Acute tocolysis for uterine tachysystole or suspected fetal distress.

BACKGROUND: Uterine tachysystole (more than 5 contractions per 10 minutes in 2 consecutive intervals) is common during labour, particularly with use of labour-stimulating agents. Tachysystole may reduce fetal oxygenation by interrupting maternal blood flow to the placenta during contractions. Reducing uterine contractions may improve placental blood flow, improving fetal oxygenation. This review aimed to evaluate the use of tocolytics to reduce or stop uterine contractions for improvement of the condition of the fetus in utero. This new review supersedes an earlier Cochrane Review on the same topic. OBJECTIVES: To assess the effects of the use of acute tocolysis during labour for uterine tachysystole or suspected fetal distress, or both, on fetal, maternal and neonatal outcomes. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (2 February 2018), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating acute tocolysis for uterine tachysystole, intrapartum fetal distress, or both. DATA COLLECTION AND ANALYSIS: We used standard methods expected by Cochrane. MAIN RESULTS: We included eight studies (734 women), conducted in hospital settings, predominantly in high-income countries (USA, Austria, Uruguay). Two trials were conducted in upper and lower middle-income countries (South Africa, Sri Lanka). The hospital facilities all had the capacity to perform caesarean section. Overall, the studies had a low risk of bias, except for methods to maintain blinding. All of the trials used a selective beta2 (ß2)-adrenergic agonist in one arm, however the drug used varied, as did the comparator. Limited information was available on maternal outcomes.Selective ß2-adrenergic agonist versus no tocolytic agent, whilst awaiting emergency deliveryThere were two stillbirths, both in the no tocolytic control group (risk ratio (RR) 0.23, 95% confidence interval (CI) 0.01 to 4.55; 2 studies, 57 women; low-quality evidence). One had gross hydrocephalus and the second occurred with vaginal delivery after waiting 55 minutes for caesarean section. The decision for caesarean section delivery was an inclusion criterion in both studies so we could not assess this as an outcome under this comparison. Abnormal fetal heart trace is probably lower with tocolytic treatment (RR 0.28, 95% CI 0.08 to 0.95; 2 studies, 43 women; moderate-quality evidence). The effects on the number of babies with Apgar score below seven were uncertain (low-quality evidence).Intravenous (IV) atosiban versus IV hexoprenaline (1 study, 26 women) One infant in the hexoprenaline group required > 24 hours in the neonatal intensive care unit (NICU) following a forceps delivery (RR 0.33, 95% CI 0.01 to 7.50; low-quality evidence). There were no fetal or neonatal mortalities and no Apgar scores below seven. There was one caesarean delivery in the IV hexoprenaline group (RR 0.33, 95% CI 0.01 to 7.50; low-quality evidence), and one case of abnormal fetal heart score in the atosiban group (RR 3.00, 95% CI 0.13 to 67.51; very low-quality evidence).IV fenoterol bromhydrate versus emergency delivery (1 study, 390 women) No data were reported for perinatal death, severe morbidity or fetal or neonatal mortality. IV fenoterol probably increases the risk of caesarean delivery (RR 1.12, 95% CI 1.04 to 1.22; moderate-quality evidence). Fenoterol may have little or no effect on the risk of Apgar scores below seven (RR 1.28, 95% CI 0.35 to 4.68; low-quality evidence).IV hexoprenaline versus no tocolytic agent, whilst awaiting emergency delivery (1 study, 37 women) No data were reported for perinatal death or severe morbidity. There were two fetal deaths in the no tocolytic control group (RR 0.23, 95% CI 0.01 to 4.55; low-quality evidence). The rate of caesarean delivery was not reported. There were two babies with Apgar scores below seven in the control group and none in the hexoprenaline group (RR 0.24, 95% CI 0.01 to 4.57; 35 women; low-quality evidence).Subcutaneous terbutaline versus IV magnesium sulphate (1 study, 46 women)No data were reported for perinatal death, severe morbidity or fetal or neonatal mortality. The decision for caesarean section was an inclusion criterion, so we could not assess this. The effects on abnormal fetal heart trace are uncertain (very low-quality evidence).Subcutaneous terbutaline with continuation of oxytocic infusion versus cessation of oxytocic infusion without tocolytic agent (1 study, 28 women) No data were reported for perinatal death, severe morbidity or fetal or neonatal mortality. There may be little or no difference in the rates of caesarean delivery in the subcutaneous terbutaline (8/15) and control groups (4/13) (RR 1.73, 95% CI 0.68 to 4.45; low-quality evidence). There were no cases of Apgar scores below seven or abnormal fetal heart trace.Subcutaneous terbutaline versus no tocolytic agent, whilst awaiting emergency delivery (1 study, 20 women) No data were reported for perinatal death or severe morbidity. There were no fetal or neonatal mortalities. The decision for caesarean section was an inclusion criterion, so we could not assess this. There were two babies with Apgar scores below seven in the control group and none in the terbutaline group (RR 0.17, 95% CI 0.01 to 3.08; low-quality evidence).IV terbutaline versus IV nitroglycerin (1 study, 110 women)No data were reported for perinatal death or severe morbidity or fetal or neonatal mortality. There may be little or no difference in the rates of caesarean delivery between the IV terbutaline (30/57) and control groups (29/53) (RR 0.96, 95% CI 0.68 to 1.36; low-quality evidence). There were no cases of Apgar scores below seven. AUTHORS' CONCLUSIONS: There is insufficient evidence to determine the effects of tocolytics for uterine tachysystole or suspected fetal distress during labour. The clinical significance for some of the improvements in measures of fetal well-being with tocolytics is unclear. The sample sizes were too small to detect effects on neonatal morbidity, mortality or serious adverse effects. The majority of studies are from high-income countries in facilities with access to caesarean section, which may limit the generalisability of the results to lower-resource settings, or settings where caesarean section is not available.Further well-designed and adequately powered RCTs are required to evaluate clinically relevant indicators of maternal and neonatal morbidity and mortality.

