Drugs Affecting the Reproductive System PDF
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Andres Bonifacio College
Sharika L. Colaljo, RN
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This document provides information on drugs acting on the reproductive system during pregnancy. It covers the effects of hormones like estrogen and progesterone on the body and discusses relevant nursing implications. The document is part of a presentation or educational material.
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Drugs Acting on the Reproductive System Prepared by: Sharika L. Colaljo, RN What are the hormones produced in the ovaries? ESTROGEN Growth of genitalia (in preparation for childbirth) Growth of breast tissue (in preparation for pregnancy and lactation) Characteristic female pubic hair dist...
Drugs Acting on the Reproductive System Prepared by: Sharika L. Colaljo, RN What are the hormones produced in the ovaries? ESTROGEN Growth of genitalia (in preparation for childbirth) Growth of breast tissue (in preparation for pregnancy and lactation) Characteristic female pubic hair distribution (a triangle) Stimulation of protein building (important for the developing fetus) ESTROGEN Increased total blood cholesterol (for energy for the mother as well as the developing fetus) with an increase in high-density lipoprotein levels (“good” cholesterol, which serves to protect the female blood vessels against atherosclerosis) Retention of sodium and water (to provide cooling for the heat generated by the developing fetus and to increase diffusion of sodium and water to the fetus through the placenta) ESTROGEN Inhibition of calcium resorption from the bones (helps to deposit calcium in the fetal bone structure; when this property is lost at menopause, osteoporosis, or loss of calcium from the bone, is common) Alteration of pelvic bone structure to a wider and flaring pelvis (to promote easier delivery) ESTROGEN Closure of the epiphyses (to conserve energy for the fetus by halting growth of the mother) Increased thyroid hormone globulin (metabolism needs to be increased greatly during pregnancy, and the increase in thyroid hormone facilitates this) Increased elastic tissue of the skin (to allow for the tremendous stretch of the abdominal skin during pregnancy) ESTROGEN Increased vascularity of the skin (to allow for radiation loss of heat generated by the developing fetus) Increased uterine motility (estrogen is high when the ovum first leaves the ovary, and increased uterine motility helps to move the ovum toward the uterus and to propel the sperm toward the ovum) Proliferative endometrium (to prepare the lining of the uterus for implantation with the fertilized egg) ESTROGEN Thin, clear cervical mucus (allows easy penetration of the sperm into the uterus as ovulation occurs; used in fertility programs as an indication that ovulation will soon occur) Anti-insulin effect with increased glucose levels (to allow increased diffusion of glucose to the developing fetus) T-cell inhibition (to protect the non-self-cells of the embryo from the immune surveillance of the mother) ESTROGEN Progesterone is released into circulation after ovulation. Progesterone has many effects that support the early development of the fetus. PROGESTERONE Decreased uterine motility (to provide increased chance that implantation can occur) Development of a secretory endometrium (to provide glucose and a rich blood supply for the developing placenta and embryo) Thickened cervical mucus (to protect the developing embryo and keep out bacteria and other pathogens; this is lost at the beginning of labor as the mucous plug) PROGESTERONE Breast growth (to prepare for lactation) Increased body temperature (a direct hypothalamic response to progesterone, which stimulates metabolism and promotes activities for the developing embryo; this increase in temperature is monitored in the “rhythm method” of birth control to indicate that ovulation has occurred) PROGESTERONE Increased appetite (this is a direct effect on the satiety centers of the hypothalamus and results in increased nutrients for the developing embryo) Depressed