Nitric oxide donors for the treatment of preterm labour

Preterm birth (birth before 37 weeks) increases the baby's risk of death or disability. Several drugs are available to try and slow down labour so that corticosteroid drugs can be given to help the baby's lungs mature quickly. Nitric oxide donors (glyceryl trinitrate) are drugs that may slow down contractions. They can cause headaches, low blood pressure and increased heart rate for the mother, but they might cause fewer problems than some of the other options. This review gathered the evidence on nitric oxide donors compared with no treatment and compared with other drugs to inhibit preterm labour.

We identified 12 trials involving 1227 women. We found that there is not enough evidence to show whether or not nitric oxide donors can slow down preterm labour.

Authors' conclusions: 

There is currently insufficient evidence to support the routine administration of nitric oxide donors in the treatment of threatened preterm labour.

Read the full abstract...

A number of tocolytics have been advocated for the treatment of threatened preterm labour in order to delay birth. The rationale is that a delay in birth may be associated with improved neonatal morbidity or mortality. Nitric oxide donors, such as nitroglycerin, have been used to relax the uterus. This review addresses their efficacy, adverse effects and influence on neonatal outcome.


To determine whether nitric oxide donors administered in threatened preterm labour are associated with a delay in birth, adverse effects or improved neonatal outcome.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013).

Selection criteria: 

Randomised controlled trials of nitric oxide donors administered for tocolysis.

Data collection and analysis: 

Two review authors independently assessed trial quality and extracted data.

Main results: 

Twelve trials, including a total of 1227 women at risk of preterm labour, contributed data to this updated review. The methodological quality of trials was mixed; trials comparing nitric oxide donors with other types of tocolytics were not blinded and this may have had an impact on findings.

Three studies compared nitric oxide donors (glyceryl trinitrate (GTN)) with placebo. There was no significant evidence that nitric oxide donors prolonged pregnancy beyond 48 hours (average risk ratio (RR) 1.19, 95% confidence interval (CI) 0.74 to 1.90, two studies, 186 women), and although for most adverse effects there was no significant difference between groups, women in the active treatment group in one study were at higher risk of experiencing a headache. For infant outcomes there was no significant evidence that nitric oxide donors reduced the risk of neonatal death or serious morbidity (stillbirth RR 0.36, 95% CI 0.01 to 8.59, one study, 153 infants; neonatal death RR 0.43, 95% CI 0.06 to 2.89, two studies, 186 infants). One study, using a composite outcome, reported a reduced risk of serious adverse outcomes for infants in the GTN group which approached statistical significance (RR 0.29, 95% CI 0.08 to 1.00, 153 infants). Overall, these studies were underpowered to identify differences between groups for most outcomes.

When nitric oxide donors were compared with other tocolytic drugs there was no significant evidence that nitric oxide donors performed better than other tocolytics (betamimetics, magnesium sulphate, a calcium channel blocker or a combination of tocolytics) in terms of pregnancy prolongation, although nitric oxide donors appeared to be associated with a reduction in most adverse effects, apart from headache. There was no significant difference between groups for infant morbidity or mortality outcomes.