Preterm Labor: Magnesium Sulfate vs. Nifedipine

[winewinn]

Hello!

I am presently at a hospital where I was admitted for PROM at 31 weeks. Was about 2cm dilated and put on magnesium sulfate. I am wondering what others think of using Nifedipine as a substitute for mag sulfate? For the past three days, I've experienced only 2 contractions on the mag sulfate and the dose has been lowered to about 1.5 grams.

The reason I ask, is because in a pregnancy where I delivered at 27 weeks (also due to PROM - complete rupture), I was put on mag sulfate as a first line of treatment for two days in order to receive betamethasone shots, and then put on Nifedipine. I was able to carry about 3 weeks on the Nifedipine before delivering in this situation. The reason my OB chose Nifedipine at the time was because it seemed to carry fewer side effect for both myself and baby.

Being in a different hospital with this baby, I do not even have a rapport with the OB who was assigned to me. He is an older OB and pretty set in his ways, and I can understand he probably has had many babies delivered fine on mag sulfate. In this hospital, I was told that their usual course of treatment is magnesium sulfate until I deliver, which is hopefully three weeks later. Since this child shows enlarged kidneys (having fluid) on ultrasound, that has increased my worry as to what medication is best for fending off preterm labor. At this point, I would like the least amount of risk for both baby and myself.

Can Nifedipine and Magnesium Sulfate both be as effective in preventing pre-term labor?

Which has the least amount of risk?

Any opinions are welcome...

Oh, also... my baby that was born at 27 weeks did quite well in the NICU. She was able to breathe on her own initially; no brain bleeds. She really seemed to beat the odds. She is a walking and talking 3.5 year old today. With her treatment being so successful, I guess that I why I am hesitant to remain on the mag sulfate and would prefer to switch to Nifedipine at this point.

[winewinn]

I'm curios are you still leaking fluid???????

Yes you can get fluid to send for fetal lung maturity without an amnio one of two ways lay down for a couple hours and not get up then sit on a bedpan and see what trickles out (amniotic fluid) You can also go in with a speculum and collect the fluid with a syringe.

I am still leaking fluid, and the leaking has been quite a bit today. I inquired with this OB today about testing for fetal lung maturity as I had the betamethasone shots at about 26 weeks. He said we may as well assume they are immature until about 35 weeks. Over the weekend, the fluid leaking had decreased. Today, though, there is an increase of fluid gushing. Could be from the baby's position, I guess.

So... the lung maturity test was a no-go with him...

Jennifer

[Jolie, BSN]

Again, I'm sorry for your experience and lack of comfort with your care. It is an added stressor you do not need.

I'm assuming that you were admitted to a referral hospital some distance from your home and regular OB. That can be intimidating, as you probably don't know how to navigate the system to find an alternate OB or even just get a second opinion.

First of all, I haven't worked OB since my own healthy preemie was born, so my opinions may not reflect current practice. Deb and mugwump could be of more help. But it does concern me that you are being monitored on such an "occasional" basis. I know that continuous fetal monitoring of preemies is difficult, as they tend to be very mobile, and swim away from the transducer. Continuous monitoring can also interfere with mom's ability to get comfortable and rest, but given that you have diminished fluid levels, it seems that some schedule of monitoring would be prudent. If the baby is non-reactive (which may be due to the MgSO4), then perhaps a BPP would be in order. In the absence of a BPP, it seems that an U/S could shed some light on your amniotic fluid levels. If it is possible to obtain a fluid specimen in a non-invasive manner (without further increasing your risk of infection), then having information on lung maturity would be helpful also. I think you are quite reasonable in requesting some or all of this testing.

As far as finding an OB for a second opinion...Does this hospital have a perinatologist? That seems like an easy first step. If not, then can you speak with your nurse or the unit manager and express your concern and desire to be evaluated by another physician? Can you call your regular OB and ask him/her to intervene on your behalf? Even if your regular doc can't see you, perhaps s/he can make some calls for you and locate a colleague who will.

I understand your concerns, and will keep you in my prayers. Take care!

[SmilingBluEyes]

We require continuous monitoring on any pregnant mom on mag sulfate. I dont' quite understand the cavalier attitude in this case on so many things. I guess I just dont' know enough make anymore recommendations or judgements at this time. I feel for you, OP. I do hope things turn out ok. Remember, it is fine to ask for other opinions/consultations on your case if you feel you are being mishandled. Hugs to you.

