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Lorthe E, Marchand-Martin L, Letouzey M, Aubert AM, Pierrat V, Benhammou V, Delorme P, Marret S, Ancel PY, Goffinet F, L'Hélias LF, Kayem G. Tocolysis after preterm prelabor rupture of membranes and 5-year outcomes: a population-based cohort study. Am J Obstet Gynecol 2024; 230:570.e1-570.e18. [PMID: 37827270 DOI: 10.1016/j.ajog.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/29/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND The administration of tocolytics after preterm prelabor rupture of membranes remains a controversial practice. In theory, reducing uterine contractility should delay delivery and allow for optimal antenatal management, thereby reducing the risks for prematurity and adverse consequences over the life course. However, tocolysis may be associated with neonatal death or long-term adverse neurodevelopmental outcomes, mainly related to prolonged fetal exposure to intrauterine infection or inflammation. In a previous study, we showed that tocolysis administration was not associated with short-term benefits. There are currently no data available to evaluate the impact of tocolysis on neurodevelopmental outcomes in school-aged children born prematurely in this clinical setting. OBJECTIVE This study aimed to investigate whether tocolysis administered after preterm prelabor rupture of membranes is associated with neurodevelopmental outcomes at 5.5 years of age. STUDY DESIGN We used data from a prospective, population-based cohort study of preterm births recruited in 2011 (referred to as the EPIPAGE-2 study) and for whom the results of a comprehensive medical and neurodevelopmental assessment of the infant at age 5.5 years were available. We included pregnant individuals with preterm prelabor rupture of membranes at 24 to 32 weeks' gestation in singleton pregnancies with a live fetus at the time of rupture, birth at 24 to 34 weeks' gestation, and participation of the infant in an assessment at 5.5 years of age. Exposure was the administration of any tocolytic treatment after preterm prelabor rupture of membranes. The main outcome was survival without moderate to severe neurodevelopmental disabilities at 5.5 years of age. Secondary outcomes included survival without any neurodevelopmental disabilities, cerebral palsy, full-scale intelligence quotient, developmental coordination disorders, and behavioral difficulties. A propensity-score analysis was used to minimize the indication bias in the estimation of the treatment effect on outcomes. RESULTS Overall, 596 of 803 pregnant individuals (73.4%) received tocolytics after preterm prelabor rupture of membranes. At the 5.5-year follow-up, 82.7% and 82.5% of the children in the tocolysis and no tocolysis groups, respectively, were alive without moderate to severe neurodevelopmental disabilities; 52.7% and 51.1%, respectively, were alive without any neurodevelopmental disabilities. After applying multiple imputations and inverse probability of treatment weighting, we found no association between the exposure to tocolytics and survival without moderate to severe neurodevelopmental disabilities (odds ratio, 0.93; 95% confidence interval, 0.55-1.60), survival without any neurodevelopmental disabilities (odds ratio, 1.02; 95% confidence interval, 0.65-1.61), or any of the other outcomes. CONCLUSION There was no difference in the neurodevelopmental outcomes at age 5.5 years among children with and without antenatal exposure to tocolysis after preterm prelabor rupture of membranes. To date, the health benefits of tocolytics remain unproven, both in the short- and long-term.
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Affiliation(s)
- Elsa Lorthe
- Unit of Population Epidemiology, Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland; Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France.
| | - Laetitia Marchand-Martin
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France
| | - Mathilde Letouzey
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France; Department of Neonatal Pediatrics, Poissy Saint Germain Hospital, Poissy, France
| | - Adrien M Aubert
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France
| | - Véronique Pierrat
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France; Department of Neonatology, Centre Hospitalier Intercommunal Créteil, Créteil, France
| | - Valérie Benhammou
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France
| | - Pierre Delorme
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France; Department of Gynecology and Obstetrics, Armand Trousseau Hospital, APHP, FHU Prema, Paris Sorbonne University, Paris, France
| | - Stéphane Marret
- Department of Neonatal Pediatrics, Intensive Care, and Neuropediatrics, Rouen University Hospital, Rouen, France; Inserm Unit 1245, Team Perinatal Handicap, School of Medicine of Rouen, Normandy University, Normandy, France
| | - Pierre-Yves Ancel
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France; Clinical Research Unit, Center for Clinical Investigation P1419, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Goffinet
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France; AP-HP Centre, Maternité Port-Royal, Department of Obstetrics and Gynaecology, Université Paris Cité, FHU PREMA, Paris, France
| | - Laurence Foix L'Hélias
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France; Department of Neonatal Pediatrics, Armand Trousseau Hospital, APHP, FHU Prema, Paris Sorbonne University, Paris, France
| | - Gilles Kayem
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France; Department of Gynecology and Obstetrics, Armand Trousseau Hospital, APHP, FHU Prema, Paris Sorbonne University, Paris, France
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La Verde M, Torella M, Ronsini C, Riemma G, Cobellis L, Marrapodi MM, Capristo C, Rapisarda AMC, Morlando M, De Franciscis P. The association between fetal Doppler and uterine artery blood volume flow in term pregnancies: a pilot study. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024; 45:184-189. [PMID: 37068749 DOI: 10.1055/a-2075-3021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
PURPOSE To investigate the relationship between uterine artery blood volume flow and fetal Doppler indices in term pregnancies. MATERIALS AND METHODS A prospective observational study in a tertiary-care university hospital was performed between December 2021 and May 2022. We included only term pregnancies that received accurate ultrasound scans until a week before the birth. The uterine artery (UtA) diameter and UtA volume blood flow were estimated and recorded. The volume of each artery was summed to obtain the total uterine artery volume blood flow (QUtA). The following fetal Doppler indices were evaluated: Umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV), and cerebroplacental ratio (CPR). Linear regression analysis was performed to investigate the relationship between the QUtA and the fetal Doppler indices. RESULTS 49 pregnancies were included. The UA pulsatility index (PI) analysis showed a significant association with QUtA (r2=0.40, p=0.01), demonstrating a decrease of the UA PI when the QUtA increased. The same relationship was noted between the UtA mean PI and QUtA (r2=0.41, p=0.005). A weak correlation between the newborn weight and the QUtA was also noted (r2=0.31, p=0.048), with an elevated newborn weight when the QUtA was high. CONCLUSION This study showed that UA, UtA PI, and birth weight seem to be linked to QUtA. QUtA had an inverse correlation with UA and UtA PI. In addition, increasing the QUtA showed a linear increase in fetal birth weight. These findings could be helpful in high-risk pregnancy management, but additional research is needed to identify how QUtA in the third trimester impacts labor and fetal outcomes.
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Affiliation(s)
- Marco La Verde
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Marco Torella
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gaetano Riemma
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luigi Cobellis
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Maria Maddalena Marrapodi
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Carlo Capristo
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Maddalena Morlando
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Pasquale De Franciscis
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
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Wilson A, Hodgetts-Morton VA, Marson EJ, Markland AD, Larkai E, Papadopoulou A, Coomarasamy A, Tobias A, Chou D, Oladapo OT, Price MJ, Morris K, Gallos ID. Tocolytics for delaying preterm birth: a network meta-analysis (0924). Cochrane Database Syst Rev 2022; 8:CD014978. [PMID: 35947046 PMCID: PMC9364967 DOI: 10.1002/14651858.cd014978.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Preterm birth is the leading cause of death in newborns and children. Tocolytic drugs aim to delay preterm birth by suppressing uterine contractions to allow time for administration of corticosteroids for fetal lung maturation, magnesium sulphate for neuroprotection, and transport to a facility with appropriate neonatal care facilities. However, there is still uncertainty about their effectiveness and safety. OBJECTIVES To estimate relative effectiveness and safety profiles for different classes of tocolytic drugs for delaying preterm birth, and provide rankings of the available drugs. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov (21 April 2021) and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing effectiveness or adverse effects of tocolytic drugs for delaying preterm birth. We excluded quasi- and non-randomised trials. We evaluated all studies against predefined criteria to judge their trustworthiness. