Continuous Tocolysis Research Articles

Current Approach for External Cephalic Version in Germany.

Introduction Fetal breech presentation at terms occurs in 3 – 6% of pregnancies. External cephalic version can reduce the number of cesarean sections and vaginal breech deliveries. Different approaches are used to carry out external cephalic version. This study looked at the different approaches used in Germany and compared the approach used with the recommendations given in German and international guidelines. Material and Methods An anonymized online survey of 234 hospitals in Germany was carried out in 2018. In addition to asking about hospital structures, questions also focused on how external version was carried out in practice (preparations, tocolysis, anesthetics, etc.), on relative and absolute contraindications and on the success rate. Results 37.2% of the hospitals approached for the survey participated in the study. Of these, 98.8% performed external version procedures. The majority of participating hospitals were university hospitals (26.4%) and maximum care hospitals (35.6%) with an average number of more than 2000 births per year (60.9%). External cephalic version is the preferred (61.7%) obstetrical procedure to deal with breech presentation, rather than vaginal breech birth or primary cesarean section. 45.8% of respondents carry out external version procedures on an outpatient basis, and 42.1% of hospitals perform the procedure as an inpatient intervention, especially from the 37th week of gestation. Prior to performing an external version procedure, 21.6% of surveyed institutions carry out a vaginal examination to evaluate possible fixation of the fetal rump. 95.5% of institutions used fenoterol for tocolytic therapy; the majority using it for continuous tocolysis (70.2%). 1 – 3 attempts at external version (8.4%) were usually carried out by a specific senior physician. In most cases, no analgesics were administered. The reported rate of emergency cesarean sections was very low. The most common indication for emergency C-section was pathological CTG (56,7%). The assessment of relative and absolute contraindications varied, depending on the surveyed hospital. 67.5% asked patients to empty their bladders before carrying out external version, while 10.8% carried out external version when the bladder was filled. The reported success rate was more than 45%. After successful version, only 14.8% of hospitals arranged for patients to wear an abdominal binder. For 32.4%, the decision to apply an abdominal binder was taken on a case-by-case basis. Conclusion The approach used in Germany to carry out external cephalic version is based on the (expired) German guideline on breech presentation. Based on the evidence obtained, a number of individual recommendations should be re-evaluated. More recent international guidelines could be useful to update the standard procedure.

Comparison study between nifedipine and progesterone as maintenance tocolysis after arrested preterm labor

Objective The aim was to compare the efficacy and safety of nifedipine and progesterone for maintenance tocolysis after arrested preterm labor and their perinatal outcomes. Background Preterm birth (before 37 completed weeks of gestation) is a 'major cause of death' and a significant cause of long-term loss of human potential. Maintenance tocolysis is continued tocolysis after arrested preterm labor to prevent the recurrence of preterm labor pains. Patients and methods A prospective randomized comparative clinical study was carried out on 66 pregnant women who had preterm labor (six cases lost to follow-up) and attended the Obstetrics and Gynecology Outpatient Clinic at Menoufia Teaching Hospital during the period from March to August 2017. Detailed history, laboratory investigations, obstetric, and ultrasound follow-up study were performed. Results There was no significant difference (P > 0.5) between nifedipine and progesterone groups regarding maternal age and gestational age on admission (weeks), mode of delivery, and neonatal birth weight. However, there was a statistically significant difference (P ≤ 0.05) regarding mean blood pressure before and after treatment in nifedipine group. Moreover, there were less occurrences of neonatal respiratory distress and neonatal ICU admission in the nifedipine group. Additionally, onset of labor between 24 and 34 and between 34 and 37 weeks was significantly less frequent in progesterone group than in nifedipine group. Conclusion We found a superiority of progesterone over nifedipine for maintenance tocolysis. We would only comment that progesterone looks like a promising drug in this regard, and further large studies are required to establish this fact.

Nifedipine maintenance tocolysis and perinatal outcome: an individual participant data meta-analysis.

