Tocoliticos en la amenaza de parto prematuro / Tocolitics in premature labor

La amenaza de parto prematuro se considera hoy en día como una urgencia obstétrica en la que, si no se realiza alguna intervención desemboca en un parto prematuro. Por tanto, una vez confirmado el diagnóstico, el tratamiento consiste en la administración de tocolíticos, cuyo objetivo principal es el retraso del nacimiento ganando tiempo para administrar maduración pulmonar y neuroprotección con el fin de disminuir el síndrome de dificultad respiratoria y parálisis cerebral, así como lograr el traslado de la madre a un centro de referencia, si fuere el caso. La elección de un fármaco u otro debe basarse en una adecuada valoración riesgo-beneficio, una vez tenida en cuenta la situación clínica de cada gestante. El empleo de tocolíticos al inicio de este proceso es esencial y en esta revisión se analiza la información disponible sobre su uso en la amenaza de parto prematuro

The preterm labour is now considered an obstetric emergency in which, if no intervention is performed, it leads to premature delivery. Therefore, once the diagnosis has been confirmed, the treatment consists of the administration of tocolytics, whose main objective is to delay the birth by gaining time to administer lung maturation and neuroprotection in order to reduce respiratory distress syndrome and cerebral palsy, as well as to achieve the transfer of the mother to a reference center, if necessary. The choice of one drug or another should be based on an adequate risk-benefit assessment, once the clinical situation of each pregnant woman has been taken into account. The use of tocolytics at the beginning of this process is essential and in this review the available information on their use in threatened preterm labor is analyzed.

Días de gestación ganados con diferentes técnicas de cerclaje en pacientes con insuficiencia cervical / Gestational days gained with different cerclage techniques in patients with cervical incompetence

Resumen OBJETIVO: Reportar la experiencia en la práctica de cerclajes con indicación profiláctica y terapéutica en pacientes con embarazo único o múltiple, con insuficiencia cervical. Además, informar los días de gestación ganados y comparar las técnicas quirúrgicas con los cerclajes. MATERIALES Y MÉTODOS: Estudio retrospectivo, descriptivo, comparativo y transversal efectuado entre enero de 2011 y enero de 2018. Criterios de inclusión: pacientes a quienes se efectuó un cerclaje y el embarazo finalizó en nuestra unidad. Variables de estudio: edad, IMC, embarazos, abortos, días de gestación ganados, días en que se efectuó el procedimiento quirúrgico, semanas de gestación cumplidas a la finalización del embarazo, tiempo quirúrgico, medicamentos (tocolíticos y antibióticos), complicaciones a partir del cerclaje hasta la finalización del embarazo. Para el análisis descriptivo se utilizó el paquete estadístico IBM SPSS (versión 22); la distribución se obtuvo con t de Student, se aplicó la prueba de normalidad Shapiro-Wilk y las variables con distribución normal se analizaron, comparativamente, con ANOVA y las de distribución anormal con la prueba Kruskal-Wallis. RESULTADOS: Se analizaron 37 casos en los que el cerclaje prolongó 116.14 ± 47.4 días la gestación, con finalización promedio del embarazo a los 246.41 ± 26.54 días. El cerclaje Shirodkar fue superior: prolongó la gestación 134.69 días con finalización del embarazo a las 36 ± 2 semanas. CONCLUSIONES: En pacientes con insuficiencia cervical el cerclaje es una opción para prolongar el embarazo. La técnica Shirodkar tuvo márgenes de mayor seguridad hasta la finalización del embarazo (más de 34 semanas). El comportamiento en embarazos múltiples es similar, por lo que en caso de insuficiencia cervical debe aplicarse.