T-cell function (this protects the non-self-cells of the developing embryo from the immune system) Anti-insulin effect (to generate a higher blood glucose concentration to allow rapid diffusion of glucose to the developing embryo) Therapeutic Drugs in Pregnancy IRON Supplementation with iron is not generally necessary until the second trimester, when the fetus begins to store iron; the goal is to prevent maternal iron deficiency anemia, not to supply the fetus. Common side effects of iron supplements include nausea, constipation, black tarry stools, GI irritation, epigastric pain, vomiting, discoloration of urine, and diarrhea. IRON Nursing Implications Liquid forms can cause temporary tooth discoloration and therefore should be diluted and administered through a straw. Iron supplements are best absorbed when administered with water or juice on an empty stomach. Vitamin C increases the absorption of iron. If gastric irritation does occur, administer the iron with food. IRON Nursing Implications Store iron in a light-resistant container. Recognize that patient may have false-positive result of occult blood in stool if taking iron. Folic Acid Folic acid deficiency early in pregnancy can result in spontaneous abortion or birth defects, especially neural tube defects; a failure of the embryonic neural tube to close properly can lead to spina bifida or skull and brain malformations. Side effects of folic acid supplementation are uncommon but include allergic bronchospasm, rash, pruritus, erythema, and general malaise. Patients should be aware that folic acid supplementation may cause urine to turn more intensely yellow. Multiple Vitamins Prenatal vitamin preparations are routinely recommended for pregnant women. These preparations generally supply vitamins A, B-complex, B12, C, calcium, D, E, iron, and other minerals. Drugs for Minor Discomforts of Pregnancy Nausea and Vomiting Nausea and vomiting (“morning sickness”) during early pregnancy are major complaints for about 88% of pregnant patients, but hyperemesis gravidarum—severe nausea and vomiting that may require hospitalization for hydration and nutrition Nausea and Vomiting Pharmacologic measures: Pyridoxine Antihistamine plus B6 analogue Phenothiazine – Promethazine Anticholinergic – Scopolamine Prokinetic – Metoclopramide Ondansetron Nausea and Vomiting Nonpharmacologic measures: (1) eating crackers, dry toast, or other carbohydrates before rising; (2) avoiding high-fat or highly seasoned foods; (3) eating small, frequent meals; (4) drinking fluids between, rather than with, meals; (5) drinking apple juice or flat soda between meals; (6) eating a high-protein bedtime snack; (7) stopping smoking; (8) taking an iron supplement at bedtime Heartburn (Pyrosis) a burning sensation in the epigastric and sternal regions that occurs with reflux of acidic stomach contents. Pregnant patients experience decreased motility in the GI tract as a result of the normal increase in the hormone progesterone. Heartburn Nonpharmacologic measures: (1) limiting the size of meals; (2) avoiding highly seasoned or greasy foods; (3) avoiding gas-forming foods (e.g., cabbage, onions); (4) eating slowly and chewing thoroughly; (5) avoiding citrus juices; (6) drinking adequate fluids, but not with meals; and (7) avoiding reclining immediately after eating Heartburn First line therapy: ANTACIDS (nonsystemic low-sodium products containing aluminum and magnesium in combination) Amphojel Heartburn Nursing Implication: Advise patient that antacids should not be taken within 1 hour of taking an enteric-coated tablet, because the acid-resistant coating may dissolve in the increased alkaline condition of the stomach, and the medication will not be released in the intestine as intended. Stomach upset may result. Iron and antacids should be taken 2 hours apart if both are prescribed. Heartburn Nursing Implication: Advise patient that there may be a change in bowel habits when taking antacids. Aluminum and calcium carbonate products can cause constipation, whereas magnesium products can cause diarrhea. Many antacids contain a combination of ingredients to reduce adverse