patient. Side Effects: bleeding Immune mediated thrombocytopenia. Severe neurological injury for PT undergoing spinal surgery or epidural or eye surgey.
• Caution when used with other anitplatelets or anticoag drugs.

Warfarin (Coumadin, Jantoven)

• Derived from plants.
• Vitamin K is the antidote.
• Class: vitamin K antagonist.
• Has a delayed onset because of oral administration.
• Action suppresses coagulation by decreasing the production of VII, IX, X, and prothrombin, where vit K is the dependent clotting factors.
• Warfarin stops vit K from converting into the active form.
• Primarily used for long term prophylaxis of thrombosis (vein specific).
• Used for preventing venous thrombosis and pulmonary embolism, prevent thrombosis during A-fib, and decrease risk of recurrent transient ischemic attacks and recurrent MI.
• Adverse effects include hemorrage (vitamin k for toxicity), tetal hemorrage during breast feeding.
• Frequent monitoring for PT INR should be done first 5 days or, during weeks 1 and 2, 2x /week or, during weeks 1-2 months 1 x / week.
• Drug interactions: increased anticoags effects (aspirin, sulfa, acetaminophen) and increase bleeding (clopidogrel, dabigatran), which require lab monitoring.
• Contraindications: Severe thrombocytopenia, Alcohol abuse, and Pregnancy.

EXTREME CAUTION for Warfarin

• Used in hypertensive patients and increased capillary permeability.
• Education provided for a dosage adjusted by PT & INR.
• Keep vitamin K intake steady.

Dabigatran Etexilate (Pradaxa)

• The antidote is idarucizumab (praxbind).
• Stops/inhibits thrombin by directly acting as a reversible inhibitor of thrombin.
• Unlike heparin, it substitutes for warfarin by attaching to the thrombin free floating in blood, breaking up any clots.
• Fixed dose (doesn't require monitoring with a lower risk for adverse effects.)
• Good for A-fib, prophylaxis for knee replacement, and treating DVT.
• Adverse effects - bleeding (lower risk).
• Can lead to abdominal pain, constipation, or a GI ulcer. -
• Monitor kidney functions since it is eliminated via kidneys, stopping 1-5 days before a procedure.
• Patients should not combine this med with any other metabolic interactions, especially quinidine, ketoconazole, amidarone, and verpamil due to high dabigatran and bleeding complications.
• It has rapid and short-term affects. Patients need to swallow oral tablet whole.

Rivaroxaban (Xarelto)

• NOT for use in pregnancy which increases hemorrhage.
• The antidote is andexanet.
• Oral anticoags with selective inhibition of factor Xa.
• Binds directly to inactivation of factor Xa, Like warfarin, and to stop prothrombin from converting to thrombin.
• For used to prevent stroke in pts with A-fib, prevent recurrent deep vein thrombosis, or pulmonary embolism
• Interacting by being altered by CYP3A4 can be altered by CYP3A4 and P-glycoprotein (azoles).
• It has bleeding, permanent spinal dura hematoma, severe liver impairment.
• Dose is oral use with fixed does not require monitoring.

Aspirin

• Prevention of arterial/atherosclerotic thrombosis.
• Class: antiplatelet, which blocks cyclooxygenase with leads to vasodilation.
• Uses in heart disease.
• Maintain a dosage of 81 mg.
• Patient can stop 5 days before their elective surgery.
• EC tablets may decrease GI effects.

Clopidogrel

• Class: ADP receptor antagonists.
• Prevent ADP stimulating aggregation.
• Irrerversible = Stays on platelet for it's life.
• Rapidly absorbed by the GI with or without food.

Eptifibatide (integrilin)

• Inhibits final step in aggregation and clotting clustering.
• Uses for short term ischemic events, decreases risk reocclusion.
• Monitor the interactions of other medications with CAUTION due to being combo drugs that promote bleeding.

Alteplase

• Antidote: Aminocaproic Acid.
• Alteplase is the class: Thrombolytic Drugs and is given to remove thrombi.
• Binds to plasminogen from an active complex.
• USED IN BRAIN active clot in a blacked C/V catheter.
• Risk for intracranial bleeding because it can hit both good and bad clotS. Management.

Osteoporosis and Calcium

• Oral calcium salts are used to combat mild hypocalcemia by providing dietary supplements in adolescents, older adults, and post-menopausal women.
• Excessive intake can lead to hypercalcemia, causing GI upset like constipation, kidney dysfunction like polyuria/nephrolithiasis, CNS effects, and cardiac dysrhythmias.
• Certain medications like tetracycline, thiazide diuretics, and glucocorticoids can decrease calcium's absorption.
• Oxalic acid and phytic acid found in foods like spinach can also interfere. Dosing usually involves chewable tablets, given parenterally for severe hypocalcemia, in amounts no more than 600mg at a time.

Calcium Gluconate OR Calcium Chloride

• Addresses severe hypocalcemia.
• Route: IV ONLY Give it SLOW to prevents tissue irritation.

Vitamin D Supplements

• Activated in the kidneys and liver.
• Vitamin D supplements treat rickets, osteomalacia, and hypoparathyroidism.
• Adverse effects include weakness, fatigue, cardiac dysrhythmia, and calcium deposits in soft tissue.
• Calcitriol is used for hypoparathyroidism and hypocalcemia in dialysis patients, while Doxercalciferol and Paricalcitol help prevent secondary hyperparathyroidism in dialysis patients.
• Take with food.

Calcitonin Salmon (Miraculin)

• A type of hormone that inhibits action of osteoclasts responsible for bone breakdown.
• Decreases bone reabsorption and results in increased calcium secretion.
• Treats post-menopausal osteoporosis with a common side effect of intranasal dryness and irritation.

Alendronate (fosamax)

• Class: oral bisphosphonate use for osteoporosis.
• Function is to increase bone mineral density, decrease decreases height.
• Prevent and treat bone Metastasis - Adverse effects: Esophagitis esophageal cancer, osteonecrosis of the jaw is rare.

Raloxifene (evista)

• Class: Selective Estrogen Receptor Modulator.
• Acts like estrogen that promotes bone, lipid, blood, and prevents breast and endometrial growth.
• Contraindication when the PT is PREGOS for a no prego.

INSULIN DRUGS

• Short duration acts rapidly, such as short duration, acts rapidly, such as food within 15 minutes. Adverse effects: hypoglycemia, lipohypertrophy, and allergic relation.
• The long duration 1x day and never mix it.

Hyperglycemia: diabetic ketoacidosis state.

• Treatment IV fluid/ Electrolyte.
• Diabetes complications: so lipids/ heart issues, Hypertension.
• The glucoses blood test for casual.

Type 2 Drug

• Action increase setitity of insulin/
• Lower’s A1C levels which improved glycemia control.
• With that that. Act in in testis.

Drug Interactions

• Betty to decreased and take with food or sulfonluerea, but avoid alchol.
• To help decrease carbs with diabetes.

Thyroid Drugs

• Doc for hypothyroid that have angina. Is Meth- kills babes and safe with pregos. Not give if Pt is going to have hypoglycemia. Give with food.
• Short half-life with iodine for Graves disease or better if they is going to have.

Hormones

• Estrogen: +effct is to build bones.
• Progestin: import for reproductive.
• ANDrogens: builds muscle.

Anti-Diarrheal

• Prokinetic agents increase tone and mobility.

Anti-Emetics

• Ondansetron is in class: for antagonist, block and maybe in combo or no in combo. Side are that Pts could need more intervention IF there electrolyte levels are off.