Preterm birth is the leading cause of neonatal mortality and morbidity in developed countries. Whether continued tocolysis after 48hours of rescue tocolysis improves neonatal outcome is unproven. To evaluate the effectiveness of maintenance tocolytic therapy with oral nifedipine on the reduction of adverse neonatal outcomes and the prolongation of pregnancy by performing an individual patient data meta-analysis (IPDMA). We searched PubMed, Embase, and Cochrane databases for randomised controlled trials of maintenance tocolysis therapy with nifedipine in preterm labour. We selected trials including pregnant women between 24 and 36(6/7) weeks of gestation (gestational age, GA) with imminent preterm labour who had not delivered after 48hours of initial tocolysis, and compared maintenance nifedipine tocolysis with placebo/no treatment. The primary outcome was perinatal mortality. Secondary outcome measures were intraventricular haemorrhage (IVH), necrotising enterocolitis (NEC), infant respiratory distress syndrome (IRDS), prolongation of pregnancy, GA at delivery, birthweight, neonatal intensive care unit admission, and number of days on ventilation support. Pre-specified subgroup analyses were performed. Six randomised controlled trials were included in this IPDMA, encompassing data from 787 patients (n=390 for nifedipine; n=397 for placebo/no treatment). There was no difference between the groups for the incidence of perinatal death (risk ratio, RR1.36; 95% confidence interval, 95%CI 0.35-5.33), intraventricular haemorrhage (IVH)≥gradeII (RR0.65; 95%CI 0.16-2.67), necrotising enterocolitis (NEC) (RR1.15; 95%CI 0.50-2.65), infant respiratory distress syndrome (IRDS) (RR0.98; 95%CI 0.51-1.85), and prolongation of pregnancy (hazard ratio, HR0.74; 95%CI 0.55-1.01). Maintenance tocolysis is not associated with improved perinatal outcome and is therefore not recommended for routine practice. Nifedipine maintenance tocolysis is not associated with improved perinatal outcome or pregnancy prolongation.

The Effect of Proactive Dose Acceleration in Triplets Receiving Continuous Subcutaneous Tocolysis*

The Effect of Proactive Dose Acceleration in Triplets Receiving Continuous Subcutaneous Tocolysis*

Clinical and Economic Outcomes of Continuous Subcutaneous Tocolysis

Clinical and Economic Outcomes of Continuous Subcutaneous Tocolysis

Pulsatile vs. continuous parenteral tocolysis: comparison of side effects

Bolus tocolysis has been developed to reduce the dose of fenoterol compared to continuous tocolysis. Whereas the high efficacy of pulsatile application of fenoterol has been shown, the proof of reduced side effects is still lacking. A total of 59 patients with preterm labor were divided in three groups: (1) continuous tocolysis and oral application of magnesium ( n=19), (2) continuous tocolysis and parenteral application of magnesium ( n=20), (3) pulsatile tocolysis (bolus tocolysis) and oral application of magnesium ( n=20). Heart rate, systolic and diastolic blood pressure, serum K + and serum Mg ++ were quantified before tocolysis and after 2, 8 and 24 h. β-blockers and water balance were recorded over 24 h. Subjective side effects were quantified using a questionnaire with scales graduated covering palpitations, tremor, diaphoresis, thirst, precardialgia and nausea/vomiting. The analysis of the data revealed significantly fewer side effects concerning heart rate, plasma K + level and the subjective side effects among patients treated with bolus tocolysis than among those treated with continuous tocolysis. Between the latter two groups, no significant difference was found. Concerning blood pressure and need for β-blockers, no significant differences were found between the three groups. The results of the present study show that especially the side effects subjectively found to be disagreeable by the patients are reduced by pulsatile tocolysis, whereas other side effects show only slight differences between the study groups.

