1
|
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: 15] [Impact Index Per Article: 7.5] [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.
Collapse
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
| |
Collapse
|
2
|
Ran Y, He J, Peng W, Liu Z, Mei Y, Zhou Y, Yin N, Qi H. Development and validation of a transcriptomic signature-based model as the predictive, preventive, and personalized medical strategy for preterm birth within 7 days in threatened preterm labor women. EPMA J 2022; 13:87-106. [PMID: 35273661 PMCID: PMC8897543 DOI: 10.1007/s13167-021-00268-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/24/2021] [Indexed: 12/08/2022]
Abstract
Preterm birth (PTB) is the leading cause of neonatal death. The essential strategy to prevent PTB is the accurate identification of threatened preterm labor (TPTL) women who will have PTB in a short time (< 7 days). Here, we aim to propose a clinical model to contribute to the effective prediction, precise prevention, and personalized medical treatment for PTB < 7 days in TPTL women through bioinformatics analysis and prospective cohort studies. In this study, the 1090 key genes involved in PTB < 7 days in the peripheral blood of TPTL women were ascertained using WGCNA. Based on this, the biological basis of immune-inflammatory activation (e.g., IFNγ and TNFα signaling) as well as immune cell disorders (e.g., monocytes and Th17 cells) in PTB < 7 days were revealed. Then, four core genes (JOSD1, IDNK, ZMYM3, and IL1B) that best represent their transcriptomic characteristics were screened by SVM and LASSO algorithm. Therefore, a prediction model with an AUC of 0.907 was constructed, which was validated in a larger population (AUC = 0.783). Moreover, the predictive value (AUC = 0.957) and clinical feasibility of this model were verified through the clinical prospective cohort we established. In conclusion, in the context of Predictive, Preventive, and Personalized Medicine (3PM), we have developed and validated a model to predict PTB < 7 days in TPTL women. This is promising to greatly improve the accuracy of clinical prediction, which would facilitate the personalized management of TPTL women to precisely prevent PTB < 7 days and improve maternal-fetal outcomes.
Collapse
Affiliation(s)
- Yuxin Ran
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Rd, Yuzhong District, Chongqing, 400016 China
- Chongqing Health Center for Women and Children, No. 120 Longshan Road, Yubei District, Chongqing, 401120 China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
- Joint International Research Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
| | - Jie He
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Rd, Yuzhong District, Chongqing, 400016 China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
- Joint International Research Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
| | - Wei Peng
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Rd, Yuzhong District, Chongqing, 400016 China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
- Joint International Research Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
| | - Zheng Liu
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Rd, Yuzhong District, Chongqing, 400016 China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
- Joint International Research Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
| | - Youwen Mei
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Rd, Yuzhong District, Chongqing, 400016 China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
- Joint International Research Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
| | - Yunqian Zhou
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Rd, Yuzhong District, Chongqing, 400016 China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
- Joint International Research Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
| | - Nanlin Yin
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Rd, Yuzhong District, Chongqing, 400016 China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
- Joint International Research Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
- Center for Reproductive Medicine, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Rd, Yuzhong District, Chongqing, 400016 China
| | - Hongbo Qi
- Chongqing Health Center for Women and Children, No. 120 Longshan Road, Yubei District, Chongqing, 401120 China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
- Joint International Research Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, No. 1 Yixueyuan Rd, Yuzhong District, Chongqing, 400016 China
| |
Collapse
|
3
|
Leal-Júnior CC, Amorim MMR, Souza GFA, Lima AKS, Souza ASR. Effectiveness of an oral versus sublingual loading dose of nifedipine for tocolysis. Int J Gynaecol Obstet 2019; 148:310-315. [PMID: 31774552 DOI: 10.1002/ijgo.13067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/24/2019] [Accepted: 11/25/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the effectiveness of an oral versus sublingual loading dose of nifedipine for tocolysis. METHODS An open, randomized clinical trial conducted between March 1, 2013, and April 31, 2014. Participants were pregnant women with a diagnosis of premature labor, single live fetus, topical pregnancy, gestational age 24-36 weeks, normal fetal vitality, cervical dilatation less than or equal to 4 cm, cervical effacement less than or equal to 80%, and intact amniotic membranes. They were randomized into two groups, oral and sublingual nifedipine, 20 mg loading dose, repeated every 30 minutes (maximum dose of 60 mg). The primary endpoint was the time until tocolysis and the secondary endpoints were the effectiveness of tocolysis within 90 minutes, 12 hours, and 48 hours; premature delivery within 48 hours; and maternal hemodynamic parameters and side effects. RESULTS There were 80 patients randomized to oral (n=40) and sublingual (n=40) nifedipine. The time required for tocolysis was significantly less with sublingual nifedipine (160 minutes vs 340 minutes; P=0.0003). Sublingual nifedipine was also more successful than oral nifedipine at inhibiting premature labor within 90 minutes (n=8 [20.0%] vs n=1 [2.5%], P=0.014). There was no statistically significant difference between the groups for the other secondary endpoints. CONCLUSION Compared with oral administration, a sublingual loading dose of nifedipine resulted in faster tocolysis in patients with premature labor. Brazilian Clinical Trials Registry (ReBEC): U1111-11566186.
