Tocolytics for delaying preterm birth: a network meta-analysis (0924)
- PMID: 35947046
- PMCID: PMC9364967
- DOI: 10.1002/14651858.CD014978.pub2
Tocolytics for delaying preterm birth: a network meta-analysis (0924)
Abstract
Background: Preterm birth is the leading cause of death in newborns and children. Tocolytic drugs aim to delay preterm birth by suppressing uterine contractions to allow time for administration of corticosteroids for fetal lung maturation, magnesium sulphate for neuroprotection, and transport to a facility with appropriate neonatal care facilities. However, there is still uncertainty about their effectiveness and safety.
Objectives: To estimate relative effectiveness and safety profiles for different classes of tocolytic drugs for delaying preterm birth, and provide rankings of the available drugs.
Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov (21 April 2021) and reference lists of retrieved studies.
Selection criteria: We included all randomised controlled trials assessing effectiveness or adverse effects of tocolytic drugs for delaying preterm birth. We excluded quasi- and non-randomised trials. We evaluated all studies against predefined criteria to judge their trustworthiness.
Data collection and analysis: At least two review authors independently assessed the trials for inclusion and risk of bias, and extracted data. We performed pairwise and network meta-analyses, to determine the relative effects and rankings of all available tocolytics. We used GRADE to rate the certainty of the network meta-analysis effect estimates for each tocolytic versus placebo or no treatment.
Main results: This network meta-analysis includes 122 trials (13,697 women) involving six tocolytic classes, combinations of tocolytics, and placebo or no treatment. Most trials included women with threatened preterm birth, singleton pregnancy, from 24 to 34 weeks of gestation. We judged 25 (20%) studies to be at low risk of bias. Overall, certainty in the evidence varied. Relative effects from network meta-analysis suggested that all tocolytics are probably effective in delaying preterm birth compared with placebo or no tocolytic treatment. Betamimetics are possibly effective in delaying preterm birth by 48 hours (risk ratio (RR) 1.12, 95% confidence interval (CI) 1.05 to 1.20; low-certainty evidence), and 7 days (RR 1.14, 95% CI 1.03 to 1.25; low-certainty evidence). COX inhibitors are possibly effective in delaying preterm birth by 48 hours (RR 1.11, 95% CI 1.01 to 1.23; low-certainty evidence). Calcium channel blockers are possibly effective in delaying preterm birth by 48 hours (RR 1.16, 95% CI 1.07 to 1.24; low-certainty evidence), probably effective in delaying preterm birth by 7 days (RR 1.15, 95% CI 1.04 to 1.27; moderate-certainty evidence), and prolong pregnancy by 5 days (0.1 more to 9.2 more; high-certainty evidence). Magnesium sulphate is probably effective in delaying preterm birth by 48 hours (RR 1.12, 95% CI 1.02 to 1.23; moderate-certainty evidence). Oxytocin receptor antagonists are probably effective in delaying preterm birth by 48 hours (RR 1.13, 95% CI 1.05 to 1.22; moderate-certainty evidence), are effective in delaying preterm birth by 7 days (RR 1.18, 95% CI 1.07 to 1.30; high-certainty evidence), and possibly prolong pregnancy by 10 days (95% CI 2.3 more to 16.7 more). Nitric oxide donors are probably effective in delaying preterm birth by 48 hours (RR 1.17, 95% CI 1.05 to 1.31; moderate-certainty evidence), and 7 days (RR 1.18, 95% CI 1.02 to 1.37; moderate-certainty evidence). Combinations of tocolytics are probably effective in delaying preterm birth by 48 hours (RR 1.17, 95% CI 1.07 to 1.27; moderate-certainty evidence), and 7 days (RR 1.19, 95% CI 1.05 to 1.34; moderate-certainty evidence). Nitric oxide donors ranked highest for delaying preterm birth by 48 hours and 7 days, and delay in birth (continuous outcome), followed by calcium channel blockers, oxytocin receptor antagonists and combinations of tocolytics. Betamimetics (RR 14.4, 95% CI 6.11 to 34.1; moderate-certainty evidence), calcium channel blockers (RR 2.96, 95% CI 1.23 to 7.11; moderate-certainty evidence), magnesium sulphate (RR 3.90, 95% CI 1.09 to 13.93; moderate-certainty evidence) and combinations of tocolytics (RR 6.87, 95% CI 2.08 to 22.7; low-certainty evidence) are probably more likely to result in cessation of treatment. Calcium channel blockers possibly reduce the risk of neurodevelopmental morbidity (RR 0.51, 95% CI 0.30 to 0.85; low-certainty evidence), and respiratory