effects. Heartburn Sucralfate (Carafate) TUMS are frequently taken by pregnant patients for heartburn, but because TUMS are calcium based, excessive use may contribute to constipation. Constipation Nonpharmacologic measures: (1) increased fluid intake, (2) increased dietary fiber intake, and (3) moderate physical exercise Constipation Pharmacologic measures: Metamucil Docusate Sodium (Colace) Constipation Avoid during pregnancy: Castor oil – stimulate uterine contractions Mineral oil - reduce the absorption of fat-soluble vitamins like vitamin K which leads to neonatal hemorrhage. Pain Nonpharmacologic measures: (1) Rest and calming environment; (2) relaxation exercises; (3) alteration in routine; (4) mental imagery; (5) ice packs or warm, moist heat; (6) postural changes; (7) correct body mechanics; and (8) changes in footwear. Pain Pharmacologic measures: Acetaminophen - most commonly ingested nonprescription drug during pregnancy. Acetaminophen may be used during all trimesters of pregnancy in therapeutic doses on a short-term basis for its analgesic and antipyretic effects Maximum daily dose recommendation: 3,000 mg Pain Aspirin - can inhibit the initiation of labor and prolong labor through its effects on uterine contractility; therefore, its use is not recommended during pregnancy Ibuprofen - may cause premature closure of the ductus arteriosus Ductus arteriosus closes 2 days after birth PAIN Nursing Implications Advise patient to take acetaminophen rather than aspirin during pregnancy; aspirin and ibuprofen are particularly contraindicated during the third trimester. Counsel patient against ingesting multiple OTC pain or cough/cold preparations, because many OTC products contain acetaminophen. PAIN Nursing Implications Advise patient not to take nonsteroidal anti-inflammatory drugs (NSAIDs) with acetaminophen. Advise patient not to take NSAIDS after second trimester. (NSAID use during the third trimester may cause premature closure of the fetal ductus arteriosus, fetal renal impairment, inhibition of platelet aggregation, and may delay labour and birth.) NSAIDs Drugs That Decrease Uterine Muscle Contractility PRETERM LABOR (PTL) labor that occurs between 20 and 37 weeks of pregnancy, involving a fetus with an estimated weight between 500 and 2499 g. Regular contractions occur at less than 10-minute intervals over 30 to 60 minutes and are strong enough to result in 2-cm cervical dilation and 80% effacement PRETERM LABOR (PTL) Nonpharmacologic Measures: a) bed rest, b) hydration (ingestion of six to eight glasses of fluids daily or more, IV fluid bolus), c) pelvic rest (no sexual intercourse or douching), and d) screening for intrauterine and urinary tract infections. TOCOLYTIC THERAPY - drug therapy to decrease uterine muscle contractions using beta2-adrenergic receptor agonists (e.g., terbutaline) or, more commonly, the calcium antagonist magnesium sulfate The goals in tocolytic therapy are to: (1) interrupt or inhibit uterine contractions to create additional time for fetal maturation in utero, (2) delay delivery so antenatal corticosteroids can be delivered to facilitate fetal lung maturation, and (3) allow safe transport of the patient to an appropriate facility if required TOCOLYTIC THERAPY - Calcium channel blockers prevent the influx of calcium ions, resulting in relaxation of the myometrium. - Prostaglandin or cyclooxygenase (COX, or prostaglandin synthase) is the enzyme responsible for converting acrachidonic acid and increasing available intracellular calcium. Therefore, prostaglandin inhibitors limit the available calcium for uterine contractions. TOCOLYTIC THERAPY Beta-Sympathomimetic Drugs - act by stimulating beta2- receptors on uterine smooth muscle. The frequency and intensity of uterine contractions decrease as the muscle relaxes. - Terbutaline is used in the late second and early third trimesters TOCOLYTIC THERAPY TOCOLYTIC THERAPY Beta-Sympathomimetic Drugs Adverse Reactions Maternal side effects include tremors, dizziness, nervousness, tachycardia, hypotension, chest pain, palpitations, nausea, vomiting, hyperglycemia, and hypokalemia Fetal side effects include