Effectiveness of dydrogesterone, 17-OH progesterone and micronized progesterone in prevention of preterm birth in women with a short cervix.

OBJECTIVE: To compare the efficacy of dydrogesterone, 17-OH progesterone (17OHP) and oral or vaginal micronized progesterone with cerclage for the prevention of preterm birth in women with a short cervix. METHODS: The study included 95 women with singleton gestation and cervical length (CL) ≤ 25 mm. Among these, 35 women were asymptomatic at 15-24 weeks and 60 had symptoms of threatened late miscarriage (LM) or preterm delivery (PD) at 15-32 weeks. Patients were randomized to receive dydrogesterone, 17OHP or oral/vaginal micronized progesterone; after one week of therapy 15 women underwent cerclage. RESULTS: Efficacy of vaginal progesterone (VP) for the prevention of preterm birth reached 94.1%. In asymptomatic women pregnancy outcomes were comparable to cerclage. In women with threatened LM/PD, combination therapy with VP, indomethacin and treatment of bacterial vaginosis (BV) with the subsequent use VP until 36 weeks together with CL monitoring significantly decreased the rate of preterm birth (RR 0.01; 0.0001-0.24) and low birth weight (LBW) (RR 0.04; 0.01-0.96). CL increase during the first week of treatment with a subsequent plateau phase indicated treatment efficacy. Dydrogesterone, 17OHP, and micronized oral progesterone (OP) were associated with PD in 91.7% of women. CONCLUSIONS: Combination management strategy including VP significantly benefits pregnancy outcomes in women with a short cervix compared with cerclage. Dydrogesterone, 17OHP, and OP were not found to be efficacious.

[Effective tocolysis without ß-agonists].

UNLABELLED: Many years the ß-mimetics (Partussisten, Gynipral) were first line tocolytic agents in terms of delaying premature delivery in our country. As these medicaments have been withdrawn from the pharmacy network, some concerns began to appear among our colleges considering the administration of other tocolytics and their effectiveness. Our goal is to compare the efficacy of other tocolytics with ß-mimetics. That is why we reviewed the structure of premature deliveries in the University Hospital "Stoyan Kirkovich", Stara Zagora for two periods: 01.01.2013 - 31.12. 2013 and 01.01.2014 - 01.06.2014. RESULTS: 45 of 326 pregnancies (13.8%) > 20 weeks of gestation for 2013, treated with Gynipral have ended with a premature delivery vs. 13 of 110 pregnancies (11.8%), treated with magnesium (Mg SO4, Magnerich, Magnerot), calcium channel blockers and spasmolyticsfor the period - 01:01.2014 - 01.06.2014. CONCLUSION: The results show, that at this stage, several months after the cessation of use of ß-mimetics, there is no rise of number and percentage of premature deliveries, but there is even a tendence of decline. Larger periods and greater number of cases are needed to formulate conclusions with greater significance.

