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Re: I have a need for help!!!From: dahmd@gate.netMon May 20 15:28:31 1996
In article ibernste@moose.uvm.edu (Ira Mark Bernstein) writes:
>I believe it is important to be specific about what beta mimetics have been
>1. Ingemarssen AJOG 1976 125:520 IRA: I would agree that tocolytic agents are often useful for diminishing the frequency and intensity of contractions, and as such might benefit the patient we are discussing. They may also help obtain 48 hours for steroids to "kick in", and are also useful for resuscitation of fetal distress following tetanic contractions. However, I'm not so sure that many of the studies done in this area really show a benefit from *oral* tocolytics. Brown and Tejani (Obstet Gynecol 1981;57;22) used ethanol for tocolysis then randomized 46 patients to either oral terbutaline or placebo. While they showed an increase in birth weight and time gained before delivery, they used regular contractions, and not cervical change, as a criteria for "preterm labor." Creasy et al (AJOG 1980:137;212) also randomized 55 patients with oral ritodrine or placebo, and "only" noted the significant finding of increased preterm labor episodes in the placebo group (2.7 vs 1.1) but did not find a difference in weight, number of days gained, age at delivery, or RDS. Again, it is not clear from their paper if they used cervical change, or simply regular contractions, to define preterm labor. I have a problem with studies of preterm labor not using cervical change to define the condition. Parilla et al (AJOG 1993;169:965-9) performed a prospective, randomized study of 55 patients between 28-35 weeks with *documented cervical change* who received tocolysis with MgSO4, then were randomized to either oral terbutaline or placebo. There were no differences noted for age at delivery, recurrent preterm labor, regular contractions, birth weight, or RDS. Finally, Macones et al (Obstet Gynecol 1995;85:313-7) did a meta-analysis of oral beta-agonist therapy and included 4 of the 6 trials identified, and concluded that "the available data do not support a role for beta-agonist maintenance therapy after resolution of an acute episode of preterm labor in reducing the incidence of preterm delivery, increasing the interval to delivery, or reducing the incidence of recurrent preterm labor." Like many therapies in Ob/Gyn, there are controversies with oral tocolytics. The studies contain small numbers, and some studies seem to have design problems. My main concern with using a treatment that has (apparently) negligible benefit is that in a number of cases the risks will outweigh the benefits. For example, I just can't justify having an A1 diabetict on oral beta-mimetics who now requires insulin due to glucose intolerance, with the additional risk to both the patient and her baby of hypoglycemia, etc. Thanks, Ashley D. Ashley Hill, M.D. dahmd@gate.net
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