DRUG PRESCRIBING PATTERN IN OBSTETRICS

1. DRUG PRESCRIBING PATTERN IN OBSTETRICS A CASE STUDY OF UNIVERSITY OF BENIN TEACHING HOSPITAL (UBTH), NIGERIA BY DR TAIWO FILUSI, DR PATRICK ERAH AND DR ADEDAPO ANDE

2. AUTHORS DR TAIWO EMMANUEL FILUSI; B.PHARM, PHARM D PHARMACIST COUNCIL OF NIGERIA, LAGOS DR PATRICK ERAH; B.PHARM, M PHARM, PHD DEPT OF CLINCAL PHARMACY AND PHARMACY PRACTICE, UNIVERSITY OF BENIN, NIGERIA DR ADEDAPO ANDE; BSc, MB:ChB, FWACS, FICS,MPH CONSULTANT OBSTETRICIAN AND GYNAECOLOGIST UBTH, NIGERIA

3. DEFINITIONS • Obstetrics- The science that deals with management of pregnancy from prenatal, parturition, to pueperal stages. • Prenatal- Between the last menstrual period and delivery (usually 40 weeks) • Parturition- Labour or act of delivery • Pueperium- The period immediately following delivery till involution. (usually 6-8 weeks)

4. The Thalidomide Tragedy • Thalidomide – A wonder drug that turned to a wasteful dragon ………………

5. Summary of Other Sordid tales • Margaret from USA took Isotretinoin (Acutane) for 6 weeks for treatment of acne but had a premature deliver at 34 weeks of a baby with water in brain and heart deformities • Deborah in the UK was given Ritodrine (Yutopar) to inhibit premature labour. She died as a result of adverse drug reactions due to an error in mixing the drug with saline solution instead of dextrose solution.

6. REMEMBER • Drugs can have harmful effects at anytime during pregnancy • 1st trimester- drugs cause congenital malformations (teratogenesis) • 2nd & third trimesters- growth and functional development and fetal tissues are affected • Before term/Labour –Labour complications and effect on the neonate. • However, irrational fear of using drugs during pregnancy can also result in harm

7. RULES FOR PRESCRIBING IN PREGNANCY ........... • If possible, review patients and counsel them before planning a pregnancy • Question the real need for any drug in pregnancy giving due consideration to alternative methods of treatment • Review all drug regimens carefully to minimize risks • Use medicines that have been widely employed in pregnancy for years in preference to the latest drugs

8. CONDITIONS WHEN DRUGS MIGHT BE USED IN PREGNANCY ……… • Infertility, when drugs may be used to stimulate ovulation • Acute conditions that arise during pregnancy (pain, fever, infections, coughs and colds) or chronic conditions unrelated to pregnancy (Asthma, Epilepsy, Diabetics). • Conditions commonly related to pregnancy (morning sickness, hypertension, anaemia) • Complications of pregnancy and labour (threatened abortion, premature labour, toxaemia, pain in childbirth.

9. TERATOGENIC DRUGS Few essential drugs conclusively proven to be teratogenic in human include: • Alkylating agents, e.g Cyclophosphamide, Chlormethidine, • Antimetabolite agents e.g. Cytarabine, Fluorouracil, Mercaptopurine, Methotrexate etc. • Carbamazepine • Common anticoagulants e.g Warfarin • Lithium • Penicillamine • Phenytoin • Valproic acid

10. SAFETY OF ANTIBIOTICS DURING PREGNANCY • All drugs, including antibiotics should be avoided during pregnancy, however when necessary, the following guideline can be used

11. SAFETY OF ANTIBIOTICS DURING PREGNANCY

12. SAFETY OF ANTIBIOTICS DURING PREGNANCY CONTD

13. WHO Core Prescribing Indicators The WHO Core indicators provide an objective evaluation of drug use situation in a country, region or individual health facility. They include:- • Average no of drugs per encounter • % of drugs prescribed by generic name • % of encounters with an antibiotic prescribed • % of encounter with an injection prescribed • % of drugs prescribed from the essential drug list or formulary.

