PRESCRIPTION WRITING IN OBSTETRICS BY DR SHASHWAT JANI

1. Prescription Writing In
Obstetrics
Dr. Shashwat Jani.
M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Definition
A prescription is a written, verbal, or
electronic order from a practitioner or
designated agent to a pharmacist for a
particular medication for a specific patient..

3. Contents of the Prescription
 Date of the order
 Patient Name and Address
 Name of the drug
 Strength of the drug
 Quantity of the drug
 Directions for use
 Practitioner Name, Address, Telephone
number , Registration Number

4. Parts of prescription:
 Superscription: name, professional degree, contact no.
address of ! prescriber,
! date when ! order is written.
name, address & age of ! patient; & ! symbol Rx (an
abbreviation for "recipe," ! Latin for "take thou." _
 Inscription : ! body of ! Pres. containing ! name, strength
of each drug, & dosage form of ! Tr.
 Subscription: quantity to be dispensed. ! directions to !
pharmacist, usually consisting of a short sentence: "make a
solution," "mix & place into 10 capsules," or "dispense 10
tablets."
 Transcription : labeling of instruction to ! Patient,
 Prescriber's signature.

5. Contents of the Prescription
Name of the drug
Multiple drugs per prescription can
add to confusion.
KEEP IT SIMPLE.
 LEGIBLE
Preferably in CAPITAL LETTERS.

6. Abbreviation Potential Problem Preferred Term
U (unit) Mistaken as zero, four Write “unit”
IU (international unit) Mistaken as IV or 10 Write “international unit”
Q.D., Q.O.D. Mistaken for each other.
Period after Q and O after Q
can be mistaken for “I”
Write “daily” and “every
other day”
MS, MSO4, MgSO4 Confused for one another Write “morphine sulfate” or
“magnesium sulfate”
List of dangerous abbreviations, acronyms, and
symbols

7. Contents of the Prescription
 Strength of the drug
 Decimal points
 Avoid trailing zeros.
EX. 5 mg vs. 5.0 mg; can be mistaken for 50 mg
 Always use leading zeros.
EX. 0.8 ml vs. .8 ml; can be mistaken for 8 ml

8. Principles for writing prescription :
Prescribers should:
 ALWAYS write legibly in ink (clear writing)
 Use metric system (g, L)
 ALWAYS sign & date ! the prescription
 Precise
 Accurate
 Use precautions to remind patients about SE
 NEVER abbreviate drug names

9.  “ Prescription writing is a
Science and art conveying message
from Prescriber to the Patient. “
 One of the least-developed areas
of clinical pharmacology and drug
research is the use of medication
during pregnancy and lactation.
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10.  Requires special considerations
 Is challenging to provide effective Rx
while avoiding harm to embryo,fetus
or neonate.
 Centered on risk/benefit ratio.
 Effects of drugs not always known.
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11. Rational prescribing:
Like any other process in health care, writing a
prescription should be based on a series of
rational steps:
1- Make a specific diagnosis
2- Consider ! pathophysiologic implications of !
diagnosis
3- Select a specific therapeutic objective
4- Select a drug of choice
5- Determine ! appropriate dosing regimen
6- Devise a plan for monitoring ! drug’s action &
determine an end point for therapy
7- Plan a program of patient education.

12.  The average woman takes between 3 to 5
medications during her pregnancy making
reproductive toxicity a very important topic for
healthcare professionals.
 Many years ago, the placenta was thought
to be a complete barrier to the outside world.
 As modern medicine is now aware, almost
all substances can cross the placenta. What
differs is how much or to what degree those
substances pass.
 In addition to concern over the effects of
these medications, the effect of the untreated
disease state, which often has its own
undesirable effects, must be considered.
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13. Any drug taken by the pregnant or
breastfeeding patient has the
potential to reach the fetus by
way of maternal circulation or
neonate by way of breastmilk…!!!

14. EFFECTS OF DRUGS ON THE
EMBRYO, FETUS, OR NEONATE
 May vary---
 No effect.
 Little
 Serious- fetal toxicity
 Spontaneous abortion
 Death
 Fetal malfunction
 Fetal malformations.

15. DRUG THERAPY DURING
PREGNANCY
 Centered on risk/benefit
ratio
 Effects of some medication
are known
 Unknown- new
medications, different
combinations, deficiency in
maternal metabolism
 No drug is absolutely safe.

16. RECENT STUDIES
 75% of pregnant clients use 3-10 different
drugs(prescription or otc’s) other than
vitamins/mineral supplements during their
pregnancy.
 Otc’s were used 4 times that of prescription
drugs.

17. Other Obstetricians….
 Others who spoil your Prescription …
 Relatives ( Mother in law & Mother )
 Friends
 Distant relatives
 Dai
 Sometimes Nursing Staff
 Neighbors

18. PHARMACOKENETICS OF DRUGS
DURING PREGNANCY
 Absorption- decreased gi motility causes
increased drug absorption.
 Distribution- protein binding is decreased
causes increased free drug to be available.
 Metabolism-increased hepatic metabolism
occurs for some drugs

19. PHARMACOKINETICS
 Excretion- in the 3rd trimester increased
renal blood flow & GFR causes some
drugs to clear the body faster.