[Peculiarities of treatment of ulcerative gastrointestinal hemorrhage in pregnant women].

The occurrence rate of gastrointestinal hemorrhage (GIH) of nonvaricosal genesis in pregnant women was analyzed. The risk of complications occurrence in the pregnancy course while performing local endoscopic hemostasis and prophylaxis of the hemorrhage recurrence occurrence was established. Application of elaborated treatment method for GIH of nonvaricosic genesis in pregnant women have promoted reduction of the severe complications rate in the pregnancy course, applying elimination of the vasoconstrictor and uterotonic effects of adrenalin, reduction of esophagogastroduodenoscopy duration. While application of this procedure in pregnant women of a main group operative cessation of GIH was not applied. In a comparison group a hemostasis, using operative way, was done in 2 (13.3%) women patients with subsequent occurrence of preeclampsy, what resulted in antenathal fetal death.

Betamimetics for inhibiting preterm labour.

BACKGROUND: Preterm birth is a major contributor to perinatal mortality and morbidity worldwide. Tocolytic agents are drugs used to inhibit uterine contractions. Betamimetics are tocolytic agents that have been widely used, especially in resource-poor countries. OBJECTIVES: To assess the effects of betamimetics given to women with preterm labour. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2013) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials of betamimetics, administered by any route or any dose, in the treatment of women in preterm labour where betamimetics were compared with other betamimetics, placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two review authors assessed risk of bias and extracted the data independently. MAIN RESULTS: Twenty-eight trials were assessed as eligible for inclusion in the review, but eight did not report any outcome data relevant to the review. Results are based on the 20 trials that contributed data.Twelve trials, involving 1367 women, compared betamimetics with placebo. Betamimetics decreased the number of women in preterm labour giving birth within 48 hours (average risk ratio (RR) 0.68, 95% confidence interval (CI) 0.53 to 0.88, 10 trials, 1209 women). There was a decrease in the number of births within seven days (average RR 0.80; 95% CI 0.65 to 0.98, five trials, 911 women) but there was no evidence of a reduction in preterm birth (before 37 weeks' gestation) (RR 0.95; 95% CI 0.88 to 1.03, 10 trials, 1212 women). No benefit was demonstrated for betamimetics for perinatal death (RR 0.84; 95% CI 0.46 to 1.55, 11 trials, 1332 infants), or neonatal death (RR 0.90; 95% CI 0.27 to 3.00, six trials, 1174 infants). No significant effect was demonstrated for respiratory distress syndrome (RR 0.87; 95% CI 0.71 to 1.08, eight trials, 1239 infants). A few trials reported on cerebral palsy, infant death and necrotising enterocolitis; no significant differences between groups were identified for any of these outcomes. Betamimetics were significantly associated with the following outcomes: withdrawal from treatment due to adverse effects; maternal chest pain; dyspnoea; palpitation; tremor; headaches; hypokalaemia; hyperglycaemia; nausea or vomiting; nasal stuffiness; and fetal tachycardia.Nine trials compared different types of betamimetics. Other betamimetics were compared with ritodrine in five trials (n = 948). Other comparisons were examined in single trials: hexoprenaline compared with salbutamol (n = 140), slow versus moderate release salbutamol (n = 52) and salbutamol compared with terbutaline (n = 200). Trials were small, varied, and of insufficient quality to delineate any consistent patterns of effect. AUTHORS' CONCLUSIONS: Betamimetics help to delay birth, which may give time to allow women to be transferred to tertiary care or to complete a course of antenatal corticosteroids. However, multiple adverse effects must be considered. The data are too few to support the use of any particular betamimetic.

Tocolysis for preterm labor: expert opinion.

