Abstract
BackgroundSubcutaneous terbutaline (SQ terbutaline) infusion by pump is used in pregnant women as a prolonged (beyond 48–72 h) maintenance tocolytic following acute treatment of preterm contractions. The effectiveness and safety of this maintenance tocolysis have not been clearly established. We aimed to systematically evaluate the effectiveness and safety of subcutaneous (SQ) terbutaline infusion by pump for maintenance tocolysis.Methodology/Principal FindingsMEDLINE, EMBASE, CINAHL, the Cochrane Library, the Centre for Reviews and Dissemination databases, post-marketing surveillance data and grey literature were searched up to April 2011 for relevant experimental and observational studies.Two randomized trials, one nonrandomized trial, and 11 observational studies met inclusion criteria. Non-comparative studies were considered only for pump-related harms. We excluded case-reports but sought FDA summaries of post-marketing surveillance data. Non-English records without an English abstract were excluded. Evidence of low strength from observational studies with risk of bias favored SQ terbutaline pump for the outcomes of delivery at <32 and <37 weeks, mean days of pregnancy prolongation, and neonatal death. Observational studies of medium to high risk of bias also demonstrated benefit for other surrogate outcomes, such as birthweight and neonatal intensive care unit (NICU) admission. Several cases of maternal deaths and maternal cardiovascular events have been reported in patients receiving terbutaline tocolysis.Conclusions/SignificanceAlthough evidence suggests that pump therapy may be beneficial as maintenance tocolysis, our confidence in its validity and reproducibility is low, suggesting that its use should be limited to the research setting. Concerns regarding safety of therapy persist.
Highlights
Preterm birth is defined as delivery before the completion of the 37th week of gestation and affects 13 percent (542 893 births in 2006) of live births in the United States [1]
In light of a recent ‘‘black box’’ warning issued by the FDA, this review provides a contemporary and definitive summary of the available literature on the benefits and harms of terbutaline maintenance tocolysis
Despite meta-analysis, evidence from the two small RCTs remained underpowered for differences in the outcomes of benefit and harms
Summary
Preterm birth is defined as delivery before the completion of the 37th week of gestation and affects 13 percent (542 893 births in 2006) of live births in the United States (http://www.cdc.gov/ nchs/fastats/birthwt.htm) [1]. Terbutaline sulfate has been used off-label in selected patients as a maintenance therapy to inhibit uterine contractions for extended periods of time following primary tocolysis with first-line agents. Despite previous reviews which questioned the effectiveness and safety of subcutaneous terbutaline infusion, the use of such therapy is not uncommon in the United States [3,4]. The exact frequency of use of subcutaneous terbutaline infusion for the prevention of preterm birth is not known. Subcutaneous terbutaline (SQ terbutaline) infusion by pump is used in pregnant women as a prolonged (beyond 48–72 h) maintenance tocolytic following acute treatment of preterm contractions. The effectiveness and safety of this maintenance tocolysis have not been clearly established. We aimed to systematically evaluate the effectiveness and safety of subcutaneous (SQ) terbutaline infusion by pump for maintenance tocolysis
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