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Coler BS, Shynlova O, Boros-Rausch A, Lye S, McCartney S, Leimert KB, Xu W, Chemtob S, Olson D, Li M, Huebner E, Curtin A, Kachikis A, Savitsky L, Paul JW, Smith R, Adams Waldorf KM. Landscape of Preterm Birth Therapeutics and a Path Forward. J Clin Med 2021; 10:2912. [PMID: 34209869 PMCID: PMC8268657 DOI: 10.3390/jcm10132912] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 12/24/2022] Open
Abstract
Preterm birth (PTB) remains the leading cause of infant morbidity and mortality. Despite 50 years of research, therapeutic options are limited and many lack clear efficacy. Tocolytic agents are drugs that briefly delay PTB, typically to allow antenatal corticosteroid administration for accelerating fetal lung maturity or to transfer patients to high-level care facilities. Globally, there is an unmet need for better tocolytic agents, particularly in low- and middle-income countries. Although most tocolytics, such as betamimetics and indomethacin, suppress downstream mediators of the parturition pathway, newer therapeutics are being designed to selectively target inflammatory checkpoints with the goal of providing broader and more effective tocolysis. However, the relatively small market for new PTB therapeutics and formidable regulatory hurdles have led to minimal pharmaceutical interest and a stagnant drug pipeline. In this review, we present the current landscape of PTB therapeutics, assessing the history of drug development, mechanisms of action, adverse effects, and the updated literature on drug efficacy. We also review the regulatory hurdles and other obstacles impairing novel tocolytic development. Ultimately, we present possible steps to expedite drug development and meet the growing need for effective preterm birth therapeutics.
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Affiliation(s)
- Brahm Seymour Coler
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Oksana Shynlova
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; (O.S.); (A.B.-R.); (S.L.)
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada
| | - Adam Boros-Rausch
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; (O.S.); (A.B.-R.); (S.L.)
| | - Stephen Lye
- Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada; (O.S.); (A.B.-R.); (S.L.)
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5G 1E2, Canada
| | - Stephen McCartney
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Kelycia B. Leimert
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2R7, Canada; (K.B.L.); (W.X.); (D.O.)
| | - Wendy Xu
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2R7, Canada; (K.B.L.); (W.X.); (D.O.)
| | - Sylvain Chemtob
- Departments of Pediatrics, Université de Montréal, Montréal, QC H3T 1J4, Canada;
| | - David Olson
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB T6G 2R7, Canada; (K.B.L.); (W.X.); (D.O.)
- Departments of Pediatrics and Physiology, University of Alberta, Edmonton, AB T6G 2S2, Canada
| | - Miranda Li
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
- Department of Biological Sciencies, Columbia University, New York, NY 10027, USA
| | - Emily Huebner
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Anna Curtin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Alisa Kachikis
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Leah Savitsky
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
| | - Jonathan W. Paul
- Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; (J.W.P.); (R.S.)
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - Roger Smith
- Mothers and Babies Research Centre, School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia; (J.W.P.); (R.S.)
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
- John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
| | - Kristina M. Adams Waldorf
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, USA; (B.S.C.); (S.M.); (M.L.); (E.H.); (A.C.); (A.K.); (L.S.)
- Department of Global Health, University of Washington, Seattle, WA 98195, USA
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Stelzl P, Kehl S, Rath W. Maintenance tocolysis: a reappraisal of clinical evidence. Arch Gynecol Obstet 2019; 300:1189-1199. [PMID: 31576452 DOI: 10.1007/s00404-019-05313-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/19/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Maintenance tocolysis, mostly defined as the continuation of tocolytic treatment beyond 48 h, remains a matter of debate. There is no sufficient evidence from randomized controlled trials, that maintenance tocolysis is able to prolong pregnancy significantly and to reduce severe neonatal morbidity and mortality. Hence, it is not recommended in current guidelines. On the contrary, maintenance tocolysis is commonly used in clinical practice and subject of current clinical-scientific investigations. TOCOLYTICS FOR MAINTENANCE TREATMENT None of the conventional tocolytics (beta-sympathomimetics, calcium-channel blockers, magnesium, cyclooxygenase inhibitors, and oxytocin receptor antagonists) have proven to be appropriate for maintenance treatment. Progesterone and 17-α-hydroxyprogesterone caproate have shown promising results in low-quality randomized trials, but not in high-quality studies. DISCUSSION Basically, the value of studies regarding maintenance tocolysis is limited by a considerable heterogeneity, its mostly low quality, significant differences in methodology as well as the inadequate statistical power due to the small number of women studied. So far, maintenance tocolysis is a case-by-case decision outweighing the benefits and harms of tocolytic treatment.
