The use of tocolytic therapy in a pregnant trauma patient

Date First Published:
June 9, 2008
Last Updated:
March 11, 2009
Report by:
Helene Svinos, Medical Student (University of Manchester)
Search checked by:
Anna O' Malley, University of Manchester
Three-Part Question:
In a [pregnant trauma patient] does [tocolytic therapy] improve [outcome for mother and foetus]?
Clinical Scenario:
A pregnant woman of 32 weeks gestation is admitted to the ED after a fall. She has blunt abdominal trauma and is having what seem to be uterine contractions. You wonder whether you start tocolytic therapy to try to prevent or delay a premature delivery and so prevent some of the possible complications for both mother and baby.
Search Strategy:
Medline 1950 to November week 1 2008 using Ovid Interface
EMBASE 1980-2008 Week 1
The Cochrane Library
Search Details:
[{exp pregnancy/ OR pregnancy.mp.} AND {exp “Wounds and Injuries”/ OR trauma.mp.} AND {exp tocolysis/ tocolysis.mp.}] LIMIT to human and English Language
Outcome:
20 papers were found of which 3 were relevant. One additional paper was found from the references.
Three Cochrane Reviews provided useful background information on tocolytic agents.
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Betamimetics for inhibiting preterm labour. Anotayanonth S, Subhedar NV, Neilson JP, Harigopal S.
Evaluation of blunt abdominal trauma in the third trimester of pregnancy: Maternal and fetal considerations. Williams JK, McClain L, Rosemurgy AS, Colorado NM. 1990 USA 84 patients with major abdominal trauma in the third trimester admitted for observation Jan 1985 - June 1987. 17 patients went into premature labor and were given tocolytic therapy. Retrospective review Effectiveness of tocolysis 14 of the 17 patients delivered at term. Of the 3 preterm deliveries, 1 failed tocolysis, 1 had an elective caesarian after successful tocolysis, 1 was discharged after successful tocolysis but returned later. No uniform tocolysis protocol. Five patients responded to just one dose of sc terbutaline (were they really in premature labor?). Eight patients were given magnesium sulphate iv and 4 were given ritodrine hydrochloride iv.
Pregnancy outcome and foetomaternal hemorrhage after noncatastrophic trauma. Goodwin TM, Breen MT. 1990 USA 205 pregnant women at >18 weeks' gestation with noncatastrophic trauma over an 18 month period from Jan 87 – Sep 88. 10 patients with premature labour were given tocolytic therapy. Cohort study Response to tocolytic therapy All responded initially, although three were delivered within 10 hours of trauma for premature separation of the placenta. The others had premature deliveries but 2 - 7 weeks later. Small study of patients in premature labour after trauma.
No information as to type of tocolytic drug.
Is adverse pregnancy outcome predictable after blunt abdominal trauma? Pak LL, Reece EA, Chan L 1998 USA 85 85 pregnant women with noncatatsophic blunt abdominal trauma assessed and monitored July 1994 - August 1997. Prospective cohort study Factors associated with preterm delivery Tocolysis with magnesium sulphate in 31% preterm group v 7% in term group. No differences in the groups with respect to gestational age, length of hospital stay, abdominal pain, abdominal tenderness, pattern of uterine contractions. Magnesium sulphate used as tocolytic to avoid the tachycardia associated with betamimetics.
Peripartum complications 46.2% in preterm group v 12.5% in term group (P<0.05)
Primary repair of a cornual rupture occurring at 21 weeks gestation and successful pregnancy outcome. Wang PH, Chao HT, Too LL, Yuan CC. 1999 Taiwan Patient 31 yrs old 21 weeks pregnant Case report Patient was administered tocolytic agent after repair of a cornual rupture. Premature labour did not commence until 33 weeks gestation and a healthy baby was delivered Only one case and one tocolytic agent (ritodrine hydrochloride, a betamimetic).
Author Commentary:
Uterine contractions are the most common problem associated with blunt abdominal trauma in pregnancy.
Although there is evidence for the use of betamimetics (Anotayanonth et al. 2004) and calcium channel blockers (King et al. 2003) to suppress uterine contractions (tocolysis) and so delay premature birth and improve foetal outcomes, the use of tocolytic drugs in cases of trauma is controversial.
The cases reported suggest that tocolytic may be useful. Which agent to use is unclear. It has been argued that betamimetics should be avoided in trauma patients as they will interfere with the response to hypovolaemia. The study by Pak et al (1998) and a Cochrane Review have suggested that magnesium sulphate is ineffective at delaying birth and is associated with increased peripartum complications and infant mortality (Crowther et al. 2002).
Bottom Line:
There is not enough evidence to support the early use of tocolytics in trauma pregnant patients.
The decision to use them should be made by the obstetrician managing the patient.
References:
  1. Anotayanonth S, Subhedar NV, Neilson JP, Harigopal S. . Betamimetics for inhibiting preterm labour.
  2. King JF, Flenady VJ, Paptsonis DNM, Dekker GA, Carbonne B.. Calcium channel blockers for inhibiting preterm labour
  3. Williams JK, McClain L, Rosemurgy AS, Colorado NM.. Evaluation of blunt abdominal trauma in the third trimester of pregnancy: Maternal and fetal considerations.
  4. Goodwin TM, Breen MT. . Pregnancy outcome and foetomaternal hemorrhage after noncatastrophic trauma.
  5. Pak LL, Reece EA, Chan L. Is adverse pregnancy outcome predictable after blunt abdominal trauma?
  6. Wang PH, Chao HT, Too LL, Yuan CC. . Primary repair of a cornual rupture occurring at 21 weeks gestation and successful pregnancy outcome.
  7. Crowther CA, Hiller JE, Doyle LW.. Magnesium sulphate for preventing preterm birth in threatened preterm labour.