14. Aims and objectives Main Objective:- To investigate drug prescribing pattern by obstetricians in UBTH Specific Objectives • To assess rational prescribing by obstetricians in UBTH using WHO core prescribing indicators • To determine the most frequently prescribed drugs in prenatal, parturition, and puerperium • To determine the most commonly prescribed classes of drugs in prenatal, perinatal, and puerperium

15. Aims and objectives…… 4. To determine the most commonly prescribed antibiotics 5. To determine the most frequently diagnosed illness. 6. To determine the most commonly prescribed drug for the most frequently diagnosed illness

16. Methodology Study Location Obstetrics and gynaecology department, UBTH. UBTH is 550 bed, tertiary health care facility, having all the basic areas of medical specialty. It also serves as a teaching hospital for medicine, pharmacy, nursing, and medical laboratory students. • Sample Selection: Case notes of patients from each of the ten consulting units in Jan.–Dec. 2003 were randomly selected and reviewed retrospectively for drug use from antenatal booking through labour and delivery to six weeks post partum. • Sample Size: 473 encounters and 839 prescriptions

17. Procedure • Consent to undertake the study was obtained • Familiarization with the department, operations and staff • Discussion and consultation with relevant staff • Casenotes retrospectively reviewed through prenatal, perinatal and postnatal care • Data recorded in a customised data sheet • Consultants were asked questions arising from case-note review

18. Data management and analysis Evaluation was done using: 1.WHO core prescribing indicators 2. Other parameters 3.Microsoft excel 4. Manual calculations

19. Results.. Subspecialty division and consultant distribution

20. Results... Prescribers Distribution in the ten consulting units

21. Results…..Pharmacists staffing and cadre at O &G Pharmacy

22. Results…Age distribution of booking (Prenatal) patients

23. Results…Conformity of prescribers to WHO prescribing indicators

24. Summary of most frequently prescribed drugs and diagnosed illness

25. Summary of most frequently prescribed drugs and diagnosed illness

26. Four Most Frequently Prescribed drugs in Prenatal care • Routine Haematinics includes Ferrous Sulphate tablets, folic acid tablets and pyremethamine (Daraprim) tablets. • Total number of prescriptions - 218

27. 30 25 20 No. of time prescribed 15 Series1 10 5 0 Oxytocin inj Sosegon inj Vitamin K inj Paracetamol Ergotamine tablets inj Results…. Five most frequently prescribed drugs in perinatal • Total number of prescriptions - 218 • Total number of prescriptions - 218 • Total number of prescriptions - 218 • Total number of prescriptions - 218 • Total number of prescriptions - 218 • Total number of prescriptions - 218 • Total number of prescriptions - 218 • Total number of prescriptions - 218 • Total number of prescriptions - 218

28. 40 35 30 25 No. of time prescribed 20 15 10 5 0 Fersolate Tabs Folic Acid Tabs Vitamin C Tabs Augmentin Tabs Paracetamol Tabs Metronidazole Tabs Results…. Six most frequently prescribed drugs in puerperium

29. Results…… Five most frequently prescribed classes of drugs in prenatal

30. Results… Four most frequently prescribed classes of drugs in parturition

31. Results... Five most commonly prescribed classes of Drugs in Puerperium

32. Results… Three most commonly prescribed classes of drugs in prenatal, Parturition, Puerperium

33. Results…Seven most commonly prescribed antibiotics in Prenatal, Parturition and Puerperium

34. Results…Three most frequently diagnosed illness (in Prenatal)

35. Results…Frequency of Antimalarial Prescription

36. RECOMMENDATIONS • Pharmacists like Medical Doctors, need more concentration or specialization in basic clinical areas to enhance their professional relevance in medical practice. • WHO should conduct studies in Obstetrics to establish standard core prescribing indicators, because the currently available standard are not applicable to Obstetrics • Use of Daraprim (Pyrimethamine) as routine drug in first trimester should be reconsidered since Pyrimethamine (Daraprim) is a folate antagonist and in fact theoretically teratogenic.

37. RECOMMENDATIONS ….. • The obstetricians need more awareness on the necessity of prescribing in generics as advocated by WHO. • There is need to repeat this study using another facility to compare and contrast the results. • It is pertinent to note that ACT use is now incorporated in the Malaria Treatment Policy for management of malaria in pregnant women in Nigeria. There is need for caution in order to avoid another “Thalidomide tragedy”.

38. CONCLUSION • The WHO prescribing indicators are useful partly but not absolutely in analyzing rational prescribing in obstetrics. • UBTH Obstetricians conform to applicable indicators except prescription in generics which fell below standard. • Malaria and Anaemia were the most commonly diagnosed illness in pregnancy. • Overall, prescriptions compare favourably with documented standard and drugs that commonly pose risk to faeto-maternal well being are not used in UBTH.

39. REFERENCES • Chetley A., problem drugs, ‘Drugs in Pregnancy’ Amsterdam health action International, 1992, p. 125 – 135. • How to investigate drug use in health facilities – selected drug use indicators, WHO, Geneva, 1993, (WHO/DAP/93.1). • WHO, Geneva, 1993, (WHO/DAP/93.1). • WHO Model Formulary, WHO, U.K, 2002. P. 477.478.

40. Thank you for your attention