Mamas on Bedrest: The Terbutaline Debate Continues

May 25th, 2011

I am a blog contributor on Lamaze International’s blog, Science and Sensibility. On April 12th, I wrote a commentary on the new guidelines and warnings issued by the FDA regarding the use of Terbutaline for the prevention of preterm labor. It created quite a stir.

In a nutshell, obstetricians were irritated (pun intended!) with my tone in that I feel that the use of Terbutaline should be severely limited if not completely banned. They challenged my authority to question their medical judgement and to demand full disclosure be given to patients regarding the off label use, the potential risks and complications as well as potential long term side effects. They all swore that most obstetricians follow ACOG guidelines for the use of Terbutaline for the prevention of preterm labor and that Terbutaline is always used responsibly and not for more then 48-72 hrs, just long enough to stabilize their patients.

However, the stories recounted by women who were on Terbutaline or who had been given Terbutaline to halt their preterm labor symptoms revealed an entirely different story. Women recounted being placed on continuous drips, daily injections and for being on the medication for weeks to months. Additionally, most of the women stated that they had not been fully informed about Terbutaline, knew nothing about it being used off label and had no idea of the potential risks and side effects. They were basically given the medication without any say whatsoever and were told it was what was needed to maintain their pregnancies.

Although that particular debate has waned, the controversy regarding the use of Terbutaline continues and underscores the pressing need for additional treatment options for high risk pregnancy and preterm labor.

Chavi Karkowsky, a second year Maternal Fetal Medicine Fellow at Albert Einstein College of Medicine/Montefiore Medical Center in New York City, wrote a blog post/case study on Medscape asking readers to indicate how they would manage a young pregnant woman with symptoms of preterm labor.

Karkowsky  provided 5 possible treatment options. Readers were also able to write in their treatment plans. The results were very interesting. Most all of the readers wanted to give the patient something-even though it wasn’t clear that the patient was experiencing preterm labor (the Fetal Fibronectin test, a test that can definitively predict preterm labor, was unavailable). Interestingly, many of the responders felt that the patient was not in preterm labor, but wanted to give her something based on her presentation, social situation and her potential for complications. Here is how the  treatment options ranked among clinician response.

Poll Results

a) She’s not in labor with that cervix. Send her home, with strict cautions. 15% (17)

b) She’s not in labor with that cervix, but she’s a little nervous-making, right? Let’s give her a dose of terb. I think she’ll eventually go home. I don’t want to give her steroids, since I think she won’t deliver within 7 days, but we’ll follow her closely as an outpatient.  9% (10)c) She’s not in labor, but terbutaline is bad, bad stuff. Didn’t you read the recent updates? Let’s give her a dose of nifedipine or indomethacin. I think I will send her home if her contractions abate, with close follow-up.  18% (21)

d) Let’s admit her- come on! She has a terrible social situation, and who knows where she’ll end up. I know her cervix is closed and long, but I want to tocolyse her properly and give her steroids. I will likely give her magnesium, given the recent data on neuroprotection.  21% (24)

e) Same as (d), but can we use a tocolytic that actually tocolyses? I’m voting for nifedipine to get her steroids on board.

31% (35)

Other Answers  6% (7)

As Karkowsky’s poll shows, there is little agreement among clinicians about the treatment of preterm labor and at times, it seems to be a bit of a crap shoot.

What I found interesting and what was advocated by a handful of practitioners was conservative observation at home, with home health nursing follow up. Novel approach? Not so much and one that is used with frequent regularity in countries with universal healthcare. Home care  with professional follow up can provide a level of surveillence similar to that of being a hospital in patient in a more comfortable environment for the patient and at a fraction of the cost of a hospital admission. But in our health care climate of “managed care”, reimbursement and litigation, this is not going to be a first line option and one that many patients would in fact prefer.

Management of high risk pregnancy and the use of Terbutaline for the prevention of preterm labor in particular will continue to be a hot bed issue. As long as we have so few treatment options for the prevention of preterm labor, until we as a culture honor pregnancy and childbearing and provide women with modified work schedules and/or paid maternity leave,  and until there is an incentive within our current health care system for less intervention and more preventive health care this debate will continue.

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