Collapse
Affiliation(s)
- Carlos C Leal-Júnior
- Women's Healthcare Center, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Pernambuco, Brazil
| | - Melania M R Amorim
- Women's Healthcare Center, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Pernambuco, Brazil.,Department of Obstetrics and Gynecology, Federal University of Campina Grande (UFCG), Campina Grande, Paraíba, Brazil.,Department of Obstetrics, Elpídio de Almeida Health Institute (ISEA), Campina Grande, Paraíba, Brazil
| | - Gustavo F A Souza
- Biological Sciences and Health Center, Catholic University of Pernambuco (UNICAP), Recife, Pernambuco, Brazil
| | - Anna K S Lima
- Department of Maternal and Child Healthcare, Federal University of Pernambuco (UFPE), Recife, Pernambuco, Brazil
| | - Alex S R Souza
- Women's Healthcare Center, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Pernambuco, Brazil.,Biological Sciences and Health Center, Catholic University of Pernambuco (UNICAP), Recife, Pernambuco, Brazil.,Department of Maternal and Child Healthcare, Federal University of Pernambuco (UFPE), Recife, Pernambuco, Brazil
| |
Collapse
|
4
|
Faron G, Balepa L, Parra J, Fils JF, Gucciardo L. The fetal fibronectin test: 25 years after its development, what is the evidence regarding its clinical utility? A systematic review and meta-analysis. J Matern Fetal Neonatal Med 2018; 33:493-523. [PMID: 29914277 DOI: 10.1080/14767058.2018.1491031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: The identification of women at risk for preterm birth should allow interventions which could improve neonatal outcome. Fetal fibronectin, a glycoprotein which acts normally as glue between decidua and amniotic membranes could be a good marker of impending labour when its concentration in cervicovaginal secretions between 22 and 36 weeks of gestation is ≥50 ng/mL. Many authors worldwide have tested this marker with many different methodologies and clinical settings, but conclusions about its clinical use are mixed. It is time for a comprehensive update through a systematic review and meta-analysis.Methods: We searched PubMed, Cochrane Library, and Embase, supplemented by manual search of bibliographies of known primary and review articles, international conference papers, and contact with experts from 1-1990 to 2-2018. We have selected all type of studies involving fetal fibronectin test accuracy for preterm delivery. Two authors independently extracted data about study characteristics and quality from identified publications. Contingency tables were constructed. Reference standards were preterm delivery before 37, 36, 35, 34, and 32 weeks, within 28, 21, 14, or 7 d and within 48 h. Data were pooled to produce summary likelihood ratios for positive and negative tests results.Results: One hundred and ninety-three primary studies were identified allowing analysis of 53 subgroups. In all settings, none of the summary likelihood ratios were >10 or <0.1, thus indicating moderate prediction, particularly in asymptomatic women and in multiple gestations.Conclusions: The fetal fibronectin test should not be used as a screening test for asymptomatic women. For high-risk asymptomatic women, and especially for women with multiple pregnancies, the performance of the fetal fibronectin test was also too low to be clinically relevant. Consensual use as a diagnostic tool for women with suspected preterm labor, the best use policy probably still depends on local contingencies, future cost-effectiveness analysis, and comparison with other more recent available biochemical markers.
Collapse
Affiliation(s)
- Gilles Faron
- Department of Obstetrics and Prenatal Medicine, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lisa Balepa
- Department of Obstetrics and Prenatal Medicine, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - José Parra
- Department of Statistics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Leonardo Gucciardo
- Department of Obstetrics and Prenatal Medicine, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
5
|
van Baaren GJ, Vis JY, Wilms FF, Oudijk MA, Kwee A, Porath MM, Scheepers HCJ, Spaanderman MEA, Bloemenkamp KWM, Haak MC, Bax CJ, Cornette JMJ, Duvekot JJ, Nij Bijvanck BWA, van Eyck J, Franssen MTM, Sollie KM, Vandenbussche FPHA, Woiski M, Bolte AC, van der Post JAM, Bossuyt PMM, Opmeer BC, Mol BWJ. Cost-effectiveness of diagnostic testing strategies including cervical-length measurement and fibronectin testing in women with symptoms of preterm labor. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:596-603. [PMID: 28370518 DOI: 10.1002/uog.17481] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/29/2017] [Accepted: 03/22/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of combining cervical-length (CL) measurement and fetal fibronectin (fFN) testing in women with symptoms of preterm labor between 24 and 34 weeks' gestation. METHODS This was a model-based cost-effectiveness analysis evaluating seven test-treatment strategies based on CL measurement and/or fFN testing in women with symptoms of preterm labor from a societal perspective, in which neonatal outcomes and costs were weighted. Estimates of disease prevalence, test accuracy and costs were based on two recently performed nationwide cohort studies in The Netherlands. RESULTS Strategies using fFN testing and CL measurement separately to predict preterm delivery are associated with higher costs and incidence of adverse neonatal outcomes compared with strategies that combine both tests. Additional fFN testing when CL is 15-30 mm was considered cost effective, leading to a cost saving of €3919 per woman when compared with a treat-all strategy, with a small deterioration in neonatal health outcomes, namely one additional perinatal death and 21 adverse outcomes per 10 000 women with signs of preterm labor (incremental cost-effectiveness ratios €39 million and €1.9 million, respectively). Implementing this strategy in The Netherlands, a country with about 180 000 deliveries annually, could lead to an annual cost saving of between €2.4 million and €7.6 million, with only a small deterioration in neonatal health outcomes. CONCLUSION In women with symptoms of preterm labor at 24-34 weeks' gestation, performing additional fFN testing when CL is between 15 and 30 mm is a viable and cost-saving strategy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- G-J van Baaren