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed the trials for inclusion and risk of bias, and extracted data. We performed pairwise and network meta-analyses, to determine the relative effects and rankings of all available tocolytics. We used GRADE to rate the certainty of the network meta-analysis effect estimates for each tocolytic versus placebo or no treatment. MAIN RESULTS This network meta-analysis includes 122 trials (13,697 women) involving six tocolytic classes, combinations of tocolytics, and placebo or no treatment. Most trials included women with threatened preterm birth, singleton pregnancy, from 24 to 34 weeks of gestation. We judged 25 (20%) studies to be at low risk of bias. Overall, certainty in the evidence varied. Relative effects from network meta-analysis suggested that all tocolytics are probably effective in delaying preterm birth compared with placebo or no tocolytic treatment. Betamimetics are possibly effective in delaying preterm birth by 48 hours (risk ratio (RR) 1.12, 95% confidence interval (CI) 1.05 to 1.20; low-certainty evidence), and 7 days (RR 1.14, 95% CI 1.03 to 1.25; low-certainty evidence). COX inhibitors are possibly effective in delaying preterm birth by 48 hours (RR 1.11, 95% CI 1.01 to 1.23; low-certainty evidence). Calcium channel blockers are possibly effective in delaying preterm birth by 48 hours (RR 1.16, 95% CI 1.07 to 1.24; low-certainty evidence), probably effective in delaying preterm birth by 7 days (RR 1.15, 95% CI 1.04 to 1.27; moderate-certainty evidence), and prolong pregnancy by 5 days (0.1 more to 9.2 more; high-certainty evidence). Magnesium sulphate is probably effective in delaying preterm birth by 48 hours (RR 1.12, 95% CI 1.02 to 1.23; moderate-certainty evidence). Oxytocin receptor antagonists are probably effective in delaying preterm birth by 48 hours (RR 1.13, 95% CI 1.05 to 1.22; moderate-certainty evidence), are effective in delaying preterm birth by 7 days (RR 1.18, 95% CI 1.07 to 1.30; high-certainty evidence), and possibly prolong pregnancy by 10 days (95% CI 2.3 more to 16.7 more). Nitric oxide donors are probably effective in delaying preterm birth by 48 hours (RR 1.17, 95% CI 1.05 to 1.31; moderate-certainty evidence), and 7 days (RR 1.18, 95% CI 1.02 to 1.37; moderate-certainty evidence). Combinations of tocolytics are probably effective in delaying preterm birth by 48 hours (RR 1.17, 95% CI 1.07 to 1.27; moderate-certainty evidence), and 7 days (RR 1.19, 95% CI 1.05 to 1.34; moderate-certainty evidence). Nitric oxide donors ranked highest for delaying preterm birth by 48 hours and 7 days, and delay in birth (continuous outcome), followed by calcium channel blockers, oxytocin receptor antagonists and combinations of tocolytics. Betamimetics (RR 14.4, 95% CI 6.11 to 34.1; moderate-certainty evidence), calcium channel blockers (RR 2.96, 95% CI 1.23 to 7.11; moderate-certainty evidence), magnesium sulphate (RR 3.90, 95% CI 1.09 to 13.93; moderate-certainty evidence) and combinations of tocolytics (RR 6.87, 95% CI 2.08 to 22.7; low-certainty evidence) are probably more likely to result in cessation of treatment. Calcium channel blockers possibly reduce the risk of neurodevelopmental morbidity (RR 0.51, 95% CI 0.30 to 0.85; low-certainty evidence), and respiratory morbidity (RR 0.68, 95% CI 0.53 to 0.88; low-certainty evidence), and result in fewer neonates with birthweight less than 2000 g (RR 0.49, 95% CI 0.28 to 0.87; low-certainty evidence). Nitric oxide donors possibly result in neonates with higher birthweight (mean difference (MD) 425.53 g more, 95% CI 224.32 more to 626.74 more; low-certainty evidence), fewer neonates with birthweight less than 2500 g (RR 0.40, 95% CI 0.24 to 0.69; low-certainty evidence), and more advanced gestational age (MD 1.35 weeks more, 95% CI 0.37 more to 2.32 more; low-certainty evidence). Combinations of tocolytics possibly result in fewer neonates with birthweight less than 2500 g (RR 0.74, 95% CI 0.59 to 0.93; low-certainty evidence). In terms of maternal adverse effects, betamimetics probably cause dyspnoea (RR 12.09, 95% CI 4.66 to 31.39; moderate-certainty evidence), palpitations (RR 7.39, 95% CI 3.83 to 14.24; moderate-certainty evidence), vomiting (RR 1.91, 95% CI 1.25 to 2.91; moderate-certainty evidence), possibly headache (RR 1.91, 95% CI 1.07 to 3.42; low-certainty evidence) and tachycardia (RR 3.01, 95% CI 1.17 to 7.71; low-certainty evidence) compared with placebo or no treatment. COX inhibitors possibly cause vomiting (RR 2.54, 95% CI 1.18 to 5.48; low-certainty evidence). Calcium channel blockers (RR 2.59, 95% CI 1.39 to 4.83; low-certainty evidence), and nitric oxide donors probably cause headache (RR 4.20, 95% CI 2.13 to 8.25; moderate-certainty evidence). AUTHORS' CONCLUSIONS Compared with placebo or no tocolytic treatment, all tocolytic drug classes that we assessed (betamimetics, calcium channel blockers, magnesium sulphate, oxytocin receptor antagonists, nitric oxide donors) and their combinations were probably or possibly effective in delaying preterm birth for 48 hours, and 7 days. Tocolytic drugs were associated with a range of adverse effects (from minor to potentially severe) compared with placebo or no tocolytic treatment, although betamimetics and combination tocolytics were more likely to result in cessation of treatment. The effects of tocolytic use on neonatal outcomes such as neonatal and perinatal mortality, and on safety outcomes such as maternal and neonatal infection were uncertain.
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Affiliation(s)
- Amie Wilson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Ella J Marson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Eva Larkai
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Doris Chou
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Katie Morris
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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van Winden TMS, Nijman TAJ, Kleinrouweler CE, Salim R, Kashanian M, Al-Omari WR, Pajkrt E, Mol BW, Oudijk MA, Roos C. Tocolysis with nifedipine versus atosiban and perinatal outcome: an individual participant data meta-analysis. BMC Pregnancy Childbirth 2022; 22:567. [PMID: 35840927 PMCID: PMC9284745 DOI: 10.1186/s12884-022-04854-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Worldwide, nifedipine and atosiban are the two most commonly used tocolytic agents for the treatment of threatened preterm birth. The aim of this study was to evaluate the effectiveness of nifedipine and atosiban in an individual participant data meta-analysis (IPDMA). Methods We investigated the occurrence of adverse neonatal outcomes in women with threatened preterm birth by performing an IPDMA, and sought to identify possible subgroups in which one treatment may be preferred. We searched PubMed, Embase, and Cochrane for trials comparing nifedipine and atosiban for treatment of threatened preterm birth between 240/7 and 340/7 weeks’ gestational age. Primary outcome was a composite of perinatal mortality and neonatal morbidities including respiratory distress syndrome, intraventricular haemorrhage, periventricular leucomalacia, necrotising enterocolitis, and sepsis. Secondary outcomes included NICU admission, prolongation of pregnancy and GA at delivery. For studies that did not have the original databases available, metadata was used. This led to a two-stage meta-analysis that combined individual participant data with aggregate metadata. Results We detected four studies (N = 791 women), of which two provided individual participant data (N = 650 women). The composite neonatal outcome occurred in 58/364 (16%) after nifedipine versus 69/359 (19%) after atosiban (OR 0.76, 95%CI 0.47–1.23). Perinatal death occurred in 14/392 (3.6%) after nifedipine versus 7/380 (1.8%) after atosiban (OR 2.0, 95%CI 0.80–5.1). Nifedipine results in longer prolongation of pregnancy, with a 18 days to delivery compared with 10 days for atosiban (HR 0.83 (96% CI 0.69–0.99)). NICU admission occurred less often after nifedipine (46%) than after atosiban (59%), (OR 0.32, 95%CI 0.14–0.75). The sensitivity analysis revealed no difference in prolongation of pregnancy for 48 hours (OR 1.0, 95% CI 0.73–1.4) or 7 days (OR 1.3, 95% CI 0.85–5.8) between nifedipine and atosiban. There was a non-significant higher neonatal mortality in the nifedipine-exposed group (OR 1.4, 95% CI 0.60–3.4). Conclusions In this IPDMA, we found no differences in composite outcome between nifedipine and atosiban in the treatment of threatened preterm birth. However, the non-significant higher mortality after administering nifedipine warrants further investigation of the use of nifedipine as a tocolytic drug. Study registration We conducted this study according to a prospectively prepared protocol, registered with PROSPERO (the International Prospective Register of Systematic Reviews) under CRD42016024244. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04854-1.
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Affiliation(s)
- Tijn M S van Winden
- Department of Obstetrics, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Tobias A J Nijman
- Department of Obstetrics and Gynecology, Medisch Centrum Haaglanden, The Hague, Netherlands
| | - C Emily Kleinrouweler
- Department of Obstetrics, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Raed Salim
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
| | - Maryam Kashanian
- Department of Obstetrics & Gynecology, Akbarabadi Teaching Hospital, Tehran, Iran
| | - Wafa R Al-Omari
- Department of Obstetrics and Gynecology, Medical City Teaching Hospital, Baghdad, Iraq
| | - Eva Pajkrt
- Department of Obstetrics, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Martijn A Oudijk
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands. .,Department of Obstetrics, Amsterdam UMC, location Vrije Universiteit Amsterdam, Boelelaan, 1117, Amsterdam, The Netherlands. .,Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Location AMC, H4-275, PO Box 22660, Amsterdam, 1100, DD, the Netherlands.
| | - Carolien Roos
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands.,Department of Obstetrics, Amsterdam UMC, location Vrije Universiteit Amsterdam, Boelelaan, 1117, Amsterdam, The Netherlands
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5
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Helmer H, Saleh L, Petricevic L, Knöfler M, Reinheimer TM. Barusiban, a selective oxytocin receptor antagonist: placental transfer in rabbit, monkey, and human†. Biol Reprod 2021; 103:135-143. [PMID: 32307542 PMCID: PMC7313255 DOI: 10.1093/biolre/ioaa048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/03/2020] [Accepted: 04/15/2020] [Indexed: 11/13/2022] Open
Abstract
The use of drugs in pregnancy always raises concerns regarding potential fetal exposure and possible adverse effects through their accumulation in fetal tissues and organs. Barusiban is an oxytocin antagonist under development for potential use as tocolytic in preterm-labor patients. It displays greater affinity for the oxytocin receptor compared to vasopressin V1A receptor and would thus not interfere with vasopressin-induced effects of the V1A receptor. Barusiban placental transfer was determined in the rabbit and cynomolgus monkey and in an ex vivo human cotyledon model. In the rabbit, there was an approximately 5% transfer of barusiban from the maternal to the fetal blood, without significant accumulation in any of the investigated fetal tissues. In the cynomolgus monkeys, the mean fetal plasma barusiban concentration was 9.1% of the maternal level. This was similar to the percentage of barusiban transfer in the human placental single cotyledon, which once equilibrated ranged between 9.3 and 11.0% over the observation period. The transfer of the small-molecule antipyrine as a comparator in this human model was approximately three times greater. The similarity in the degree of transfer in the cynomolgus monkey and human cotyledon, while being less in the rabbit, may reflect the species-specific placental barrier structure between the maternal and fetal compartments. In conclusion, limited placental transfer of barusiban occurred in all three models. The similarity of barusiban transfer in the cynomolgus and the human placental single cotyledon suggests the latter ex vivo model to be useful in assessing future drug candidates to be used in pregnant women.