morbidity (RR 0.68, 95% CI 0.53 to 0.88; low-certainty evidence), and result in fewer neonates with birthweight less than 2000 g (RR 0.49, 95% CI 0.28 to 0.87; low-certainty evidence). Nitric oxide donors possibly result in neonates with higher birthweight (mean difference (MD) 425.53 g more, 95% CI 224.32 more to 626.74 more; low-certainty evidence), fewer neonates with birthweight less than 2500 g (RR 0.40, 95% CI 0.24 to 0.69; low-certainty evidence), and more advanced gestational age (MD 1.35 weeks more, 95% CI 0.37 more to 2.32 more; low-certainty evidence). Combinations of tocolytics possibly result in fewer neonates with birthweight less than 2500 g (RR 0.74, 95% CI 0.59 to 0.93; low-certainty evidence). In terms of maternal adverse effects, betamimetics probably cause dyspnoea (RR 12.09, 95% CI 4.66 to 31.39; moderate-certainty evidence), palpitations (RR 7.39, 95% CI 3.83 to 14.24; moderate-certainty evidence), vomiting (RR 1.91, 95% CI 1.25 to 2.91; moderate-certainty evidence), possibly headache (RR 1.91, 95% CI 1.07 to 3.42; low-certainty evidence) and tachycardia (RR 3.01, 95% CI 1.17 to 7.71; low-certainty evidence) compared with placebo or no treatment. COX inhibitors possibly cause vomiting (RR 2.54, 95% CI 1.18 to 5.48; low-certainty evidence). Calcium channel blockers (RR 2.59, 95% CI 1.39 to 4.83; low-certainty evidence), and nitric oxide donors probably cause headache (RR 4.20, 95% CI 2.13 to 8.25; moderate-certainty evidence).
Authors' conclusions: Compared with placebo or no tocolytic treatment, all tocolytic drug classes that we assessed (betamimetics, calcium channel blockers, magnesium sulphate, oxytocin receptor antagonists, nitric oxide donors) and their combinations were probably or possibly effective in delaying preterm birth for 48 hours, and 7 days. Tocolytic drugs were associated with a range of adverse effects (from minor to potentially severe) compared with placebo or no tocolytic treatment, although betamimetics and combination tocolytics were more likely to result in cessation of treatment. The effects of tocolytic use on neonatal outcomes such as neonatal and perinatal mortality, and on safety outcomes such as maternal and neonatal infection were uncertain.
Trial registration: ClinicalTrials.gov NCT01429545 NCT00306462 NCT02132533 NCT00811057 NCT00185900 NCT00599898 NCT02538718 NCT00185952 NCT00116623 NCT00463736 NCT00525486 NCT00620724 NCT00641784 NCT01314859 NCT01360034 NCT01577121 NCT01796522 NCT01985594 NCT02438371 NCT02583633 NCT03040752 NCT00486824 NCT03369262 NCT03976063 NCT00466128 NCT01869361 NCT02725736 NCT03129945 NCT03298191 NCT03542552 NCT04404686 NCT04846621.
Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Conflict of interest statement
This project was supported by the National Institute for Health Research, via ESP Incentive Award Scheme funding to Cochrane Pregnancy and Childbirth (award number NIHR150766).
Ioannis D Gallos: The World Health Organization provided payment to Ioannis Gallos for working on this review. Ioannis is a health professional at Birmingham Women's Hosptital. Ioannis is an Associate Editor for Cochrane Pregnancy and Childbirth, but had no involvement in the editorial processing of this review. Ioannis was also awarded an NIHR ESP incentive award for completion of this review (NIHR150766).
Amie Wilson: works as a Midwife at Birmingham Women's and Children's Hospital Foundation Trusth, and has no declarations of interest.
Victoria A Hodgetts‐Morton: works as a NIHR clinical lecturer in O&G at the University of Birmingham and Birmingham Women's Hospital. Victoria reports personally receiving funds from Hologic, LLC as an Independent Contractor.
Ella Marson: has no declarations of interest.
Alexandra Markland: has no declarations of interest.
Eva Larkai: has no declarations of interest.
Argyro Papadopoulou: is currently a PhD student at the University of Birmingham, UK. Her tuition fees are paid by Tommy's charity, Tommy's National Centre for Miscarriage Research. Tuition fees are directly paid to the University of Birmingham. Argyro works as a Resident at Alexandra University Hosptial, Athens, Greece.
Arri Coomarasamy: has no declarations of interest.
Aurelio Tobias: has no declarations of interest.
Doris Chou: in terms of guideline and recommendation synthesis, I manage the maternal/perinatal living guideline process within the World Health Organization. The technical group may consider this review in deliberations related to the use of tocolytics. During these meetings, I do not carry any voting capacity.