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Affiliation(s)
- Patrick Stelzl
- Frauenklinik, Universitätsklinikum Erlangen, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Universitätsstrasse 21-23, 91054, Erlangen, Germany
| | - Werner Rath
- Medizinische Fakultät Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Takehara K, Kato S, Sasaki A, Jwa SC, Kakee N, Sago H, Noguchi Y, Aoki T, Inoue E, Nitta C, Ishii Y. Efficacy of advice from healthcare professionals to pregnant women on avoiding constrictive clothing around the trunk: a study protocol for a randomised controlled trial. BMJ Open 2015; 5:e008252. [PMID: 26423851 PMCID: PMC4593137 DOI: 10.1136/bmjopen-2015-008252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION As a component of midwife care, eliminating clothing that constricts the trunk has been shown to markedly elevate the uterine fundus, soften the uterus and abdomen, and reduce the abdominal wall tension in women admitted to hospital due to the risk of miscarriage or premature delivery. However, no prospective study has conclusively verified the efficacy of avoiding constrictive clothes around the trunk in pregnant women. We aim to verify the efficacy of instructing pregnant women to wear loose clothing that does not constrict the trunk to reduce the risk of premature birth and improve quality of life (QoL) during pregnancy. METHODS AND ANALYSIS We will conduct a randomised controlled trial of pregnant women scheduled to deliver at the National Center for Child Health and Development in Tokyo, Japan. A total of 616 pregnant women, from whom written informed consent will be obtained, will be allocated randomly to an intervention group or a control group. Women in the control group will be provided with anaemia prevention leaflets at 20 weeks' gestation and skin-care leaflets at 30 weeks' gestation. Women in the intervention group will be provided with the same leaflets and will also receive health advice from health professionals to avoid constrictive clothing around the trunk. The primary outcome will be a difference between these groups in the frequency of any one of the following category variables: (1) cervical length <30 mm up to 28 weeks' gestation, (2) hospital admission for threatened premature delivery, or (3) premature delivery. Secondary outcomes will include QoL during pregnancy, maternal state of health, and status of fetal development. ETHICS AND DISSEMINATION The Institutional Review Board and Ethics Committee at the National Center for Child Health and Development, Japan, has approved this study. Our findings will be widely disseminated through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER UMIN000016853.
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Affiliation(s)
- Kenji Takehara
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
| | - Sachiko Kato
- Department of Nursing, National Center for Child Health and Development, Tokyo, Japan
| | - Aiko Sasaki
- Division of Obstetrics, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seung Chik Jwa
- Division of Obstetrics, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Naoko Kakee
- Division of Bioethics, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Division of Obstetrics, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yuko Noguchi
- Department of Nursing, National Center for Child Health and Development, Tokyo, Japan
| | - Tomoko Aoki
- Department of Nursing, National Center for Child Health and Development, Tokyo, Japan
| | - Eisuke Inoue
- Department of Education for Clinical Research, National Center for Child Health and Development, Tokyo, Japan
| | - Chieko Nitta
- Department of Nursing, National Center for Child Health and Development, Tokyo, Japan
| | - Yumiko Ishii
- Department of Nursing, National Center for Child Health and Development, Tokyo, Japan
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Liu Z, Guo F, Gu J, Wang Y, Li Y, Wang D, Lu L, Li D, He F. Similarity-based prediction for Anatomical Therapeutic Chemical classification of drugs by integrating multiple data sources. Bioinformatics 2015; 31:1788-95. [DOI: 10.1093/bioinformatics/btv055] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 01/26/2015] [Indexed: 11/13/2022] Open
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Abstract
Spontaneous preterm labor is a complex process characterized by the interplay of multiple different pathways. Prevention of preterm labor and delivery is also complicated. The most effective interventions for prevention of preterm birth (PTB) are progestin prophylaxis and lifestyle modifications, with cerclage placement also playing a role in selected populations. Interventions such as activity modification, home tocometry, and routine antibiotic use have fallen out of favor because of lack of effectiveness and possibility of harm. The solution to the problem of PTB remains elusive, and researchers and clinicians must collaborate to find a cure for preterm labor.
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Affiliation(s)
- Kara B Markham
- Maternal Fetal Medicine Division, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, 395 West 12th Avenue, 5th Floor, Columbus, OH 43210, USA.