Tocolysis is an important treatment in the improvement of outcome in preterm labor and preterm birth, provided that its use follows clear evidence-based recommendations. In this expert opinion, the most recent evidence about efficacy and side effects of different tocolytics is being reviewed and evidence-based recommendation about diagnosis and treatment of preterm labor is given. Further aspects such as progesterone administration or antibiotic treatment for the prevention of preterm birth are included. Our review demonstrates that an individualized choice of different tocolytics and additional treatments is necessary to improve short- and long-term neonatal outcome in preterm labor and preterm birth.

Tocolysis with the ß-2-sympathomimetic hexoprenaline increases occurrence of infantile haemangioma in preterm infants.

BACKGROUND: Infantile haemangioma (IH) is the most commonly observed tumour in children. Off-label pharmacological treatment of IH with the beta-blocker propranolol induces regression of IH. Based on the fact that IH are more frequently observed in premature babies than in mature babies and the evidence that beta-blocker therapy leads to regression of IH, the authors generated the hypothesis that the use of ß-2-sympathomimetics during pregnancy for inhibiting premature labour might increase occurrence of IH in preterm infants. METHODS: For group comparison t test, Mann-Whitney U test and Fisher's exact test were used. Logistic regression was carried out by the forward stepwise method with Wald statistics. RESULTS: Data of 328 preterm infants (<32 gestational weeks) or with a birth weight of less than 1500 g (<36 gestational weeks) born between January 2006 and December 2008 were analysed. A total of 15 were excluded due do death within the 1st month of life, 38 because of lost to follow-up and six due to incomplete data. Complete data of 269 preterm infants were retrospectively analysed. During the follow-up period of median 1.6 years, 50 infants developed one or more IH within their first 6 months of life. IH occurred in 40/181 patients with intrauterine exposure to the ß-2-sympathomimetic hexoprenaline and in 10/88 without exposure (OR=4.3; 95% CI 1.4 to 13.8). Furthermore, the influence of antenatal exposure to glucocorticosteroids for induction of lung development was analysed. Prenatally exposed subjects showed reduced occurrence of IH (OR=0.2; 95% CI 0.05 to 0.8). CONCLUSION: Intrauterine exposure to the ß-2-sympathomimetic hexoprenaline might increase the occurrence of IH in preterm infants.

Arg16 homozygosity of the beta2-adrenergic receptor improves the outcome after beta2-agonist tocolysis for preterm labor.

BACKGROUND: Beta(2)-adrenergic receptor (beta(2)AR) agonists are not consistently successful when administered as tocolytic therapy. The beta(2)AR displays genetic variability; an arginine-to-glycine substitution at codon 16 (Arg16Gly) has been shown to increase receptor desensitization in response to agonist exposure, whereas a substitution of glutamate for glutamine at codon 27 (Gln27Glu) decreases down-regulation. We have demonstrated that homozygosity for Arg16 protects against preterm delivery. Our goal was to determine whether beta(2)-agonists are more effective in women with the Arg16 genotype and preterm labor. METHODS: Sixty white women with preterm labor between 24 and 34 weeks' gestation were treated for 48 hours with intravenous hexoprenaline. The effect of tocolysis and outcome of pregnancy were recorded. The beta(2)AR genotypes at codons 16 and 27 of ADRB2 were determined. A control group of 116 women delivered at term was also genotyped. RESULTS: Preterm labor was not associated with beta(2)AR genotype at codon 16 (17% of patients with preterm labor were Arg16 homozygotes versus 19% of control subjects) or codon 27. Gestation was significantly prolonged in Arg16 homozygotes (median, 69 days; interquartile range, 63-79 days) compared with the other 2 genotypes (median, 58 days; interquartile range, 2-72 days) (P = .04). Tocolysis was 100% successful in delaying delivery for 48 hours in Arg16 homozygotes (n = 10), just failing to achieve statistical significance (P = .069). In contrast, only 37 of 50 women carrying 1 or 2 glycine alleles (74%) had delivery delayed by more than 48 hours with tocolysis. Neonatal outcomes were significantly better in babies born to mothers homozygous for arginine than in women with 1 or 2 Gly16 alleles. CONCLUSIONS: This is the first study examining the pharmacogenetics of beta(2)AR agonist therapy for preterm labor. It appears that Arg16 homozygosity improves pregnancy outcome after beta(2)-agonist tocolysis. The relatively low frequency of Arg16 homozygotes in our population limited the power of this investigation. Future assessments of tocolytic therapy may need to assess beta(2)AR genotype.

