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Stelzl P, Kehl S, Oppelt P, Mayr A, Fleckenstein T, Maul H, Enengl S, Berger R, Rath W. Maintenance tocolysis, tocolysis in preterm premature rupture of membranes and in cervical cerclage - a Germany-wide survey on the current practice after dissemination of the German guideline. J Perinat Med 2023:jpm-2022-0572. [PMID: 36972689 DOI: 10.1515/jpm-2022-0572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/26/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To investigate the adherence of German perinatal specialist units and those of basic obstetric care to the national guideline we compared data from a nation-wide survey on the practice of maintenance tocolysis, tocolysis in preterm premature rupture of membranes and in the perioperative setting of cervical cerclage, and bedrest during and after tocolysis with recommendations from the current German Guideline 015/025 "Prevention and Treatment of Preterm Birth". METHODS 632 obstetric clinics in Germany were approached and received a link to an online questionnaire. Data were descriptively analyzed by performing measures of frequency. To compare two or more groups Fisher's exact test was used. RESULTS The response rate was 19%; 23 (19.2%) of respondents did not perform maintenance tocolysis, while 97 (80.8%) conducted maintenance tocolysis; 30 (25.0%) of obstetric units performed cervical cerclage without tocolysis and 90 (75.0%) combined cervical cerclage with tocolysis; 11 (9.2%) of respondents did not use tocolytics in patients with preterm premature rupture of membranes, while 109 (90.8%) conducted tocolysis in these patients; 69 (57.5%) of obstetric units did not recommend bed rest during tocolysis, whereas 51 (42.5%) favored bedrest. Perinatal care centers of basic obstetric care recommend bed arrest during tocolysis statistically significant more often to their patients than those of higher perinatal care levels (53.6 vs. 32.8%, p=0.0269). CONCLUSIONS The results of our survey are in accordance to others from different countries and reveal considerable discrepancies between evidence-based guideline recommendations and daily clinical practice.
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Affiliation(s)
- Patrick Stelzl
- Universitätsklinik für Gynäkologie, Geburtshilfe und gynäkologische Endokrinologie, Kepler Universitätsklinikum, Johannes Kepler Universität Linz, Linz, Austria
- Frauenklinik, Universitätsklinikum Erlangen, Universitätsstrasse 21 - 23, Erlangen, Germany
| | - Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Universitätsstrasse 21 - 23, Erlangen, Germany
| | - Peter Oppelt
- Universitätsklinik für Gynäkologie, Geburtshilfe und gynäkologische Endokrinologie, Kepler Universitätsklinikum, Johannes Kepler Universität Linz, Linz, Austria
| | - Andreas Mayr
- Institut für Medizinische Biometrie, Informatik und Epidemiologie, Medizinische Fakultät, Universität Bonn, Bonn, Germany
| | - Tobias Fleckenstein
- Institut für Medizinische Biometrie, Informatik und Epidemiologie, Medizinische Fakultät, Universität Bonn, Bonn, Germany
| | - Holger Maul
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, c/o. Asklepios Klinik Barmbek, Hamburg, Germany
| | - Sabine Enengl
- Universitätsklinik für Gynäkologie, Geburtshilfe und gynäkologische Endokrinologie, Kepler Universitätsklinikum, Johannes Kepler Universität Linz, Linz, Austria
| | - Richard Berger
- Marienhaus Klinikum St. Elisabeth, Klinik für Gynäkologie und Geburtshilfe, Neuwied, Germany
| | - Werner Rath
- Medizinische Fakultät Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Girault A, Blondel B, Goffinet F, Le Ray C. Frequency and determinants of misuse of augmentation of labor in France: A population-based study. PLoS One 2021; 16:e0246729. [PMID: 33561131 PMCID: PMC7872232 DOI: 10.1371/journal.pone.0246729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/25/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction While use of augmentation of labor (AL) is appropriate for labor dystocia, it is frequently used inadequately and unnecessarily. The objective was to assess at a national level, the frequency and determinants of misuse of augmentation of labor (AL). Material and methods Women of the French perinatal survey of 2016 with a singleton cephalic fetus, delivering at term after a spontaneous labor were included. “Misuse of AL” was defined by artificial rupture of the membranes (ROM) and/or oxytocin within one hour of admission and/or duration between ROM and oxytocin of less than one hour. Women, labor and maternity unit’s characteristics were compared between the “misuse of AL” and “no misuse of AL” groups by bivariate analysis. To identify the determinants of misuse of AL, a multivariable multilevel logistic regression was performed taking into account the data’s hierarchical structure (first level: women, second level: maternity units). Results Among the 7196 women included, 1524 (21.2%) had a misuse of AL. The determinants of misuse of AL were middle school educational level (reference high school), aOR = 1.21; 95%CI[1.01–1.45], gestational age at delivery ≥41weeks (reference 39–40 weeks), aOR = 1.19; 95%CI[1.00–1.42], cervical dilation ≥6cm at admission (reference <3cm), aOR = 1.39; 95%CI[1.10–1.76], epidural analgesia aOR = 1.63; 95%CI[1.35–1.96], delivery in a private hospital (reference public teaching hospital), aOR = 2.25; 95%CI[1.57–3.23]; and maternity units with <1000 deliveries/year and 1000–1999 deliveries/year (reference ≥3000 deliveries/year), respectively aOR = 1.52; 95%CI[1.11–2.08] and aOR = 1.42; 95%CI[1.05–1.92]. Less than 3% of the variance was explained by women characteristics, and 24.17% by the maternity units’ characteristics. Conclusions In France, one spontaneous laboring woman among five is subject to misuse of AL. The misuse is mostly explained by maternity unit’s characteristics. The determinants identified in this study can be used to implement targeted actions in small and private maternity units.
