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Acute Tocolysis in Labour ‘Tocolysis’ – ‘Emergency uterine relaxation’. S.Arulkumaran Professor & Head Division of Obstetrics & Gynaecology St.George’s Hospital Medical School University of London. Tocolysis - Indications. Acute fetal distress/ especially with uterine hypertonus

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acute tocolysis in labour tocolysis emergency uterine relaxation

Acute Tocolysis in Labour‘Tocolysis’ – ‘Emergency uterine relaxation’

S.Arulkumaran

Professor & Head

Division of Obstetrics & Gynaecology

St.George’s Hospital Medical School

University of London

tocolysis indications
Tocolysis - Indications
  • Acute fetal distress/ especially with uterine hypertonus
  • Cord prolapse
  • Fetal entrapment during delivery

- Transverse lie at time of CS – esp. preterm, dorso-inferior, prolonged ROM, advanced labour

After coming head of pre-term breech at CS

slide3
Conversion of category 1 to 2The ‘Category 1’ Caesarean SectionRisk management and intrauterine resuscitation
  • To reduce the risk to the mother –GA to regional
  • To improve the condition of the fetus even without uterine hyperstimulation
  • Problem with getting a busy obstetrician/anaesthetist – 2’nd obstetrician or anaesthetist
  • Difficulty in getting the second theatre
tocolysis indications4
Tocolysis - Indications
  • External cephalic version
  • Delivery of second twin – for external cephalic or internal podalic version
  • Cephalic replacement and CS in shoulder dystocia (Zavanelli manoeuvre)
  • Retained but separated placenta
  • Manual replacement of uterine inversion
emergency uterine relaxation
Emergency uterine relaxation
  • Need for short lived profound relaxation
  • GA and halogenated agents
  • GA and it’s potential complications
  • Halothane – action unpredictable, not the desired effect, reversal unpredictable> PPH, Halothane toxicity
  • Amyl nitrite – highly volatile, flammable liquid administered by inhalation; action inadequate?
  • More CS done under regional block – use tocolytics that can be used under regional block
nitroglycerin
Nitroglycerin
  • Sublingual or Intravenous
  • Sublingual aerosol spray 400 ug – absorption and action not predictable
  • Intravenous – More predictable response
  • Nitroglycerine 5 mg in 1 ml vial – diluted in 100 ml saline – 50 ug/ml – 20 ml syringe
  • Initial dose 200 ug – repeat at 1-2 min intervals till desired effect
  • Desired effect in 90 secs – lasts for 1-2 mins – rapid degradation in 1-3 mins
  • 100 ug doses in third stage – Must correct hypotension/ hypovolaemia before its use
nitroglycerin ester of nitric acid
Nitroglycerin – ester of nitric acid
  • Rapidly metabolised by the liver – half life 2 - 2.5 mins
  • Molecular weight 227 – crosses the placenta – no adverse fetal or neonatal effects
  • Maternal hypotension – peripheral vasodilatation and reduced venous tone
  • Vasodilatation reversed by ephedrine
  • Uterine relaxation reversed by oxytocics
  • ‘Contraindications’ - hypovolaemia / hypotension
beta adrenergics
Beta adrenergics
  • Preferred drug for uterine hypertonus/ FHR changes
  • Discontinue oxytocin infusion/ remove PG (propace) – Variable absorption of PG
  • Ritodrine 6 mg in 10 ml saline - 2-3 mins
  • Terbutaline 0.25 mg (1/2 vial) in 5ml saline IV over 5 mins (0.25 mg SC – NICE)
  • Improves FHR – labour can continue & NVD, even if delivery by CS –baby in better condition
  • Useful – if delay in getting OT/ Obstetrician/ Anaesthetist
slide9
Single injection of terbutaline in term labour –1. Effect on fetal pH in cases with prolonged bradycardia

33 – prolonged bradycardia FHR<100bpm > 3 min or < 80 bpm > 2min

Stopped oxytocin, nursed on the side, O2

If no recovery by 4 min > terbutaline 0.25 mg IV > scalp pH within 40 min ; if pH <7.24 repeat scalp pH within 40 min

If abdominal delivery needed within a short time – 1 to 2 mg propranolol IV after del.

