7: Obstetrics, gynaecology, and urinary tract disorders

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1 Original Date of issue: 31/12/2005 Last eviewed: 11/11/2011 Version:4 Page 1 of 6 7: Obstetrics, gynaecology, and urinary tract disorders 7.1 Drugs used in obstetrics Prostaglandins and oxytocics Carboprost Injection (250micrograms/1ml) Dinoprostone Vaginal Gel (1mg/2.5ml, 2mg/2.5ml) Dinoprostone Vaginal Delivery System (10mg/24 hours) Ergometrine Injection (500micrograms/1ml) Gemeprost Pessaries (1mg) Oxytocin Injection (5units/1ml, 10units/1ml) Syntometrine Injection (1ml) Misoprostol tablets 200micrograms (unlicensed) ectal use Misoprostol tablets 200micrograms Vaginal and oral use Comments For second-line treatment of PPH after oxytocin / ergometrine or if oxytocin / ergometrine inappropriate For medical management of miscarriages Ibuprofen Injection 5mg/ml For treatment of patent ductus arteriosus Mifepristone Mifepristone Tablets (200mg) Myometrial relaxants Atosiban 6.75mg injection Atosiban 37.5mg injection concentrate Use in accordance with protocol for pre-term labour between 28 and 33 weeks taking into account fibronectin test. For labour ward only

2 Original Date of issue: 31/12/2005 Last eviewed: 11/11/2011 Version:4 Page 2 of Treatment of vaginal and vulval conditions Preparations for vaginal atrophy Estriol Vaginal Cream (80g, 15g) Estradiol Vaginal Tablets (25micrograms) Estriol Pessaries (500micrograms) Vaginal and vulval infections Clindamycin Vaginal Cream 2% (40g with 7 applicators) Clotrimazole 2% and 10% Vaginal Cream (5g) Clotrimazole Pessaries (100mg, 500mg) Miconazole 2% Vaginal Cream (78g) Miconazole Pessaries (100mg) 7.3 Contraceptives Combined hormonal contraceptives Cilest Tablets Evra Transdermal patches Femodene Tablets Femodette Tablets Loestrin 20 & 30 Tablets Logynon Tablets Marvelon Tablets Mercilon Tablets Microgynon Tablets Norimin Tablets Ovysmen Tablets Trinovum Tablets Yasmin Tablets

3 Original Date of issue: 31/12/2005 Last eviewed: 11/11/2011 Version:4 Page 3 of Progesterone-only contraceptives Oral progesterone only contraceptives Desogestrel Tablets 75micrograms (Cerazette) Levonorgestrel Tablets 15micrograms, 30micrograms (Norgeston) Norethisterone Tablets 350micrograms (Noriday) Etynodiol Tablets 500micrograms (Femulen) Parenteral progesterone only contraceptives Medroxyprogesterone acetate injection 150mg/ml C Etonogestrel Implant (68mg) Implanon Family planning clinic doctors only who have been trained to insert it Intra-uterine progesterone only device Mirena IU System Spermicidal contraceptives Gygel (30g) Contraceptive devices Coils Flexi T 300 Gynefix interval Nova -T 380 Multiload copper coil T-Safe 380A TT-380 slimline coil UT 380 short coil Caps Diaphragm Flat Spring (60mm, 65mm, 70mm, 75mm, 80mm, 85mm, 90mm) Diaphragm arching spring (various sizes bought in as necessary) Femidom