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Affiliation(s)
- Aude Girault
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, Paris, France
- Maternité Port Royal, AP-HP, Hôpital Cochin, FHU PREMA, Paris, France
- * E-mail:
| | - Béatrice Blondel
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, Paris, France
| | - François Goffinet
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, Paris, France
- Maternité Port Royal, AP-HP, Hôpital Cochin, FHU PREMA, Paris, France
| | - Camille Le Ray
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, Paris, France
- Maternité Port Royal, AP-HP, Hôpital Cochin, FHU PREMA, Paris, France
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Rousseau A, Azria E, Baumann S, Deneux‐Tharaux C, Senat MV. Do obstetricians apply the national guidelines? A vignette‐based study assessing practices for the prevention of preterm birth. BJOG 2019; 127:467-476. [DOI: 10.1111/1471-0528.16039] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2019] [Indexed: 01/20/2023]
Affiliation(s)
- A Rousseau
- Midwifery Department Versailles Saint Quentin University Montigny‐le‐Bretonneux France
- EA 7285 Versailles Saint Quentin University Montigny le Bretonneux France
| | - E Azria
- Maternity Unit Notre Dame de Bon Secours Paris Saint Joseph Hospital Paris Descartes University Paris France
- National Institute for Health and Medical Research (INSERM) Unit 1153 Obstetrical Perinatal and Paediatric Epidemiology Research Team (EPOPé) Center for Epidemiology and Statistics Sorbonne Paris Cité DHU Risks in Pregnancy Paris University Paris France
| | - S Baumann
- Midwifery Department Versailles Saint Quentin University Montigny‐le‐Bretonneux France
| | - C Deneux‐Tharaux
- National Institute for Health and Medical Research (INSERM) Unit 1153 Obstetrical Perinatal and Paediatric Epidemiology Research Team (EPOPé) Center for Epidemiology and Statistics Sorbonne Paris Cité DHU Risks in Pregnancy Paris University Paris France
| | - MV Senat
- Department of Obstetrics and Gynaecology Bicêtre Hospital AP‐HP Kremlin Bicêtre France
- Paris Sud Paris Saclay University Le Kremlin Bicêtre France
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Stelzl P, Kehl S, Rath W. Maintenance tocolysis: a reappraisal of clinical evidence. Arch Gynecol Obstet 2019; 300:1189-1199. [PMID: 31576452 DOI: 10.1007/s00404-019-05313-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/19/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Maintenance tocolysis, mostly defined as the continuation of tocolytic treatment beyond 48 h, remains a matter of debate. There is no sufficient evidence from randomized controlled trials, that maintenance tocolysis is able to prolong pregnancy significantly and to reduce severe neonatal morbidity and mortality. Hence, it is not recommended in current guidelines. On the contrary, maintenance tocolysis is commonly used in clinical practice and subject of current clinical-scientific investigations. TOCOLYTICS FOR MAINTENANCE TREATMENT None of the conventional tocolytics (beta-sympathomimetics, calcium-channel blockers, magnesium, cyclooxygenase inhibitors, and oxytocin receptor antagonists) have proven to be appropriate for maintenance treatment. Progesterone and 17-α-hydroxyprogesterone caproate have shown promising results in low-quality randomized trials, but not in high-quality studies. DISCUSSION Basically, the value of studies regarding maintenance tocolysis is limited by a considerable heterogeneity, its mostly low quality, significant differences in methodology as well as the inadequate statistical power due to the small number of women studied. So far, maintenance tocolysis is a case-by-case decision outweighing the benefits and harms of tocolytic treatment.
