Antenatal Corticosteroid Therapy

7/31/2019 Antenatal Corticosteroid Therapy

1/44

Utilization of Antenatal Corticosteroids onpremature babies of 27-34 weeks of gestational age

born at ***** during 2003-2004


2/44


3/44

Introduction

ANS is a corticosteroid treatment givenintramuscular to the pregnant mother atrisk of premature delivery.

This corticosteroid will cross bloodplacental barrier and act upon prematurelungs of fetus and help enhancing itsmaturity.


4/44

Premature newborns of 27-34 weeksgestation are at high risk of developingrespiratory distress syndrome (RDS) dueto lack of surfactant in their premature lung

also called Hyaline membrane disease.(HMD)


5/44

Surfactant is a natural substance produced bypneumocytes II In the lungs.

It is a heterogenous mixture of lipids and proteins.Dipamitoyl phosphatidyl choline is the main

component of the surfactant.

It spreads in the lung tissue- air interface

preventing alveolar collapse duringexpiration, to open easily at next inspiration.


6/44

Hyaline Membrane Distress (HMD) occursdue to inadequate production of pulmonarysurfactant in premature lung and is seen iflabour occurs before 32-34 weeks ofpregnancy.


7/44

The alveolar wall collapses duringexpiration and each inspiration will requireconsiderable effort.

This situation rapidly leads to fatigue,decreased respiratory effort, Hypoxia,cynosis, acidosis and eventually death, ifnot corrected by immediate treatment.


8/44

The steroids given IM to mothers passesacross blood placental barrier and act uponthe pneumocytes type II of lung, inducingproduction of surfactant and these help inpreventing the HMD.

Steroids used are usually Betamethasone orDexamethasone.


9/44

Antenatal Corticosteroid apart fromreducing RDS (HMD) also reduceintraventricular hemorrhage and neonatalmortality.


10/44

Indication of Antenatal corticosteroid:

1. Indicated to all women pregnant of 24 to34 weeks at risk of premature deliverywithin 7 days followed.

2. The women of 34-36 weeks can also begiven ANS in certain critical condition

e.g. elective c.s for these clinical cases in7 days following the ANC , e.g. gestationalDiabetes mellitus, PIH, Placenta praevia


11/44

Contra indication of Antenatal corticosteroid :

woman suffering from systemic infectionincluding T.B

Caution is advised if suspectedchorioamnionitis is diagnosed.


12/44

Dosage & Route of administration:

Treatment of choice:2 doses of Betamethasone 12mg given IM 24 hrsapart.

2nd line of treatment:-4 doses of dexamethasone 6mg given IM 12 hrs

apart-2 doses of 12 mg given IM 12 to 24 hrs apart.


13/44

Betamethasone is not available in public servicein M********.

Most extensively used regimen used inM*********:2 doses of Dexamethasone 12mg IM 12 to 24hrs apart

Most recently some doctors are using singledose of ANS in view of side effect of ANS.


14/44

The optimacy of treatment:

The optimal treatment- delivery interval foradministration of ANS is more than 24 hrsbut fewer than 7 days after start oftreatment.


15/44

History of ANS Therapy

Benefits are well known since 1972. Liggins and Howic were the first who described

the benefit of ANS in 1972.

Controlled trial of Betamethasone therapy wascarried out in 282 mothers with threatenedpremature delivery before 37 weeks.

There was no death with HMD or IVH in infantsof mother who had received Betamethasone atleast 24 hrs before delivery.


16/44

Justification for study on ANS

Mortality Rate : 1973 1998 2001 2004

Infantile Mortality rate per 1000 livebirths

63.3 19.4 13.9 14.0

Perinatal per 1000 total births 56.5 23.5 19.9 16.5

Early neonatalper 1000 live births

22.8 12 7.7 7.5

Late neonatalpour 1000 live births

7 2.5 2.5 2.8

In M*********,in years 70s after independence day, IMR was very highdue to very high neonatal and perinatal rates.

After the integration of MCH (Maternal & Child Health) programme,antenatal service improved at primary health centre ** and became easily

accessible to all & hence mortality rates started decreasing.


17/44

Comparison between African countries in 2000

AfricanCountries

PerinatalMortality

Rates

Early neonatalMortality

Rates

Late neonatalmortality

Rates

B******** 217 27 36

C******** 81 38 48

S******** 33 15 21

M******* 22.1 8.8 3.6


18/44

Comparison with developed countries &R****** Island in 2000

Developedcountries

Taux de mortalitprinatal pour

1000 naissancestotales

Taux de mortalitneonatal prcoce

pour 1000naissances

vivantes

Taux de mortalitneonatal tardive

pour 1000naissances

vivantes

Australia 6 3 3

France 7 2 3

England 8 3 3

USA 7 4 5

R****** 14 3 4

M****** 22.1 8.8 3.6


19/44

For further improvement, NICU services startedin M*******.

At **********, in 1999At *********, in 2001

But the services are very costly & big economicburden on Government.

ANS therapy decreases the risk of HMD, hencedecrease the need of NICU treatment & hence thecost of treatment.


20/44

To describe the utilization of ANS in pregnanciesof 27-34 weeks with high risk of prematuredeliveries.

Describe the outcome of premature babies in 3groups according to ANS:With no ANS treatmentWith ANS incomplete or suboptimal treatmentWith complete & optimal ANS therapy

Objective of Study


21/44

Methodology

It is a retrospective descriptive observationalstudy on premature babies of 27-34 weeks bornat ***** Hospital during Jan 2003 to Dec 2004.

