IS THERE JUSTIFICATION FOR USING INDOMETHACIN IN PRETERM LABOR - AN ANALYSIS OF NEONATAL RISKS AND BENEFITS

OBJECTIVE: Recent: reports have suggested that the use of indomethacin for tocolysis may independently increase the risk for major adverse n eonatal events such as intraventricular hemorrhage and necrotizing ent erocolitis. The objective of this study was to determine whether this potential risk of indomethacin is outweighed by the benefit of deliver y delay at gestational ages <32 weeks. STUDY DESIGN: We constructed se parate decision trees to compare strategies of tocolysis with indometh acin versus no tocolysis for hypothetic cohorts of patients with idiop athic preterm labor at 24, 26, 28, 30, and 32 weeks' gestation. Probab ilities for these decision models, including estimates of indomethacin efficacy and the potential for increase in adverse neonatal events wi th indomethacin, were obtained from the medical literature. The primar y outcome was the number of expected adverse neonatal events per 1000 women for each strategy at each gestational age. RESULTS: In the base case analysis tocolysis with indomethacin was a more favorable strateg y than no tocolysis across all gestational ages that we studied, ks ex pected, the difference in the number of events between the two strateg ies declined with advancing gestational age because of a decreasing ba seline risk for adverse neonatal events as gestational age increased. The models al 26, 28, 30, or 32 weeks were not sensitive to our estima tes of indomethacin efficacy, nor to our estimates of baseline neonata l morbidity or steroid efficacy, or to the relative increase in some n eonatal morbidities with indomethacin use. CONCLUSIONS: On the basis o f current estimates, the benefits of indomethacin outweigh the potenti al risks to the neonate at gestational ages less than or equal to 32 w eeks. Thus the use of indomethacin for tocolysis at these ages is a re asonable strategy.