Betamimetics for inhibiting preterm labour.

BACKGROUND: Preterm birth is a major contributor to perinatal mortality and morbidity worldwide. Tocolytic agents are drugs used to inhibit uterine contractions. The most widely used tocolytic agents are betamimetics especially in resource-poor countries. OBJECTIVES: To assess the effects of betamimetics given to women with preterm labour. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (May 2003) without language restrictions. SELECTION CRITERIA: Randomised controlled trials of betamimetics, administered by any route or any dose, in the treatment of women in preterm labour where betamimetics are compared with other betamimetics, placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two reviewers evaluated independently methodological quality and extracted the data. We sought additional information to enable assessment of methodology and conduct intention-to-treat analyses. We present the results using the relative risk for categorical data and the weighted mean difference for continuous data. MAIN RESULTS: Eleven randomised controlled trials, involving 1332 women, compared betamimetics with placebo. Betamimetics decreased the number of women in preterm labour giving birth within 48 hours (relative risk (RR) 0.63; 95% confidence interval (CI) 0.53 to 0.75) but there was no decrease in the number of births within seven days after carrying out a sensitivity analysis of studies with adequate allocation of concealment. No benefit was demonstrated for betamimetics on perinatal death (RR 0.84; 95% CI 0.46 to 1.55, 7 trials, n = 1332), or neonatal death (RR 1.00; 95% CI 0.48 to 2.09, 5 trials, n = 1174). No significant effect was demonstrated for respiratory distress syndrome (RR 0.87; 95% CI 0.71 to 1.08, 8 trials, n = 1239). A few trials reported the following outcomes, with no difference detected: cerebral palsy, infant death and necrotizing enterocolitis. Betamimetics were significantly associated with the following: withdrawal from treatment due to adverse effects; chest pain; dyspnoea; tachycardia; palpitation; tremor; headaches; hypokalemia; hyperglycemia; nausea/vomiting; and nasal stuffiness; and fetal tachycardia. Other betamimetics were compared with ritodrine in five trials (n = 948). Trials were small, varied and of insufficient quality to delineate any consistent patterns of effect. REVIEWERS' CONCLUSIONS: Betamimetics help to delay delivery for women transferred to tertiary care or completed a course of antenatal corticosteroids. However, multiple adverse effects must be considered. The data are too few to support the use of any particular betamimetics.

[Comparison of the cost of treatment of premature labor with atosiban or beta-sympathomimetics from the perspective of the health care payer--a pharmacoeconomic model]. / Srovnání nákladu na lécbu predcasného porodu atosibanem nebo beta-sympatomimetiky z perspektivy plátce zdravotní péce--farmakoekonomický model.

OBJECTIVE: To evaluate the cost of treating premature delivery with atosiban or beta-sympatomimetic drugs (fenoterol and hexoprenalin) from the perspective of health care payer--the medical insurance company. DESIGN: A pharmaco-economic model based on the results of randomized, controlled clinical study. SETTING: Hospital Pharmacy at Vitkovice Hospital of Blessed Mary Antonia, Ostrava. METHODS: The study is based on the application of clinical decision-making analysis, which includes results of a randomized controlled clinical study as well as data on the cost of clinical interventions and cost of drug therapy. The pharmaco-economic model was created from the perspective of the payer of health care--the insurance company. This model presumes the administration of atosiban or beta-sympatomimetic drugs (fenoterol and hexoprenalin) for the period of 18 and 48 h and the therapy of possible untoward effects for the next 72 h after the administration of the drugs. The analysis of sensitivity of pharmacokinetic model also employs so called low and high estimate of supplementary cost for the treatment of untoward effects. RESULTS: After the administration of the drugs for the period of 18 h the total cost of the payer of medical care was in the range of 21,914.5-21,974.4 CKr in atosiban, 19,878.7-22,661.4 CKr in fenoterol and 19,942.9-21,974.4 CKr in hexoprenalin. In the administration of the drugs for 48 h, the overall cost of the payer of medical care was in the range of 43,082.5-43,142.4 CKr in atosiban, 19,960.3-23,150.7 CKr in fenoterol and 20,131.3-23,574.0 in hexoprenalin. CONCLUSIONS: This study compared overall cost associated with hospitalization of a premature delivery from the perspective of the medical care payer, i.e. the health insurance company. The authors applied a pharmaco-economic model evaluating hospitalization for the period of 48 h and subsequent therapy of possible untoward effects for the period of up to 72 h. In case of a shorter administration of atosiban (up to 18 h) the overall cost of hospitalization for premature delivery for the period of 48 h from the point of view of medical insurance company is basically comparable with the administration of beta-sympatomimetic drugs. If atosiban is administered for more than 18 h, the overall cost of hospitalization is higher than with beta-sympatomimetic drugs, and the cost increases in relation to the duration of atosiban administration.