| | - Mark Klebanoff
- Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Obstetrics and Gynecology, The Ohio State University, 395 West 12th Avenue, 5th Floor, Columbus, OH 43210, USA; Division of Epidemiology, The Ohio State University College of Public Health, 250 Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, USA; Center for Perinatal Research, The Research Institute, Nationwide Children's Hospital, 700 Children's Drive, WB 5231, Columbus, OH 43205, USA
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Chawanpaiboon S, Laopaiboon M, Lumbiganon P, Sangkomkamhang US, Dowswell T. Terbutaline pump maintenance therapy after threatened preterm labour for reducing adverse neonatal outcomes. Cochrane Database Syst Rev 2014; 2014:CD010800. [PMID: 24659357 PMCID: PMC11193541 DOI: 10.1002/14651858.cd010800.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND After successful inhibition of threatened preterm labour women are at high risk of recurrent preterm labour. Terbutaline pump maintenance therapy has been used to reduce adverse neonatal outcomes. This review replaces an earlier Cochrane review, published in 2002, which is no longer being updated by the team. OBJECTIVES To determine the effectiveness of terbutaline pump maintenance therapy after threatened preterm labour in reducing adverse neonatal outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2014) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials comparing terbutaline pump therapy with alternative therapy, placebo, or no therapy after arrest of threatened preterm labour. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion and then extracted data as eligible for inclusion in qualitative and quantitative synthesis (meta-analysis). MAIN RESULTS Four studies were included with a total of 234 women randomised. The overall methodological quality of the included studies was mixed; two studies provided very little information on study methods, there was high sample attrition in one study and in three studies the risk of performance bias was high. We found no strong evidence that terbutaline maintenance therapy offered any advantages over saline placebo or oral terbutaline maintenance therapy in reducing adverse neonatal outcomes by prolonging pregnancy among women with arrested preterm labour. The mean difference (MD) for gestational age at birth was -0.14 weeks (95% confidence interval (CI) -1.66 to 1.38) for terbutaline pump therapy compared with saline placebo pump for two trials combined. One trial reported a risk ratio (RR) of 1.17 (95% CI 0.79 to 1.73) for preterm birth (less than 37 completed weeks) and a RR of 0.97 (95% CI 0.51 to 1.84) of very preterm birth (less than 34 completed weeks) for terbutaline pump compared with saline placebo pump. We found no evidence that terbutaline pump therapy was associated with statistically significant reductions in infant respiratory distress syndrome, or neonatal intensive care unit admission compared with placebo. Compared with oral terbutaline, we found no evidence that pump therapy increased the rate of therapy continuation, or reduced the rate of infant complications or maternal hospital re-admissions. One study suggested that pump therapy resulted in significantly increased weekly cost/woman, $580 versus $12.50 (P < 0.01). No data were reported on long-term infant outcomes. AUTHORS' CONCLUSIONS We found no evidence that terbutaline pump maintenance therapy decreased adverse neonatal outcomes. Taken together with the lack of evidence of benefit, its substantial expense and the lack of information on the safety of the therapy do not support its use in the management of arrested preterm labour. Future use should only be in the context of well-conducted, adequately powered randomised controlled trials.
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Affiliation(s)
- Saifon Chawanpaiboon
- Faculty of Medicine, Siriraj Hospital, Mahidol UniversityDepartment of Obstetrics and Gynaecology2 Prannok, BangkoknoiBangkokThailand10700
| | - Malinee Laopaiboon
- Khon Kaen UniversityDepartment of Biostatistics and Demography, Faculty of Public HealthKhon KaenThailand40002
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Ussanee S Sangkomkamhang
- Khon Kaen HospitalDepartment of Obstetrics and GynaecologySrichan RoadMaungKhon KaenThailand40000
| | - Therese Dowswell
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Naik Gaunekar N, Raman P, Bain E, Crowther CA. Maintenance therapy with calcium channel blockers for preventing preterm birth after threatened preterm labour. Cochrane Database Syst Rev 2013:CD004071. [PMID: 24173691 DOI: 10.1002/14651858.cd004071.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Calcium channel blocker maintenance therapy is one of the types of tocolytic therapy that may be used after an episode of threatened preterm labour (and usually an initial dose of tocolytic therapy) in an attempt to prevent the onset of further preterm contractions. OBJECTIVES To assess the effects of calcium channel blockers as maintenance therapy on preventing preterm birth after threatened preterm labour. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials of calcium channel blockers used as maintenance therapy to prevent preterm birth after threatened preterm labour, compared with placebo or no treatment. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. MAIN RESULTS We included six trials that enrolled 794 women and their babies and all assessed nifedipine as calcium channel blocker maintenance therapy. The six trials were judged to be at a moderate risk of bias overall. No differences in the incidence of preterm birth (risk ratio (RR) 0.97; 95% confidence interval (CI) 0.87 to 1.09; five trials, 681 women), birth within 48 hours of treatment (RR 0.46; 95% CI 0.07 to 3.00; two trials, 128 women) or neonatal mortality (average RR 0.75; 95% CI 0.05 to 11.76; two trials, 133 infants) were seen when nifedipine maintenance therapy was compared with placebo or no treatment. No stillbirths were reported in the one trial that provided data for this outcome. No trials reported on longer-term follow-up of infants.Women receiving nifedipine maintenance therapy were significantly more likely to have their pregnancy prolonged (mean difference (MD) 5.35 days; 95% CI 0.49 to 10.21; four trials, 275 women); however, no differences between groups were shown for birth at less than 34 weeks' gestation, birth at less than 28 weeks' gestation, birth within seven days of treatment, or gestational age at birth. No significant differences were shown between the nifedipine and control groups for any of the secondary neonatal morbidities reported. Similarly, no significant differences were seen for the outcomes relating to the use of health services, except for in one trial, where infants whose mothers received nifedipine were significantly more likely to have a longer length of hospital stay as compared with infants born to mothers who received a placebo (MD 14.00 days; 95% CI 4.21 to 23.79; 60 infants). AUTHORS' CONCLUSIONS Based on the current available evidence, maintenance treatment with a calcium channel blocker after threatened preterm labour does not prevent preterm birth or improve maternal or infant outcomes.
