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7/31/2019 Antenatal Corticosteroid Therapy
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Utilization of Antenatal Corticosteroids onpremature babies of 27-34 weeks of gestational age
born at ***** during 2003-2004
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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.
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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)
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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.
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Hyaline Membrane Distress (HMD) occursdue to inadequate production of pulmonarysurfactant in premature lung and is seen iflabour occurs before 32-34 weeks ofpregnancy.
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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.
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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.
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Antenatal Corticosteroid apart fromreducing RDS (HMD) also reduceintraventricular hemorrhage and neonatalmortality.
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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
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Contra indication of Antenatal corticosteroid :
woman suffering from systemic infectionincluding T.B
Caution is advised if suspectedchorioamnionitis is diagnosed.
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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.
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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.
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The optimacy of treatment:
The optimal treatment- delivery interval foradministration of ANS is more than 24 hrsbut fewer than 7 days after start oftreatment.
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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.
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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.
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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
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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
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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.
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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
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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.
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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
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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
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Grading of prematurity
Extreme premature: G.A of 26-32 weeksno=5
Severe premature: 28-31 weeksno=55
Mild premature: 32-34 weeksno=52
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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
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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%
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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
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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
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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.
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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%
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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%)
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It is costly when we use surfactant &ventilation.
Optimal ANS will help in decreasing thecost of treatment.
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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)
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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)
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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
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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.
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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.
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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.
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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.
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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
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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.
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