evidence for steroids Flashcards
What is the big RCT what looks and recurrent steroid dosing?
Who did they treat?
What follow up are they now up to?
ACTORDS
Lancet 2006
Crowther and Haslam
Repeated dosing under 32 weeker / still at risk PTL
Outcomes: Reduces RDS RR 0.82, need less oxygen therapy, shorter duration of mechanical ventilation, and less severe lung disease
Up to 6-8 year follow up
No benefit no harm
Cochrane review 2015 - 10 trials 5000 woman
Less RDS and major neonatal morbidity
Small reduction in birth size (disappeared when adjusted for GA)
17 woman treated to reduce 1 RDS
17% reduction in RDS
Impression = repeat should be considered and full counselling should occur
No change in maternal infection or likelihood of a caesarean
No long term harm – no benefit
is there benefit for steroids beyond 34 weeks?
What is trial?
2016 NEJM
Gyamfi-Bannerman + Thorn
Doubles blinded multicentre RCT
34 – 36+6 at risk late PTB
Even up to 36+6 steroids reduce respiratory morbidity
Primary outcome composite neonatal outcomes within the first 72 hours
Risk reduction 0.8
No difference in infection
Secondary: Resp complications TTN, reduced (no difference in RDS)
Neonatal hypoglycaemia more common in steroid group
What is the evidence around Steroids for el lscs?
+ explanation
ASTECS – antenatal steroids at term elective CS
BMJ 2005 1000 woman RCT - not blinded Steroids for LSCS at term RR of admission to NICU 0.46 TTN 0.54 4% - 2 % RDS RR 0.21 1.1% - 0.2%
During labour and at birth, the mature lung switches from active chloride and fluid secretion to active sodium and fluid absorption.18–20 The reduced incidence of transient tachypnoea in the steroid group is consistent with the hypothesis that corticosteroids, increased in mother and fetus through the stress of labour, encourage the expression of the epithelial channel gene and allow the lung to switch from fluid secretion to fluid absorption. Without another source of corticosteroid, elective caesarean section will disrupt this process. Thereafter admission with respiratory distress to a special unit separates mother and baby, potentially disrupting bonding, and increasing the cost of care and the risk of complications.21 22 Furthermore, neonatal respiratory morbidity increases the risk of asthma in childhood.
Cochrane review for steroids
what are the benefits?
What are the risks?
Reduction in
Perinatal death RR 0.72 neonatal death RR 0.69 RDS RR 0.66 Moderate and severe RDS RR 0.59 intraventricular haemorrhage 0.55 necrotising enterocolitis 0.5 Need for mechanical ventilation 0.68 Systemic infections in the first 48 hours RR 0.6
No difference in chronic lung disease
mean birthweight
neurodevelopmental delay in childhood
death in adaulthood
No increased risk of chorioamnionitis, or endometirtis
No increase in maternal death
What is the NZ guideline for steroids for ELLSCS
For elective caesarean section at term, where possible, plan at ≥39 weeks’ gestation.
Use antenatal corticosteroids 48 hours prior to caesarean birth planned beyond 34 weeks’ and 6 days gestation if there is known fetal lung immaturity.
Shall we routinely given steroids to twins?
nope - need more this factors then just twins