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Affiliation(s)
- Naguesh Naik Gaunekar
- Suite 28, Mater Medical Centre, 76 Willetts Road, Mackay, Queensland, Australia, 4740
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Chawanpaiboon S, Laopaiboon M, Lumbiganon P, Sangkomkamhang US, Dowswell T. Terbutaline pump maintenance therapy after threatened preterm labour for reducing adverse neonatal outcomes. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Papatsonis DNM, Flenady V, Liley HG. Maintenance therapy with oxytocin antagonists for inhibiting preterm birth after threatened preterm labour. Cochrane Database Syst Rev 2013:CD005938. [PMID: 24122673 DOI: 10.1002/14651858.cd005938.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In some women, an episode of preterm labour settles and does not result in immediate preterm birth. Subsequent treatment with tocolytic agents such as oxytocin receptor antagonists may then have the potential to prevent the recurrence of preterm labour, prolonging gestation, and preventing the adverse consequences of prematurity for the infant. OBJECTIVES To assess the effects of maintenance therapy with oxytocin antagonists administered by any route after an episode of preterm labour in order to delay or prevent preterm birth. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013), sought ongoing and unpublished trials by contacting experts in the field and searched the reference lists of relevant articles. SELECTION CRITERIA Randomised controlled trials comparing oxytocin antagonists with any alternative tocolytic agent, placebo or no treatment, used for maintenance therapy after an episode of preterm labour. DATA COLLECTION AND ANALYSIS We used the standard methods of The Cochrane Collaboration and the Cochrane Pregnancy and Childbirth Group. Two review authors independently undertook evaluation of methodological quality and extracted trial data. MAIN RESULTS This review includes one trial of 513 women. When compared with placebo, atosiban did not reduce preterm birth before 37 weeks (risk ratio (RR) 0.89; 95% confidence intervals (CI) 0.71 to 1.12), 32 weeks (RR 0.85; 95% CI 0.47 to 1.55), or 28 weeks (RR 0.75; 95% CI 0.28 to 2.01). No difference was shown in neonatal morbidity, or perinatal mortality. AUTHORS' CONCLUSIONS There is insufficient evidence to support the use of oxytocin receptor antagonists to inhibit preterm birth after a period of threatened or actual preterm labour. Any future trials using oxytocin antagonists or other drugs as maintenance therapy for preventing preterm birth should examine a variety of important infant outcome measures, including reduction of neonatal morbidity and mortality, and long-term infant follow-up. Future research should also focus on the pathophysiological pathways that precede preterm labour.
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Affiliation(s)
- Dimitri N M Papatsonis
- Department of Obstetrics and Gynaecology, Amphia Hospital Breda, Langendijk 75, Breda, Netherlands, 4819 EV
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Han S, Crowther CA, Moore V. Magnesium maintenance therapy for preventing preterm birth after threatened preterm labour. Cochrane Database Syst Rev 2013; 2013:CD000940. [PMID: 23728634 PMCID: PMC7063385 DOI: 10.1002/14651858.cd000940.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Magnesium maintenance therapy is one of the types of tocolytic therapy used after an episode of threatened preterm labour (usually treated with an initial dose of tocolytic therapy) in an attempt to prevent the onset of further preterm contractions. OBJECTIVES To assess whether magnesium maintenance therapy is effective in preventing preterm birth after the initial threatened preterm labour is arrested. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013). SELECTION CRITERIA Randomised controlled trials of magnesium therapy given to women after threatened preterm labour. DATA COLLECTION AND ANALYSIS The review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. We checked data entry. MAIN RESULTS We included four trials involving 422 women. Three trials had high risk of bias and none included any long-term follow-up of infants. No differences in the incidence of preterm birth or perinatal mortality were seen when magnesium maintenance therapy was compared with placebo or no treatment; or alternative therapies (ritodrine or terbutaline). The risk ratio (RR) for preterm birth (less than 37 weeks) for magnesium compared with placebo or no treatment was 1.05, 95% confidence interval (CI) 0.80 to 1.40 (two trials, 99 women); and 0.99, 95% CI 0.57 to 1.72 (two trials, 100 women) for magnesium compared with alternative therapies. The RR for perinatal mortality for magnesium compared with placebo or no treatment was 5.00, 95% CI 0.25 to 99.16 (one trial, 50 infants); and 5.00, 95% CI 0.25 to 99.16 (one trial, 50 infants) for magnesium compared with alternative treatments.Women taking magnesium preparations were less likely to report side effects (RR 0.67, 95% CI 0.47 to 0.96, three trials, 237 women), including palpitations or tachycardia (RR 0.26, 95% CI 0.13 to 0.52, three trials, 237 women) than women receiving alternative therapies. Women receiving magnesium were however, more likely to experience diarrhoea (RR 6.79, 95% CI 1.26 to 36.72, three trials, 237 women). AUTHORS' CONCLUSIONS There is not enough evidence to show any difference between magnesium maintenance therapy compared with either placebo or no treatment, or alternative therapies (ritodrine or terbutaline) in preventing preterm birth after an episode of threatened preterm labour.