Olufemi T Oladapo: is an Editor with Cochrane Pregnancy and Childbirth, but had no involvement with the editorial processing of this review.
Malcolm J Price: has no declarations of interest.
Katie Morris: has acted as an Independent Contractor for the British Maternal and Fetal Medicine Society, NHS England, Royal College of Obstetricians and Gynaecologists and Tommy's Baby Charity and did not receive funds personally for this work. Kate has also acted as an Independent Contractor for Surepulse and received consultant fees personally for this work. Her institution received funds for a National Institute for Health Research grant, which she held. Kate has published several invited reviews and book chapters related to preterm birth and works as a Consultant in Maternal Fetal Medicine at Birmingham Womens and Childrens Hospital NHS Foundation Trust.
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Larsen 1986 {published data only}
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Lees 1999 {published data only}
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Moutquin 2000 {published data only}
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Neri 2009 {published data only}
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Nonnenmacher 2009 {published data only}
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Papatsonis 1997 {published data only}
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Parilla 1997 {published data only}
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Raymajhi 2003 {published data only}
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Romero 2000 {published data only}
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Saade 2021 {published data only}
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- EUCTR2014-003326-41-GB. Randomized, double-blind, multicenter, phase III study comparing the efficacy and safety of retosiban versus placebo for women in spontaneous Preterm labor - NEWBORN-1. https://trialsearch.who.int/?TrialID=EUCTR2014-003326-41-IT (first received 2015).
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- NCT02377466. A phase III efficacy and safety study of intravenous retosiban versus placebo for women in spontaneous preterm labor. https://clinicaltrials.gov/show/NCT02377466 (first received 26 February 2015).
Sakamoto 1985 {published data only}
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- Sakamoto S. Effectiveness of oral ritodrine hydrochloride on preventing tocolysis: a multicentre double-blinded trial. Igaku No Ayumi 1985;133(10):734-51.
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- NCT00599898. Nifedipine compared to atosiban for treating preterm labor. https://clinicaltrials.gov/ct2/show/NCT00599898 (first received 8 January 2008).
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- Salim R, Garmi G, Nachum Z, Zafran N, Baram S, Shalev E. Nifedipine compared with atosiban for treating preterm labor: a randomized controlled trial. Obstetrics and Gynecology 2012;120(6):1323-31. [DOI: ] - PubMed
Schleussner 2003 {published data only}
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Schorr 1998 {published data only}
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Smith 1999 {published data only}
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Smith 2007 {published data only}ISRCTN20129681
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Tchilinguirian 1984 {published data only}
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Thornton 2009 {published data only}
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Tohoku 1984 {published data only}
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Van Vliet 2016 {published data only}
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- Wang H, Zeng W, Liu H, Ou Y. A randomized controlled trial on the treatment of preterm labor with ritodrine hydrochloride and magnesium sulfate. Hua Xi Yi Ke da Xue Xue Bao [Journal of West China University of Medical Sciences] 2000;31(4):515-7.
Wani 2004 {published data only}
Weerakul 2002 {published data only}
Wilkins 1988 {published data only}
Zhang 2002 {published data only}
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References to studies excluded from this review
ACTRN12616000748415 {published data only}
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- ACTRN12616000748415. Comparative study between Nifedipine, progesterone and ritodrine for maintenance tocolysis in management of preterm labour. http://www.who.int/trialsearch/Trial2.aspx?TrialID=ACTRN12616000748415 (first received 2016).
ACTRN12617001639314 {published data only}
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- ACTRN12617001639314. A randomised controlled trial of sulindac to delay premature birth in pregnancies complicated by a short cervix. http://www.who.int/trialsearch/Trial2.aspx?TrialID=ACTRN12617001639314 (first received 2017).
Alavi 2015a {published data only}
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- Alavi A, Moallemi N, Zolfaghari G, Amjadi N. A comparison between tocolytic effect of nifedipine and magnesium sulfate in preterm labor pain. International Journal of Gynecology and Obstetrics 2015;131 Suppl 5:E477.
Alavi 2015b {published data only}
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- Alavi A, Moallemi N, Zolfaghari G, Amjadi N. Effect of maintenance therapy with isoxsuprine in prevention of preterm labor. International Journal of Gynaecology and Obstetrics 2015;131 Suppl 5:E477.
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Anonymous 2004 {published data only}
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Barden 1990 {published data only}
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Bedoya 1972 {published data only}
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- Bedoya JM. Use of orciprenaline in the treatment of threatened premature labour. In: International Symposium on the Treatment of Fetal Risks; 1972; Baden, Austria. 1972:27-9.
