Tocolysis for women in preterm labour and Antental Corticosteroids to reduce neonatal mortality - GT1b and GT7

Question 1

What is the mortality rate of <37+6/40 (and compared to overall risk)?

Answer 1

42/1000

Compared to 5/1000 overall

Question 2

What is the mortality rate at 1 year of very preterm births (<32+0/40) (and compared to overall risk)?

Answer 2

144/1000

Compared to 1.8/1000 overall

Question 3

What % of UK births are very preterm (<32/40)?

How many infant deaths are very preterm?

Answer 3

1.4% births

51% of infant deaths

Question 4

What are the contraindications to tocolysis?

Answer 4

Known lethal malformation
Intrauterine infection
Severe PET
Abruption
Advanced dilatation
Fetal compromise
Evidence of placental insufficiency

(Relative: mild haemorrhage in known placenta praevia, suspcious CTG, FGR, Multiple pregnancy)

Question 5

When should nifedipine be avoided as a tocolytic?

Answer 5

Cardiac disease

Caution in DM and multiple pregnancy due to risk of pulmonary oedema

Question 6

Which is the most effective tocolytic?

Answer 6

Nifedipine and atosiban comparable

b-agonists have highest rate adverse effects - avoid multiple drugs

Question 7

What is the cost difference between atosiban and nifedipine?

Answer 7

Atosiban costs 10x more

Question 8

What are the dosage regimens for nifedipine and atosiban?

Answer 8

Nifedipine: 20mg stat, 10-20mg TDS - QDS adjusted to activity for 48 hours

Atosiban: Bolus 6.75mg over 1 min
Infuse 18mg/hr for 3 hours
6mg/hr for up to 45 hours (max 330mg)

Question 9

What is the reduction in risk for cerebral palsy with MgSO4 use in preterm labour?

Answer 9

RR 0.68

Question 10

What are the side effects of nifedipine?

Answer 10

Flushing, palpitations
Nausea and vomiting
Hypotension

Question 11

What are the side effects of ritodrine (b-agonist)?

Answer 11

Tremor
Palpitations
Nausea and vomiting
Headache
Dyspnoea
Chest pain
Main cause to discontinue: pulmonary oedema

Question 12

What are the side effects of atosiban?

Answer 12

Nausea
Headache
Vomiting
Chest pain
Dyspnoea
Main cause to discontinue: injection site reactions

Question 13

What is the reduction in risk of neonatal death in women at risk of preterm birth who receive corticosteroids?

Answer 13

31%

Question 14

What is the reduction in risk of neonatal RDS in women at risk of preterm birth who receive corticosteroids?

Answer 14

44%

Question 15

What is the reduction in risk of intraventricular haemorrhage in women at risk of preterm birth who receive corticosteroids?

Answer 15

46%

Question 16

What are the other benefits to baby if mum receives antenatal corticosteroids?

Answer 16

Decreased chance of NEC
Less respiratory support
Less likely to need ICU admission
Few systemic infections in the first 48 hours

Question 17

Which patients should be offered antenatal corticosteroids?

Answer 17

24+0 to 34+6 at risk of preterm birth (or multiples at risk of imminent delivery at this gestation)
Consider for 23+0 to 23+6 (at senior level)
All women having elCS <38+6
Babies with FGR at risk of delivery 24+0 to 35+6

Question 18

When are steroids most effective at reducing RDS?

Answer 18

In those that deliver within 24 hrs - 7 days after 2nd dose (but will still reduce NND within 24 hrs outside this)

Question 19

What % chance will babies need NICU following el C/S at 37 and 38 weeks with and without steroids?

Answer 19

37/40 - 11% vs 5%

38/40 - 6.2% vs 2.8%

Question 20

What were the disadvantages of giving repeat doses of steroids?

Answer 20

Reduced birthweight and head circumference

May consider rescue course (single) if first course given <26/40

Question 21

When should corticosteroids be given with caution?

Answer 21

Maternal sepsis or latent TB