The threat of premature labor (accouchement) and tocolysis
Extreme prematurity, defined by a gestational age strictly less than 33 weeks. The threat of premature birth occurs between 22 and 36 weeks of amenorrhea (SA), the prognosis of prematurity is committed and the risk of respiratory and neurological complications is possible.
If the definition of preterm birth raises no ambiguity, that of preterm labor (accouchement) is more complex, the latter is usually defined by the occurrence of painful uterine contractions, persistent, near, accompanying a change in the neck, the result In the absence of medical intervention, is a premature birth.
40 to 50% of women with these signs have been treated with a placebo in randomized studies, they have not given birth in the week following the onset of symptoms.
To treat preterm labor (accouchement) is associated tocolytic therapy, rest, steroids, treatment of any aggravating factor or infectious trigger and a simple adjuvant therapy. Pregnancy is prolonged by most tocolytics, they reduce the proportion of births to 24 hours, 48 hours a week. But the effect of these treatments remain unproven on the neonatal prognosis.
In case of genital bleeding associated with a moderate placenta previa or infection without maternal chorioamnionitis, tocolysis may be considered. The way to delay preterm delivery is inhibition of uterine contractions by tocolysis, whatever the stage of pregnancy. To achieve this goal, we can use in current clinical practice several tocolytic agents such as: antagonists of oxytocin, the betamimetics and calcium channel blockers. Must be considered in the choice of tocolytic indications, cons, indications, side effects, especially cardiovascular and economic constraints. It is important to know that the duration of treatment is limited by the medical literature to 48 hours.
Symptomatic treatment of uterine contraction is tocolytic therapy. It is used during the threat of premature birth, by which we try to delay preterm labor and improve morbidity and mortality, so the neonatal prognosis.
Allow the maintenance of pregnancy to an end when the morbidity and mortality related to the age of birth are acceptable with minimal side effects for both mother and child is the ideal outcome of treatment the threat of premature delivery.
Delaying preterm delivery to allow one hand the administration to the mother of a full course of corticosteroids, and secondly, to organize a TIU in a maternity hospital that provide care tailored to the status of newborn The second is a realistic aim and more realistic goal. If the treatment meets the following requirements: speed of action, the absence of a general-cons or obstetric minimal side effects and effectiveness that can delay the delivery of at least two days, we can achieve these two objectives in perfect conditions.
To define the threat of premature delivery, uterine contraction is a symptom that lack of specificity and sensitivity. The etiologies of preterm labor are varied and specific treatment is required for certain causes. So the risk of including wrongly patients who show no real threat of delivery is possible. To determine an upper or lower limit of gestational age to establish a tocolysis until now there is no objective argument.
Between 34 and 36 weeks, is the upper limit, it estimates the benefits expected from neonatal tocolysis based on reception conditions of the newborn and maternal side effects and risks of treatments used. After a prescribed effective tocolysis for 48 hours, there is no argument for prescribing maintenance therapy or study that provides evidence of the efficacy of the combination of tocolytics in relation to the use of monotherapy . You should know that the tocolytic treatment combinations may potentiate the side effects of drugs
The cons-indications to tocolytic therapy are:
-The chorioamnionitis, but treatment can be discussed in case of another infectious disease, such as urinary tract infections.
-The bleeding of undetermined origin and abundant
By-cons, in case of placenta previa, bleeding is most often associated uterine activity and delivery can be delayed by tocolysis without increased bleeding risk.
If disease-Kindergarten cons of whether the continuation of pregnancy is marked by a pathology cons mother as uncontrolled hypertension, thyrotoxicosis, severe maternal heart disease, cholestasis of pregnancy, preeclampsia eclampsia, HELLP syndrome. In cases of severe fetal disease scalable, we discuss each case the absence of tocolysis and the termination of pregnancy.
In the international literature betamimetics two were studied: ritodrine and salbutamol. In France, Prime no longer marketed in this indication only salbutamol is authorized placing on the market (AMM). The intravenous route is the only one that has proven its effectiveness.
Also used as tocolytics outside any MA calcium channel blockers. In obstetrics, nifedipine is the molecule most studied of which the MA is the treatment of hypertension. Several randomized trials have proven effective tocolytic, the results are in favor of a much higher tolerance and efficacy comparable to betamimetics.
The synthetic analogs that act as antagonists by competing for receptors are "antagonist of oxytocin. In case of MAP, atosiban was granted marketing authorization for tocolysis in France. In more than 700 patients, the efficacy of atosiban was similar to that of betamimetics on the rate of prolongation of pregnancy within 48 hours in a large multicenter international comparison. However, side effects such as tremor and cardiovascular effects (tachycardia, palpitation, dyspnea), resulting in many interruptions in treatment are more frequent with betamimetics.
In case of intravenous tocolysis, tocolytic of choice, influencing the choice of the vector. In a parturient transferred to preterm labor, especially in case of twin pregnancy, atosiban should be chosen for tocolysis because of the absence of cardiovascular effects observed with this tocolytic, which enables a transport non-medical.
In establishing the applicant's TIU benefit / cost ratio is very positive, so the use of atosiban generates extra costs being largely offset by savings made on transport MUG, which is much more expensive than transport paramdicalise or ambulance simple. The brake on the development of this type of transport is the lack of pricing by the paramedical health insurance. However, solving this problem is needed soon to reduce the number of requests for TIU medicalized preterm labor received by the ambulance about 50%.