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - J Y Vis
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F F Wilms
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - M A Oudijk
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - A Kwee
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M M Porath
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - H C J Scheepers
- Department of Obstetrics and Gynecology, University Hospital Maastricht, Maastricht, The Netherlands
| | - M E A Spaanderman
- Department of Obstetrics and Gynecology, University Hospital Maastricht, Maastricht, The Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - C J Bax
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - J M J Cornette
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J J Duvekot
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - B W A Nij Bijvanck
- Department of Obstetrics and Gynecology, Isala Clinics, Zwolle, The Netherlands
| | - J van Eyck
- Department of Obstetrics and Gynecology, Isala Clinics, Zwolle, The Netherlands
| | - M T M Franssen
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - K M Sollie
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - F P H A Vandenbussche
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - M Woiski
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - A C Bolte
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - J A M van der Post
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - P M M Bossuyt
- Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - B C Opmeer
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - B W J Mol
- Department of Obstetrics and Gynecology, The Robinson Institute, School of Pediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia
| |
Collapse
|
6
|
Abstract
BACKGROUND To reduce the morbidity and mortality associated with preterm birth, home uterine activity monitoring aims for early detection of increased contraction frequency, and early intervention with tocolytic drugs to inhibit labour and prolong pregnancy. However, the effectiveness of such monitoring is disputed. OBJECTIVES To determine whether home uterine activity monitoring is effective in improving the outcomes for women and their infants considered to be at high risk of preterm birth, when compared with care that does not include home uterine activity monitoring. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2016), CENTRAL (Cochrane Library 2016, Issue 5), MEDLINE (1966 to 28 June 2016), Embase (1974 to 28 June 2016), CINAHL (1982 to 28 June 2016), and scanned reference lists of retrieved studies. SELECTION CRITERIA Randomised control trials of home uterine activity monitoring, with or without patient education programmes, for women at risk of preterm birth, compared with care that does not include home uterine activity monitoring. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We did not attempt to contact authors to resolve queries. We assessed the evidence using the GRADE approach. MAIN RESULTS There were 15 included studies (6008 enrolled participants); 13 studies contributed data. Women using home uterine monitoring were less likely to experience preterm birth at less than 34 weeks (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; three studies, 1596 women; fixed-effect analysis) (GRADE high). This difference was not evident when we carried out a sensitivity analysis, restricting the analysis to studies at low risk of bias based on study quality (RR 0.75, 95% CI 0.57 to 1.00; one study, 1292 women). There was no difference in the rate of perinatal mortality (RR 1.22, 95% CI 0.86 to 1.72; two studies, 2589 babies) (GRADE low).There was no difference in the number of preterm births at less than 37 weeks (average RR 0.85, CI 0.72 to 1.01; eight studies, 4834 women; random-effects, Tau2 = 0.03, I2 = 68%) (GRADE very low). Infants born to women using home uterine monitoring were less likely to be admitted to neonatal intensive care unit (average RR 0.77, 95% CI 0.62 to 0.96; five studies, 2367 babies; random-effects, Tau2 = 0.02, I2 = 32%) (GRADE moderate). This difference was not maintained when we restricted the analysis to studies at low risk of bias (RR 0.86, 95% CI 0.74 to 1.01; one study, 1292 babies). Women using home uterine monitoring made more unscheduled antenatal visits (mean difference (MD) 0.48, 95% CI 0.31 to 0.64; two studies, 1994 women) (GRADE moderate). Women using home uterine monitoring were also more likely to have prophylactic tocolytic drug therapy (average RR 1.21, 95% CI 1.01 to 1.45; seven studies, 4316 women; random-effects, Tau2 = 0.03, I2 = 62%), but this difference was no longer evident when we restricted the analysis to studies at low risk of bias (average RR 1.22, 95% CI 0.90 to 1.65; three studies, 3749 women; random-effects, Tau2 = 0.05, I2 = 76%) (GRADE low). The number of antenatal hospital admissions did not differ between home groups (RR 0.91, 95% CI 0.74 to 1.11; three studies, 1494 women (GRADE low)). We found no data on maternal anxiety or acceptability. AUTHORS' CONCLUSIONS Home uterine monitoring may result in fewer admissions to a neonatal intensive care unit but in more unscheduled antenatal visits and tocolytic treatment; the level of evidence is generally low to moderate. Important group differences were not evident when we undertook sensitivity analysis using only trials at low risk of bias. There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.