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Affiliation(s)
- Shanshan Han
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, The Robinson Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Caroline A Crowther
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, The Robinson Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Vivienne Moore
- University of AdelaideDepartment of Public HealthLevel 6, Bice BuildingRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia5005
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Diguisto C, Le Ray C, Maillard F, Khoshnood B, Verspyck E, Perrotin F, Goffinet F. Individual and organisational determinants associated with maintenance tocolysis in the management of preterm labour: a multilevel analysis. PLoS One 2012; 7:e50788. [PMID: 23272071 PMCID: PMC3521755 DOI: 10.1371/journal.pone.0050788] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 10/24/2012] [Indexed: 11/18/2022] Open
Abstract
Background Clinical guidelines do not recommend maintenance tocolysis for the management of preterm labour. The French national survey EVAPRIMA revealed it was administered to more than 50% of women hospitalised for preterm labour. Our aim was to identify the individual and organisational determinants associated with maintenance tocolysis. Methods The study was a secondary analysis of the prospective population-based EVAPRIMA study database. Population study included every women hospitalised for preterm labour and at risk of receiving maintenance tocolysis, over a one month period, in 99 randomly selected French maternity units. Main outcome was the prescription of maintenance tocolysis. The association between maintenance tocolysis and individual (maternal or obstetrical) and organisational determinants were evaluated with multilevel analysis. Results Of the 531 women included, 68.9% (95% CI 0.65–0.73) received maintenance tocolysis. The only individual factor associated with maintenance tocolysis was gestational age at admission; the rate of maintenance tocolysis was higher among women hospitalised before 32 weeks of gestation. The significantly different rates between maternity units demonstrated the existence of a maternity unit effect. Maintenance tocolysis was also associated with organisational determinants and was more frequent in level 1 (ORa = 6.54[2.21–19.40]) and level 2 maternity units (ORa = 3.68[1.28–10.59]), in units with less than 1500 deliveries/year (ORa = 5.27[4.43–19.44]), and in specific areas of France. Conclusion A maternity unit effect, explained partly by the organisational characteristics of the units, plays a major role in the practice of maintenance tocolysis. Widespread dissemination of these results might improve adherence to clinical guidelines.
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Affiliation(s)
- Caroline Diguisto
- INSERM UMR S953, Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, Pierre et Marie Curie University, Paris, France.
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Abstract
BACKGROUND Some women who have threatened to give birth prematurely, subsequently settle. They may then take oral tocolytic maintenance therapy to prevent preterm birth and to prolong gestation. OBJECTIVES To assess the effects of oral betamimetic maintenance therapy after threatened preterm labour for preventing preterm birth. SEARCH METHODS We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 9 November 2012. SELECTION CRITERIA Randomised controlled trials comparing oral betamimetic with alternative tocolytic therapy, placebo or no therapy, for maintenance following treatment of threatened preterm labour. DATA COLLECTION AND ANALYSIS Two review authors independently applied the selection criteria and carried out data extraction and quality assessment of studies. MAIN RESULTS We did not identify any new trials from the updated search so the results remain unchanged as follows.We included 13 randomised controlled trials (RCTs) with a total of 1551 women. We found no differences for admission to the neonatal intensive care unit when betamimetics were compared with placebo (risk ratio (RR) 1.28, 95% confidence interval (CI) 0.68 to 2.41; two RCTs of terbutaline with 2600 women) or with magnesium (RR 0.80, 95% CI 0.43 to 1.46; one RCT of 137 women). The rate of preterm birth (less than 37 weeks) showed no significant difference in six RCTs, four comparing ritodrine with placebo/no treatment and two comparing terbutaline with placebo/no treatment (RR 1.11, 95% CI 0.91 to 1.35; 644 women). We observed no differences between betamimetics and placebo, no treatment or other tocolytics for perinatal mortality and morbidity outcomes. Some adverse effects such as tachycardia were more frequent in the betamimetics groups than the groups allocated to placebo, no treatment or another type of tocolytic. AUTHORS' CONCLUSIONS Available evidence does not support the use of oral betamimetics for maintenance therapy after threatened preterm labour.
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Affiliation(s)
- Jodie M Dodd
- School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide,Australia.
