INSTITUT LATIHAN KEMENTERIAN

KESIHATAN MALAYSIA
KEJURURAWATAN KUBANG KERIAN
ADVANCE DIPLOMA IN MIDWIFERY
INTAKE MARCH 2020
MWMS 4023 BASIC MEDICAL SCIENCE :
PHARMACOLOGY AND IMMUNOLOGY

TUTOR : PUAN LIM THO HUAI

GROUP 2 : TOCOLYTIC DRUG

NUR HIDAYU BINTI WAHAB

NORAZIMAH BINTI MAT JUSOH
NURUL NAZIFI BINTI ZAILANI
NURUL HIDAYAH BINTI CHE AJID
NOR MARINI BINTI ABDULLAH
NORHAYATI BINTI ZAKARIA
ZAIMIERA BINTI CHE LAH @ YAZID
What is tocolytic drug
Tocolytics are medication used to suppress premature labor. Tocolytic therapy is
provided when delivery would result in premature birth, postponing delivery long
enough for the administration of glucocorticoids, which accelerate fetal lung maturity
but may take one to two days before its effects are seen.

Types of agent
Drug Mechanism of action Description
Terbutaline Beta agonist A beta-2 adrenergic agonist used as a
broncholdilator and to prevent
premature labor
Ritodrine Beta agonist An adrenergic beta agonist used to
treat premature labor
Fenoterol Beta agonist A beta-2 adrenergic agonist and
bronchodilator used for the
symptomatic treatment of asthma
Salbutamol/ Beta agonist A beta-2 adrenergic receptor agonist
Ventolin used to treat asthma, bronchitis,
COPD, as well as prevent exercise
induced bronchospasm
Hexoprenalin Beta agonist Is a stimulant of beta-2 adrenergic
e receptors, it is used as a
bronchodilator, anti asthmatic and
tocolytic agent
Nifedipine Calcium channel A dihydropyridine calcium channel
blocker blocker indicated for the management
of several subtypes of angina pectoris
and hypertension
Atosiban Oxytocin receptor An inhibitor of oxytocin and
vasopressin used to delay imminent
preterm birth in pregnant adult women
displaying specific clinical observations
Indomethacin NSAIDS A nonsteroidal anti immflamatoty used
for sympthomatic management of
chronic musculoskeletal pain conditions
and to induce closure of a
hemodynamically significant patens
ductus arteriosus in premature infants
Magnesium Myosin light chain A drug used to treat convulsions during
sulphate inhibitor pregnancy, nephritis in children,
 magnesium deficiency and tetany

Indication of tocolytic
- Drugs that used to preterm labor immature birth by suppressing uterine
contractions ( TOCOLYSIS ), Agents used to delay premature uterine activity
include magnesium sulfate, oxytocin antagonists, calcium channel inhibitors
and adrenergic beta – receptor agonists

Contraindication of tocolytic
● Mother has severe pregnancy – induced hypertension,
eclampsia/preeclampsia, active vaginal bleeding, placenta abruption, or
another condition such as tachycardia – sensitive maternal cardiac condition
which indicates that the pregnancy should not continue

Side effect of tocolytic therapy

● Tachycardia
● Hypotension
● Palpitations
● Shortness of breath
● Chest pain
● Pulmonary edema
● Hypokalemia
● Hyperglycemia

COMMON USED OF TOCOLYTIC THERAPY

Name of medicine
1) VENTOLIN
Trade name : Salbutamol
Generic name : Albuterol

Indication :

● For the management of uncomplicated premature labor.

● To arrest labor between 24 and 33 weeks of gestation in patients with no
medical or obstetric contraindication of tocolytic therapy

Contraindication :

● Hypersensitivity to any component of the preparationor related

sympathomimetic amines
● At a gestational age <24 weeks
● intrauterine foetal death, known lethal congenital or lethal chromosomal
malformation
● any condition of the mother or foetus in which prolongation of the pregnancy
is hazardous (e.g. maternal cardiac disease, uncontrolled hypertension,
severe preeclampsia, active uterine bleeding, premature rupture of the
membranes with associated chorioamnionitis, compression of the umbilical
cord, fetal acidosis (pH 7.2) or hypoxia (PaO2 18 mm Hg)
● in patients with pulmonary hypertension, pre-existing ischaemic heart disease
or those patients with significant risk factors for ischaemic heart disease.
● Bronchial asthma
● Diabetes
● Uncompensated potassium depletion, hypercalcaemia
● Maternal hyperthyroidism
● Ileus
● Unconsciousness
● Renal insufficiency
● Glaucoma
● Paroxysmal tachycardia