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Affiliation(s)
- Hanns Helmer
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Leila Saleh
- Reproductive Biology Unit, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Ljubomir Petricevic
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Martin Knöfler
- Reproductive Biology Unit, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
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Ali AA, Sayed AK, El Sherif L, Loutfi GO, Ahmed AMM, Mohamed HB, Anwar AT, Taha AS, Yahia RM, Elgebaly A, Abdel-Daim MM. Systematic review and meta-analysis of randomized controlled trials of atosiban versus nifedipine for inhibition of preterm labor. Int J Gynaecol Obstet 2019; 145:139-148. [PMID: 30784056 DOI: 10.1002/ijgo.12793] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 11/11/2018] [Accepted: 02/19/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Two tocolytic drugs-atosiban and nifedipine-are currently used for first-line treatment of preterm labor (PTL). OBJECTIVE To compare the efficacy and safety of atosiban with nifedipine for PTL treatment. SEARCH STRATEGY In May 2017, we searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Clinical Trials with search terms including "nifedipine", "atosiban", and "preterm labor". SELECTION CRITERIA Randomized controlled trials of women with PTL. DATA COLLECTION AND ANALYSIS Data were extracted for study design, patient characteristics, risk of bias domains, and study outcomes. A random-effects model was used to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS We included seven studies that enrolled 992 patients. There was no significant difference between atosiban and nifedipine for pregnancy prolongation of 48 hours or more regarding efficacy (RR 1.06, 95% CI 0.92-1.22; P=0.440) or effectiveness (0.93, 0.84-1.03; P=0.177). Pregnancy prolongation for 7 days or more also did not differ between groups for efficacy (RR 1.04, 95% CI 0.89-1.21; P=0.656) or effectiveness (0.91, 0.79-1.05; P=0.177). Atosiban-however-was associated with fewer maternal side-effects than nifedipine. CONCLUSION Atosiban resulted in fewer maternal side-effects than nifedipine, with no difference in pregnancy prolongation. PROSPERO registration: CRD42018090223.
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Affiliation(s)
- Aya Ashraf Ali
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Ahmed Kamal Sayed
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Loalo'a El Sherif
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Gihan Ossam Loutfi
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Abdullah Mahmoud Mohamed Ahmed
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Hajer Bassem Mohamed
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Ahmad Tareq Anwar
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Abdullah Salah Taha
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Reem Mohamed Yahia
- Faculty of Medicine, Minia University, Minia, Egypt.,Minia Medical Research Society (MMRS), Minia University, Minia, Egypt
| | - Ahmed Elgebaly
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt.,Medical Research Education and Practice Association (MREP), Cairo, Egypt
| | - Mohamed M Abdel-Daim
- Pharmacology Department, Faculty of Veterinary Medicine, Suez Canal University, Ismailia, Egypt
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Sotiriadis A, Hernandez-Andrade E, da Silva Costa F, Ghi T, Glanc P, Khalil A, Martins WP, Odibo AO, Papageorghiou AT, Salomon LJ, Thilaganathan B. ISUOG Practice Guidelines: role of ultrasound in screening for and follow-up of pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:7-22. [PMID: 30320479 DOI: 10.1002/uog.20105] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/15/2018] [Accepted: 07/22/2018] [Indexed: 06/08/2023]
Affiliation(s)
- A Sotiriadis
- Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Hernandez-Andrade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Hutzel Women Hospital, Wayne State University, Detroit, MI, USA
| | - F da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - T Ghi
- Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - P Glanc
- Department of Radiology, University of Toronto, Toronto, Ontario, Canada
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine and Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - A O Odibo
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - A T Papageorghiou
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Nuffield Department of Obstetrics and Gynecology, University of Oxford, Women's Center, John Radcliffe Hospital, Oxford, UK
| | - L J Salomon
- Department of Obstetrics and Fetal Medicine, Hopital Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, Paris Descartes University, Paris, France
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Pinto Cardoso G, Houivet E, Marchand-Martin L, Kayem G, Sentilhes L, Ancel PY, Lorthe E, Marret S. Association of Intraventricular Hemorrhage and Death With Tocolytic Exposure in Preterm Infants. JAMA Netw Open 2018; 1:e182355. [PMID: 30646165 PMCID: PMC6324618 DOI: 10.1001/jamanetworkopen.2018.2355] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
IMPORTANCE No trials to date have demonstrated the benefits of tocolysis on death and/or neonatal morbidity in preterm infants; tocolytics may affect the fetal blood-brain barrier. OBJECTIVES To assess the risks associated with tocolysis in women delivering prematurely as measured by death and/or intraventricular hemorrhage (IVH) in preterm infants and to compare the association of calcium channel blockers (CCBs) nifedipine and nicardipine hydrochloride vs atosiban used for tocolysis with death and/or IVH. DESIGN, SETTINGS, AND PARTICIPANTS The French 2011 EPIPAGE-2 (Enquête Épidémiologique sur les Petits Âges Gestationnels) cohort was limited to mothers admitted for preterm labor without fever, who delivered from 24 to 31 weeks of gestation from April 1 through December 31, 2011. Groups of preterm infants with vs without tocolytic exposure and groups with atosiban vs CCB exposure were compared. Data analysis was performed from June 7, 2014, through September 3, 2017. EXPOSURES Tocolytics. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death and/or IVH in preterm infants. Secondary outcomes included death, IVH, and a composite of death and/or grades III to IV IVH. RESULTS A total of 1127 mothers (mean [SD] age, 25.5 [6.0] years) experienced preterm labor and gave birth to 1343 preterm infants with a male to female ratio of 1.23 and mean (SD) gestational age of 27 (2.5) weeks. Of these, 789 mothers (70.0%) received tocolytics; 314 (39.8%) received only atosiban, and 118 (15.0%) received only a CCB. In the first analysis, the primary outcome (death and/or IVH) was not significantly different in preterm infants with vs without tocolytic exposure (183 of 363 [50.4%] vs 207 of 363 [57.0%]; relative risk [RR], 0.88; 95% CI, 0.77-1.01; P = .07). The secondary outcome (death and/or grades III-IV IVH) was significantly lower in preterm infants with vs without tocolytic exposure (92 of 363 [25.3%] vs 118 of 363 [32.5%]; RR, 0.78; 95% CI, 0.62-0.98; P = .03). Other outcomes did not differ significantly. In the secondary analysis, death and/or IVH was not significantly different in preterm infants with atosiban vs CCB exposure (96 of 214 [44.9%] vs 62 of 121 [51.2%]; RR, 0.88; 95% CI, 0.70-1.10; P = .26), nor was IVH (77 of 197 [39.1%] vs 48 of 106 [45.3%]; RR, 0.86; 95% CI, 0.66-1.13; P = .29). CONCLUSIONS AND RELEVANCE In this population-based study, findings suggest that tocolytics were associated with a reduction of death and severe IVH. Other studies are necessary to compare perinatal outcomes after use of atosiban vs CCBs.