4 Original Date of issue: 31/12/2005 Last eviewed: 11/11/2011 Version:4 Page 4 of 6 Emergency Contraception Hormonal methods Hormonal emergency contraceptives include levonorgestrel and ulipristal (non formulary): either drug should be taken as soon as possible after unprotected intercourse to increase efficacy. Levonorgestrel is effective if taken within 72 hours of unprotected intercourse and may also be used between 72 and 120 hours after unprotected intercourse (unlicensed) but efficacy decreases Ulipristal, a progesterone receptor modulator, is effective if taken within 120 hours of unprotected intercourse. Levonorgestrel is less effective than insertion of an intrauterine device (see below). Ulipristal is as effective as levonorgestrel, but its efficacy compared to an intra-uterine device is not yet known. If vomiting occurs within 2 hours of taking levonorgestrol or within 3 hours of taking ulipristal, a replacement dose should be given. If an antiemetic is required domperidone is preferred. When prescribing hormonal emergency contraception the doctor should explain: That the next period may be early or late That the barrier method of contraception needs to be used until the next period The need to return promptly if any lower abdominal pain occurs because this could signify ectopic pregnancy See BNF for further details Levonorgestrol tablets 1.5mg Intrauterine device Insertion of an intrauterine device is more effective than oral levonorgestrel for emergency contraception. A copper intrauterine device (section 7.3.4) can be inserted up to 120 hours after unprotected intercourse; sexually transmitted disease should be tested for and insertion of the device should usually be covered by antibacterial prophylaxis. If intercourse has occurred more than 5 days previously the device can still be inserted up to 5 days after the earliest likely calculated ovulation ( i.e. within the minimum period before implantation), regardless of the number of episode of unprotected intercourse earlier in the cycle.

5 Original Date of issue: 31/12/2005 Last eviewed: 11/11/2011 Version:4 Page 5 of 6 Drugs for genitor urinary disorders Drugs for urinary retention Alfuzosin Tablets (2.5mg, 10mg) Doxazosin Tablets (1mg, 2mg, 4mg) Tamsulosin M/ Tablets /Capsules (400micrograms) Terazosin Tablets (2mg, 5mg) Drugs for urinary frequency, enuresis, and incontinence First line Second line Oxybutynin Tablets (2.5mg, 3mg, 5mg) Oxybutynin Elixir (2.5mg/5ml) Oxybutinin M/ Tablets (5mg, 10mg) Tolterodine M/ Capsules (4mg) Tolterodine Tablets (1mg, 2mg) Trospium Tablets (20mg) Solifenacin tablets (5mg, 10mg) Comments Modified release oxybutynin is expensive compared with the standard release preparations. They should only be used where compliance is a problem 2 nd line use by Consultant Urologists and Gynaecologists for patients with known detrusor instability, who are unable to tolerate oxybutynin C Duloxetine capsules (20mg, 40mg) (Yentreve ) Oxybutynin patches (3.9mg/24 hours) Consultant Urologist / Gynaecologist use only for stress urinary incontinence as an alternative to surgical treatment. Use third line after other treatments

6 Original Date of issue: 31/12/2005 Last eviewed: 11/11/2011 Version:4 Page 6 of Drugs used in urological pain Potassium Citrate Mixture Sodium hyaluronate intravesicle solution (40mg/50ml) (Cystistat) For use by Consultant Surgeon only for patients with intractable interstitial cystitis Bladder instillations and urological surgery Glycine 1.5% Irrigation (1L, 3L Easyflow) Solution G (100ml) Sodium chloride 0.9% bladder irrigation (100ml) Urotainer BCG Intravesical (81mg) For Consultant Urologists use in patients with carcinoma in situ of the bladder BCG Diluent (Immucyst) For Consultant Urologists use in patients with carcinoma in situ of the bladder Drugs for erectile dysfunction Alprostadil Applicator (1mg, 500micrograms) Muse Alprostadil Injection (5micrograms, 10micrograms, 20micrograms, 40micrograms) Sildenafil Tablets (25mg, 50mg, 100mg) Tadalafil Tablets (10mg, 20mg) Vardenafil Tablets (5mg, 10mg, 20mg) Papaverine Injection 40mg/1ml Although not licensed the smooth muscle relaxant papaverine has also been given by intracavernosal injection for erectile dysfunction. Patient with neurological or psychogenic impotence are more sensitive to the effects of papaverine than those with vascular abnormalities.