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Affiliation(s)
- Patrick Stelzl
- Frauenklinik, Universitätsklinikum Erlangen, Universitätsstrasse 21-23, 91054, Erlangen, Germany.
| | - Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Universitätsstrasse 21-23, 91054, Erlangen, Germany
| | - Werner Rath
- Medizinische Fakultät Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Dehaene I, Bergman L, Turtiainen P, Ridout A, Mol BW, Lorthe E. Maintaining and repeating tocolysis: A reflection on evidence. Semin Perinatol 2017; 41:468-476. [PMID: 28943054 DOI: 10.1053/j.semperi.2017.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
It is inherent to human logic that both doctors and patients want to suppress uterine contractions when a woman presents in threatened preterm labor. Tocolysis is widely applied in women with threatened preterm labor with a variety of drugs. According to literature, tocolysis is indicated to enable transfer to a tertiary center as well as to ensure the administration of corticosteroids for fetal maturation. There is international discrepancy in the content and the implementation of guidelines on preterm labor. Tocolysis is often maintained or repeated. Nevertheless, the benefit of prolonging pregnancy has not yet been proven, and it is not impossible that prolongation of the pregnancy in a potential hostile environment could harm the fetus. Here we reflect on the use of tocolysis, focusing on maintenance and repeated tocolysis, and compare international guidelines and practices to available evidence. Finally, we propose strategies to improve the evaluation and use of tocolytics, with potential implications for future research.
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Affiliation(s)
- Isabelle Dehaene
- Department of Gynecology and Obstetrics, UZ Gent, De Pintelaan 185, 9000 Ghent University, Ghent, Belgium.
| | - Lina Bergman
- Department for Women and Children's Health, Uppsala University, Uppsala, Sweden; Center for Clinical Research, Falun, Sweden
| | - Paula Turtiainen
- Department of Gynecology and Obstetrics, Tampere University Hospital, Tampere, Finland
| | | | - Ben Willem Mol
- Department of Obstetrics and Gynecology, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Elsa Lorthe
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM, Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
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Practice patterns in the management of threatened preterm labor in Korea: A multicenter retrospective study. Obstet Gynecol Sci 2015; 58:203-9. [PMID: 26023669 PMCID: PMC4444516 DOI: 10.5468/ogs.2015.58.3.203] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/07/2015] [Accepted: 04/08/2015] [Indexed: 11/17/2022] Open
Abstract
Objective This study aimed to examine clinical practice patterns in the management of pregnant women admitted with threatened preterm labor (TPL) in Korea. Methods Data from women admitted with a diagnosis of TPL were collected from 22 hospitals. TPL was defined as regular uterine contractions with or without other symptoms such as pelvic pressure, backache, increased vaginal discharge, menstrual-like cramps, bleeding/show and cervical changes. Data on general patient information, clinical characteristics at admission, use of tocolytics, antibiotics, and corticosteroids, and pregnancy outcomes were collected using an online data collections system. Results A total of 947 women with TPL were enrolled. First-line tocolysis was administered to 822 (86.8%) patients. As a first-line tocolysis, beta-agonists were used most frequently (510/822, 62.0%), followed by magnesium sulfate (183/822, 22.3%), calcium channel blockers (91/822, 11.1%), and atosiban (38/822, 4.6%). Of the 822 women with first-line tocolysis, second-line tocolysis were required in 364 (44.3%). Of 364 with second-line, 199 had third-line tocolysis (37.4%). Antibiotics were administered to 29.9% of patients (284/947) with single (215, 22.7%), dual (26, 2.7%), and triple combinations (43, 4.5%). Corticosteroids were administered to 420 (44.4%) patients. Betamethasone was administered to 298 patients (71.0%), and dexamethasone was administered to 122 patients (29.0%). Conclusion Practice patterns in the management of TPL in Korea were quite various. It is needed to develop standardized practice guidelines for TPL management.
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Utilisation des inhibiteurs des canaux calciques (ICC) en tocolyse en France et à l’étranger. ACTA ACUST UNITED AC 2015; 44:312-23. [DOI: 10.1016/j.jgyn.2014.12.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 12/02/2014] [Indexed: 11/22/2022]
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Faut-il craindre les fermetures et fusions de maternités en France ? ACTA ACUST UNITED AC 2013; 42:407-9. [DOI: 10.1016/j.jgyn.2013.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Accepted: 06/25/2013] [Indexed: 11/22/2022]
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Carrez S, Sibiude J. [Maintenance tocolysis with nifedipine]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2013; 41:465-466. [PMID: 23890715 DOI: 10.1016/j.gyobfe.2013.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 05/21/2013] [Indexed: 06/02/2023]
Affiliation(s)
- S Carrez
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, Colombes, France
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