Title: CLINICAL GUIDELINES ID TAG Preterm Labour and Tocolysis Authors: Designation: Speciality / Division: Directorate: Dr L Bell, Dr K Price, Dr G McKeown, Mr D Sim Trainee, Trainee, CAH Consultant, DHH Consultant Obstetrics- IMWH Acute Services Date: May 2014 Consulted upon: Approved by: (Name of AMD) Applicable to: (delete Yes / No as appropriate) Review Date (Every 3 years or sooner if required): Clinical Guideline ID: Yes Mr D Sim, Patricia McStay Dept./Division Only: YES- IMWH Directorate Only: NO Trust-wide: NO 1 st May 2017 CG0029
Preterm Labour and Tocolysis Definition Onset of labour at less than 37+0 weeks of gestation (uterine activity AND cervical change) Risk factors include History of preterm labour, delivery or cervical incompetence Positive fetal fibronectin test result in previous fourteen days Multiple pregnancy Cervical length <25mm (TVUSS) 2 or more LLETZ procedures Low pre-pregnancy weight Maternal stress Diagnosis Symptoms Regular uterine contractions >1hr Backache/stomach cramping Abdominal pain/pressure PV Change in discharge/spotting Signs Uterine activity with cervical change (effacement and dilatation) Descent of presenting part Investigation Fetal fibronectin (refer to full guideline) prior to any vaginal examination, see exclusions HVS / Urinalysis +/- MSSU if indicated Maternal observations/ assessment of cervix CTG greater than 26 weeks gestation if possible USS for fetal growth and wellbeing Consider TVUSS for cervical length if appropriately trained Obtain IV access and take bloods if indicated Management Negative FFN + low risk pt discharge home Negative FFN + high index of clinical suspicion +/or high risk pt consider admission, steroids +/- TVUSS Positive FFN admit, steroids +/- tocolysis Liaise with NNU re: Cots prior to admission Commence tocolysis if appropriate
TOCOLYSIS No clear evidence that tocolytic drugs improve outcome and therefore it is reasonable not to use them. However should be considered if few days gained can be put to good use Tocolysis most likely to benefit those in very preterm labour (<32 weeks), those needing in utero transfer and those yet to complete corticosteroids Avoid when there is a contraindication to prolonging pregnancy: Lethal congenital or chromosomal malformation Intrauterine infection Severe pre-eclampsia Placental abruption Advanced cervical dilatation Evidence of fetal +/or placental insufficiency Relative contraindications: Suspicious CTG Intrauterine growth restriction Multiple pregnancy Nifedipine + atosiban have comparable effectiveness (atosiban 10X more costly) Nifedipine is unlicensed for management of preterm labour Compared with Beta agonists, Nifedipine is associated with improvement in neonatal outcome although there are no long term data NIFEDIPINE REGIME: CAH Guidance 20mg PO STAT followed by 10-20mg PO TID-QID Adjusted according to uterine activity for up to 48hrs Total dose >60mg associated with increased adverse effects (x3-4 fold) Monitor pulse/bp/continuous CTG Contraindications to Nifedipine as per BNF, eg: severe aortic stenosis, recent MI within 1 month, unstable angina, porphyria Caution with multiple pregnancy and in diabetes as increased risk pulmonary oedema Side-effects: palpitations, nausea and vomiting, hypotension
SALBUTAMOL REGIME: DHH Guidance PREPARATION Remove 10mls from 100ml infusion bag of 5% dextrose solution. Add 10mgs of Salbutamol solution (this comes in vials of 5mls, 1mg per ml).the Solution will then contain Salbutamol of a concentration of 100mcgs per ml. INITIAL INFUSION RATE Start at 6mls per hour. INCREMENTS Increase the rate every 10 minutes by 1.5mls per hour until contractions begin to diminish. The rate may be increased further by 1ml per hour until contractions cease. The maximum infusion rate is 27mls per hour. The rate should be maintained for 1 hour after contractions have stopped and then gradually decreased by 1ml per hour, whilst contractions remain inhibited. OBSERVATIONS - BP, pulse every 15 minutes for the first three hours, followed by hourly observations. - Continuous CTG until contractions have ceased, then 12 hourly CTGs until infusion is discontinued. - Strict intake and output chart. - Chest auscultation for pulmonary oedema every 12 hours. - Glucometer readings every 6 hours. SIDE EFFECTS - Nausea, vomiting, flushing, sweating, tremor, headache, chest pain, dyspnoea, hypokalaemia, tachycardia, palpitations and hypotension. - Pulmonary oedema may occur in combination with steroids. ATOSIBAN REGIME: bolus 6.75mg over 1 min followed by IV infusion 18mg/hr for 3 hrs then 6mg/hr for up to 45 hrs (to a max of 330mg) Usual practice to discontinue atosiban if transferred in from another unit and start tocolytic of choice dependant on site
Notes 1. All tocolytics should be administered in labour ward with appropriate monitoring for side effects in mother and fetus 2. Duration of tocolytic therapy should generally not exceed 48 hours 3. Maintenance tocolytic therapy is not recommended 4. Antenatal corticosteroids should be offered to women between 24+0 and 34+6 weeks gestation at risk of preterm labour. <24 weeks consultant decision 5. Women with spontaneous preterm labour with intact membranes and no clinical evidence of overt infection should not routinely be prescribed antibiotics. There is evidence that antibiotics given under these circumstances increases the risk to their offspring of functional impairment and cerebral palsy 6. Co-amoxiclav should be avoided in women at risk of preterm delivery due to the increased risk of neonatal necrotising enterocolitis References RCOG Greentop Guideline No. 1b, Tocolysis for Women in Preterm Labour. February 2011 Southern Health + Social Care Trust Standards + Guidelines Committee, Fibronectin Testing. June 2012 Craigavon Area Hospital, Guideline: Preterm Labour and Tocolytic Drugs. (archived) Daisy Hill Hospital, Guideline: Premature Labour and Use of Salbutamol. Dec 2012 RCOG Scientific Impact Paper no.33, Preterm Labour, Antibiotics and Cerebral Palsy. February 2013 Authors Dr L Bell, ST2, CAH Dr K Price, F2, CAH Dr G McKeown, Consultant, CAH Dr D Sim, Consultant, DHH (provided guidance on salbutamol use)