Side effects :
Cardiovascular
● Cardiovascular effects such as Hypotension, tachycardia and therefore
increased cardiac oxygen demands
● Ventolin Obstetric Injection may be dangerous in patients with angina as it
may precipitate coronary insufficiency. Disturbances of cardiac rhythm and
rate are sometimes seen.
● Ventolin Obstetric Injection may cause tachycardia but the incidence and
severity is less than with some other beta receptor agonists, eg, isoxsuprine.
● Increases in maternal heart rate of the order of 20 to 40 beats per minute
usually accompany the infusion. The maternal heart rate should be monitored
and not normally allowed to exceed a sustained rate of 120 beats per minute.
● The effect of Ventolin Obstetric Injection on maternal blood pressure is
greater on diastolic than on systolic pressure. Falls in diastolic pressure are
usually within the range of 15 to 25 mmHg.

Maternal effects Majority of patients.

● Cardiovascular. Maternal sinus tachycardia, palpitations, increased maternal
pulse pressure and increased cardiac output.
● More common reactions. Cardiovascular. High doses of beta-adrenergic
stimulants can cause peripheral vasodilation with associated hypotension,
flushing and headache. Conduction disturbances, such as supraventricular
tachycardia and extrasystoles, have been reported with high doses.
● Endocrine. Disturbance of carbohydrate metabolism and ketosis (particularly
in diabetic patients).
● Nervous system. Hand tremors, nervousness, restlessness, headache,
emotional upset or anxiety have been reported.
● Nausea, vomiting and dizziness have been reported.
● Hypersensitivity reactions including anaphylactic shock, angioedema,
urticaria, bronchospasm, hypotension and collapse have been reported rarely.
There have been very rare reports of muscle cramps and hyperactivity.
● To uterus : Membrane rupture and cervical dilation. A reduction in the
effectiveness of salbutamol should be anticipated if the membrane ruptures or
if cervical dilation exceeds 4 cm.
●
Neonatal effects
● Fetal tachycardia has been reported after maternal administration by the
intravenous route. Infrequently reported symptoms include hypo-glycaemia
and ileus.

Route :
● Infusion: Use of an infusion pump will facilitate accurate adjustment and
control of salbutamol infusion.
● Ventolin Obstetric Injection should not be administered in the same syringe or
infusion as any other medication.

Dilution :
● A suitable solution for infusion may be prepared by diluting the contents of
ampoules of Ventolin Obstetric Injection (5 mg in 5 mL) in 500 mL of Sodium
Chloride Injection BP, Dextrose Injection BP, or Sodium Chloride and
Dextrose Injection BP.

2) BRICANYL
Trade name : Bricanyl
Generic name : Terbutaline

Indications :
● Bronchodilation
● Terbutaline is a selective beta2-adrenergic agonist recommended for the
relief of bronchospasm in bronchial asthma and other bronchopulmonary
disorders in which bronchospasm is a complicating factor.
● For the short term management of uncomplicated premature labour
● To arrest labour between 22 and 37 weeks of gestation in patients with no
medical or obstetric contraindication to tocolytic therapy

Contraindications :
● In the treatment of premature labour Bricanyl is contraindicated in the
following conditions:
● A gestational age of < 22 weeks.
● As a tocolytic agent in patients with pre-existing ischaemic heart disease
or those patients with significant risk factors for ischaemic heart disease
● Threatened abortion during the 1st and 2nd trimester.
● Any condition of the mother or foetus in which prolongation of the
pregnancy is hazardous, e.g. severe toxaemia, intrauterine infection,
vaginal bleeding resulting from placenta praevia, eclampsia or severe
preeclampsia, placental abruption, or cord compression.
● Intrauterine fetal death, known lethal congenital or lethal chromosomal
malformation
 Side effects :
● Increasing in maternal heart rate.
● Generally maternal pulse rate should not be allowed to exceed a steady
rate of 120 beats per minute
● Maternal blood pressure may fall slightly during the infusion.
● The effect being greater on diastolic than on systolic pressure. Falls in
diastolic pressure are usually within the range of 10 to 20 mmHg
● As maternal pulmonary oedema.
● Patients with predisposing factors including multiple pregnancies, fluid
overload, maternal infection and pre-eclampsia may have an increased
risk of developing pulmonary oedema

● Blood glucose and lactate levels should be monitored in mothers with

diabetes and diabetic treatment adjusted accordingly to meet the needs of the
diabetic mother during tocolysis
● Hyperthyroidism. Bricanyl should only be administered cautiously to patients
suffering from thyrotoxicosis after careful evaluation of the benefits and risks
of treatment.

Route :
● Parenteral - subcutaneous, intramuscular, intravenous.

