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The use of tocolytic therapy in a pregnant trauma patient

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

[{exp pregnancy/ OR} AND {exp “Wounds and Injuries”/ OR} AND {exp tocolysis/}] LIMIT to human and English Language

Search 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)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Williams et al.
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 reviewEffectiveness of tocolysis14 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.
Goodwin TM, Breen MT
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 studyResponse to tocolytic therapyAll 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.
Pak et al.
85 85 pregnant women with noncatatsophic blunt abdominal trauma assessed and monitored July 1994 - August 1997.Prospective cohort studyFactors associated with preterm deliveryTocolysis 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 complications46.2% in preterm group v 12.5% in term group (P<0.05)
Wang PH et al
Patient 31 yrs old 21 weeks pregnantCase reportPatient was administered tocolytic agent after repair of a cornual rupture.Premature labour did not commence until 33 weeks gestation and a healthy baby was deliveredOnly one case and one tocolytic agent (ritodrine hydrochloride, a betamimetic).


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).

Clinical 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.


  1. Anotayanonth S, Subhedar NV, Neilson JP, Harigopal S. Betamimetics for inhibiting preterm labour. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004352.
  2. King JF, Flenady VJ, Paptsonis DNM, Dekker GA, Carbonne B. Calcium channel blockers for inhibiting preterm labour Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No CD002255
  3. Williams JK, McClain L, Rosemurgy AS, Colorado NM. Evaluation of blunt abdominal trauma in the third trimester of pregnancy: Maternal and fetal considerations. Obstetrics and Gynecology 1990, 75 (1): 33-37
  4. Goodwin TM, Breen MT. Pregnancy outcome and foetomaternal hemorrhage after noncatastrophic trauma. American Journal of Obstetrics and Gynecology 1990 162: 665-671
  5. Pak LL, Reece EA, Chan L Is adverse pregnancy outcome predictable after blunt abdominal trauma? American Journal of Obstetrics and Gynecology 1998, 179 (5): 1140-1144
  6. Wang PH, Chao HT, Too LL, Yuan CC. Primary repair of a cornual rupture occurring at 21 weeks gestation and successful pregnancy outcome. Human Reproduction 1999;14(7);1894-5
  7. Crowther CA, Hiller JE, Doyle LW. Magnesium sulphate for preventing preterm birth in threatened preterm labour. Cochrane Database of Systematic Reviews 2002;(4):CD001060.