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Affiliation(s)
- Gaëlle Pinto Cardoso
- Department of Neonatal Pediatrics and Intensive Care, Neuropediatrics and Rehabilitation Center, Reference Centre for Learning Disabilities of the Child, Rehabilitation Centre, Rouen University Hospital–Charles Nicolle Hospital, Rouen, France
- Institut National de la Santé et de la Recherche Medicale (INSERM) U1245, NEOVASC Team, Research and Biomedical Innovation Institute, Rouen Medical School, Normandy University, Rouen, France
| | - Estelle Houivet
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Laetitia Marchand-Martin
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Maternité Port-Royal, Paris Descartes University France, Département Hospitalo-Universitaire Risk in Pregnancy, Paris, France
- Unité de Recherche Clinique, Centre d’Investigation Clinique P1419, Cochin Hotel-Dieu Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Gilles Kayem
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Maternité Port-Royal, Paris Descartes University France, Département Hospitalo-Universitaire Risk in Pregnancy, Paris, France
- Department of Obstetrics and Gynecology, Armand Trousseau Hospital, Paris, France
- Sorbonne Universités, Université Pierre and Marie Curie Paris 06, Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Pierre-Yves Ancel
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Maternité Port-Royal, Paris Descartes University France, Département Hospitalo-Universitaire Risk in Pregnancy, Paris, France
- Unité de Recherche Clinique, Centre d’Investigation Clinique P1419, Cochin Hotel-Dieu Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Elsa Lorthe
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Maternité Port-Royal, Paris Descartes University France, Département Hospitalo-Universitaire Risk in Pregnancy, Paris, France
| | - Stéphane Marret
- Department of Neonatal Pediatrics and Intensive Care, Neuropediatrics and Rehabilitation Center, Reference Centre for Learning Disabilities of the Child, Rehabilitation Centre, Rouen University Hospital–Charles Nicolle Hospital, Rouen, France
- Institut National de la Santé et de la Recherche Medicale (INSERM) U1245, NEOVASC Team, Research and Biomedical Innovation Institute, Rouen Medical School, Normandy University, Rouen, France
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Nijman TAJ, Goedhart MM, Naaktgeboren CN, de Haan TR, Vijlbrief DC, Mol BW, Benders MJN, Franx A, Oudijk MA. Effect of nifedipine and atosiban on perinatal brain injury: secondary analysis of the APOSTEL-III trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:806-812. [PMID: 28452086 DOI: 10.1002/uog.17512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 04/03/2017] [Accepted: 04/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Brain injury in neonates born prematurely is associated strongly with poor neurodevelopmental outcome. The aim of this study was to evaluate whether tocolysis with nifedipine or atosiban in women with threatened preterm birth can reduce the incidence of overall brain injury in neonates born prematurely. METHODS This was a secondary analysis of the APOSTEL-III trial (Dutch Clinical Trial Registry, no. NTR2947), a randomized clinical trial in which women with threatened preterm labor between 25 and 34 weeks of gestation were allocated to treatment with nifedipine or atosiban. In this secondary analysis, women delivered at ≤ 32 weeks of gestational age in the two main contributing centers were included. Primary outcome was the presence of neonatal brain injury, which was defined as presence of abnormalities on ultrasound investigation and classified into mild and severe. To evaluate type and severity of brain injury, all neonatal ultrasounds performed during neonatal intensive and medium care admission were analyzed. To test the robustness of our results, a sensitivity analysis was performed assessing differences in baseline or known risk factors for brain injury. RESULTS A total of 117 neonates (from 102 women) were studied, of which 51 had been exposed to nifedipine and 66 to atosiban. Brain injury was observed in 22 (43.1%) neonates in the nifedipine group compared with 37 (56.1%) in the atosiban group (OR, 0.60; 95% CI, 0.29-1.24). Presence of mild brain injury was comparable between the nifedipine (33.3%) and atosiban (48.5%) groups (OR, 0.53; 95% CI, 0.25-1.13). Severe brain injury was also comparable between the groups, observed in 9.8% of neonates in the nifedipine vs 7.6% of those in the atosiban group (OR, 1.33; 95% CI, 0.36-4.85). Intraventricular hemorrhage (≥ Grade I) was the most frequently seen ultrasound abnormality, observed in 18 (35.3%) neonates in the nifedipine group vs 25 (37.9%) in the atosiban group (OR, 0.90; 95% CI, 0.42-1.91). The sensitivity analysis, with adjustment for maternal age and gestational age at randomization, showed no statistical difference between the groups for presence of brain injury (OR, 0.58; 95% CI, 0.27-1.27). CONCLUSION In children born before 32 weeks of gestation after the use of tocolytics, the prevalence of brain injury was high. No significant differences were found with respect to overall brain injury between neonates exposed to nifedipine and those exposed to atosiban. However, as this study was a secondary analysis of the APOSTEL III trial, it was underpowered for brain injury. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- T A J Nijman
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Obstetrics and Gynecology, Haaglanden Medical Center, The Hague, The Netherlands
| | - M M Goedhart
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C N Naaktgeboren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T R de Haan
- Department of Neonatology, Academic Medical Center, Amsterdam, The Netherlands
| | - D C Vijlbrief
- Department of Neonatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B W Mol
- The Robinson Research Institute, School of Pediatrics and Reproductive Health and The South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, Australia
| | - M J N Benders
- Department of Neonatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A Franx
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M A Oudijk
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
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10
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Knaven O, Ganzevoort W, de Boer M, Wolf H. Fetal heart rate variation after corticosteroids for fetal maturation. Eur J Obstet Gynecol Reprod Biol 2017; 216:38-45. [PMID: 28715659 DOI: 10.1016/j.ejogrb.2017.06.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 06/24/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Several studies report a decrease of fetal heart rate (FHR) short-term variation (STV) after corticosteroids for improvement of fetal maturity and advice not to deliver a fetus for low STV within 2-3days after corticosteroids. However, literature is not unanimous in this respect. This study intends to asses STV longitudinally after corticosteroid administration. MATERIAL AND METHODS A retrospective cohort study in a tertiary perinatal centre from 2009 to 2015 included all women who had been treated with corticosteroids at gestational age of 26-34 weeks, had a computerized cardiotocography (cCTG) before and after medication and did not deliver within 48h. FHR and STV were stratified over 12-h periods and compared before and after corticosteroids. Women with imminent preterm labour (including PPROM) and women with placental problems (fetal growth restriction (FGR) or preeclampsia) (PE) were analysed separately. The effect of co-medication and gestational age was assessed. RESULTS The study included 406 women, 211 with imminent preterm labour, 195 with FGR-PE. After corticosteroids STV increased 1-2ms (median 1.4; IQR 0.1-3.1) during the first 36h after start of corticosteroids. Thereafter a small decrease of less than 1ms (median -0,6; IQR -1.6 to 0.3) compared to before CC was seen. CONCLUSIONS The most conspicuous effect of corticosteroids is a short term increase of STV and decrease of FHR. A slight decrease after 48-71h is possible, but abnormally low values should be considered as a sign of fetal distress. The clinical guidance, given by some, not to intervene because of a low STV after corticosteroids appears invalid.
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Affiliation(s)
- Olga Knaven
- Department of Obstetrics and Gynecology, Academic Medical Centre, PO Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Centre, PO Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Marjon de Boer
- Department of Obstetrics and Gynecology, VU Medical Centre, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Hans Wolf
- Department of Obstetrics and Gynecology, Academic Medical Centre, PO Box 22660, 1100DD, Amsterdam, The Netherlands.
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11
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Doret M, Kayem G. La tocolyse en cas de menace d’accouchement prématuré à membranes intactes. ACTA ACUST UNITED AC 2016; 45:1374-1398. [DOI: 10.1016/j.jgyn.2016.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
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12
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Verdurmen KMJ, Hulsenboom ADJ, van Laar JOEH, Oei SG. Effect of tocolytic drugs on fetal heart rate variability: a systematic review. J Matern Fetal Neonatal Med 2016; 30:2387-2394. [PMID: 27756155 DOI: 10.1080/14767058.2016.1249844] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Tocolytics may cause changes in fetal heart rate (HR) pattern, while fetal heart rate variability (HRV) is an important marker of fetal well-being. We aim to systematically review the literature on how tocolytic drugs affect fetal HRV. MATERIALS AND METHODS We searched CENTRAL, PubMed and EMBASE up to June 2016. Studies published in English, using computerized or visual analysis to describe the effect of tocolytics on HRV in human fetuses were included. Studies describing tocolytics during labor, external cephalic version, pre-eclampsia and infection were excluded. Eventually, we included six studies, describing 169 pregnant women. RESULTS Nifedipine, atosiban and indomethacin administration show no clinically important effect on fetal HRV. Following administration of magnesium sulfate decreased variability and cases of bradycardia are described. Fenoterol administration results in a slight increase in fetal HR with no changes in variability. After ritodrine administration increased fetal HR and decreased variability is seen. The effect of co-administration of corticosteroids should be taken into account. CONCLUSION In order to prevent iatrogenic preterm labor, the effects of tocolytic drugs on fetal HRV should be taken into account when monitoring these fetuses.
