Antenatal corticosteroids to reduce neonatal morbidity and mortality Flashcards
Antenatal steroids - benefit
Given within 7 days prior to PTB reduces perinatal and neonatal death and respiratory distress syndrome
Reduces neonatal death when the first dose is given within the 48 hours prior to birth, benefit also seen when given <24h of birth
Antenatal steroids - Caesarean birth 37+0 to 38+6
Discuss risk risks/ benefits
May reduce admission to NICU for respiratory morbidity
Uncertain if any reduction in respiratory distress syndrome, transient tachypnoea of the newborn or neonatal unit admission overall
May result hypoglycaemia and potential developmental delay in neonate
Antenatal steroids - when to offer
24+0 to 34+6 weeks in whom PTB is anticipation (established PTL, PPROM, planned PTB)
Antenatal steroids - multiple pregnancy
Offer targeted antenatal corticosteroids for early birth in line with recommendations for singletons
Antenatal corticosteroids - 22+0 to 34+6 - BENEFITS
Highly likely to reduce
- Perinatal mortality
- Neonatal death
- Neonatal respiratory distress
Likely to reduce
- Intraventricular haemorrhage
- Developmental delay
Most likely seen if 24-48h prior to birth
Reduction in respiratory morbidity (NOT mortality or IVH) if birth <7 days of treatement
Antenatal corticosteroids - 22+0 to 34+6 - HARMS
Likely to: Affect maternal BMs (up to 5 days)
Reduce BW if birth >7 days after
No benefits likely to be seen if birth >7 days after
MAY increase psychiatric and behavioural diagnoses if children born at term
Antenatal corticosteroids - 35+0 to 36 - BENEFITS
Likely to: reduce respiratory support
Antenatal corticosteroids - 35+0 to 36 - HARMS
Likely to: increase neonatal hypoglycaemia
May increase psychiatric and behavioral diagnoses if children born at term
Antenatal corticosteroids - before plan CS at 37-39 weeks - BENEFITS
May decrease admission to NNU with resp morbidity
Antenatal corticosteroids - rescue course if treatment >7 days ago - BENEFITS
Likely to reduce respiratory spport
Antenatal corticosteroids - before plan CS at 37-39 weeks - HARMS
May reduce educational attainment at school age
Antenatal corticosteroids - rescue course if treatment >7 days ago - HARMS
Likely to reduce birthweight, head circumference and neonatal BP
Antenatal corticosteroids - in GDM
Maternal blood glucose risk after administration for up to 5 days
Diabetes should not be considered a contraindication to antenatal corticosteroids for fetal lung maturation (NICE)
Antenatal corticosteroid administration in GDM
Insulin-treated diabetes - additional insulin should be given according to an agreed protocol and the women should be monitored closely
Antenatal corticosteroids - in hypertensive disorders
Offer if planned early birth for hypertension in pregnancy (NICE) - but do not delay birth for steroids
Cochrane Systematic Review
- No differences in corticosteroid effects on perinatal mortality, neonatal mortality and fetal death seen between women with and without hypertension syndromes
- Subgroup analyses = potentially a larger reduction in RDS seen in hypertensive mothers than other groups (uncertain)
Antenatal corticosteroids - in PPROM
Corticosteroids to women with PPROM reduces the risks of RDS
No difference was observed between steroid and control groups concerning the risk necrotising enterocolitis, neonatal sepsis and Apgar score of <7 @5 minutes
Perinatal mortality was similar between steroid and control groups
Antenatal corticosteroids - in FGR
Little evidence to suggest that steroids will perform differently in babies with growth restriction compared to the overall preterm population
RCOG guidance on SGA babies recommends that women with a SGA baby should receive antenatal corticosteroids to accelerate fetal lung maturation
Beneficial Effects of Antenatal Magnesium (BEAM) randomised control trial
Investigated 1641 women with PPROM who received either one or two courses of antenatal corticosteroids
Similar rate of neonatal sepsis for 1 vs 2 courses of steroids
Secondary analysis = no increased risk of chorioamnionitis between the groups
Antenatal corticosteroids - dose and route of administration
24mg dexamethasone IM in two divided doses
- 12mg 24 hours apart
- OR four divided doses of 6mg 12 hours apart
ALTERNATIVE
24 mg betamethasone sodium phosphate/acetate mix IM in two divided doses
- 12mg 24 hours apart
Antenatal corticosteroids - dexamethasone vs betamethasone
Dexamethasone = reduced risk fo intra-ventricular haemorrhage
Betamethasone acetate/phosphate = most trialled formulation
May reduce risk of chorioamnionitis compared to dexamethasone
Antenatal corticosteroids - betamethasone forumlations
Betamethasone sodium phosphate
- soluble
- short half-life
Betamethasone sodium acetate
- insoluble
- long half-life
(Available in 50:50 mixture in some countries)
Antenatal corticosteroids - why not hydrocortisone?
Crosses placenta (and insufficient evidence to recommend)
Antenatal corticosteroids - when are they effective?
Within 48h - reduces neonatal death
Within 24h - benefit also seen (still give)
Within 7 days (if 2nd dose) - most effective in reducing RDS
Antenatal corticosteroids - when are they effective? Evidence
EPICE group demonstrated that any antenatal corticosteroid was associated with reduced mortality with the largest effect 24 hours to seven days after first injection (adjRR 0.5; 95% CI 0.4–0.6)
Further analysis demonstrated a significant risk reduction inmortality of 50% with a time of administration to birth interval of 18–36 hours
Antenatal corticosteroids - repeat course?
Limited evidence to recommend repeat courses if imminent risk of PTB after 7 days
Further course may reduce need for respiratory support
No reduction in serious morbidity or long-term benefits have been seen with repeat corticosteroids
Babies who receive repeat doses of antenatal corticosteroids are smaller
Antenatal corticosteroids - maximum number of courses (WHO guidance)
Single rescue course of antenatal corticosteroids if women remain at high risk of preterm birth and >7 days elapsed since previous treatment
Antenatal corticosteroids - maximum number of courses
3