Collapse
Affiliation(s)
- Christine Urquhart
- Aberystwyth UniversityDepartment of Information StudiesLlanbadarn FawrAberystwythCeredigionUKSY23 3AS
| | - Rosemary Currell
- Suffolk NHS Primary Care TrustPublic Health DirectorateRushbrook HousePaper Mill LaneBramford, IpswichSuffolkUKIP8 4DE
| | - Francoise Harlow
- Norfolk and Norwich University HospitalColney LaneNorwichUKNR4 7UY
| | - Liz Callow
- University of OxfordJohn Radcliffe HospitalOxfordUK
| | | |
Collapse
|
7
|
Noguchi T, Sado T, Naruse K, Kobayashi H. Vaginal fluid pH and buffer capacity for predicting false preterm labor in Japanese women. Int J Gynaecol Obstet 2016; 134:69-74. [PMID: 27039048 DOI: 10.1016/j.ijgo.2015.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/16/2015] [Accepted: 02/22/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine the relationship between preterm labor and delivery, and the pH and buffer capacity of vaginal secretions. METHODS Between January 1, 2009 and March 31, 2012, two cohorts of patients at 22-36weeks of pregnancy were enrolled in a prospective cohort study at Nara Medical University Hospital, Japan. Patients experiencing preterm contractions and a control group of patients experiencing normal pregnancies were included. The pH and buffer capacity of vaginal secretions were measured and compared. RESULTS Of the 237 patients enrolled, 48 (20.3%) were experiencing symptoms of preterm labor and 189 (79.7%) were included in the control group. The pH was higher (P<0.001) and the buffer capacity was lower (P=0.0135) in the vaginal secretions of the patients experiencing preterm contractions compared with the control group. There was no difference in the pH and buffer capacity of the vaginal secretions of symptomatic patients who would experience preterm delivery and those who would not. Receiver operating characteristic curve analyses demonstrated that vaginal-secretion pH and buffer capacity could differentiate between patients experiencing preterm contractions and those not, but could not differentiate between patients who would experience preterm delivery and those who would not. CONCLUSION Vaginal-secretion pH and buffer capacity could be useful in diagnosing preterm labor; further studies are needed to determine potential practical diagnostic criteria.
Collapse
Affiliation(s)
- Taketoshi Noguchi
- Department of Obstetrics and Gynecology, Nara Medical University, Nara, Japan
| | - Toshiyuki Sado
- Department of Obstetrics and Gynecology, Nara Medical University, Nara, Japan
| | - Katsuhiko Naruse
- Department of Obstetrics and Gynecology, Nara Medical University, Nara, Japan
| | - Hiroshi Kobayashi
- Department of Obstetrics and Gynecology, Nara Medical University, Nara, Japan.
| |
Collapse
|
8
|
Wilms FF, Vis JY, Oudijk MA, Kwee A, Porath MM, Scheepers HCJ, Spaanderman MEA, Bloemenkamp KWM, Bolte AC, Bax CJ, Cornette JMJ, Duvekot JJ, Nij Bijvanck BWA, Eijck JV, Franssen MTM, Sollie KM, Vandenbussche FPHA, Woiski MD, van der Post JAM, Bossuyt PMM, Opmeer BC, Mol BWJ, van Baaren GJ. The impact of fetal gender and ethnicity on the risk of spontaneous preterm delivery in women with symptoms of preterm labor. J Matern Fetal Neonatal Med 2016; 29:3563-9. [PMID: 26911700 DOI: 10.3109/14767058.2016.1139566] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The objective of this study is to evaluate the relation among fetal gender, ethnicity, and preterm labor (PTL) and preterm delivery (PTD). METHODS A secondary analysis was performed of a prospective cohort study including women with symptoms of PTL between 24 and 34 weeks. The proportion of women carrying a male or female fetus at the onset of PTL was calculated. Gestational age at delivery and risk of PTD of both fetal genders was compared and interaction of fetal gender and maternal ethnicity on the risk of PTD was evaluated. RESULTS Of the 594 included women, 327 (55%) carried a male fetus. Median gestational age at delivery in women pregnant with a male fetus was 37 5/7 (IQR 34 4/7-39 1/7) weeks compared with 38 1/7 (IQR 36 0/7-39 5/7) weeks in women pregnant with a female fetus (p = 0.032). The risk of PTD did not differ significantly. In Caucasians, we did find an increased risk of PTD before 37 weeks in women pregnant with a male fetus (OR 1.9 (95% CI 1.2-3.0)). CONCLUSIONS The majority of women with PTL are pregnant with a male fetus and these women deliver slightly earlier. Race seems to affect this disparity.
Collapse
Affiliation(s)
- Femke F Wilms
- a Department of Obstetrics & Gynecology , Máxima Medical Center , Veldhoven , Netherlands
| | - Jolande Y Vis
- b Department of Clinical Chemistry & Haematology , University Medical Center Utrecht , Utrecht , the Netherlands
| | - Martijn A Oudijk
- c Department of Obstetrics & Gynecology , University Medical Center Utrecht , Utrecht , Netherlands
| | - Anneke Kwee
- c Department of Obstetrics & Gynecology , University Medical Center Utrecht , Utrecht , Netherlands
| | - Martina M Porath
- a Department of Obstetrics & Gynecology , Máxima Medical Center , Veldhoven , Netherlands
| | - Hubertina C J Scheepers
- d Department of Obstetrics & Gynecology , Maastricht University Medical Center , Maastricht , Netherlands
| | - Marc E A Spaanderman
- d Department of Obstetrics & Gynecology , Maastricht University Medical Center , Maastricht , Netherlands
| | - Kitty W M Bloemenkamp
- e Department of Obstetrics & Gynecology , Leiden University Medical Center , Leiden , Netherlands
| | - Antoinette C Bolte
- f Department of Obstetrics & Gynecology , VU University Medical Center , Amsterdam , Netherlands