A prospective randomised trial of atosiban versus hexoprenaline for acute tocolysis and intrauterine resuscitation.

OBJECTIVE: The aim of this study was to compare the efficacy and side effect profile of atosiban with hexoprenaline when used for intrauterine resuscitation of intrapartum fetal distress. STUDY DESIGN: Women in labour with acute intrapartum fetal distress detected by cardiotocography were randomly assigned to receive intravenous atosiban or hexoprenaline. SETTING: Department of Obstetrics and Gynecology, Karl Franzens University of Graz and General Hospital Graz, Austria. POPULATION OR SAMPLE: One thousand and four hundred and thirty-one women with singleton pregnancy at term and cephalic presentation were enrolled in the study during October 2000 and May 2001. METHODS: A prospective, randomised, pilot study with no a priori sample size calculation. MAIN OUTCOME MEASURE: Efficacy of treatment for stopping uterine contractions and the resumption of contractions determined by fetal heart rate monitoring. RESULTS: Tocolysis was achieved in 92% (12/13) of the women receiving atosiban and 100% (13/13) of those receiving hexoprenaline. Maternal tachycardia developed in 1/13 women, receiving atosiban and 10/13 women hexoprenaline. Hypertension occurred in 1/13 on atosiban and 3/13 women on hexoprenaline. Palpitations were only reported by 10/13 women receiving hexoprenaline. Uterine contractions resumed after 8 minutes (+/-3) in the atosiban group and 14 minutes (+/-4) in the hexoprenaline group (P < 0.001). CONCLUSION: Atosiban and hexoprenaline were similarly effective for stopping uterine contractions. Women receiving atosiban had significantly fewer adverse events than those receiving hexoprenaline. Uterine contractions resumed more promptly in the atosiban group. Considering the low incidence of mild maternal adverse events, atosiban may be an option for acute intrapartum tocolysis for fetal distress.

Tocolytics for suspected intrapartum fetal distress.

BACKGROUND: Prophylactic tocolysis with betamimetics and other agents has become widespread as a treatment for fetal distress. Uterine relaxation may improve placental blood flow and therefore fetal oxygenation. However there may also be adverse maternal cardiovascular effects. OBJECTIVES: The objective of this review was to assess the effects of tocolytic therapy for suspected fetal distress on fetal, maternal and perinatal outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: February 1999. SELECTION CRITERIA: Randomised trials comparing tocolytic therapy with no treatment or treatment with another tocolytic agent for suspected fetal distress. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data. MAIN RESULTS: Three studies were included. Compared with no treatment, there were fewer failed improvements in fetal heart rate abnormalities with tocolytic therapy (relative risk 0.26, 95% 0.13 to 0.53). Betamimetic therapy compared with magnesium sulphate showed a non-significant trend towards reduced uterine activity (relative risk 0.07, 95% confidence interval 0.00 to 1.10). REVIEWER'S CONCLUSIONS: Betamimetic therapy appears to be able to reduce the number of fetal heart rate abnormalities and perhaps reduce uterine activity. However there is not enough evidence based on clinically important outcomes to evaluate the use of betamimetics for suspected fetal distress.

Betamimetics in fetal distress: randomised controlled trial.