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Gaudet LM, Singh K, Weeks L, Skidmore B, Tsertsvadze A, Ansari MT. Effectiveness of terbutaline pump for the prevention of preterm birth. A systematic review and meta-analysis. PLoS One 2012; 7:e31679. [PMID: 22363704 PMCID: PMC3283660 DOI: 10.1371/journal.pone.0031679] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 01/16/2012] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND 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. METHODOLOGY/PRINCIPAL FINDINGS MEDLINE, 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/SIGNIFICANCE Although 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.
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Affiliation(s)
- Laura M. Gaudet
- Evidence-Based Practice Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Horizon Health Network, Department of Obstetrics and Gynecology, The Moncton Hospital, Moncton, New Brunswick, Canada
- University of Ottawa, Ottawa, Ontario, Canada
| | - Kavita Singh
- Evidence-Based Practice Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Laura Weeks
- Evidence-Based Practice Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Becky Skidmore
- Evidence-Based Practice Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alexander Tsertsvadze
- Evidence-Based Practice Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mohammed T. Ansari
- Evidence-Based Practice Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Han S, Crowther CA, Moore V. Magnesium maintenance therapy for preventing preterm birth after threatened preterm labour. Cochrane Database Syst Rev 2010:CD000940. [PMID: 20614423 DOI: 10.1002/14651858.cd000940.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Magnesium maintenance therapy is one of the types of tocolytic therapy used after an episode of threatened preterm labour (usually treated with an initial dose of tocolytic therapy) in an attempt to prevent the onset of further preterm contractions. OBJECTIVES To assess whether magnesium maintenance therapy is effective in preventing preterm birth after the initial threatened preterm labour is arrested. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2010). SELECTION CRITERIA Randomised controlled trials of magnesium therapy given to women after threatened preterm labour. DATA COLLECTION AND ANALYSIS The review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. We checked data entry. MAIN RESULTS We included four trials, which recruited 422 women. Three trials had high risk of bias and none included any long-term follow up of infants. No differences in the incidence of preterm birth or perinatal mortality were seen when magnesium maintenance therapy was compared with placebo or no treatment; or alternative therapies (ritodrine or terbutaline). The risk ratio (RR) for preterm birth (less than 37 weeks) for magnesium compared with placebo or no treatment was 1.05, 95% confidence interval (CI) 0.80 to 1.40 (two trials, 99 women); and 0.99, 95% CI 0.57 to 1.72 (2 trials, 100 women) for magnesium compared with alternative therapies. The RR for perinatal mortality for magnesium compared with placebo or no treatment was 5.00, 95% CI 0.25 to 99.16 (one trial, 50 infants) and also compared with alternative treatments, was 5.00, 95% CI 0.25 to 99.16 (one trial, 50 infants). Women taking magnesium preparations were less likely to report palpitations or tachycardia than women receiving alternative therapies (RR 0.26, 95% CI 0.13 to 0.52, three trials, 237 women) but were much more likely to experience diarrhoea (RR 7.66, 95% CI 2.18 to 26.98, three trials, 237 women). AUTHORS' CONCLUSIONS There is not enough evidence to show any difference between magnesium maintenance therapy compared with either placebo or no treatment, or alternative therapies (ritodrine or terbutaline) in preventing preterm birth after an episode of threatened preterm labour.
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Affiliation(s)
- Shanshan Han
- ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women's and Children's Hospital, 72 King William Road, Adelaide, South Australia, Australia, 5006
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15
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Turner TJ, Barnes H, Reid J, Garrubba M. Evidence for perinatal and child health care guidelines in crisis settings: can Cochrane help? BMC Public Health 2010; 10:170. [PMID: 20350326 PMCID: PMC3091544 DOI: 10.1186/1471-2458-10-170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 03/29/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is important that healthcare provided in crisis settings is based on the best available research evidence. We reviewed guidelines for child and perinatal health care in crisis situations to determine whether they were based on research evidence, whether Cochrane systematic reviews were available in the clinical areas addressed by these guidelines and whether summaries of these reviews were provided in Evidence Aid. METHODS Broad internet searches were undertaken to identify relevant guidelines. Guidelines were appraised using AGREE and the clinical areas that were relevant to perinatal or child health were extracted. We searched The Cochrane Database of Systematic Reviews to identify potentially relevant reviews. For each review we determined how many trials were included, and how many were conducted in resource-limited settings. RESULTS Six guidelines met selection criteria. None of the included guidelines were clearly based on research evidence. 198 Cochrane reviews were potentially relevant to the guidelines. These reviews predominantly addressed nutrient supplementation, breastfeeding, malaria, maternal hypertension, premature labour and prevention of HIV transmission. Most reviews included studies from developing settings. However for large portions of the guidelines, particularly health services delivery, there were no relevant reviews. Only 18 (9.1%) reviews have summaries in Evidence Aid. CONCLUSIONS We did not identify any evidence-based guidelines for perinatal and child health care in disaster settings. We found many Cochrane reviews that could contribute to the evidence-base supporting future guidelines. However there are important issues to be addressed in terms of the relevance of the available reviews and increasing the number of reviews addressing health care delivery.