Abstract OBJECTIVE: To report the experience in the practice of cerclages with prophylactic and therapeutic indication in patients with single or multiple pregnancy, with cervical incompetence. In addition, report the days of pregnancy gained, compare surgical techniques and cerclages in single and multiple gestations. MATERIALS AND METHODS: Retrospective, descriptive, comparative and cross-sectional study carried out between January 2011 and January 2018. Inclusion criteria: patients who had a cerclage and the pregnancy ended in our unit. Study variables: age, BMI, pregnancies, abortions, days of gestation earned, days in which they were placed, weeks of gestation completed at the end of pregnancy, surgical time, medications (tocolytics and antibiotics), complications from the placement of the cerclage until the end of pregnancy. For the descriptive analysis the statistical package IBM SPSS (version 22) was used; the distribution was obtained with Student's t test, the Shapiro-Wilk normality test was applied and the variables with normal distribution were analyzed, comparatively, with ANOVA and those with abnormal distribution with the Kruskal-Wallis test. RESULTS: 37 cases were analyzed in which the placement of cerclage prolonged 116.14 ± 47.4 days gestation, with an average termination of pregnancy at 246.41 ± 26.54 days. The Shirodkar cerclage was superior: it extended gestation 134.69 days with the end of pregnancy at 36 ± 2 weeks. CONCLUSIONS: In patients with cervical incompetence cerclages are an option to prolong pregnancy. The Shirodkar technique had higher safety margins until the end of pregnancy (more than 34 weeks). The behavior in multiple pregnancies is similar, so in case of cervical incompetence should be applied.

Evaluation of clinical efficacy and safety of natural micronized progesterone in prevention of preterm labor: a prospective study at tertiary care teaching hospital in India

Background: Uterine relaxants (UR) are used in management of in Preterm labour (PTL), which is responsible for considerable morbidity and mortality in mother as well as preterm infant. Author are yet to discover an ideal UR which is highly effective yet safe. Literature supports the use of natural micronized progesterone (NP) during threatened PTL. However, little data exists for Indian population. Therefore, present study becomes imperative.Methods: A comparative clinical study was carried out on 78 patients (aged 19 to 35 years with singleton pregnancy and gestational age between 28 and 37 weeks with cervix ?4 cm dilated) who were diagnosed with threatened PTL were included. Those who refused treatment were allocated to control group (n= 29) and received only bed rest. NP was given orally 200 mg twice a day to 21 patients and 200 mg intra vaginal twice a day to 28 patients and was continued until delivery or 37 weeks of gestation whichever occurred first. The efficacy was proven if PTL was prevented and patient did not require an alternative UR for ?48 hours.Results: The mean age of patients was 23±3.2 years, majority being multipara. Author observed that both oral and vaginal formulation of NP was found to be highly effective (p <0.05) as primary UR and maintenance therapy in preventing PTL as compared to the control group. However, difference between them was not statistically significant. None of the patients were lost to follow-up and no adverse events linked to the treatment were reported.Conclusions: Although, the data obtained from this study was limited and the sample size was small, findings of this study support the use of NP in prolonging threatened PTL.

A Comparative Study Of The Efficacy And Side Effects Of Isoxsuprine And Magnesium Sulphate In The Management Of Preterm Labour

Preterm labour, the most important single determinant of adverse infant outcome in terms of both survival and quality of life, is problematic because of the several neonatal complications and the long term sequelae. Preterm birth affects 12 – 18% of all births in India. Tocolytic therapy is the most commonly used strategy to arrest preterm labour. Isoxsuprine, a ß sympathomimetic agent is a drug that is currently used as a tocolytic but is associated with serious side effects. Magnesium sulphate is another Tocolytic which has also been the focus of recent research for its neuroprotective effects on preterm babies. We have compared the two in this study. Objectives: To compare the efficacy of Isoxsuprine with magnesium sulphate with respect to 1. Cessation of labour pains and prolongation of gestational age 2. Drug related side effects 3. The perinatal outcome Methodology : 50 patients who came to Jubilee Mission Medical College hospital with preterm labour from November 2012 to April 2014 were randomised into two groups of 25 each. Group I was given Isoxsuprine 90mg intravenously in 1000ml Ringer lactate solution at the rate of 0.05 – 0.20 mg/min. Group M was given magnesium sulphate, loading dose of 4gm diluted in 100ml normal saline intravenously, followed by a continuous infusion of 2gm/hr for at least 12 hours. The vitals, urine output and patellar reflex of the patients were monitored. Results: The mean number of days gained in utero in group I and group M were 30.88 ±21.24 and 27.26±18.79 days respectively. The percentage of NICU admissions in group I was 28% and group M was 28%. Maternal side effects were noted in 32% in group I and 20% in group M. Conclusion: Magnesium sulphate is comparable to Isoxsuprine in its efficacy in managing preterm labour with less maternal and neonatal side effect