| | - Caroline J Bax
- f Department of Obstetrics & Gynecology , VU University Medical Center , Amsterdam , Netherlands
| | - Jérôme M J Cornette
- g Department of Obstetrics & Gynecology , Erasmus University Medical Center , Rotterdam , Netherlands
| | - Johannes J Duvekot
- g Department of Obstetrics & Gynecology , Erasmus University Medical Center , Rotterdam , Netherlands
| | | | - Jim van Eijck
- h Department of Obstetrics & Gynecology , Isala Clinics , Zwolle , Netherlands
| | - Maureen T M Franssen
- i Department of Obstetrics & Gynecology , University Medical Center Groningen , Groningen , Netherlands
| | - Krystyna M Sollie
- i Department of Obstetrics & Gynecology , University Medical Center Groningen , Groningen , Netherlands
| | - Frank P H A Vandenbussche
- j Department of Obstetrics & Gynecology , Radboud University Hospital Nijmegen , Nijmegen , Netherlands
| | - Mallory D Woiski
- j Department of Obstetrics & Gynecology , Radboud University Hospital Nijmegen , Nijmegen , Netherlands
| | - Joris A M van der Post
- k Department of Obstetrics & Gynecology , Academic Medical Center , Amsterdam , Netherlands
| | - Patrick M M Bossuyt
- l Clinical Research Unit, Academic Medical Center , Amsterdam , Netherlands , and
| | - Brent C Opmeer
- l Clinical Research Unit, Academic Medical Center , Amsterdam , Netherlands , and
| | - Ben W J Mol
- m The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide , Adelaide , Australia
| | - Gert-Jan van Baaren
- k Department of Obstetrics & Gynecology , Academic Medical Center , Amsterdam , Netherlands
| |
Collapse
|
9
|
Bruijn MMC, Vis JY, Wilms FF, Oudijk MA, Kwee A, Porath MM, Oei G, Scheepers HCJ, Spaanderman MEA, Bloemenkamp KWM, Haak MC, Bolte AC, Vandenbussche FPHA, Woiski MD, Bax CJ, Cornette JMJ, Duvekot JJ, Nij Bijvanck BWA, van Eyck J, Franssen MTM, Sollie KM, van der Post JAM, Bossuyt PMM, Opmeer BC, Kok M, Mol BWJ, van Baaren GJ. Quantitative fetal fibronectin testing in combination with cervical length measurement in the prediction of spontaneous preterm delivery in symptomatic women. BJOG 2015; 123:1965-1971. [DOI: 10.1111/1471-0528.13752] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2015] [Indexed: 11/29/2022]
Affiliation(s)
- MMC Bruijn
- Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| | - JY Vis
- Clinical Chemistry and Haematology; University Medical Centre Utrecht; Utrecht the Netherlands
| | - FF Wilms
- Obstetrics and Gynaecology; Catharina Hospital; Eindhoven the Netherlands
| | - MA Oudijk
- Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| | - A Kwee
- Obstetrics and Gynaecology; University Medical Centre Utrecht; Utrecht the Netherlands
| | - MM Porath
- Obstetrics and Gynaecology; Máxima Medical Centre; Veldhoven the Netherlands
| | - G Oei
- Obstetrics and Gynaecology; Máxima Medical Centre; Veldhoven the Netherlands
| | - HCJ Scheepers
- Obstetrics and Gynaecology; University Hospital Maastricht; Maastricht the Netherlands
| | - MEA Spaanderman
- Obstetrics and Gynaecology; University Hospital Maastricht; Maastricht the Netherlands
| | - KWM Bloemenkamp
- Obstetrics; Leiden University Medical Centre; Leiden the Netherlands
| | - MC Haak
- Obstetrics; Leiden University Medical Centre; Leiden the Netherlands
| | - AC Bolte
- Obstetrics and Gynaecology; Radboud University Medical Centre; Nijmegen the Netherlands
| | - FPHA Vandenbussche
- Obstetrics and Gynaecology; Radboud University Medical Centre; Nijmegen the Netherlands
| | - MD Woiski
- Obstetrics and Gynaecology; Radboud University Medical Centre; Nijmegen the Netherlands
| | - CJ Bax
- Obstetrics and Gynaecology; VU University Medical Centre; Amsterdam the Netherlands
| | - JMJ Cornette
- Obstetrics and Gynaecology; Erasmus Medical Centre; Rotterdam the Netherlands
| | - JJ Duvekot
- Obstetrics and Gynaecology; Erasmus Medical Centre; Rotterdam the Netherlands
| | - BWA Nij Bijvanck
- Obstetrics and Gynaecology; Isala Clinics; Zwolle the Netherlands
| | - J van Eyck
- Obstetrics and Gynaecology; Isala Clinics; Zwolle the Netherlands
| | - MTM Franssen
- Obstetrics and Gynaecology; University Medical Centre Groningen; Groningen the Netherlands
| | - KM Sollie
- Obstetrics and Gynaecology; University Medical Centre Groningen; Groningen the Netherlands
| | - JAM van der Post
- Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| | - PMM Bossuyt
- Clinical Epidemiology, Biostatistics and Bioinformatics; Academic Medical Centre; Amsterdam the Netherlands
| | - BC Opmeer
- Clinical Research Unit; Academic Medical Centre; Amsterdam the Netherlands
| | - M Kok
- Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| | - BWJ Mol
- The Robinson Institute; School of Paediatrics and Reproductive Health; University of Adelaide; Adelaide SA Australia
| | - G-J van Baaren
- Obstetrics and Gynaecology; Academic Medical Centre; Amsterdam the Netherlands
| |
Collapse
|
10
|
Oude Rengerink K, Logtenberg S, Hooft L, Bossuyt PM, Mol BW. Pregnant womens' concerns when invited to a randomized trial: a qualitative case control study. BMC Pregnancy Childbirth 2015; 15:207. [PMID: 26341516 PMCID: PMC4560072 DOI: 10.1186/s12884-015-0641-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 08/28/2015] [Indexed: 02/05/2023] Open
Abstract