Ingemarsson I, Arulkumaran S et al Am J O&G 1985

possible events related to the episode of prolonged bradycardia
Possible events related to the episode of prolonged bradycardia
  • Abnormal uterine activity

Spontaneous 7; Induced 6; VE 1; IUP 1

  • Abruptio placentae 2
  • Cord prolapse 2
  • Epidural top up 1
  • Ominous FHR &/ or meconium 4
  • Unknown 9
single injection of terbutaline i effect on fetal ph with prolonged bradycardia
Single injection of terbutaline - I. Effect on fetal pH with prolonged bradycardia
  • Fetal acidosis was more common if the rate was < 80 bpm –particularly if the BLV was <3 for > 4 min
  • FHR improved in 30 cases: 23 had vaginal delivery – newborns in good condition
  • Terbutaline is a temporary measure –whilst waiting for FHR to recover – prepare for CS

Ingemarsson I, Arulkumaran S, Ratnam SS. Am J O&G. 1985;153:859

prolonged bradycardia 80bpm for 3 min
Prolonged Bradycardia (<80bpm for > 3 min)
  • 3 – 6 – 9 – 12 – 15 min ‘rule’ – Immediate CS
  • Exclude abruption, cord prolapse, scar rupture – 3 min – decision
  • Examine the clinical situation – IUGR, TMS with scanty fluid, IU infection, Post term & oligohydramnios, bleeding – 6min
  • Check FHR prior to bradycardia – suspicious or abnormal – 6 min
  • Low risk – No recovery by 9 min > decision for CS > To OT by 12 min > Delivery by 15 min
  • In OT – Check FHR – if recovered – review clinical situation and decide
slide17
Do not do a FBS with prolonged bradycardia
  • Review CTG & clinical situation carefully
  • Audit cases of immediate CS – compromises the mother – baby’s condition may be improved with tocolysis
single injection of terbutaline in term labor ii effect on uterine activity
Single injection of terbutaline in term labor. II. Effect on uterine activity
  • Compared decrease in uterine activity for 60 min
  • a) stopped oxytocin (no terbutaline)– uterine activity reduced by 50 % in 45 mins
  • b) stopped oxytocin and gave bolus dose of terbutaline – ‘reduced’ uterine activity by 75% in 15 min & remained so for 45 mins (mean)
  • Spontaneous labour 85% reduction in 15 min & took 45 min to recover to 50% of pre-existing uterine activity
  • Ingemarsson I, Arulkumaran S, Ratnam SS. Am J O&G 1985; 153:865
slide24
Can terbutaline be used as a nebuliser instead of intravenous injection for inhibition of uterine activity?

Group A – 1 mg (4 puffs via an air chamber)

Group B – 2 mg (8 puffs via an air chamber)

Group C – 0.25 mg IV

Uterine activity, maternal & fetal parameters

Kurup A, Arulkumaran S, Tay D et.al. Gynecol Obstet invest.1991;32:84

can terbutaline be used as a nebuliser instead of iv for inhibition of uterine activity
Can terbutaline be used as a nebuliser instead of IV for inhibition of uterine activity?
  • Although convenient to use – 1 or 2mg doses did not reduce the uterine activity
  • 0.25 mg IV significantly reduced the uterine activity
  • Maternal parameters – significant rise in pulse rate, slight change in BP (50% had palpitations) with IV use
  • There was no significant alteration in FHR or it’s pattern