Dilution :
● The recommended infusion fluid is 5% dextrose. If a syringe pump is
available, the concentration of the drug infused should be 0.1 mg/ml (10 ml
Bricanyl Injection should be added to 40 ml of 5% dextrose).
● If no syringe pump is available, the concentration of the drug should be 0.01
mg/ml (10 ml Bricanyl Injection should be added to 490 ml of 5% dextrose).
3) NIFEDIPINE
Trade name : Adalat, Afeditab
Generic name : Nifedipine

Indications :

● Nifedipine is used to treat hypertension (high blood pressure). It’s also used to
treat two types of angina (chest pain): vasospastic angina and chronic stable
angina.
● Calcium channel blockers (CCBs), commonly used to reduce blood pressure,
can also be used to relax uterine contractions and postpone a preterm birth

Contraindications :

● Known hypersensitivity reaction to nifedipine

Side effects :

● Constipation
● Diarrhea
● Nausea
● Feeling dizzy
● Feeling faint
● Headache
● Low blood pressure
● Redness of the skin
● Heart palpitations
● Skin rash
● Otherwise nifedipine has no side effect to baby

Route :
● The recommended protocol consists of 20 mg orally stat, followed by 20 mg
orally after 30 minutes if contractions persist, followed by 20 mg orally every
 3-8 hours for 48-72 hours as indicated. The maximum dose is 160 mg/day.
After 72 hours, if maintenance is required, patients can be changed to long-
acting nifedipine 30-60 mg daily

4) ATOSIBAN
Trade name : Tractocile, Antocin, Atosiban SUN
Generic name : Atosiban acetate

Indication :

● Regular uterine contractions of at least 30 seconds’ duration at a rate of ≥ 4

per 30 minutes
● A cervical dilation of 1 to 3 cm (0-3 for nulliparas) and effacement of ≥ 50%
● A gestational age from 24 until 33 completed weeks
● A normal fetal heart rate

Contraindication :
● Hepatic and renal failure

Side effects :
● Nausea
● Vomiting
● Dyspnea
● Chest pain

Route :
● As a solution for injection and as a concentrate that is made up into a solution
for infusion (drip) into a vein. It is given into a vein in three stages, over a
maximum of 48 hours: an initial injection into a vein (6.75 mg), followed by a
high-dose infusion (18 mg per hour) over three hours, then a lower-dose
infusion (6 mg per hour) lasting up to 45 hours
Q&A
MEQ

1) What is the role of nifedipine in the treatment of preterm labor?

Answer :
Nifedipine, a calcium channel blocker, is commonly used to treat
high blood pressure and heart disease because of its ability to
inhibit contractility in smooth muscle cells by reducing calcium
influx into cells. Consequently, nifedipine has emerged as an
effective and safe alternative tocolytic agent for the management
of preterm labor.

2) What is the contraindication of nifedipine used in tocolytic therapy

Answer :
Contraindications of nifedipine therapy include allergy to
nifedipine, hypotension, hepatic dysfunction, concurrent use of
beta-mimetics or MgSO4, transdermal nitrates, or other
antihypertensive medication. Other commonly reported side
effects of nifedipine are maternal tachycardia, palpitations,
flushing, headaches, dizziness, and nausea. Continuous
monitoring of the fetal heart rate is recommended as long as the
patient has contractions; the patient's pulse and blood pressure
should be carefully monitored. Pregnant women with liver disease
should not be prescribed nifedipine.

3) What are contraindications for tocolytic therapy in the treatment of

preterm labor?
Answer :
- Gestational age below 24 or 33 completed
- Premature rupture of membrane
- Abnormal fetal heart rate
- Eclampsia and severe pre-eclampsia
- Intra uterine fetal dead
- Placenta praevia
- Abruptio placenta
MCQ
1) Tocolytic succeed only if
a) Cervical dilatation <4cm and reducing of delivery within 24 – 48
hours
b) Cervical dilatation >4cm and increasing of delivery in 24 hours
c) In between 24 hours of delivery
d) Os <4cm

2) Terbutaline sulphate is used for muscle relaxion and to stop premature

contraction. It is used
a) Between 24 – 33 weeks of pregnancy
b) Between 24 & 37 weeks of pregnancy
c) 12 weeks of pregnancy
d) Before labor

3) Below is the true statement regarding tocolytic therapy EXCEPT

a) It is used to suppress the premature labor
b) Save to be used for all pregnant woman
c) Monitoring of maternal condition is important in tocolytic therapy
administration
d) It can’t be administered to maternal which is less than 24 hours of
pregnancy

4) The following are side effect of Adalat EXCEPT

a) Blur vision
b) Headache
c) Nausea and vomiting
d) Urticaria

5) What is the medicine that used for premature labor between on 24 – 33

weeks of pregnancy?
a) Terbutaline
b) B2 receptor stimulation
c) Prostaglandin synthase inhibitor
d) Morphine sulphate