tachycardia and potential hypoglycemia resulting from fetal hyperinsulinemia caused by maternal hyperglycemia TOCOLYTIC THERAPY TOCOLYTIC THERAPY TOCOLYTIC THERAPY TOCOLYTIC THERAPY Magnesium Sulfate - a calcium antagonist and central nervous system depressant, relaxes the smooth muscle of the uterus through calcium displacement and is more commonly given as a tocolytic. - Administered IV, the drug has a direct depressant effect on uterine muscle contractility. - It increases uterine perfusion, which has a therapeutic effect on the fetus. TOCOLYTIC THERAPY Magnesium Sulfate Contraindicated in patients with myasthenia gravis, and impaired kidney function or recent myocardial infarction (MI) Adverse Reactions Dosage-related side effects in the patient include flushing, feelings of increased warmth, perspiration, dizziness, nausea, headache, lethargy, slurred speech, sluggishness, nasal congestion, heavy eyelids, blurred vision, decreased GI action, increased pulse rate, and hypotension. TOCOLYTIC THERAPY Magnesium Sulfate Increased severity is evidenced by depressed reflexes, confusion, and magnesium toxicity (respiratory depression and arrest, circulatory collapse, cardiac arrest). If maternal neurologic, respiratory, or cardiac depression is evidenced, the antidote is calcium gluconate (1 g IV push over 3 minutes). TOCOLYTIC THERAPY Nursing Interventions: Monitor vital signs, FHR, fetal activity, and uterine activity as ordered. Report respirations fewer than 12 per minute, which may indicate magnesium sulfate toxicity. Monitor intake and output (I&O). Report urinary output below 30 mL/hour. Assess breath and bowel sounds as ordered or at least every 4 hours. Assess deep tendon reflexes (DTRs) and clonus before initiation of therapy and as ordered. Notify the health care provider of changes in DTRs (areflexia or hyporeflexia) and clonus. TOCOLYTIC THERAPY Nursing Interventions: Assess pain and uterine contractions. Weigh daily at the same time. Monitor serum magnesium levels as ordered (therapeutic level is 4 to 7 mg/dL). Have calcium gluconate (1 g given IV over 3 minutes) available as an antidote. Observe the newborn for 24 to 48 hours for magnesium effects if drug was given to the mother before delivery. Corticosteroid Therapy in Preterm Labor CORTICOSTEROID THERAPY Patients at risk for preterm delivery should receive antenatal corticosteroid therapy with betamethasone (Celestone) or dexamethasone. Administration of antenatal corticosteroids accelerates lung maturation and lung surfactant development in the fetus in utero, decreasing the incidence and severity of respiratory distress syndrome (RDS) and increasing survival of preterm infants. CORTICOSTEROID THERAPY Surfactant is made up of two major phospholipids: sphingomyelin and lecithin. Sphingomyelin initially develops in greater quantity (from about the 24th week) than lecithin. However, by the 33rd to 35th weeks of gestation, lecithin production peaks, making the ratio of the two substances about 2:1 in favor of lecithin. This is called the L/S (lecithin/ sphingomyelin) ratio, measured in the amniotic fluid. The L/S ratio is a predictor of fetal lung maturity and risk for neonatal RDS. PRENATAL THERAPY FOR SURFACTANT DEVELOPMENT DRUGS FOR GESTATIONAL HYPERTENSION Gestational Hypertension elevated blood pressure without proteinuria after 20 gestational weeks in patient's normotensive before pregnancy Has 2 categories: Preeclampsia and Eclampsia Preeclampsia/Eclampsia Pharmacologic Measures: a) Magnesium sulfate (Therapeutic levels: 4-7 mEq/L) First sign of Magnesium Toxicity: Loss of patellar reflexes b) Methyldopa c) Hydralazine d) Labetalol DRUGS FOR PAIN CONTROL DURING LABOR Nonpharmacologic Measures: (1) ambulation, (2) supportive positioning of the gravid uterus and promotion of uterine perfusion, (3) touch and massage, (4) hygiene and comfort measures, (5) support persons, (6) breathing and relaxation techniques, (7) transcutaneous electrical nerve stimulation, (8) hypnosis, (9) acupuncture, and (10)hydrotherapy (warm-water baths or showers) Sedative-Tranquilizer Drugs most commonly given for false labor, latent labor, or with