Kurup A, Arulkumaran S, Tay D et.al. Gynecol Obstet Invest 1991;32:84

oxytocics reverse the tocolytic effect of gtn on the human uterus
Oxytocics reverse the tocolytic effect of GTN on the human uterus
  • GTN reduced the amplitude & frequency in a concentrations specific manner
  • The concentration for complete inhibition varied from 44 – 705 uM/ml
  • In the presence of GTN the decreased contractions were reversed to the untreated (GTN) or higher level of uterine activity by oxytocin 20mU/ml; ergometrine 6.15uM & PG F2a 6.15 uM)
  • Lau LC, Adaikan PG, Arulkumaran S et.al. Br J Obstet & Gynecol.2001;108:164
acute tocolysis
Acute tocolysis
  • Useful in obstetric emergencies
  • Has contraindications – e.g.Severe cardiac disease, Haemorrhage, Hypotension – because of vasodilator effect and tachycardia
  • Reversal needed in some situations
  • Further studies needed on drugs that act specifically on the uterus (e.g. Atosiban) – with little cardiovascular side effects
atosiban tractocile oxytocin antagonist
Atosiban – TractocileOxytocin antagonist
  • Atosiban acetate 7.5 mg/ml (£20/=)
  • Dose – 6.75 mg IV over 1 min – followed by 300 ug/ min IV infusion
  • 18 mg/ hr over 3 hours
  • 100 ml saline bag – withdraw 10 ml saline & replace with 10 ml atosiban (7.5mg/ml) – 750 ug/ml
  • Nausea, vomiting, tachycardia, hypotension, dizziness, hot flushes, hyperglycaemia !!
clinical safety maternal i

Atosiban(n=361)

Beta-agonists(n=372)

Clinical safety: maternal I

75

30

25

% Incidence

20

*this single patient

case occurred

after switch to

beta-agonist therapy

15

10

5

*

0

œdema

Hyper-

kalaemia

Hypo-

glycaemia

ischaemia

Dyspnœa

Palpitation

Chest pain

Pulmonary

Myocardial

Tachycardia

clinical safety maternal ii

Atosibann=361

Beta-agonistsn=372

Clinical safety: maternal II

25

20

15

% Incidence

10

5

0

Tremor

Nausea

Vomiting

Headache

Hypotension

Hypertension

clinical safety fetal

Atosiban(n=361)

Beta-agonists(n=372)

Clinical safety: fetal

30

25

20

% Incidence

15

10

5

0

distress

Hypoxia

Fetal

Asphyxia

Fetaldeath

Bradycardia

Tachycardia

clinical safety neonatal

Atosiban(n=406)

Beta-agonists(n=432)

Clinical safety: neonatal

20

18

16

14

12

% Incidence

10

8

6

4

2

0

RDS

Apnœa

Arrhythmia

Bradycardia

Hypotension

Cerebral

haemorrhage

acute tocolysis recommended reading
Acute tocolysis – Recommended reading
  • Ingemarsson I, Arulkumaran S, Ratnam SS. Single injection of terbutaline in term labour. I. Effect of fetal pH on cases with prolonged bradycardia. Am J Obstet Gynecol. 1985;153:859-865.
  • Ingemarsson I, Arulkumaran S, Ratnam SS. Single injection of terbutaline in term labour. II. Effect on uterine activity. Am J Obstet Gynecol. 1985;153:866-891.
  • Kurup A. Chua S, Arulkumaran S. Terbutaline used as a nebuliser does not cause relaxation of uterine activity. Asia & Oceania J Obstet Gynaecol. 1991;
  • Lau LC, Adaikan PG, Arulkumaran S, Ng SC. Oxytocics reverse the tocolytic effect of glyceryl trinitrate on the human uterus. Br J Obstet Gynaecol 2001;108:164-168.
  • Andersson I, Ingemarsson I, Persson CGA. Effects of terbutaline on human uterine motility at term. Acta Obstet Gynecol Scand 1974;53:1-8.
acute tocolysis recommended reading42
Acute tocolysis - Recommended Reading
  • Desimone CA…..Intravenous nitroglycerin aids manual extraction of a retained placenta. Anaesthesiology 1990;73:787
  • Mayer DC …. Antepartum uterine relaxation with nitroglycerin at caesarean delivery. Can J Anaesth 1992;39:166
  • Mercier FJ …… Intravenous nitroglycerin to relieve intrapartum fetal distress related to uterine hyperactivity: a prospective observational study. Anesth Analg 1997;84:1117
  • Redick LF & Livingston EA. A new preparation of nitroglycerin for uterine relaxation. Int J Obstet Anesth 1995;4:14
  • Riley ET …. Intravenous nitroglycerin: A potent uterine relaxant for emergency obstetric procedures. Review of literature and report of three cases. Int J Obstet Anesth 1996;5:264