20. Major congenital anomalies Functional & minor anomaliesEmbryo Death
Highly sensitive period Less sensitive period
1 2 3 4 5 6 7 8 9 16 32 38
TA, ASD, and VSD
Amelia/Meromelia
Cleft lip
CNS
TEETH
EARS
PALATE
GENITALIA
Early development Main embryonic period (weeks) Fetal period (weeks)
EYES
Masculinsation
Neural tube defects Mental retardation
HEART
LIMBS
UPPER LIP
Low-set malformed ears and deafness
Microphthalmia, cataracts,glaucoma
Enamel hypoplasia
Cleft palate
Common site(s) of action

21. 12-Apr-16 Dr Shashwat Jani 9909944160 21

22. A challenge …
 Prescribing drugs in pregnancy is an
unusual risk-benefit situation.
 Drugs that may be of benefit or even
life-saving to the mother can deform or
kill the fetus. However, the risk to the
fetus should not be exaggerated.
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23. The FDA Categorization of Drugs
in Pregnancy
 Category A- Controlled studies in women fail
to demonstrate a risk to the fetus in the any
trimester and the possibility of fetal harm
appears remote
 Category B- Animal studies have not
demonstrated a fetal risk but there are no
controlled studies in pregnant women,
12-Apr-16 Dr Shashwat Jani 9909944160 23

24.  Category – C : Drugs should be given only if
the potential benefit justifies the potential risk to
the fetus.
 Category – D : If the drug is needed in a life-
threatening situation for which safer drugs
cannot be used or are ineffective.
 Category – X : The drug is contraindicated in
women who are or may become pregnant
12-Apr-16 Dr Shashwat Jani 9909944160 24

25. Controversy
 Determining the risk of use of a particular medication in
pregnancy is extremely difficult.
 First, pregnant women are almost always excluded from
clinical trials of new medications. Studies are typically conducted in
pregnant animals; however teratogenicity is often species specific
meaning that animal data is not predictive of human risk.
 The risk remains unknown for approximately 90% of the
medications on the market today.
 To further complicate this issue, the baseline rate of congenital
malformations has been reported to be in the range of 1-4%.
 Due to this confounder, a single malformation that occurs
following the use of a medication cannot automatically be linked to
the medication.
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26.  The classic example of a teratogen is
thalidomide.
 Although thalidomide, a medication
widely prescribed in the 1960s as a
treatment for morning sickness, is
associated with a high incidence of a very
specific severe limb deformity, it took
three years to make the connection
between the defect and the drug and to
stop using it in pregnant women.

27. Very high doses of vitamin A, D and E in
pregnancy have been linked to birth
defects.
Professor Owens said doctors should
not underestimate the dosage of vitamin
supplements that some pregnant women
consumed, particularly if they used high-
potency multivitamins.
Professor Julie Owens, from Adelaide
University's school of pediatrics and
reproductive health,

28. Some prescription meds can harm fetus :
November 17, 2009 .
More than six percent of expectant mothers in
Quebec consume prescription drugs that are
known to be harmful to their fetuses,
according to a Université de Montréal
investigation published in the British Journal
of Obstetrics and Gynaecology.

29. Asthmatic children: Did mom use her
pump during pregnancy?
October 5, 2009
Expectant mothers who eschew asthma treatment during
pregnancy heighten the risk transmitting the condition to
their offspring, according to one of the largest studies of its
kind published in the European Respiratory Journal.
A research team from the Université de Montréal, the Hôpital
du Sacré-Cœur de Montréal and Sainte-Justine University
Hospitl Research Center found that 32.6 percent of
children born to mothers who neglected to
treat their asthma during pregnancy
developed the respiratory illness themselves.

30. Sexually transmitted disease,
Urinary tract infections
may be bad combination for birth defect
June 20, 2008
[B]Chances of gastroschisis increase fourfold
in babies whose moms have both
infections[/B]
University of Utah researchers report in the
online British Medical Journal.

31. One wrong or illegible prescribed drug
& …….

32. Commonly prescribed teratogenic Drugs…

33. Frequently used drugs in
pregnancy:
 Vitamins,
 anti-emetics,
 analgesics,
 antipyretics,
 sedatives,
antibiotics,
laxatives,
antacids,
diuretics,
antihistamines

34. Medications used to manage serious medical
complications / pregnancy complications:
 Hypertension, PIH, diabetes, cardiac disease,
bronchial asthma, thyroid disease, cancers,
poly-hydramnios, pre-term labor, general and
local anesthetics,coagulation disorders, auto-
immune disorders, epilepsy etc…