The objective of the study was to investigate if a single dose of Hexoprenaline administered to patients diagnosed as having fetal distress improves neonatal outcome and whether there are any side effects and complications related to hexoprenaline injection. Patients with fetal distress diagnosed by electronic fetal heart rate monitoring with a gestational age of 35 weeks or more in active labor were eligible. Once the decision to deliver the patient by Cesarean section was made, patients were approached and randomised by sealed opaque envelopes to hexoprenaline or control groups. Ten micrograms of hexoprenaline were administered intravenously to study patients. Main outcomes were cord blood gas values, Apgar scores, the need for resuscitation and admission to intensive care. There were no statistically significant differences in the main outcome measures between the two groups. Fewer babies in the hexoprenaline group had a pH of < 7.2 and a base excess of < -10, but this was not statistically significant. The fetal heart rate pattern was improved in significantly more patients after hexoprenaline administration than controls. In conclusion, despite the statistically significant improvement in fetal heart rate tracings, Apgar scores and blood gas values showed only a trend towards improvement in the hexoprenaline group.

Management of supraventricular tachycardia during hexoprenaline therapy for preterm labour: benefit of cardioselective beta blockade?

A 29-year-old woman presented with preterm labour at 32 weeks of gestation. Tocolytic treatment was started with intravenous hexoprenaline. Twenty-four hours after initiation of treatment, the patient developed supraventricular tachycardia, resistant to digoxin and verapamil. Medical treatment with metoprolol finally restored sinus rhythm. We observed no adverse effects on the fetal heart rate nor on the umbilical cord blood flow.

Randomized, double blind, placebo controlled comparison of ritodrine and hexoprenaline for tocolysis prior to external cephalic version at term.

External cephalic versions in the study period were performed in a double blind design by 2 experienced practitioners. Sixty-three patients were allocated to treatment with either placebo, ritodrine or hexoprenaline. The main outcome measure studied was successful completion of external cephalic version. Hexoprenaline, but not ritodrine, was statistically more likely to be associated with successful version than placebo (p = 0.04 versus p = 0.22).

[Uterine-placental-fetal blood flow and fetal cardiac activity during the ginipral treatment of premature labor]. / Sostoianie matochno-platsentarno-plodovogo krovotoka i serdechnoi deiatel'nosti ploda pri lechenii ginipralom prezhdevremennykh rodov.

Effects of intravenous and oral hinipral on the uteroplacentofetal blood flow and fetal heart work were studied in tocolytic therapy of preterm labor in 27 pregnant women at terms 25-35 weeks. Intravenous infusions of hinipral resulted in a significant reduction of the systolic-diastolic ratio in the umbilical artery, with the blood flow in the uterine arteries persisting stable, and in a significant reduction of the fetal heart rate and increase of fetal heart rhythm variability, as evidenced by cardiotocogram. In oral tocolysis the reduction of the umbilical artery was related to the pregnancy term; fetal heart rate and heart rhythm variability were within the normal range over the course of the investigation. The results evidence no negative effects of the drug on the uteroplacentofetal blood flow and fetal cardiovascular system both in oral and parenteral forms of tocolysis.

[Incidence and therapy of hyperstimulation following local prostaglandin administration for labor induction]. / Häufigkeit und Therapie der Uberstimulation nach lokaler Prostaglandingabe zur Geburtseinleitung.

A major cause of concern with respect to local prostaglandin (PG) E2 application is uterine hyperstimulation. The purpose of the present study was to evaluate the incidence of hyperstimulation and the possibility of treating this complication. A total of 181 cases were registered in two obstetric centres over a 51-month period. The rates of hyperstimulation were 7.3% in the group receiving intravaginal PG E 2 tablets (3 mg), 2.9% with intravaginal gel (2.5 mg), and 0.5% with intracervical gel (0.5 mg). In 178 cases (98.3%) the infusion of a beta-2 adrenergic drug (hexoprenaline or terbutaline) led, without adverse effects, to the rapid resolution of the alarming findings. Caesarean section was necessary in 3 patients. Depressed Apgar scores and an umbilical artery pH less than 7.20 were uncommon and, indeed, no more frequent than in PG E 2-treated cases without hyperstimulation. We conclude that uterine hyperstimulation is uncommon after low-dose PG E 2 therapy and is usually rapidly reversible, without apparent untoward intrapartum or neonatal effects.