ruptured membranes without true labor. may also be administered to minimize maternal anxiety and fear. promote rest and relaxation and decrease fear and anxiety, but they do not provide pain relief. Sedative-Tranquilizer Drugs Secobarbital (Seconal) pentobarbital (Nembutal) promethazine (Phenergan) hydroxyzine pamoate (Vistaril) Narcotic Agonists second group of drugs given for active labor These drugs interfere with pain impulses at the subcortical level of the brain. To effect pain relief, opioids interact with mu and kappa receptors. Narcotic Agonists Meperidine is the most commonly prescribed synthetic opioid for pain control during labor. A second narcotic agonist used for pain relief during labor is fentanyl Mixed Narcotic Agonist-Antagonists These drugs exert their effects at more than one site— often an agonist at one site and an antagonist at another. A primary advantage of these drugs is their dose-ceiling effect - additional doses do not increase the degree of respiratory depression The respiratory depression ceiling effect is believed to result from activation of kappa agonists and weak mu antagonists Mixed Narcotic Agonist-Antagonists Butorphanol tartrate Nalbuphine DRUGS THAT ENHANCE UTERINE MUSCLE CONTRACTILITY Dinoprostone the naturally occurring form of prostaglandin E2 (PGE2) Intra-cervically or intravaginally administered PGE2 acts to create cervical effacement and softening Dinoprostone Side effects: uterine hyperstimulation Adverse effects: chills, fever, vomiting, and diarrhea Contraindications: active vaginal bleeding, known allergies to prostaglandins, hepatic or renal disease, glaucoma, previous cesarean delivery or hysterotomy Oxytocin facilitates smooth-muscle contraction in the uterus of a patient already in labor but experiencing inadequate uterine contractility (tightening and shortening of uterine muscles) diluted and administered IV piggyback for induction or augmentation of labor Oxytocin Nursing Interventions: Have tocolytic drugs, such as terbutaline, and oxygen readily available. Monitor intake and output. Monitor maternal pulse and BP, uterine activity, and FHR during oxytocin infusion. The medication is diluted and administered by IV piggyback for induction or augmentation of labor. Oxytocin Nursing Interventions: Maintain the patient in a sitting or lateral recumbent position to promote placental infusion. Monitor for signs of uterine rupture, which include FHR decelerations, sudden increased pain, loss of uterine contractions, hemorrhage, and rapidly developing hypovolemic shock. Use an IV pump to administer drug. DRUGS USED DURING THE POSTPARTUM PERIOD Pharmacologic and nonpharmacologic measures used during the postpartum period have five primary purposes: (1) to prevent uterine atony and postpartum hemorrhage; (2) to relieve pain from uterine contractions, perineal wounds, and hemorrhoids; (3) to enhance or suppress lactation, production and release of milk by the mammary glands; (4) to promote bowel function; (5) to enhance immunity Pain Relief for Uterine Contractions Because some systemic analgesics (e.g., codeine, meperidine) can cause decreased alertness, it is important for the nurse to observe the patient as she cares for her newborn to ensure safety. Assess for bowel function and respirations. Frequently, nonsteroidal agents like ibuprofen and ketorolac tromethamine are used to control postpartum discomfort and pain. NSAIDs commonly cause GI irritation, and it is recommended that patients take them with a full glass of water or with food Pain Relief for Perineal Wounds and Hemorrhoids Pregnancy and the delivery process increase the pressure on perineal soft tissue causing it to become ecchymotic or edematous. Increased edema, ecchymosis, and pain may occur if an episiotomy, incision made to enlarge the vaginal opening to facilitate newborn delivery, or perineal laceration is present. Pain Relief for Perineal Wounds and Hemorrhoids Comfort measures include: 1. ice packs immediately after birth 2. tightening of the buttocks before sitting, 3. use of peribottles and cool or warm sitz baths) 4. topical agents (witch hazel and dibucaine ointment