Background Pregnant women were excluded from clinical trials until the 1990s, but the Food and Drug Administration nowadays allows - and even encourages - responsible inclusion of pregnant women in trials with adequate safety monitoring. Still, randomized trials in pregnant women face specific enrolment challenges. Previous studies have focused on barriers to trial participation in studies that had failed to recruit sufficient participants. Our aim was to identify barriers and motivators for participation in a range of clinical trials being conducted in the Netherlands, regardless of recruitment performance. Methods We performed a qualitative case control study in women who had been asked in 2010 to participate in one of eight clinical trials during pregnancy or shortly after giving birth. Both participants and non-participants of these clinical trials were invited for a face-to-face interview that addressed motives for participation and non-participation. We started the interview in an open fashion, asking the women for their main motive for participation or non-participation. When no new information emerged in this open part, we continued with a semi-structured interview, guided by a topic list. Transcripts of the interviews were analysed using a constant-comparative approach. Two researchers identified barriers and facilitators for participation, conjoined into main themes. Results Of 28 women invited for the interview, 21 agreed to be interviewed (12 participants and 9 non-participants). For 5 of the 12 participants, contribution to scientific research was their main motive, while 5 had participated because the intervention seemed favorable and was not available outside the trial. Key motives for non-participation (n = 9) were a negative association or a dislike of the intervention, either because it might do harm (n = 6) or for practical reasons (n = 3). Combining the open and topic list guided interviews we constructed seven main themes that influence the pregnant women’s decision to participate: external influence, research and healthcare, perception own situation, study design, intervention, information and counselling, and uncertainty. Conclusions Among seven main themes that influence pregnant women’s decision to participate, uncertainty about scientific research or the intervention was reported to be of considerable importance. Measures should be taken to habituate pregnant women more to scientific research, and further evaluation of opt-out consent deserves attention. Electronic supplementary material The online version of this article (doi:10.1186/s12884-015-0641-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Katrien Oude Rengerink
- Academic Medical Center, Department of Obstetrics and Gynaecology, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Sabine Logtenberg
- Onze Lieve Vrouwen Gasthuis, Department of Obstetrics and Gynaecology, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.
| | - Lotty Hooft
- Department of Epidemiology, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Patrick M Bossuyt
- Academic Medical Center, Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam, The Netherlands.
| | - Ben Willem Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia.
| |
Collapse
|
11
|
van Baaren GJ, Bruijn MM, Vis JY, Wilms FF, Oudijk MA, Kwee A, Porath MM, Oei G, Scheepers HC, Spaanderman ME, Bloemenkamp KW, Haak MC, Bolte AC, Bax CJ, Cornette JM, Duvekot JJ, Nij Bijvanck BW, van Eijck J, Franssen MT, Sollie KM, Vandenbussche FP, Woiski M, Bossuyt PM, Opmeer BC, Mol BW. Risk factors for preterm delivery: do they add to fetal fibronectin testing and cervical length measurement in the prediction of preterm delivery in symptomatic women? Eur J Obstet Gynecol Reprod Biol 2015; 192:79-85. [DOI: 10.1016/j.ejogrb.2015.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 04/22/2015] [Accepted: 05/19/2015] [Indexed: 10/23/2022]
|
12
|
Wilms FF, van Baaren GJ, Vis JY, Oudijk MA, Kwee A, Porath MM, Scheepers HCJ, Spaanderman MEA, Bloemenkamp KWM, Bolte AC, Bax CJ, Cornette JMJ, Duvekot JJ, Nij Bijvank BWA, van Eyck J, Franssen MTM, Sollie KM, Vandenbussche FPHA, Woiski MD, van der Post JAM, Bossuyt PMM, Opmeer BC, Mol BWJ. Prescribing patterns of antenatal corticosteroids in women with threatened preterm labor. Eur J Obstet Gynecol Reprod Biol 2015; 192:47-53. [PMID: 26149479 DOI: 10.1016/j.ejogrb.2015.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 05/27/2015] [Accepted: 06/03/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the impact of cervical length (CL) measurement and fetal fibronectin testing (fFN) on the clinicians' decision to prescribe antenatal corticosteroids (ACS) to women with symptoms of preterm labor. STUDY DESIGN This is a secondary analysis of a prospective cohort study including women with symptoms of preterm labor and intact membranes between 24 and 34 weeks' gestation. We compared the proportion prescribed and completed ACS courses, preterm delivery within seven days and median intervals from ACS to delivery in four groups: group 1 CL<10 mm, group 2 CL 10-30 mm and positive fFN, group 3 CL 10-30 mm and negative fFN, group 4 CL>30 mm. RESULTS ACS were prescribed to 63/65 (97%) women in group 1, 176/192 (91%) in group 2, 111/172 women (65%) in group 3 and 55/242 (23%) in group 4. In group 1, 42 (65%) women delivered within seven days, compared to 34 (18%) in group 2, 6 (3%) in group 3 and 3 (1%) in group 4. Median intervals between ACS and delivery were 6 days (IQR 3-61 days), 44 days (IQR 17-69 days), 53 days (IQR 37-77 days) and 66 days (IQR 43-78 days) in group 1, 2, 3 and 4 respectively. CONCLUSION ACS were prescribed frequently to women with a CL of 10-30 mm and a negative fFN test or a CL>30 mm. There is room for improvement in the prescription of ACS in these low risk women.