35. Some Medications Considered Safe for Use During
Pregnancy :
Condition Medication
Asthma · Budesonide inhaled or nasal spray
(Pulmicort®, Rhinocort ®)
Bladder infection (UTI) · Nitrofurantoin (Macrobid®)
- Avoid in patients with possible
G6PD deficiency
Cough · Dextromethrophan (Robitussin DM
sugar free ®)
Constipation · Metamucil® , Citrucel®,
· Docusate (Colace®, Ducolax ®)
· Milk of magnesia.
· Polyethyelene glycol (Miralax®)

36. Diabetes · Insulin
· Glyburide (Micronase®)
· Metformin (Glucophage®)
Diarrhea · Loperamide (Imodium A-D ®)
Gas · Simethicone (Gas-X ®, Mylicon ®,
Phazyme ®)
Gastroesophageal reflux
disease (GERD),
· Ranitidine (Zantac®)
· Cimetidine (Tagamet®)
Hayfever, sneezing, runny
nose, itchy watery eyes
· Chlorpheniramine (Chlor-Trimeton
®,Efidac ®,
Teldrin ®)
· Diphenhydramine (Benadryl ®)
Clemastine (Tavist Allergy ®)
Headache or fever: · Acetaminophen
(APAP,Paracetamol,Panadol, Tylenol®)

37. High blood pressure · Methyldopa (Aldomet®)
Hyperprolactinemia · Bromocriptine (Parlodel®)
· Carbergoline (Dostinex®)
Hypothyroidism · Thyroid hormone
· Levothyroxine (Synthroid ®, Levoxyl ®)
Infection · Acyclovir (Zovirax ®)
· Azithromycin (Zithromax ®)
· Cepaholosporins
examples: Cephalexin (Keflex®),
Cefazolin (Ancef ®), cefaclor (Ceclor®)
· Clindamycin (Cleocin®)
· Erythromycin
· Penicillins
example Amoxicillin (Amoxil®),
Amoxicillin Clavulanate (Augmentin®),
methicillin, carbenicillin
· Metronidazole (Flagyl®)

38. Motion sickness · Dimenhydrinate (Dramamine ®)
Nasal congestion · Pseudoephedrine (Sudafed ®)
-Avoid in first trimester.
Nasal congestion, sneezing,
runny nose, itchy watery
eyes
· Actifed Cold and Allergy ®
Ingredients: Triprolidine,
Pseudoephedrine
-Avoid in first trimester.
Nasal congestion, sneezing,
runny nose, itchy watery
eyes, fever, and headache
· Actifed Cold and Sinus ®
Ingredients: Acetaminophen,
Chlorpheniramine,
Pseudoephedrine- Avoid in first
trimester.
Nausea · Ginger
· Pyridoxine 25 mg PO TID WITH
Unisom Sleep Tabs (Doxylamine
Succinate 25 mg) 1/2 tablet TID
· Metoclopramide (Reglan ® )

39. Preeclampsia Magnesium sulfate
Vaginal yeast infection · Clotrimazole cream (Gyne-Lotrimin®)

40. Process of writing a rational
prescription :
1. Define the patient’s problem.
2. Specify the therapeutic objective i.e.
what do you want to achieve with the
treatment.
3. Verify the suitability of your treatment
i.e. check effectiveness and safety.

41. Process of writing a rational
prescription :
4. Start the treatment.
5. Give information instructions and
warning, ask the patient to paraphrase.
6. Monitor the therapy and stop if
required.

42. Factors Influencing Prescribing
Education
Patient
Relatives
Media Peers
Product
licence
Marketing
Research
Policies
Prescriber

43. Some influences are positive ones
 Policies, guidelines
 Research evidence
 Cost and clinical effectiveness
 Clinical Experience

44. Other influences are not so
positive? Or are they?
 The prescribers personal selection list (known
as P drugs)
 Custom and practice
 Influence of opinion leaders, colleagues and
peers, Pharmas.

45. Prescription Writing is Obstetrician’s Burden

46. Take Home Message…
 Consider non drug options
 Avoid drugs if possible during weeks 6-10
 Do not start any medication unless clearly
indicated
 Do not discontinue medicines that
successfully maintain the maternal condition
unless there are clear indications to do so
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47.  Ask about and document non-prescription
medicines
 Have a pregnancy medication reference
available
 Favor older medicines with longer record of
use
 Keep doses low before delivery if possible
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48.  Consult with pediatrician.
 Educate your patient
 Report adverse outcomes
 Always consider the effect of not treating
 Remember that few drugs are absolutely
contraindicated
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49. Avoid Polypharmacy
 Optimize non-pharmacologic alternatives
 Determine whether each medication:
 Is necessary
 Is effective
 Is at lowest effective dose
 Does not adversely alter other
medication effect 49

50. Simple
 Use generics
 Use least frequent dosing needed
 Tie to scheduled daily activities, meals,
sleep/wake
 Provide legible written instructions
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51. Remember
Pregnancy is a
physiological
condition…!!!

52. Length of
prescription is
inversely
proportional to
Knowledge of the
Physician…!!!

53. Dr Shashwat Jani
9909944160
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