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Affiliation(s)
- Tari J Turner
- Monash Institute of Health Services Research, Monash University, Locked Bag 29, Clayton 3168 Australia
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Hayley Barnes
- previously of the Australasian Cochrane Centre, Monash University, Locked Bag 29, Clayton 3168 Australia
| | - Jane Reid
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Marie Garrubba
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
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Witter FR, Zimmerman AW, Reichmann JP, Connors SL. In utero beta 2 adrenergic agonist exposure and adverse neurophysiologic and behavioral outcomes. Am J Obstet Gynecol 2009; 201:553-9. [PMID: 19961985 DOI: 10.1016/j.ajog.2009.07.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 06/18/2009] [Accepted: 07/06/2009] [Indexed: 11/16/2022]
Abstract
Beta 2 adrenergic receptor overstimulation during critical periods of prenatal development can induce a permanent shift in the balance of sympathetic-to-parasympathetic tone. This is a biologically plausible mechanism whereby beta 2 adrenergic agonists can induce functional and behavioral teratogenesis, which explains their association with increases in autism spectrum disorders, psychiatric disorders, poor cognitive, motor function and school performance, and changes in blood pressure in the offspring. The use of beta 2 adrenergic agonists should be limited to proven indications when alternate drugs are ineffective or unavailable; the risks of untreated disease to the mother and fetus are greater than the risk of the beta 2 adrenergic agonist.
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Affiliation(s)
- Frank R Witter
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Roos C, Scheepers LH, Bloemenkamp KW, Bolte A, Cornette J, Derks JB, Duvekot HJ, van Eyck J, Kok JH, Kwee A, Merién A, Opmeer BC, van Pampus MG, Papatsonis DN, Porath MM, van der Post JA, Scherjon SA, Sollie K, Spaanderman ME, Vijgen SM, Willekes C, Mol BWJ, Lotgering FK. Assessment of perinatal outcome after sustained tocolysis in early labour (APOSTEL-II trial). BMC Pregnancy Childbirth 2009; 9:42. [PMID: 19737426 PMCID: PMC2754432 DOI: 10.1186/1471-2393-9-42] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 09/09/2009] [Indexed: 11/18/2022] Open
Abstract
Background Preterm labour is the main cause of perinatal morbidity and mortality in the Western world. At present, there is evidence that tocolysis for 48 hours is useful in women with threatened preterm labour at least before 32 weeks. This allows transfer of the patient to a perinatal centre, and maximizes the effect of corticosteroids for improved neonatal survival. It is questionable whether treatment with tocolytics should be maintained after 48 hours. Methods/Design The APOSTEL II trial is a multicentre placebo-controlled study. Pregnant women admitted for threatened preterm labour who have been treated with 48 hours corticosteroids and tocolysis will be eligible to participate in the trial between 26+0 and 32+2 weeks gestational age. They will be randomly allocated to nifedipine (intervention) or placebo (control) for twelve days or until delivery, whatever comes first. Primary outcome is a composite of perinatal death, and severe neonatal morbidity up to evaluation at 6 months after birth. Secondary outcomes are gestational age at delivery, number of days in neonatal intensive care and total days of the first 6 months out of hospital. In addition a cost-effectiveness analysis will be performed. Analysis will be by intention to treat. The power calculation is based on an expected 11% difference in adverse neonatal outcome. This implies that 406 women have to be randomised (two sided test, β 0.2 at alpha 0.05). Discussion This trial will provide evidence as to whether maintenance tocolysis reduces severe perinatal morbidity and mortality in women with threatened preterm labour before 32 weeks. Trial Registration Clinical trial registration: , NTR 1336, date of registration: June 3rd 2008.
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Affiliation(s)
- Carolien Roos
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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18
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Lang CT, Iams JD. Goals and strategies for prevention of preterm birth: an obstetric perspective. Pediatr Clin North Am 2009; 56:537-63, Table of Contents. [PMID: 19501691 DOI: 10.1016/j.pcl.2009.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Complications of prematurity surpass congenital malformations as the leading cause of infant mortality in the United States. Since 1990, there has been a steady rise in preterm birth, alarming health professionals from all disciplines. This review from a prenatal perspective confirms those concerns and describes the risks and opportunities that may attend efforts to improve the health of fetuses, newborns, and infants. Fetal and live-born outcomes are included.
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Affiliation(s)
- Christopher T Lang
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal medicine, The Ohio State University College of Medicine, Columbus, OH 43210, USA.