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Affiliation(s)
- Kim M J Verdurmen
- a Department of Obstetrics and Gynecology , Máxima Medical Center , Veldhoven , the Netherlands and
| | - Alexandra D J Hulsenboom
- a Department of Obstetrics and Gynecology , Máxima Medical Center , Veldhoven , the Netherlands and
| | - Judith O E H van Laar
- a Department of Obstetrics and Gynecology , Máxima Medical Center , Veldhoven , the Netherlands and
| | - S Guid Oei
- a Department of Obstetrics and Gynecology , Máxima Medical Center , Veldhoven , the Netherlands and.,b Faculty of Electrical Engineering , Eindhoven University of Technology , Eindhoven , the Netherlands
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13
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Nijman TAJ, van Vliet EOG, Naaktgeboren CA, Oude Rengerink K, de Lange TS, Bax CJ, Bloemenkamp KWM, van Eyck J, Kok M, Scheepers HCJ, Woiski M, Franx A, Mol BWJ, Oudijk MA. Nifedipine versus placebo in the treatment of preterm prelabor rupture of membranes: a randomized controlled trial: Assessment of perinatal outcome by use of tocolysis in early labor-APOSTEL IV trial. Eur J Obstet Gynecol Reprod Biol 2016; 205:79-84. [PMID: 27567363 DOI: 10.1016/j.ejogrb.2016.08.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 07/18/2016] [Accepted: 08/01/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Preterm birth is the most common cause of neonatal morbidity and mortality. Around one third of preterm deliveries starts with preterm prelabor rupture of membranes (PPROM). The aim of this trial was to study the effect of prolonged tocolysis with nifedipine versus placebo in women with PPROM on perinatal outcome and prolongation of pregnancy. STUDY DESIGN The Apostel IV was a nationwide multicenter randomized placebo controlled trial. We included women with PPROM without contractions between 24(+0) and 33(+6) weeks of gestation. Participants were randomly allocated to daily 80mg nifedipine or placebo, until the start of labor, with a maximum of 18 days. The primary outcome measure was a composite of poor neonatal outcome, including perinatal death, bronchopulmonary dysplasia, periventricular leukomalacia>grade 1, intraventricular hemorrhage>grade 2, necrotizing enterocolitis>stage 1 and culture proven sepsis. Secondary outcomes were gestational age at delivery and prolongation of pregnancy. Analysis was by intention to treat. To detect a reduction of poor neonatal outcome from 30% to 10%, 120 women needed to be randomized. TRIAL REGISTRY NTR 3363. RESULTS Between October 2012 and December 2014 we randomized 25 women to nifedipine and 25 women to placebo. Due to slow recruitment the study was stopped prematurely. The median gestational age at randomization was 29.9 weeks (IQR 27.7-31.3) in the nifedipine group and 27.0 weeks (IQR 24.7-29.9) in the placebo group. Other baseline characteristics were comparable. The adverse perinatal outcome occurred in 9 neonates (33.3%) in the nifedipine group and 9 neonates (32.1%) in the placebo group (RR 1.04, 95% CI 0.49-2.2). Two perinatal deaths occurred, both in the nifedipine group. Bronchopulmonary dysplasia was seen less frequently in the nifedipine group (0% versus 17.9%; p=0.03). Prolongation of pregnancy did not differ between the nifedipine and placebo group (median 11 versus 8 days, HR 1.02; 95% CI 0.58-1.79). CONCLUSION This randomized trial did not show a beneficial effect of prolonged tocolysis on neonatal outcomes or prolongation of pregnancy in women with PPROM without contractions. However, since results are based on a small sample size, a difference in effectiveness cannot be excluded.
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Affiliation(s)
- Tobias A J Nijman
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman & Baby, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Elvira O G van Vliet
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman & Baby, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Christiana A Naaktgeboren
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Katrien Oude Rengerink
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas S de Lange
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Caroline J Bax
- Department of Obstetrics and Gynecology, VU Medical Centre, Amsterdam, The Netherlands
| | - Kitty W M Bloemenkamp
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman & Baby, University Medical Centre Utrecht, Utrecht, The Netherlands; Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jim van Eyck
- Department of Obstetrics and Gynecology, Isala Clinics, Zwolle, The Netherlands
| | - Marjolein Kok
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mallory Woiski
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Arie Franx
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman & Baby, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ben Willem J Mol
- The Robinson Research Institute, School of Pediatrics and Reproductive Health and The South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, Australia
| | - Martijn A Oudijk
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman & Baby, University Medical Centre Utrecht, Utrecht, The Netherlands; Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands.
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Affiliation(s)
- Kate F Walker
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK; Department of Obstetrics and Gynaecology, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, UK
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham NG5 1PB, UK.
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15
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van Vliet EOG, Nijman TAJ, Schuit E, Heida KY, Opmeer BC, Kok M, Gyselaers W, Porath MM, Woiski M, Bax CJ, Bloemenkamp KWM, Scheepers HCJ, Jacquemyn Y, Beek EV, Duvekot JJ, Franssen MTM, Papatsonis DN, Kok JH, van der Post JAM, Franx A, Mol BW, Oudijk MA. Nifedipine versus atosiban for threatened preterm birth (APOSTEL III): a multicentre, randomised controlled trial. Lancet 2016; 387:2117-2124. [PMID: 26944026 DOI: 10.1016/s0140-6736(16)00548-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND In women with threatened preterm birth, delay of delivery by 48 h allows antenatal corticosteroids to improve neonatal outcomes. For this reason, tocolytics are often administered for 48 h; however, there is no consensus about which drug results in the best maternal and neonatal outcomes. In the APOSTEL III trial we aimed to compare the effectiveness and safety of the calcium-channel blocker nifedipine and the oxytocin inhibitor atosiban in women with threatened preterm birth. METHODS We did this multicentre, randomised controlled trial in ten tertiary and nine teaching hospitals in the Netherlands and Belgium. Women with threatened preterm birth (gestational age 25-34 weeks) were randomly assigned (1:1) to either oral nifedipine or intravenous atosiban for 48 h. An independent data manager used a web-based computerised programme to randomly assign women in permuted block sizes of four, with groups stratified by centre. Clinicians, outcome assessors, and women were not masked to treatment group. The primary outcome was a composite of adverse perinatal outcomes, which included perinatal mortality, bronchopulmonary dysplasia, sepsis, intraventricular haemorrhage, periventricular leukomalacia, and necrotising enterocolitis. Analysis was done in all women and babies with follow-up data. The study is registered at the Dutch Clinical Trial Registry, number NTR2947. FINDINGS Between July 6, 2011, and July 7, 2014, we randomly assigned 254 women to nifedipine and 256 to atosiban. Primary outcome data were available for 248 women and 297 babies in the nifedipine group and 255 women and 294 babies in the atosiban group. The primary outcome occurred in 42 babies (14%) in the nifedipine group and in 45 (15%) in the atosiban group (relative risk [RR] 0·91, 95% CI 0·61-1·37). 16 (5%) babies died in the nifedipine group and seven (2%) died in the atosiban group (RR 2·20, 95% CI 0·91-5·33); all deaths were deemed unlikely to be related to the study drug. Maternal adverse events did not differ between groups. INTERPRETATION In women with threatened preterm birth, 48 h of tocolysis with nifedipine or atosiban results in similar perinatal outcomes. Future clinical research should focus on large placebo-controlled trials, powered for perinatal outcomes. FUNDING ZonMw (the Netherlands Organisation for Health Research and Development).
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Affiliation(s)
- Elvira O G van Vliet
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Tobias A J Nijman
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Ewoud Schuit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands; Stanford Prevention Research Center, Stanford University, Stanford, CA, USA
| | - Karst Y Heida
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Brent C Opmeer
- Clinical Research Unit, Academic Medical Centre, Amsterdam, Netherlands
| | - Marjolein Kok
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, Netherlands
| | - Wilfried Gyselaers
- Department of Obstetrics and Gynecology, Ziekenhuis Oost-Limburg, Genk, Belgium; Department of Physiology, Hasselt University, Diepenbeek, Belgium
| | - Martina M Porath
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, Netherlands
| | - Mallory Woiski
- Department of Obstetrics and Gynaecology, University Medical Centre Nijmegen, Nijmegen, Netherlands
| | - Caroline J Bax
- Department of Obstetrics and Gynaecology, Vrije University Medical Centre, Amsterdam, Netherlands
| | - Kitty W M Bloemenkamp
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, Netherlands; Department of Obstetrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Yves Jacquemyn
- Department of Gynecology and Obstetrics, Antwerp University Hospital, Antwerp, Belgium
| | - Erik van Beek
- Department of Obstetrics and Gynaecology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics and Gynecology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Maureen T M Franssen
- Department of Obstetrics, University Medical Centre, University of Groningen, Groningen, Netherlands
| | | | - Joke H Kok
- Department of Neonatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Joris A M van der Post
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, Netherlands
| | - Arie Franx
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Ben W Mol
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Martijn A Oudijk
- Department of Obstetrics, Wilhelmina Hospital Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, Netherlands; Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, Netherlands.
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Spiesser-Robelet L, Martin B, Carceller AM, Bussières JF, Touzin K, Audibert F, Lachance C, Ferreira E. [Adverse effects and hemodynamic effects of nifedipine as a tocolytic]. J Gynecol Obstet Hum Reprod 2015; 44:614-620. [PMID: 25283592 DOI: 10.1016/j.jgyn.2014.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 08/01/2014] [Accepted: 08/28/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To describe maternal and fetal adverse effects, in particular cardiorespiratory, of nifedipine as tocolytic, as well as effects on hemodynamic parameters. MATERIALS AND METHODS A retrospective evaluative study describing the use of nifedipine as tocolytic at CHU Sainte-Justine in Montreal. Demographic data as well as maternal blood pressure and adverse effects, and maternal and fetal heart rate were collected from medical records of women treated with nifedipine following our tocolysis protocol between January 1st 2004 and March 1st 2007. RESULTS The medical records of 213 pregnant women were included in the study. Cardiorespiratory adverse effects were noted in 69 (32.4%); of these, 19 (8.9%) had serious cardiorespiratory adverse events, including 6 acute pulmonary edema or overload. Mean maternal systolic and diastolic blood pressures were significantly decreased and mean maternal and fetal heart rates were significantly increased after the bolus dose. Other adverse effects were reported for 100 (46.9%) women. CONCLUSION Nifedipine may cause cardiorespiratory adverse effects warranting a close monitoring.