Efficacy and side effect of ritodrine and magnesium sulfate in threatened preterm labor

OBJECTIVE: In terms of efficacy, several previous studies have shown that the success rate in inhibiting preterm labor was not different between magnesium sulfate and ritodrine. However, there is a paucity of information regarding the efficacy of both medications after consideration of intra-amniotic infection, which is one of the most important prognostic factors in patients of threatened preterm birth. The objective of this study was to compare the efficacy and safety of magnesium sulfate with that of ritodrine in preterm labor. METHODS: In this retrospective cohort study, we included patients who were admitted and treated with either ritodrine or magnesium sulfate with the diagnosis of preterm labor at 24–33.6 weeks of gestational age between January 2005 to April 2015. Patients were divided into 2 groups according to the first-used tocolytics (ritodrine group and magnesium sulfate group). We compared the efficacy and prevalence of side effect in each group. The efficacy of both tocolytics was evaluated in terms of preterm delivery within 48 hours, 7 days, or 37 weeks of gestation and need for 2nd line therapy. RESULTS: A total number of 201 patients were enrolled including 177 cases in ritodrine group and 24 cases in magnesium sulfate group. The efficacy of both tocolytics (preterm delivery within 48 hours, 7 days, or 37 weeks of gestation and need for 2nd line therapy) was not different between the 2 groups of cases. In multivariate analysis, gestational age at treatment, twin gestation, intra-amniotic infection and maternal C-reactive protein (CRP) was associated with treatment failure (preterm delivery within 48 hours), but the type of tocolytics was not significantly associated with treatment failure. The type of side effect was different in the 2 groups, but the frequency of total adverse effect, need for discontinuation of therapy because of maternal adverse effect, and severe adverse effect were not different between the two groups of cases. CONCLUSION: The efficacy and safety of magnesium sulfate was similar to ritodrine, and can be a substitute tocolytics. Additionally, failure of tocolytic therapy was determined by gestational age at treatment, twin gestation, intra-amniotic infection, and maternal CRP, not by the type of tocolytics.

A Prospective Study to Assess the Neonatal Mortality and Morbidity Associated with Preterm labor and Delivery in a Tertiary Care Hospital.

Background: Preterm labor and delivery are one of the challenging obstetric complications encountered by obstetricians, as are preterm neonates for the pediatricians. Therefore, this study was planned to identify etiological factors and to assess the neonatal mortality and morbidity associated with preterm labor and delivery. Methods: This prospective study was conducted over a 6 months period (September 2014 to February 2015) in the department of Obstetrics/Gynaecology and Paediatrics at Patliputra Medical College, Dhanbad, Jharkhand. 325 antenatal women admitted with threatened preterm labor, with or without rupture of membranes, were recruited. They were followed up from admission till delivery and discharge. Gestational age at onset of preterm labor, associated risk factors, response to tocolytics if given, gestational age at delivery, and neonatal outcome were recorded and analyzed.Results: Incidence of preterm labor was found to be 28.26% and that of preterm deliveries 25.9%. Preterm rupture of membranes and infection were the commonest causes of preterm labor. Irrespective of the use of a course of betamethasone, neonatal mortality was significantly higher (P<0.0001) in babies delivering before 34 weeks (30.4%) as compared to that in babies delivering after 34 weeks (3.4%). Septicemia, respiratory distress syndrome (RDS) and birth asphyxia were the important causes of neonatal morbidity.Conclusion: Our results revealed a high incidence of preterm labor and preterm births in comparison to developed countries. Infection is one important modifiable risk factor which can be reduced. Prolongation of delivery for 48 hours by giving tocolytics for getting the benefit of betamethasone coverage reduces morbidity due to RDS but does not reduce overall neonatal mortality below 34 weeks.

The Clinical Experience of Atosiban in Preterm Labour.