[SmilingBluEyes]

As far as finding an OB for a second opinion...Does this hospital have a perinatologist? That seems like an easy first step. If not, then can you speak with your nurse or the unit manager and express your concern and desire to be evaluated by another physician? Can you call your regular OB and ask him/her to intervene on your behalf? Even if your regular doc can't see you, perhaps s/he can make some calls for you and locate a colleague who will.

I understand your concerns, and will keep you in my prayers. Take care!

this is a great suggestion. Ask your regular OB or to consult with a perinatologist. You have that right.

[winewinn]

this is a great suggestion. Ask your regular OB or to consult with a perinatologist. You have that right.

Thanks to both of you for the words of encouragement. I will ask today for a second opinion. He did seem to be on the opposite spectrum of my former OB who treated my 27-weeker. It would be nice to just get something "inbetween."

After three non-stress tests, we finally have a BPP ordered for sometime today. Will keep you posted!

[SmilingBluEyes]

wishing you the best on the BPP!

[winewinn]

wishing you the best on the BPP!

Thank you!

I scored 8/8, so baby is well. Fluid is very low -- we were able to only find one pocket that could measure "2x2" in order to score the 2 points on the BPP for fluid. At least there is that little bit there. It took quite awhile to show some "breathing" but I am thinking that is probably pretty normal at (now) 32 weeks.

I did switch OBs today. Was able to check around and one one that is at least more "personable" and communicates well. Will be meeting with him tomorrow. This is a lot less stress. Although, I am keeping my legs crossed over the weekend as the other OB is on-call. ;-)

Thank you so much for all your input! I probably wouldn't have had the balls to switch OBs had I not gotten your opinions. This is a lot less stress on me, and since I'm happier it's a lot less stress on my family now. I have never worked with a physician where I've felt such a personality clash. It feels good to be through this.

Jennifer

[louloubell1]

Mugwump and smilingblueyes,

I was wondering if either of you know a reference that lists nifedipine as being contraindicated with MgSO4. I've looked in several pharm books since reading your posts and can't find anything about it. The sources I have read state that they should be used concurrently with caution but they don't list them as contraindicated together. I would be interested in reading something about it.

Thanks,

Lou

[winewinn]

Just wanted to let you know that at 7:27pm on Wednesday, April 13, 2005, Jasmine Adrianna decided to make her debut. Just 15 minutes after officially switching and meeting with an OB I was very comfortable with, labor began and despite increasing the mag sulfate and turbutaline it was unstoppable.

She weighed in at 4 pounds 1 ounce and 16 1/2 inches long, not too shabby of a size for 32 weeks and 2 days gestation. Mom and baby are doing well.

Her Apgar scores I think were great for her age - 8 and then 9. I can only hope she will continue to breathe on her own.

Jennifer

[MADDOG70, BSN]

I'm in the E.R. so we don't get to know this stuff. What does the nifedipine do? Stop contractions? How? Thanks for the info. I will share with others.

First of all Magnesium and nifedapine are contraindicated together. I work in a tertiary care center and high risk pregnant moms is my specialty. It depends ont he doctor, I have seen Proms remain on magnesium until deliver, I've seen them switch to nifedapine or terbutaline motrin until 32 weeks. Although one of the new trends comming out is magnesium until in the steroid window then taken off all tocolytics. (reason being infection) people who are SPPROM deliver for 1 of 2 resons usually, infection or they deliver anyway. The perinatal doctors and neonatal doctors I have spoken to prefer a health premature baby than one sick more mature baby. Magnesium can mask infection and keep a baby in longer when the body is trying to get rid of it due to infection. I don't say these things to scare anyone but ask your doctor to switch you to something if you want or express fears of infection. Good luck I am seen many women go a couple of weeks to a month OK. Also as far as your 27 weeker. That is my pet peeve as a nurse just because your 27 weeker did fine that doesn't mean a 31 weeker will do OK sure it has a better chance but each child is very very diffrent. Some 24 weekers do fine (few and far between) I've also known some 32 weekers to do not so good.

[SmilingBluEyes]

Congratulations!!!! I hope your baby does well in her next few days/weeks!

[SmilingBluEyes]

Nifedipine (Procardia) is used in some areas (it's regional) to stop preterm labor with mixed results. It acts to relax major muscles, such as the uterus, and theoretically, stop preterm contractions. It is marketed as a medication to lower blood pressure, but used off-label by some OB's to stop preterm contractions, or at least, slow them down.

Just of note, terbutaline, (Brethine) was used 'off-label" for years to stop preterm labor, too. It is now used (officially and marketed for) preterm labor. It's often the first-line treatment to stop preterm labor in the hospital and at home, before magnesium is tried, should it fail. It was originally (and still is used for) controlling asthma symptoms.