Collapse
Affiliation(s)
- Femke F Wilms
- Department of Obstetrics & Gynecology, Catharina Hospital, Eindhoven, Netherlands.
| | - Gert-Jan van Baaren
- Department of Obstetrics & Gynecology, Academic Medical Center, Amsterdam, Netherlands
| | - Jolande Y Vis
- Department of Clinical Chemistry & Haematology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics & Gynecology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Anneke Kwee
- Department of Obstetrics & Gynecology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Martina M Porath
- Department of Obstetrics & Gynecology, Maxima Medical Center, Veldhoven, Netherlands
| | - Hubertina C J Scheepers
- Department of Obstetrics & Gynecology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Marc E A Spaanderman
- Department of Obstetrics & Gynecology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Kitty W M Bloemenkamp
- Department of Obstetrics & Gynecology, Leiden University Medical Center, Leiden, Netherlands
| | - Antoinette C Bolte
- Department of Obstetrics & Gynecology, VU University Medical Center, Amsterdam, Netherlands
| | - Caroline J Bax
- Department of Obstetrics & Gynecology, VU University Medical Center, Amsterdam, Netherlands
| | - Jérôme M J Cornette
- Department of Obstetrics & Gynecology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics & Gynecology, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Jim van Eyck
- Department of Obstetrics & Gynecology, Isala Clinics, Zwolle, Netherlands
| | - Maureen T M Franssen
- Department of Obstetrics & Gynecology, University Medical Center Groningen, Groningen, Netherlands
| | - Krystyna M Sollie
- Department of Obstetrics & Gynecology, University Medical Center Groningen, Groningen, Netherlands
| | | | - Mallory D Woiski
- Department of Obstetrics & Gynecology, Radboud University Hospital Nijmegen, Nijmegen, Netherlands
| | | | | | - Brent C Opmeer
- Clinical Research Unit, Academic Medical Center, Amsterdam, Netherlands
| | - Ben W J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Australia
| |
Collapse
|
13
|
Hermans FJ, Bruijn MM, Vis JY, Wilms FF, Oudijk MA, Porath MM, Scheepers HC, Bloemenkamp KW, Bax CJ, Cornette JM, Nij Bijvanck BW, Franssen MT, Vandenbussche FP, Kok M, Grobman WA, Van Der Post JA, Bossuyt PM, Opmeer BC, Mol BWJ, Schuit E, Van Baaren GJ. Risk stratification with cervical length and fetal fibronectin in women with threatened preterm labor before 34 weeks and not delivering within 7 days. Acta Obstet Gynecol Scand 2015; 94:715-721. [DOI: 10.1111/aogs.12643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 03/29/2015] [Indexed: 01/09/2023]
Affiliation(s)
- Frederik J.R. Hermans
- Department of Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
| | - Merel M.C. Bruijn
- Department of Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
| | - Jolande Y. Vis
- Department of Clinical Chemistry and Hematology; University Medical Center Utrecht; Utrecht the Netherlands
| | - Femke F. Wilms
- Department of Obstetrics and Gynecology; University Hospital Maastricht; Maastricht the Netherlands
| | - Martijn A. Oudijk
- Department of Obstetrics and Gynecology; University Medical Center Utrecht; Utrecht the Netherlands
| | - Martina M. Porath
- Department of Obstetrics and Gynecology; Máxima Medical Center; Veldhoven the Netherlands
| | - Hubertina C.J. Scheepers
- Department of Obstetrics and Gynecology; University Hospital Maastricht; Maastricht the Netherlands
| | - Kitty W.M. Bloemenkamp
- Department of Obstetrics and Gynecology; Leiden University Medical Center; Leiden the Netherlands
| | - Caroline J. Bax
- Department of Obstetrics and Gynecology; VU University Medical Center; Amsterdam the Netherlands
| | - Jérôme M.J. Cornette
- Department of Obstetrics and Gynecology; Erasmus Medical Center; Rotterdam the Netherlands
| | | | - Maureen T.M. Franssen
- Department of Obstetrics and Gynecology; University Medical Center Groningen; Groningen the Netherlands
| | - Frank P.H.A. Vandenbussche
- Department of Obstetrics and Gynecology; Radboud University Nijmegen Medical Center; Nijmegen the Netherlands
| | - Marjolein Kok
- Department of Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
| | - William A. Grobman
- Department of Gynecology and Obstetrics; Northwestern University Medical School; Chicago IL USA
| | | | - Patrick M.M. Bossuyt
- Clinical Epidemiology, Biostatistics and Bioinformatics; Academic Medical Center; Amsterdam the Netherlands
| | - Brent C. Opmeer
- Clinical Research Unit; Academic Medical Center; Amsterdam the Netherlands
| | - Ben Willem J. Mol
- Robinson Research Institute; School of Pediatrics and Reproductive Health; University of Adelaide; Adelaide SA Australia
| | - Ewoud Schuit
- Department of Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
- Julius Center for Healthcare Research and Primary Care; University Medical Center Utrecht; Utrecht the Netherlands
- Stanford Prevention Research Center; Stanford University; Stanford CA USA
| | - Gert-Jan Van Baaren
- Department of Obstetrics and Gynecology; Academic Medical Center; Amsterdam the Netherlands
| |
Collapse
|
14
|
Driul L, Londero AP, Adorati-Menegato A, Vogrig E, Bertozzi S, Fachechi G, Forzano L, Cacciaguerra G, Perin E, Miceli A, Marchesoni D. Therapy side-effects and predictive factors for preterm delivery in patients undergoing tocolysis with atosiban or ritodrine for threatened preterm labour. J OBSTET GYNAECOL 2014; 34:684-9. [DOI: 10.3109/01443615.2014.930094] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
15
|
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.