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Papatsonis D, Flenady V, Liley H. Maintenance therapy with oxytocin antagonists for inhibiting preterm birth after threatened preterm labour. Cochrane Database Syst Rev 2009:CD005938. [PMID: 19160259 DOI: 10.1002/14651858.cd005938.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In some women, an episode of preterm labour settles and does not result in immediate preterm birth. Subsequent treatment with tocolytic agents such as oxytocin receptor antagonists may then have the potential to prevent the recurrence of preterm labour, prolonging gestation, and preventing the adverse consequences of prematurity for the infant. OBJECTIVES To assess the effects of maintenance therapy with oxytocin antagonists administered by any route after an episode of preterm labour in order to delay or prevent preterm birth. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2008), sought ongoing and unpublished trials by contacting experts in the field and searched the reference lists of relevant articles. SELECTION CRITERIA Randomised controlled trials comparing oxytocin antagonists with any alternative tocolytic agent, placebo or no treatment, used for maintenance therapy after an episode of preterm labour. DATA COLLECTION AND ANALYSIS Standard methods of the Cochrane Collaboration and the Cochrane Pregnancy and Childbirth Group were used. Two review authors independently undertook evaluation of methodological quality and extracted trial data. MAIN RESULTS This review includes one trial of 513 women. When compared with placebo, atosiban did not reduce preterm birth before 37 weeks (risk risk (RR) 0.89; 95% confidence intervals (CI) 0.71 to 1.12), 32 weeks (RR 0.85; 95% CI 0.47 to 1.55), or 28 weeks (RR 0.75; 95% CI 0.28 to 2.01). No difference was shown in neonatal morbidity, or perinatal mortality. AUTHORS' CONCLUSIONS There is insufficient evidence to support the use of oxytocin receptor antagonists to inhibit preterm birth after a period of threatened or actual preterm labour. Any future trials using oxytocin antagonists or other drugs as maintenance therapy for preventing preterm birth should examine a variety of important infant outcome measures, including reduction of neonatal morbidity and mortality, and long-term infant follow up. Future research should also focus on the pathophysiological pathways that precede preterm labour.
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Affiliation(s)
- Dimitri Papatsonis
- Department of Obstetrics and Gynaecology, Amphia Hospital Breda, Langendijk 75, Breda, Netherlands, 4819 EV.
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Iams JD, Romero R, Culhane JF, Goldenberg RL. Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth. Lancet 2008; 371:164-75. [PMID: 18191687 DOI: 10.1016/s0140-6736(08)60108-7] [Citation(s) in RCA: 300] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Interventions to reduce the morbidity and mortality of preterm birth can be primary (directed to all women), secondary (aimed at eliminating or reducing existing risk), or tertiary (intended to improve outcomes for preterm infants). Most efforts so far have been tertiary interventions, such as regionalised care, and treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. These measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Advances in primary and secondary care, following strategies used for other complex health problems, such as cervical cancer, will be needed to prevent prematurity-related illness in infants and children.
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Affiliation(s)
- Jay D Iams
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH, USA.
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Dodd JM, Crowther CA, Dare MR, Middleton P. Oral betamimetics for maintenance therapy after threatened preterm labour. Cochrane Database Syst Rev 2006:CD003927. [PMID: 16437467 DOI: 10.1002/14651858.cd003927.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Some women who have threatened to give birth prematurely, subsequently settle. They may then take oral tocolytic maintenance therapy to prevent preterm birth and to prolong gestation. OBJECTIVES To assess the effects of oral betamimetic maintenance therapy after threatened preterm labour for preventing preterm birth. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Trials Register (June 2005) and MEDLINE (from 1966 to August 2003). SELECTION CRITERIA Randomised controlled trials comparing oral betamimetic with alternative tocolytic therapy, placebo or no therapy, for maintenance following treatment of threatened preterm labour. DATA COLLECTION AND ANALYSIS Two review authors independently applied the selection criteria and carried out data extraction and quality assessment of studies. MAIN RESULTS Eleven randomised controlled trials (RCTs) were included. No differences were seen for admission to the neonatal intensive care unit when betamimetics were compared with placebo (relative risk (RR) 1.29, 95% confidence interval (CI) 0.64 to 2.60; one RCT of terbutaline with 140 women) or with magnesium (RR 0.80, 95% CI 0.43 to 1.46; one RCT of 137 women). The rate of preterm birth (less than 37 weeks) showed no significant difference in four RCTs, two comparing ritodrine with placebo/no treatment and two comparing terbutaline with placebo/no treatment (RR 1.08, 95% CI 0.88 to 1.32, 384 women). No differences between betamimetics and placebo, no treatment or other tocolytics were seen for perinatal mortality and morbidity outcomes. Some adverse effects such as tachycardia were more frequent in the betamimetics groups than the groups allocated to placebo, no treatment or another type of tocolytic. AUTHORS' CONCLUSIONS Available evidence does not support the use of oral betamimetics for maintenance therapy after threatened preterm labour.
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Affiliation(s)
- J M Dodd
- University of Adelaide, Department of Obstetrics and Gynaecology, Women's and Children's Hospital, 72 King William Road, Adelaide, South Australia, Australia, 5006.
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