Vergleichende Untersuchung maternaler Nebenwirkungen verschiedener Formen der intravenösen Therapie mit Fenoterol bei vorzeitiger Wehentätigkeit

The aim of the present study was to compare different regimes of intravenous fenoterol tocolysis concerning their side effects. A total of 59 patients with intravenous tocolysis due to preterm labor has been studied. They were chronologically alternating and thus randomly stratified into three groups: (a) continuous i.v.-tocolysis and oral application of magnesium sulfate (b) continuous i.v-tocolysis and i.v.-application of magnesium sulfate (c) pulsatile i.v.-application of fenoterol (bolus tocolysis) and oral application of magnesium sulfate. For all groups, heart rate, systolic and diastolic blood pressure, need for beta-blockers, K+, water balance over 24 hours as well as different subjective side effects were quantified. The side effects were found to be significantly less among patients treated with bolus tocolysis and they were also found to be slightly less in continuous tocolysis with i.v.- application of magnesium compared to continuous tocolysis with oral Mg2+ substitution; however, the difference between the two groups treated with continuous tocolysis was not significant. The present results suggest that bolus tocolysis shows significantly less side effects compared to the continuous tocolysis and thus it should be favored in clinical practise.

First controlled study of ???SLOW MAG??? for continued tocolysis

First controlled study of ???SLOW MAG??? for continued tocolysis

Safety and Efficacy of Combined Ritodrine and Magnesium Sulfate for Preterm Labor: A Method for Reduction of Complications

Ritodrine hydrochloride and magnesium sulfate used in combination for preterm labor tocolysis have been cited for yielding excessively high complication rates. A retrospective chart review was performed to assess the frequency of these complications and to determine whether tocolysis can be continued despite complications. Of 95 patients managed with dual tocolytics, 61 had side effects sufficiently serious to warrant cessation of tocolytic therapy for an overall complication rate of 64%. After evaluation for objective evidence of pathologic conditions, 41 (67%) patients were restarted on dual tocolytics without further complication. It was deemed inappropriate to restart tocolysis in 20 patients, resulting in a 21% rate of complications. This allowed a significant increase in the number of patients delivering after 36 weeks (19.5% versus 50%, p less than 0.02) and a decrease in neonatal intensive care unit days per infant (3 versus 15.5 days, p less than 0.02). This suggests that aggressive continued tocolysis with multiple agents can be safe and efficacious with appropriate evaluation.

Bolus tocolysis: Treatment of preterm labor with pulsatile administration of a β-adrenergic agonist

The treatment of premature labor with beta-adrenergic substances is complicated by side effects. Although most human control mechanisms are pulsatile, therapy is usually administered continuously. We designed a microprocessor-controlled pump to allow pulsatile tocolytic infusion, hoping to reduce the total dose and thus the side effects. In 33 patients pulsatile bolus tocolysis was compared with continuous tocolysis in a control group of 38 patients. Bolus tocolysis required considerably less beta-sympathomimetic agent for comparable therapeutic success (median dosage 3.0 versus 15.9 mg, p less than 0.001). Duration of therapy under bolus tocolysis was also significantly shorter (p less than 0.05). Birth weight was higher after bolus tocolysis (median 3070 versus 2580 gm, p = 0.05). Additional indicators favored bolus tocolysis but were not statistically significant: a longer gestational period, fewer infants weighing less than 2500 gm, and a lower incidence of respiratory distress syndrome. Pulmonary edema occurred in one patient during continuous tocolysis.

Tocolysis with oral magnesium

Seventeen patients in whom uterine activity responded favorably to parenteral magnesium sulfate were given oral magnesium gluconate for continued tocolysis. The mean serum magnesium level before therapy was 1.44 ± 0.22 mg/100 ml, whereas 2 hours after initiation of oral magnesium it was 2.16 ± 0.32 mg/100 ml (p < 0.05). One patient had nausea without vomiting or diarrhea. These data suggest that magnesium ingested orally can raise the serum magnesium level significantly.