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Nitroglyerine ProtocolFrom: freda seddon (fseddon@interlog.com)Wed Nov 29 21:56:38 2000
Due to the overwhelming demand, I decided to have the protocol typed for provision to the list. I will send it as a word document to those individual who emailed me privately. I work on a Mac, so no virus problems, the file will be saved for Windows- to save non-Mac users from extra work. Mac users will have not problems as Dr. Joe will tell you) But here is the protocol in the body of the email. Please do not rely on this without reviewing the references and making appropriate changes relevant to your practice, hospital resources and clientele. The Scarborough Hospital, Grace Division Maternal Newborn Department Policy - DRAFT Date: 00/06/14, Approved Drugs & Therapeutics Committee: 00/9/18 Nitroglycerine as a Tocolytic Agent for Increased Uterine Activity in Preterm Labour Recent studies suggest that Nitroglycerine may be effective as a tocolytic agent in the prolongation of pregnancy with minimal maternal/fetal side effects. Results of an International Multicenter Randomised Study indicated there was no overall difference between nitroglycerine administered as a patch and Ritodrine IV in the acute tocolysis of preterm labour. However, results suggest an advantage of nitroglycerine over Ritodrine in reducing preterm delivery rate. The maternal side effect profile and treatment discontinuation rates were fewer for the nitroglycerine group suggesting it was a safer alternative to Ritodrine. , , Indications: Nitroglycerine patches can be used for any increase in uterine activity including preterm labour, post-procedural, uterine contractions, and cervical incompetence/hour-glassing membranes. The goal of treatment with nitroglycerine is to reduce neonatal morbidity and mortality by delaying delivery until 34 weeks of pregnancy, or for 48 hours to allow for the maternal administration of corticosteroids to improve maturation of the fetus. Dosage: The standard dose is nitroglycerine 0.4 mg/hr patch with the possible addition of a second patch after 30-60 minutes if there is no reduction in contraction frequency or strength. After 24 hours, the patch(es) should be removed. A new patch(es) is applied for a further 24 hours. After 48 hours of treatment, to avoid tachyphylaxis, the nitroglycerine patch should be changed to 16 hours per day (left on from 1800h to 1000h). This may be continued for as long as the physician orders. Administration: The patch should be placed on a site out of the way of Doppler fetal monitors eg. Patch should be applied to the arm, thigh or back. Contraindications: Nitroglycerine should be used with caution with patients with hypotension and cardiovascular conditions. Nitroglycerine should not be used when there are significant fetal heart rate changes. Adverse Effects: Major side effects have not been reported but should be observed and documented. The most common side effects are headaches (30% in one study), which can usually be treated with acetaminophin. Possible more serious adverse effects include maternal hypotension, tachycardia, or significant fetal heart rate changes. In this situation, the patch should be removed and the physician notified. Maternal hypotension and fetal heart rate changes are treated with IV fluids. Minor side effects include flushed sensation or local skin irritation with the patch. Patient Care: ® Ensure patient has patent IV and has received 1000ml of Ringers Lactate or Normal Saline prior to application of the nitroglycerine patch. ® Initiate continuous electronic fetal monitoring (EFM) ® Obtain baseline BP, Maternal pulse and respirations. ® Immediately following application, monitor BP Q10 minutes over 1 hour, then every 4 hours (or as ordered by physician) ® If contractions continue, or there are cervical changes after 30-60 minutes following the application of the first patch, a second patch (in addition to the first patch) may be ordered by the physician. ® Contractions and fetal heart rate (FHR) should be continuously monitored by EFM until contractions have subsided. ® The FHR should be assessed at least every 4 hours (or as ordered by physician) once EFM has been discontinued. ® After 24 hours the patch(es) should be removed. A new patch is applied for a further 24 hours. ® Observe for side effects such as headaches, a flushed sensation or local skin irritation at the site of the patch. acetaminophin is usually effective in the treatment of headache. Supplied: Nitroglycerine transdermal patch is available as 0.2mg/hr, 0.4 mg/hr, 0.6 mg/hr and 8mg/hr patches. References 1. Mount Sinai Hospital, Study Protocol, Toronto, Ontario, Canada 2. Lees, CC et al, Glyceryl Trinitrate and Ritodrine in Tocolysis: An International Multicenter Randomised Study, Obstetrics & Gynaecology 1999:94(3);403-408. 3.Lees, C. et al., Arrest of preterm labour and prolongation of gestation with glyceryl trinitrate, a nitric oxide donor. The Lancet 1994;343;1325. 4. Bisits, A, et al., Corticotropin-Releasing Hormone: A biochemical predictor of preterm delivery in a pilot randomised trial of the treatment of preterm labour. Am. J. Obstet Gynecol 1998; 178(4);862-866
-- Freda Seddon, RN, RM Community Midwife Midwifery Care Scarborough 2680 Lawrence Ave. East, Suite 211 Toronto, Ontario M1P 4Y4 (416) 757-4848 fax 757-1562
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