Though we know that best technique for thisstudy would be the randomised clinical trial, butit was not possible due to existing circumstancesand ethical reasons.


22/44

Total premature babies born alive during2003-2004 =421

Selected for study=112

Criteria of inclusion: Babies of gestational age 27-34 weeks born at******* only including inutero transfer

Criteria of exclusion:Premature babies with congenital malformation, infantof diabetic mother, multiple pregnancies


23/44

Subdivided our population of study in 3 groups:Group of babies with suboptimal ANS therapy

(no=29)Group of babies with optimal ANS therapy (no=49)

Group of babies with no ANS (no=34)

Group suboptimal whose mothers hadIncomplete course of ANS with short intervalbetween therapy and delivery, i.e. less than 24 hrs.Group optimal whose mothers had completecourse of ANS at least 24 hrs before delivery


24/44

Grading of prematurity

Extreme premature: G.A of 26-32 weeksno=5

Severe premature: 28-31 weeksno=55

Mild premature: 32-34 weeksno=52


25/44

Criteria of diagnosis of severity of RDS

According to clinical conditionsChest X RayNeed of treatment

Mild RDS X Ray chest result, need ofO2 less than 30% fiO 2, NO need of surfactant& less tachypnia

Severe RDS X Ray result, severe tachypnia,need of O 2 more than 30% even with respiratorySupport, need of surfactant


26/44


27/44

Results

Percentage of antenatal corticotherapyType de CAN No. of pregnancies %

Sub optimal Treatment 29 25.9%

Optimal Treatment 49 43.8%

NO ANS 34 30%

Total 112 100%


28/44

About 30% of the eligible women couldnt get ANS.

Main reason :Very rapid delivery of baby; i.e. within 24 hrs of

hospitalization 26/34 (76.4%) delivered rapidly


29/44

Incidence of severe RDS (HMD)

0

5

10

15

20

25

30

SUBOPTIMAL OPTIMAL NILCORTICOTHERAPY

NUMBER OF CASES

Mild

Severe

NIL

HMD

44% (13 / 29 ) in group sub optimal treatment41.1% (14 / 34 ) in NO ANS group

10.2% (5 / 49 ) in group optimal


30/44

On comparison among 3 different groups:

Significant difference between optimal & suboptimal group (P=0.0012)

Significant difference between optimal & NOANS (P=0.0023)

No difference between group sub optimal &group NO ANS.


31/44

Utilization of surfactant on Premature babiesin different groups

Type of ANS Therapy No. of babies givensurfactant

%

Sub optimal ANStreatment

n=2911

37.9%

Optimal ANS Treatment n=494

8.16%

No ANS group n=3411

32.4%


32/44

Need for artificial ventilation

ArtificialVentilation

Sub optimalgroup

Optimal group NO ANS group Total

Yes 23(79.3%)

25(51.0%)

30(89.0%)

78(69.6%)

No 6(20.7%)

24(49%)

4(11%)

34(30.4%)

Total 29(100%)

49(100%)

34(100%)

112(100%)


33/44

It is costly when we use surfactant &ventilation.

Optimal ANS will help in decreasing thecost of treatment.


34/44

Duration of stay in NICUGroupe of ANS Stay in NICU (days)

Minimum Mean Median Maximum

Sub optimal 0 11.4 6 61

Optimal 0 9.6 10 53

NO ANS 0 13.3 10 72

No significant difference in duration of stay in NICU (P-value=0.476)


35/44

Total stay in hospitalType of ANS Total stay in hospital (days)

Minimum Mean Median Maximum

Sub Optimal 2 18.8 16 96

optimal 1 20.7 17 53

NO ANS 2 20.9 18 72

No significant difference among the 3 groups (P value=0.89)


36/44

2 principle reasons for no significant difference in

duration of stay among the 3 groups:

Very high rates of nosocomial infections in ourunits

Slow weight gain


37/44

Morbidity

No significant difference among the 3 groupsin occurrence of:

1. Patent ductus arteriosus2. Intra ventricular hemorrhage3. Broncho pulmonary dysplasia

This result is due to small size of our sample.


38/44

Mortality

No significant difference among the 3groups in results of mortality

Reason:1. Nosocomial infections are the main cause of

neonatal mortality

2. Short duration of studyIt suggests to do study on long duration andcompile more datas.


39/44


40/44

Recommendations

We propose more aggressive campaign ofsensiblisation and education of pregnant womenabout regular follow up of antenatal clinics, its

advantage.

Informing these mothers of the signs andsymptoms of complication of pregnancy whichprovoked premature labour.


41/44

Recommendations

Informing doctors conducting ANC at LHC(most often generalists) about:

o problems of premature labour

o Antenatal steroid protocol so that they canalways start treatment without delaying asdexamethasone is easily available at LHC.


42/44

Recommendations

We recommend to start useBetamethasone as drug of choice due to:

o simplicity of application & better patientcompliance

o superiority on Dexamethasone- decreased

risk of cystic peri ventricular leucomalaciaamong premature infant born at 24 th to 31week G.A


43/44

Conclusion

It is very important to give ANS at right time withright doses to achieve maximum effect.

In future, a randomised clinical trial should bedone between single dose therapy andconventional treatment so that we can establishbetter protocol without increasing any harm tobaby or mother.


44/44

Date post:	05-Apr-2018
Category:	Documents
Upload:	antishf
View:	228 times
Download:	0 times

Antenatal Corticosteroid Therapy

Documents