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Caballero 1979 {published data only}
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Cabero 1988 {published data only}
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Calder 1985 {published data only}
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- Calder AA, Patel NB. Are betamimetics worthwhile in preterm labour? In: Beard RW, Sharp F , editors(s). Preterm Labour and Its Consequences. 13th Study Group of the RCOG. London: RCOG, 1985:209-218.
Caritis 1982 {published data only}
Carr 1999 {published data only}
Castillo 1988 {published data only}
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Castren 1975 {published data only}
Cavalle‐Garrido 1997 {published data only}
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- Cavalle-Garrido T, Panter K, Smallhorn JF, Seaward D, Farine D. A RCT of indomethacin for preterm labor: effects on fetal heart and ductus arteriosus. American Journal of Obstetrics and Gynecology 1997;176(1 Pt 2):S46.
Chau 1992 {published data only}
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Chawanpaiboon 2009 {published data only}
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- Chawanpaiboon S, Sutantawibul A, Pimol K, Sirisomboon R, Worapitaksanond S. Preliminary study: comparison of the efficacy of progesterone and nifedipine in inhibiting threatened preterm labour in Siriraj Hospital. Thai Journal of Obstetrics and Gynaecology 2009;17:23-9.
Chhabra 1998 {published data only}
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- Chhabra S, Patil N. Double blind study of efficacy of isoxsuprine and ritodrine in arrest of preterm labour. Prenatal and Neonatal Medicine 1998;3 Suppl 1:202.
Cifuentes 1994 {published data only}
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- Cifuentes R, Leon J, De Trochez LM. Comparative study between nifedipine-terbutaline in preterm labor. Revista Colombiana de Obstetricia y Ginecologia 1994;45(2):117-21.
Clavin 1996 {published data only}
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- Clavin DK, Bayhi DA, Nolan TE, Rigby FB, Cork RC, Miller JM. Comparison of intravenous magnesium sulfate and nitroglycerin for preterm labor: preliminary data [abstract]. American Journal of Obstetrics and Gynecology 1996;174(1 Pt 2):307.
Csapo 1977 {published data only}
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- Csapo AI, Herczeg J. Arrest of premature labor by isoxsuprine. American Journal of Obstetrics and Gynecology 1977;129:482-8. - PubMed
Danti 2014 {published data only}
Das 1969 {published data only}
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- Das RK. Isoxsuprine in premature labour. Journal of Obstetrics and Gynaecology of India 1969;19:566-70.
Decavalas 1994 {published data only}
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- Decavalas G, Papadopoulos V, Tsapanos V, Tzingounis V. Tocolysis in patients with preterm premature rupture of membranes has any effect on pregnancy outcome? International Journal of Gynaecology and Obstetrics 1994;46:26.
Dubay 1992 {published data only}
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- Dubay P, Singhal D, Bhagoliwal A, Mishra RS. Assessment of new borns of mothers treated with nifedipine and isoxsuprine. Journal of Obstetrics and Gynaecology of India 1992;42(6):778-80.
Dunstan Boone 1990 {published data only}
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- Dunstan-Boone G, Bond A, Thornton YS. A comparison of verapamil vs ritodrine for the treatment of preterm labor. In: 10th Annual Meeting of Society of Perinatal Obstetricians; 1990 Jan 23-27; Houston, Texas, USA. 1990:83.
EUCTR2013‐002561‐19‐AT {published data only}
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- EUCTR2013-002561-19-AT. Does a long term tokolysis with atosiban provide any benefit for the pregnancy outcome, compared to the standard short term tokolysis? http://www.who.int/trialsearch/Trial2.aspx?TrialID=EUCTR2013-002561-19-AT (date received 2014).
Freeman 2008 {published data only}
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Fuchs 1976 {published data only}
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Goodwin 2003 {published data only}
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Goyal 2020 {published data only}
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Groom 2000 {published data only}
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- Groom KM, Bennett PR, Shennan AH. Randomised, double-blind, placebo controlled pilot study assessing nitroglycerin as a tocolytic [letter]. BJOG: an international journal of obstetrics and gynaecology 2000;107(9):1182-3. - PubMed
Groom 2005 {published data only}
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Guinn 1998 {published data only}
Gummerus 1985 {published data only}
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Gummerus 1987 {published data only}
Hallak 1992 {published data only}
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Hallak 1993 {published data only}
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Hobel 1990 {unpublished data only}
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Hogberg 1998 {published data only}
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NCT00463736 {published data only}
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NCT00525486 {published data only}
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NCT01360034 {published data only}
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References to studies awaiting assessment
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Jamil 2020 {published data only}
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