If the definition of preterm birth raises no ambiguity, that of preterm labor (accouchement) is more complex, the latter is usually defined by the occurrence of painful uterine contractions, persistent, near, accompanying a change in the neck, the result In the absence of medical intervention, is a premature birth.
40 to 50% of women with these signs have been treated with a placebo in randomized studies, they have not given birth in the week following the onset of symptoms.
To treat preterm labor (accouchement) is associated tocolytic therapy, rest, steroids, treatment of any aggravating factor or infectious trigger and a simple adjuvant therapy. Pregnancy is prolonged by most tocolytics, they reduce the proportion of births to 24 hours, 48 hours a week. But the effect of these treatments remain unproven on the neonatal prognosis.
In case of genital bleeding associated with a moderate placenta previa or infection without maternal chorioamnionitis, tocolysis may be considered. The way to delay preterm delivery is inhibition of uterine contractions by tocolysis, whatever the stage of pregnancy. To achieve this goal, we can use in current clinical practice several tocolytic agents such as: antagonists of oxytocin, the betamimetics and calcium channel blockers. Must be considered in the choice of tocolytic indications, cons, indications, side effects, especially cardiovascular and economic constraints. It is important to know that the duration of treatment is limited by the medical literature to 48 hours.
Symptomatic treatment of uterine contraction is tocolytic therapy. It is used during the threat of premature birth, by which we try to delay preterm labor and improve morbidity and mortality, so the neonatal prognosis.
Allow the maintenance of pregnancy to an end when the morbidity and mortality related to the age of birth are acceptable with minimal side effects for both mother and child is the ideal outcome of treatment the threat of premature delivery.
Delaying preterm delivery to allow one hand the administration to the mother of a full course of corticosteroids, and secondly, to organize a TIU in a maternity hospital that provide care tailored to the status of newborn The second is a realistic aim and more realistic goal. If the treatment meets the following requirements: speed of action, the absence of a general-cons or obstetric minimal side effects and effectiveness that can delay the delivery of at least two days, we can achieve these two objectives in perfect conditions.
To define the threat of premature delivery, uterine contraction is a symptom that lack of specificity and sensitivity. The etiologies of preterm labor are varied and specific treatment is required for certain causes. So the risk of including wrongly patients who show no real threat of delivery is possible. To determine an upper or lower limit of gestational age to establish a tocolysis until now there is no objective argument.
Between 34 and 36 weeks, is the upper limit, it estimates the benefits expected from neonatal tocolysis based on reception conditions of the newborn and maternal side effects and risks of treatments used. After a prescribed effective tocolysis for 48 hours, there is no argument for prescribing maintenance therapy or study that provides evidence of the efficacy of the combination of tocolytics in relation to the use of monotherapy . You should know that the tocolytic treatment combinations may potentiate the side effects of drugs
The cons-indications to tocolytic therapy are:
-The chorioamnionitis, but treatment can be discussed in case of another infectious disease, such as urinary tract infections.
-The bleeding of undetermined origin and abundant
By-cons, in case of placenta previa, bleeding is most often associated uterine activity and delivery can be delayed by tocolysis without increased bleeding risk.
If disease-Kindergarten cons of whether the continuation of pregnancy is marked by a pathology cons mother as uncontrolled hypertension, thyrotoxicosis, severe maternal heart disease, cholestasis of pregnancy, preeclampsia eclampsia, HELLP syndrome. In cases of severe fetal disease scalable, we discuss each case the absence of tocolysis and the termination of pregnancy.
In the international literature betamimetics two were studied: ritodrine and salbutamol. In France, Prime no longer marketed in this indication only salbutamol is authorized placing on the market (AMM). The intravenous route is the only one that has proven its effectiveness.
Also used as tocolytics outside any MA calcium channel blockers. In obstetrics, nifedipine is the molecule most studied of which the MA is the treatment of hypertension. Several randomized trials have proven effective tocolytic, the results are in favor of a much higher tolerance and efficacy comparable to betamimetics.
The synthetic analogs that act as antagonists by competing for receptors are "antagonist of oxytocin. In case of MAP, atosiban was granted marketing authorization for tocolysis in France. In more than 700 patients, the efficacy of atosiban was similar to that of betamimetics on the rate of prolongation of pregnancy within 48 hours in a large multicenter international comparison. However, side effects such as tremor and cardiovascular effects (tachycardia, palpitation, dyspnea), resulting in many interruptions in treatment are more frequent with betamimetics.
In case of intravenous tocolysis, tocolytic of choice, influencing the choice of the vector. In a parturient transferred to preterm labor, especially in case of twin pregnancy, atosiban should be chosen for tocolysis because of the absence of cardiovascular effects observed with this tocolytic, which enables a transport non-medical.
In establishing the applicant's TIU benefit / cost ratio is very positive, so the use of atosiban generates extra costs being largely offset by savings made on transport MUG, which is much more expensive than transport paramdicalise or ambulance simple. The brake on the development of this type of transport is the lack of pricing by the paramedical health insurance. However, solving this problem is needed soon to reduce the number of requests for TIU medicalized preterm labor received by the ambulance about 50%.
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