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Affiliation(s)
- L Spiesser-Robelet
- Service de pharmacie, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 9, France; Faculté de pharmacie, université d'Angers, 16, boulevard Daviers, 49045 Angers, France.
| | - B Martin
- Département de pharmacie, CHU Sainte-Justine, faculté de pharmacie, université de Montréal, Montréal, Québec, Canada
| | - A-M Carceller
- Département de pédiatrie, CHU Sainte-Justine, faculté de médecine, université de Montréal, Montréal, Québec, Canada
| | - J-F Bussières
- Département de pharmacie, CHU Sainte-Justine, faculté de pharmacie, université de Montréal, Montréal, Québec, Canada
| | - K Touzin
- Département de pharmacie, CHU Sainte-Justine, faculté de pharmacie, université de Montréal, Montréal, Québec, Canada
| | - F Audibert
- Département d'obstétrique et gynécologie, CHU Sainte-Justine, faculté de médecine, université de Montréal, Montréal, Québec, Canada
| | - C Lachance
- Département de pédiatrie, CHU Sainte-Justine, faculté de médecine, université de Montréal, Montréal, Québec, Canada
| | - E Ferreira
- Département de pharmacie, CHU Sainte-Justine, faculté de pharmacie, université de Montréal, Montréal, Québec, Canada
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Vliet EOG, Seinen L, Roos C, Schuit E, Scheepers HCJ, Bloemenkamp KWM, Duvekot JJ, Eyck J, Kok JH, Lotgering FK, Baar A, Wassenaer‐Leemhuis AG, Franssen MT, Porath MM, Post JAM, Franx A, Mol BWJ, Oudijk MA. Maintenance tocolysis with nifedipine in threatened preterm labour: 2‐year follow up of the offspring in the
APOSTEL II
trial. BJOG 2015; 123:1107-14. [DOI: 10.1111/1471-0528.13586] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2015] [Indexed: 11/28/2022]
Affiliation(s)
- EOG Vliet
- Department of Obstetrics and Gynaecology University Medical Centre Utrecht Utrecht the Netherlands
| | - L Seinen
- Department of Obstetrics and Gynaecology Radboud University Nijmegen Medical Centre Nijmegen the Netherlands
| | - C Roos
- Department of Obstetrics and Gynaecology Radboud University Nijmegen Medical Centre Nijmegen the Netherlands
| | - E Schuit
- Julius Centre for Health Sciences and Primary Care University Medical Centre Utrecht Utrecht the Netherlands
- Stanford Prevention Research Centre Department of Medicine Stanford University Stanford CA USA
| | - HCJ Scheepers
- Department of Obstetrics and Gynaecology Maastricht University Medical Centre Maastricht the Netherlands
| | - KWM Bloemenkamp
- Department of Obstetrics and Gynaecology Leiden University Medical Centre Leiden the Netherlands
| | - JJ Duvekot
- Department of Obstetrics and Gynaecology Erasmus Medical Centre Rotterdam the Netherlands
| | - J Eyck
- Department of Obstetrics and Gynaecology Isala Clinics Zwolle the Netherlands
| | - JH Kok
- Department of Neonatology Academic Medical Centre Amsterdam the Netherlands
| | - FK Lotgering
- Department of Obstetrics and Gynaecology Radboud University Nijmegen Medical Centre Nijmegen the Netherlands
| | - A Baar
- Utrecht Centre for Child and Adolescent Studies Utrecht University Utrecht the Netherlands
| | | | - MT Franssen
- Department of Obstetrics University Medical Centre University of Groningen Groningen the Netherlands
| | - MM Porath
- Department of Obstetrics and Gynaecology Máxima Medical Centre Veldhoven the Netherlands
| | - JAM Post
- Department of Obstetrics and Gynaecology Academic Medical Centre Amsterdam the Netherlands
| | - A Franx
- Department of Obstetrics and Gynaecology University Medical Centre Utrecht Utrecht the Netherlands
| | - BWJ Mol
- The Robinson Institute School of Paediatrics and Reproductive Health University of Adelaide Adelaide SA Australia
| | - MA Oudijk
- Department of Obstetrics and Gynaecology University Medical Centre Utrecht Utrecht the Netherlands
- Department of Obstetrics and Gynaecology Academic Medical Centre Amsterdam the Netherlands
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18
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Ulubaşoğlu H, Özmen Bayar Ü, Kaya C, Ungan B. The effect of nifedipine tocolysis on Doppler indices of the uterine and umbilical arteries. JOURNAL OF CLINICAL ULTRASOUND : JCU 2015; 43:322-326. [PMID: 25502008 DOI: 10.1002/jcu.22252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 09/07/2014] [Indexed: 06/04/2023]
Abstract
PURPOSE The aim of this study was to evaluate the effect of oral nifedipine on Doppler indices of the uterine artery (UtA) and umbilical artery (UA) before and 24 hours, 48 hours, and 1 week after tocolytic treatment. METHODS This was a prospective, self-controlled, cohort study of 65 pregnant women undergoing nifedipine tocolysis. Doppler assessment of the UtA and UA was performed before treatment and 24 hours, 48 hours, and 1 week after the initial 4 doses of 10 mg of oral nifedipine, administered at 20-minute intervals. The maintenance dosage was 20 mg of oral nifedipine administered every 6 hours for 48 hours, for a total dose of 80 mg/day. RESULTS There was a decrease in the 24-hour values of the UA pulsatility index, resistance index (RI), systolic-diastolic (S:D) ratio, right UtA pulsatility index, RI, S:D ratio, and left UtA RI and S:D ratio with nifedipine therapy in comparison with the values recorded prior to nifedipine therapy. However, these differences were not statistically significant. There were no statistically significant differences between the data recorded prior to nifedipine administration and those obtained at 48 hours and 1 week after treatment. CONCLUSIONS Oral nifedipine is a safe tocolytic agent with no long-term effect on fetomaternal circulation in pregnant women at risk of preterm delivery.
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Affiliation(s)
- Hasan Ulubaşoğlu
- Dr Münif İslamǒglu State Hospital, Clinic of Obstetrics and Gynecology, Kastamonu, Turkey
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Flenady V, Reinebrant HE, Liley HG, Tambimuttu EG, Papatsonis DNM. Oxytocin receptor antagonists for inhibiting preterm labour. Cochrane Database Syst Rev 2014; 2014:CD004452. [PMID: 24903678 PMCID: PMC11086629 DOI: 10.1002/14651858.cd004452.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Preterm birth, defined as birth between 20 and 36 completed weeks, is a major contributor to perinatal morbidity and mortality globally. Oxytocin receptor antagonists (ORA), such as atosiban, have been specially developed for the treatment of preterm labour. ORA have been proposed as effective tocolytic agents for women in preterm labour to prolong pregnancy with fewer side effects than other tocolytic agents. OBJECTIVES To assess the effects on maternal, fetal and neonatal outcomes of tocolysis with ORA for women with preterm labour compared with placebo or any other tocolytic agent. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013). SELECTION CRITERIA We included all randomised controlled trials (published and unpublished) of ORA for tocolysis of labour between 20 and 36 completed weeks' gestation. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated methodological quality and extracted trial data. When required, we sought additional data from trial authors. Results are presented as risk ratio (RR) for categorical and mean difference (MD) for continuous data with the 95% confidence intervals (CI). Where appropriate, the number needed to treat for benefit (NNTB) and the number needed to treat for harm (NNTH) were calculated. MAIN RESULTS This review update includes eight additional studies (790 women), giving a total of 14 studies involving 2485 women.Four studies (854 women) compared ORA (three used atosiban and one barusiban) with placebo. Three studies were considered at low risk of bias in general (blinded allocation to treatment and intervention), the fourth study did not adequately blind the intervention. No difference was shown in birth less than 48 hours after trial entry (average RR 1.05, 95% CI 0.15 to 7.43; random-effects, (two studies, 152 women), perinatal mortality (RR 2.25, 95% CI 0.79 to 6.38; two studies, 729 infants), or major neonatal morbidity. ORA (atosiban) resulted in a small reduction in birthweight (MD -138.86 g, 95% CI -250.53 to -27.18; two studies with 676 infants). In one study, atosiban resulted in an increase in extremely preterm birth (before 28 weeks' gestation) (RR 3.11, 95% CI 1.02 to 9.51; NNTH 31, 95% CI 8 to 3188) and infant deaths (up to 12 months) (RR 6.13, 95% CI 1.38 to 27.13; NNTH 28, 95% CI 6 to 377). However, this finding may be confounded due to randomisation of more women with pregnancy less than 26 weeks' gestation to atosiban. ORA also resulted in an increase in maternal adverse drug reactions requiring cessation of treatment in comparison with placebo (RR 4.02, 95% CI 2.05 to 7.85; NNTH 12, 95% CI 5 to 33). No differences were shown in preterm birth less than 37 weeks' gestation or any other adverse neonatal outcomes. No differences were evident by type of ORA, although data were limited.Eight studies (1402 women) compared ORA (atosiban only) with betamimetics; four were considered of low risk of bias (blinded allocation to treatment and to intervention). No statistically significant difference was shown in birth less than 48 hours after trial entry (RR 0.89, 95% CI 0.66 to 1.22; eight studies with 1389 women), very preterm birth (RR 1.70, 95% CI 0.89 to 3.23; one study with 145 women), extremely preterm birth (RR 0.84, 95% CI 0.37 to 1.92; one study with 244 women) or perinatal mortality (RR 0.55, 95% CI 0.21 to 1.48; three studies with 816 infants). One study (80 women), of unclear methodological quality, showed an increase in the interval between trial entry and birth (MD 22.90 days, 95% CI 18.03 to 27.77). No difference was shown in any reported measures of major neonatal morbidity (although numbers were small). ORA (atosiban) resulted in less maternal adverse effects requiring cessation of treatment (RR 0.05, 95% CI 0.02 to 0.11; NNTB 6, 95% CI 6 to 6; five studies with 1161 women).Two studies including (225 women) compared ORA (atosiban) with calcium channel blockers (CCB) (nifedipine only). The studies were considered as having high risk of bias as neither study blinded the intervention and in one study it was not known if allocation was blinded. No difference was shown in birth less than 48 hours after trial entry (average RR 1.09, 95% CI 0.44 to 2.73, random-effects; two studies, 225 women) and extremely preterm birth (RR 2.14, 95% CI 0.20 to 23.11; one study, 145 women). No data were available for the outcome of perinatal mortality. One small trial (145 women), which did not employ blinding of the intervention, showed an increase in the number of preterm births (before 37 weeks' gestation) (RR 1.56, 95% CI 1.13 to 2.14; NNTH 5, 95% CI 3 to 19), a lower gestational age at birth (MD -1.20 weeks, 95% CI -2.15 to -0.25) and an increase in admission to neonatal intensive care unit (RR 1.70, 95% CI 1.17 to 2.47; NNTH 5, 95% CI 3 to 20). ORA (atosiban) resulted in less maternal adverse effects (RR 0.38, 95% CI 0.21 to 0.68; NNTB 6, 95% CI 5 to 12; two studies, 225 women) but not maternal adverse effects requiring cessation of treatment (RR 0.36, 95% CI 0.01 to 8.62; one study, 145 women). No longer-term outcome data were included. AUTHORS' CONCLUSIONS This review did not demonstrate superiority of ORA (largely atosiban) as a tocolytic agent compared with placebo, betamimetics or CCB (largely nifedipine) in terms of pregnancy prolongation or neonatal outcomes, although ORA was associated with less maternal adverse effects than treatment with the CCB or betamimetics. The finding of an increase in infant deaths and more births before completion of 28 weeks of gestation in one placebo-controlled study warrants caution. However, the number of women enrolled at very low gestations was small. Due to limitations of small numbers studied and methodological quality, further well-designed randomised controlled trials are needed. Further comparisons of ORA versus CCB (which has a better side-effect profile than betamimetics) are needed. Consideration of further placebo-controlled studies seems warranted. Future studies of tocolytic agents should measure all important short- and long-term outcomes for women and infants, and costs.