Aims: To evaluate the efficacy, safety and tolerability of atosiban in delaying preterm labour. Study Design: A prospective, open label, non comparative study. Place of Study: Lokmanya Tilak Municipal Medical College Mumbai, India. Methodology: Pregnant women (N=110) between the gestational age of 24 to 34 weeks, presenting with signs of preterm labour were enrolled in the study. Efficacy, safety and tolerability of Atosiban were assessed for a period of 72 hrs. Results: Ninety Eight patients (89.09%) remained undelivered up to 72 hrs after completion of treatment phase and ninety seven patients (88.18%) till the end of their hospital stay (upto 7 days). There were six patients with twin and one with quadruplet pregnancy; atosiban therapy was successful in delaying labour upto discharge from hospital in all the seven patients. The study medication was well tolerated as no adverse events were observed throughout the study duration. Conclusion: Atosiban, an oxytocin receptor antagonist, has proven to be an effective and well tolerated tocolytic drug and because of its favourable safety profile, it may be the best choice as a tocolytic therapy to delay the preterm labour.

Los tocolíticos en el parto pretérmino: un dilema actual / Tocolytics in preterm delivery: a current dilemma i. en

El parto pretérmino es un gran problema de salud a escala mundial, con impacto directo en la morbilidad y mortalidad perinatal; por lo que actualmente el tratamiento con tocolíticos ha devenido un dilema. Ante tal situación, el autor de este artículo decidió revisar bibliografía actualizada sobre el tema, con vistas a describir las diferentes drogas -- mecanismos de acción, reacciones adversas, dosis, vías de administración y tiempo de utilización -- que se aplican para inhibir el parto pretérmino, así como los nuevos fármacos tocolíticos en estudio; de manera que los obstetras cuenten con la información necesaria que les permita seleccionar adecuadamente la droga, que se debe emplear con carácter individual y no poblacional.

Preterm delivery is a worldwide major health problem with direct impact on perinatal morbidity and mortality, so currently tocolytic therapy has become a dilemma. In such a situation, the author of this article decided to review current literature on the subject in order to describe different drugs -- mechanisms of action, side effects, dosage, route of administration and time of use -- administered to inhibit preterm delivery, as well as new tocolytics under study, so that obstetricians have the information necessary to enable them to properly select the drug to be used individually and not in the population.

Effects of Abdominal Breathing on State Anxiety, Stress, and Tocolytic Dosage for Pregnant Women in Preterm Labor

PURPOSE: The purpose of this study was to identify the effects of abdominal breathing on state anxiety, stress and tocolytic dosage for pregnant women in preterm labor. METHODS: The participants were 60 pregnant women in preterm labor who were hospitalized from April to July, 2009. Thirty participants were assigned to the experimental group and 30 to the control group. None of them had any other complications except preterm labor. The modified Mason's breathing technique was used with the experimental group 3 times a day for 3 days. Data were collected using a self-report questionnaire and chart review, and analyzed with the SPSS 13.0 WIN program. RESULTS: "State anxiety of the experimental group will be lower than that of the control group" was supported. "Stress of the experimental group will be lower than that of the control group" was supported. "The Ritodrine dosage for the experimental group will be lower than that of the control group" was supported. "The Atosiban dosage for the experimental group will be lower than that of the control group" was supported. CONCLUSION: These results indicate that abdominal breathing is an effective nursing intervention for pregnant women in preterm labor.

New strategies in the treatment of preterm delivery / 대한산부인과학회지

Preterm delivery is defined as delivering a fetus or fetuses before 37th gestational week. The incidence of preterm delivery has been reported to be 8-10% but is associated with 75% of perinatal mortality and morbidity, and long term sequelae such as cerebral palsy. The rates of preterm deliveries have actually increased in recent years for complex reasons despite widespread efforts to address the problem. A major drawback for the development of beneficial interventions of preterm delivery is the poor understanding of the normal physiology of human parturition. However, research efforts to elucidate this problem have risen substantially over the past decades, and there have been great advances in the understanding of the molecular and cellular pathways. This understanding has led to the development of several therapeutic strategies in terms of delaying the delivery and reducing the perinatal complications. Thus, we will discuss on the recent developments in therapeutic strategies in preterm labor and preterm premature rupture of membranes including antibiotics treatment, antenatal corticosteroid therapy and various tocolytic agents.