Collapse
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
| | | |
Collapse
|
16
|
Predictive Value of Cervical Length Measurement and Fibronectin Testing in Threatened Preterm Labor. Obstet Gynecol 2014; 123:1185-1192. [DOI: 10.1097/aog.0000000000000229] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
17
|
van Vliet EOG, Boormans EM, de Lange TS, Mol BW, Oudijk MA. Preterm labor: current pharmacotherapy options for tocolysis. Expert Opin Pharmacother 2014; 15:787-97. [PMID: 24533566 DOI: 10.1517/14656566.2014.889684] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION In the developed world, preterm birth is in quantity and in severity the most important issue in obstetric care. Adverse neonatal outcome is strongly related to gestational age at delivery. Since the pathophysiological mechanism of preterm birth is not yet completely unraveled, the development of successful preventive strategies is hampered. When preterm labor is actually threatening, current pharmacological therapies focus on inhibition of preterm contractions. This allows for transportation of the mother to a center with a neonatal intensive care unit and administration of corticosteroids to enhance fetal lung maturation. Globally, however, large practice variation exists. AREAS COVERED The aim of this review is to provide an overview of current pharmacological therapies for preterm labor. EXPERT OPINION For the initial tocolysis, the use of atosiban or nifedipine for 48 h is recommended based on the largest effectiveness and most favorable side effect profile. However, since data that convincingly indicate the beneficial effect of tocolytics on neonatal outcome are lacking, it might well be that tocolytics are ineffective. The role of progesterone in treatment of acute tocolysis is limited, but it might play a role in the prevention of preterm labor or as sensitizer for other tocolytic agents.
Collapse
Affiliation(s)
- Elvira O G van Vliet
- UMC Utrecht, Department of Obstetrics and Gynaecology , WKZ, PO Box 85090, 3508 AB Utrecht , Netherlands
| | | | | | | | | |
Collapse
|
18
|
Wilms FF, Vis JY, Mol BWJ. Reply. Am J Obstet Gynecol 2012. [DOI: 10.1016/j.ajog.2011.10.860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
19
|
Vis JY, Kuin RA, Grobman WA, Mol BWJ, Bossuyt PMM, Opmeer BC. Additional effects of the cervical length measurement in women with preterm contractions: a systematic review. Arch Gynecol Obstet 2011; 284:521-6. [PMID: 21484403 PMCID: PMC3155022 DOI: 10.1007/s00404-011-1892-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 02/24/2011] [Indexed: 11/25/2022]
Abstract
Purpose Transvaginal cervical length measurement in women with symptoms of preterm labor has been used to decide if treatment is necessary. Cervical length measurement may also have additional effects on patients, such as providing reassurance, although the evidence to support this is unclear. We explored and summarized to what extent additional effects of cervical length measurement in women with threatened preterm labor have been reported in the clinical literature and what the magnitude of these effects was. Methods We performed a systematic review of the literature to identify articles reporting on cervical length measurements in women with symptoms of preterm labor. We assessed whether these articles reported patient outcomes other than preterm delivery. Results The electronic and hand search resulted in 764 articles, of which 172 met initial criteria for further eligibility assessment. We found 12 articles that reported additional effects of cervical length measurement in symptomatic women, such as the reassurance or the sensory consequences related to the transvaginal procedure. None of the articles quantified such additional effects. Conclusions There appears to be a gap between the presumed effects of cervical length measurement on patient outcomes, such as patients’ reassurance, and the actual assessment of these effects during test evaluations. We suggest that future evaluations of prognostic preterm labor tests include a comprehensive assessment of patient outcomes.
Collapse
Affiliation(s)
- Jolande Y Vis
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
20
|
Rose CH, McWeeney DT, Brost BC, Davies NP, Watson WJ. Cost-effective standardization of preterm labor evaluation. Am J Obstet Gynecol 2010; 203:250.e1-5. [PMID: 20816147 DOI: 10.1016/j.ajog.2010.06.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Revised: 05/08/2010] [Accepted: 06/17/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the effect of a standardized evidence-based protocol for preterm labor evaluation on resource use and obstetrics outcomes. STUDY DESIGN We conducted a retrospective 12-month observational study of patients with symptoms of preterm labor at the Mayo Clinic. All patients underwent triage evaluation per a standardized protocol with a combination of cervical length measurement with contingent fetal fibronectin assay. RESULTS Of 201 patients who underwent evaluation, 3 women delivered within 7 days, and only 1 woman delivered after a negative evaluation. Mean gestational age at evaluation was 29 weeks 1 day, and delivery was at 38 weeks 3 days of gestation, with an average interval of 57.4 days until delivery. The rate of hospital admission was reduced by 56%, compared with the previous year; an estimated annual cost saving was $39,900. CONCLUSION Implementation of a standardized protocol for evaluation of preterm labor reduces the rate of unnecessary hospital admissions for observation with consequent significant reduction in expenses.
Collapse
Affiliation(s)
- Carl H Rose
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | |
Collapse
|