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Affiliation(s)
- Vicki Flenady
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)Translating Research Into Practice (TRIP) CentreLevel 2 Aubigny Place, Mater Health ServicesAnnerley Road, WoolloongabbaBrisbaneQueenslandAustralia4102
| | - Hanna E Reinebrant
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)Translating Research Into Practice (TRIP) CentreLevel 2 Aubigny Place, Mater Health ServicesAnnerley Road, WoolloongabbaBrisbaneQueenslandAustralia4102
| | - Helen G Liley
- Mater Mothers’ Hospital, Mater Research, The University of QueenslandSouth BrisbaneAustralia
| | - Eashan G Tambimuttu
- Royal Brisbane and Women's HospitalDepartment of Gynaecology Oncology/Obstetrics and GynaecologyButterfield Street, HerstonBrisbaneQueenslandAustralia4006
| | - Dimitri NM Papatsonis
- Amphia Hospital BredaDepartment of Obstetrics and GynaecologyLangendijk 75BredaNetherlands4819 EV
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Flenady V, Wojcieszek AM, Papatsonis DNM, Stock OM, Murray L, Jardine LA, Carbonne B. Calcium channel blockers for inhibiting preterm labour and birth. Cochrane Database Syst Rev 2014; 2014:CD002255. [PMID: 24901312 PMCID: PMC7144737 DOI: 10.1002/14651858.cd002255.pub2] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Preterm birth is a major contributor to perinatal mortality and morbidity, affecting around 9% of births in high-income countries and an estimated 13% of births in low- and middle-income countries. Tocolytics are drugs used to suppress uterine contractions for women in preterm labour. The most widely used tocolytic are the betamimetics, however, these are associated with a high frequency of unpleasant and sometimes severe maternal side effects. Calcium channel blockers (CCBs) (such as nifedipine) may have similar tocolytic efficacy with less side effects than betamimetics. Oxytocin receptor antagonists (ORAs) (e.g. atosiban) also have a low side-effect profile. OBJECTIVES To assess the effects on maternal, fetal and neonatal outcomes of CCBs, administered as a tocolytic agent, to women in preterm labour. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (12 November 2013). SELECTION CRITERIA All published and unpublished randomised trials in which CCBs were used for tocolysis for women in labour between 20 and 36 completed weeks' gestation. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, undertook quality assessment and data extraction. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for data measured on a continuous scale with the 95% confidence interval (CI). The number needed to treat to benefit (NNTB) and the number needed to treat to harm (NNTH) were calculated for categorical outcomes that were statistically significantly different. MAIN RESULTS This update includes 26 additional trials involving 2511 women, giving a total of 38 included trials (3550 women). Thirty-five trials used nifedipine as the CCB and three trials used nicardipine. Blinding of intervention and outcome assessment was undertaken in only one of the trials (a placebo controlled trial). However, objective outcomes defined according to timing of birth and perinatal mortality were considered to have low risk of detection bias.Two small trials comparing CCBs with placebo or no treatment showed a significant reduction in birth less than 48 hours after trial entry (RR 0.30, 95% CI 0.21 to 0.43) and an increase in maternal adverse effects (RR 49.89, 95% CI 3.13 to 795.02, one trial of 89 women). Due to substantial heterogeneity, outcome data for preterm birth (less than 37 weeks) were not combined; one placebo controlled trial showed no difference (RR 0.96, 95% CI 0.89 to 1.03) while the other (non-placebo controlled trial) reported a reduction (RR 0.44, 95% CI 0.31 to 0.62). No other outcomes were reported.Comparing CCBs (mainly nifedipine) with other tocolytics by type (including betamimetics, glyceryl trinitrate (GTN) patch, non-steriodal anti inflammatories (NSAID), magnesium sulphate and ORAs), no significant reductions were shown in primary outcome measures of birth within 48 hours of treatment or perinatal mortality.Comparing CCBs with betamimetics, there were fewer maternal adverse effects (average RR 0.36, 95% CI 0.24 to 0.53) and fewer maternal adverse effects requiring discontinuation of therapy (average RR 0.22, 95% CI 0.10 to 0.48). Calcium channel blockers resulted in an increase in the interval between trial entry and birth (average MD 4.38 days, 95% CI 0.25 to 8.52) and gestational age (MD 0.71 weeks, 95% CI 0.34 to 1.09), while decreasing preterm and very preterm birth (RR 0.89, 95% CI 0.80 to 0.98 and RR 0.78, 95% CI 0.66 to 0.93); respiratory distress syndrome (RR 0.64, 95% CI 0.48 to 0.86); necrotising enterocolitis (RR 0.21, 95% CI 0.05 to 0.96); intraventricular haemorrhage (RR 0.53, 95% CI 0.34 to 0.84); neonatal jaundice (RR 0.72, 95% CI 0.57 to 0.92); and admissions to neonatal intensive care unit (NICU) (average RR 0.74, 95% CI 0.63 to 0.87). No difference was shown in one trial of outcomes at nine to twelve years of age.Comparing CCBs with ORA, data from one study (which did blind the intervention) showed an increase in gestational age at birth (MD 1.20 completed weeks, 95% CI 0.25 to 2.15) and reductions in preterm birth (RR 0.64, 95% CI 0.47 to 0.89); admissions to the NICU (RR 0.59, 95% CI 0.41 to 0.85); and duration of stay in the NICU (MD -5.40 days,95% CI -10.84 to 0.04). Maternal adverse effects were increased in the CCB group (average RR 2.61, 95% CI 1.43 to 4.74).Comparing CCBs with magnesium sulphate, maternal adverse effects were reduced (average RR 0.52, 95% CI 0.40 to 0.68), as was duration of stay in the NICU (days) (MD -4.55, 95% CI -8.17 to -0.92). No differences were shown in the comparisons with GTN patch or NSAID, although numbers were small.No differences in outcomes were shown in trials comparing nicardipine with other tocolytics, although with limited data no strong conclusions can be drawn. No differences were evident in a small trial that compared higher- versus lower-dose nifedipine, though findings tended to favour a high dose on some measures of neonatal morbidity. AUTHORS' CONCLUSIONS Calcium channel blockers (mainly nifedipine) for women in preterm labour have benefits over placebo or no treatment in terms of postponement of birth thus, theoretically, allowing time for administration of antenatal corticosteroids and transfer to higher level care. Calcium channel blockers were shown to have benefits over betamimetics with respect to prolongation of pregnancy, serious neonatal morbidity, and maternal adverse effects. Calcium channel blockers may also have some benefits over ORAs and magnesium sulphate, although ORAs results in fewer maternal adverse effects. However, it must be noted that no difference was shown in perinatal mortality, and data on longer-term outcomes were limited. Further, the lack of blinding of the intervention diminishes the strength of this body of evidence. Further well-designed tocolytic trials are required to determine short- and longer-term infant benefit of CCBs over placebo or no treatment and other tocolytics, particularly ORAs. Another important focus for future trials is identifying optimal dosage regimens of different types of CCBs (high versus low, particularly addressing speed of onset of uterine quiescence) and formulation (capsules versus tablets). All future trials on tocolytics for women in preterm labour should employ blinding of the intervention and outcome assessment, include measurement of longer-term effects into early childhood, and also costs.
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Affiliation(s)
- Vicki Flenady
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)Translating Research Into Practice (TRIP) CentreLevel 2 Aubigny Place, Mater Health ServicesAnnerley Road, WoolloongabbaBrisbaneQueenslandAustralia4102
| | - Aleena M Wojcieszek
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)Translating Research Into Practice (TRIP) CentreLevel 2 Aubigny Place, Mater Health ServicesAnnerley Road, WoolloongabbaBrisbaneQueenslandAustralia4102
| | - Dimitri NM Papatsonis
- Amphia Hospital BredaDepartment of Obstetrics and GynaecologyLangendijk 75BredaNetherlands4819 EV
| | - Owen M Stock
- Mater Mothers' Hospital, Mater Health ServicesDepartment of Obstetrics and GynaecologyRaymond TerraceBrisbaneQueenslandAustralia4101
| | - Linda Murray
- University of TasmaniaSchool of MedicineHobartAustralia
| | - Luke A Jardine
- Mater Mothers' Hospital, Mater Medical Research Institute, The University of QueenslandDepartment of NeonatologyRaymond TerraceSouth BrisbaneQueenslandAustralia4101
| | - Bruno Carbonne
- Hopital TrousseauDepartment of Obstetrics and Gynecology26, avenue du Docteur Arnold NetterParisParisFrance75012
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Baerts W, van Bel F, Thewissen L, Derks JB, Lemmers PMA. Tocolytic indomethacin: effects on neonatal haemodynamics and cerebral autoregulation in the preterm newborn. Arch Dis Child Fetal Neonatal Ed 2013; 98:F419-23. [PMID: 23482639 DOI: 10.1136/archdischild-2012-302532] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Indomethacin has vasoactive properties in cerebral and systemic vascular beds, and it improves cerebral autoregulatory ability. We speculated that tocolytic indomethacin will improve cerebral autoregulatory ability in the very preterm infant in early postnatal life. METHODS Eighteen stable preterm infants gestational age (GA) 25.3-29.6 weeks, birth weight (BW) 660-1430 grams), whose mothers had received 50-150 mg of tocolytic indomethacin within 24 h before birth, and 18 individually matched controls (GA 25.0-29.7 weeks, BW 700-1390 grams) were studied four times for 15 min in the first 24 h of life. Autoregulation was assessed by determining correlations between mean arterial blood pressure (MABP (mm Hg)) and near-infrared spectroscopy-monitored cerebral oxygenation (rScO2). RESULTS MABPs were significantly higher in the indomethacin infants than in the control infants (p=0.03). A decreased ability to autoregulate was found in four of the indomethacin infants, and in six of the control infants, which is not significantly different. CONCLUSIONS Prenatally administered indomethacin, given as a tocolytic in doses of 50-150 mg per day, improved transitional circulation in very preterm infants by significantly raising the MABP. It did not have an effect on the ability to autoregulate the cerebral circulation. In this study, no differences in short-term outcomes, like haemorrhagic or ischaemic cerebral lesions, were observed.
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Affiliation(s)
- Willem Baerts
- Department of Neonatology, Utrecht University Medical Center, The Netherlands.
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Calcium channel blockers as tocolytics: principles of their actions, adverse effects and therapeutic combinations. Pharmaceuticals (Basel) 2013; 6:689-99. [PMID: 24276256 PMCID: PMC3816733 DOI: 10.3390/ph6060689] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 04/15/2013] [Accepted: 05/02/2013] [Indexed: 11/17/2022] Open
Abstract
Dihydropyridine Ca2+ channel blockers (CCBs) are widely accepted in the treatment of premature labour. Their mechanism of action in tocolysis involves the blockade of L-type Ca2+ channels, influenced by the Ca2+-activated K+ channels, beta-adrenergic receptors (β-ARs) and sexual hormones. In clinical practice, most experience has been gained with the use of nifedipine, whose efficacy is superior or comparable to those of β-agonists and oxytocin antagonists. Additionally, it has a favourable adverse effect profile as compared with the majority of other tocolytics. The most frequent and well-tolerated side-effects of CCBs are tachycardia, headache and hypotension. In tocolytic therapy efforts are currently being made to find combinations of tocolytic agents that yield better therapeutic action. The available human and animal studies suggest that the combination of CCBs with β-AR agonists is beneficial, although such combinations can pose risk of pulmonary oedema in multiple pregnancies and maternal cardiovascular diseases. Preclinical data indicate the potential benefit of combinations of CCBs and oxytocin antagonists. However, the combinations of CCBs with progesterone or cyclooxygenase inhibitors may decrease their efficacy. The CCBs are likely to remain one of the most important groups of drugs for the rapid inhibition of premature uterine contractions. Their significance may be magnified by further clinical studies on their combined use for tocolysis.
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Viero C, Shibuya I, Kitamura N, Verkhratsky A, Fujihara H, Katoh A, Ueta Y, Zingg HH, Chvatal A, Sykova E, Dayanithi G. REVIEW: Oxytocin: Crossing the bridge between basic science and pharmacotherapy. CNS Neurosci Ther 2010; 16:e138-56. [PMID: 20626426 PMCID: PMC2972642 DOI: 10.1111/j.1755-5949.2010.00185.x] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Is oxytocin the hormone of happiness? Probably not. However, this small nine amino acid peptide is involved in a wide variety of physiological and pathological functions such as sexual activity, penile erection, ejaculation, pregnancy, uterus contraction, milk ejection, maternal behavior, osteoporosis, diabetes, cancer, social bonding, and stress, which makes oxytocin and its receptor potential candidates as targets for drug therapy. In this review, we address the issues of drug design and specificity and focus our discussion on recent findings on oxytocin and its heterotrimeric G protein‐coupled receptor OTR. In this regard, we will highlight the following topics: (i) the role of oxytocin in behavior and affectivity, (ii) the relationship between oxytocin and stress with emphasis on the hypothalamo–pituitary–adrenal axis, (iii) the involvement of oxytocin in pain regulation and nociception, (iv) the specific action mechanisms of oxytocin on intracellular Ca2+ in the hypothalamo neurohypophysial system (HNS) cell bodies, (v) newly generated transgenic rats tagged by a visible fluorescent protein to study the physiology of vasopressin and oxytocin, and (vi) the action of the neurohypophysial hormone outside the central nervous system, including the myometrium, heart and peripheral nervous system. As a short nine amino acid peptide, closely related to its partner peptide vasopressin, oxytocin appears to be ideal for the design of agonists and antagonists of its receptor. In addition, not only the hormone itself and its binding to OTR, but also its synthesis, storage and release can be endogenously and exogenously regulated to counteract pathophysiological states. Understanding the fundamental physiopharmacology of the effects of oxytocin is an important and necessary approach for developing a potential pharmacotherapy.
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Affiliation(s)
- Cedric Viero
- Department of Cardiology, Wales Heart Research Institute, Cardiff University, UK
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Abstract
BACKGROUND Preterm birth, defined as birth before 37 completed weeks, is the single most important cause of perinatal mortality and morbidity in high-income countries. Oxytocin receptor antagonists have been proposed as effective tocolytic agents for women in preterm labour to postpone the birth, with fewer side-effects than other tocolytic agents. OBJECTIVES To assess the effects on maternal, fetal and neonatal outcomes of tocolysis with oxytocin receptor antagonists for women with preterm labour compared with placebo or no intervention and compared with any other tocolytic agent. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2004), CENTRAL (The Cochrane Library, Issue 3, 2004), MEDLINE (1965 to June 2004), EMBASE (1988 to June 2004). SELECTION CRITERIA Randomised trials of oxytocin receptor antagonists for tocolysis in the management of women in labour between 20 and 36 weeks' gestation. DATA COLLECTION AND ANALYSIS Two authors independently evaluated methodological quality and extracted trial data. We sought additional information from trial authors. MAIN RESULTS Six trials (1695 women) were included. Compared with placebo, atosiban did not reduce incidence of preterm birth or improve neonatal outcome. In one trial (583 infants), atosiban was associated with an increase in infant deaths at 12 months of age compared with placebo (relative risk (RR) 6.15; 95% confidence intervals (CI) 1.39 to 27.22). However, this trial randomised significantly more women to atosiban before 26 weeks' gestation. Use of atosiban resulted in lower infant birthweight (weighted mean difference -138.31 gm; 95% CI -248.76 to -27.86) and more maternal adverse drug reactions (RR 4.02; 95% CI 2.05 to 7.85, 2 trials, 613 women).Compared with betamimetics, atosiban increased the numbers of infants born under 1500 gm (RR 1.96; 95% CI 1.15 to 3.35, 2 trials, 575 infants). Atosiban was associated with fewer maternal drug reactions requiring treatment cessation (RR 0.04; 95% CI 0.02 to 0.11, number needed to treat 6; 95% CI 5 to 7, 4 trials, 1035 women). AUTHORS' CONCLUSIONS This review failed to demonstrate the superiority of atosiban over betamimetics or placebo in terms of tocolytic efficacy or infant outcomes. The finding of an increase in infant deaths in one placebo controlled trial warrants caution. A recent Cochrane review suggests that calcium channel blockers (mainly nifedipine) are associated with better neonatal outcome and fewer maternal side-effects than betamimetics. However, a randomised comparison of nifedipine with placebo is not available. Further well-designed randomised controlled trials of tocolytic therapy are needed. Such trials should incorporate a placebo arm.
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Affiliation(s)
- D Papatsonis
- Department of Obstetrics and Gynaecology, Amphia Hospital Breda, Langendijk 75, Breda, Netherlands, 4819 EV.
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