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7/28/2019 Chomba: Antenatal Corticosteroids for Threatened Preterm Delivery
1/23
Antenatal Corticosteroids for
Threatened Preterm Delivery
Prof. Elwyn Chomba, MBChB, DCH, MRCP
Permanent SecretaryMinistry of Community Health, Mother and Child Health,ZM
Global Network for Womens and Childrens Health Research
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Background
Global health perspective
Preterm birth (PTB) is the second leadingcause of Under-5 mortality, after pneumonia
1.1 million children die from direct
complications of preterm birth
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Key evidence-based interventions during
pregnancy and childbirth?
Background
Understand the gestational clock triggering
the onset of labour
Identify the causal pathways leading to
preterm labour and delivery
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Background
However, until there is better understanding
of the onset of labor and the causal
pathways, improved management ofpreterm birth can reduce mortality and major
morbidities
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Key Evidence-Based Interventions
for Threatened Preterm Delivery
Antenatal corticosteroids to reducemortality and major morbidities (i.e., RDS)
from prematurity
Antibiotics for premature rupture ofmembranes (pPROM) to prevent severe
morbidity
Roberts & Dalziel, 2006; Kenyon et al, 2010; Doyle LW et al, 2010;
Lawn et al, 2010
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Benefits of Antenatal
Corticosteroids
Antenatal corticosteroid administration is the
most effective intervention during pregnancy
to reduce neonatal mortality from preterm birth
ACS also reduce respiratory distress
syndrome (RDS), intraventricular hemorrhage
(IVH), sepsis, necrotizing enterocolitis, andneurodevelopmental impairment
Roberts & Dalziel, 2006
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Despite their effectiveness,antenatal corticosteroid use in low-
and middle-income countries
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Antenatal Corticosteroids Use
During Preterm Labour100%
80%
10%5%
30%4% - 71%
HIC LMIC
N=75
LMIC
N=42
Latin
America
N=6
Jones et al 2003
Darmstadt et al 2005
Born Too Soon report 2012
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Why is such an effective, safe, easy
to administer, and inexpensiveintervention is still underused in low-
and middle-income countries?
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Factors Related to the Underuse (1)
Pending questions
Is the effect similar at community level than
at hospital level?
Are they beneficial at therecommended/relevant gestational ages?
Factors related to organization Lack of availability of the drug
Difficulty in timely identification and treatment
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Factors Related to the Underuse (2)
Factors related to health providers and policy makers
Lack of awareness and familiarity with ACS
Competence to determine GA
Local regulations about who can administer the
medication
Factors related to women
Lack of access to an appropriate level of care
Lack of knowledge and awareness
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Antenatal Corticosteroids Trial in Preterm Births
to Increase Neonatal Survival in Developing
Countries (ACT Trial)
To evaluate whether a community-level multifaceted
intervention with components to:
- Improve the identification of pregnancies at high risk
of preterm birth
- Provide and facilitate the use of steroids
- Reduce neonatal mortality by 30% in preterm
newborns, compared to the standard delivery of careAlthabe F, Belizan JM, Mazzoni et al. Reproductive Health 2012, 9:22.
http://www.reproductive-health-journal.com/content/9/1/22. Global Network for Womens and
Childrens Health Research (NICHD)
http://www.reproductive-health-journal.com/content/9/1/22http://www.reproductive-health-journal.com/content/9/1/22http://www.reproductive-health-journal.com/content/9/1/22http://www.reproductive-health-journal.com/content/9/1/22http://www.reproductive-health-journal.com/content/9/1/22http://www.reproductive-health-journal.com/content/9/1/227/28/2019 Chomba: Antenatal Corticosteroids for Threatened Preterm Delivery
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ACT Trial
Cluster Randomized Controlled Trial
102 health regions (Home, PrimaryHealth Centre, and Hospital births)
6 countries
Argentina, Guatemala, India, Kenya,
Pakistan, and Zambia
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Components of the Intervention
Identification Gestational ageassessment
OR
Use PretermKit
REFER
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Obstetric Disk
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Delivery by Birth Attendant
TBA
37%
Family members19%
Physician
16%
Nurse/
midwife28%
Carlo et al. N Engl J Med. 362:614-23, 2010.
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Three Key Messages From the Born Too Soon
Care Group on Antenatal Corticosteroids
Both betamethasone and dexamethasone
are effective, but dexamethasone is less
expensive and more commonly available
ANCS may be beneficial in many contexts,
but current data supports hospital usage
The balance of risks is in favor oftreatment side effects are minimal while
potential benefit is substantial
Focus on
dexamethasone
for now
Focus on facility
use
for now
Adopt a lowthreshold for
giving
1
2
3
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Conclusions
1. ACS administration is the most effective
intervention during pregnancy to reduce
neonatal mortality
2. ACS administration is safe for the
mothers and babies
3. Use of ACS is low in developing countries
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200,000 deaths per year may
be averted if antenatalcorticosteroids use is increased
to 50% during preterm labour
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Supportive Environment Needed to
Implement ACS as Best Practice (1)
Establish national service delivery guidelines/
protocols integrated into existing guidelines.
Ensure functioning supply and delivery systems.
Incorporate updated ACS guidelines into pre-
service education for healthcare providers who
administer ACS.
Engage professional associations of healthcarecadres.
USAID and MCHIP
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Supportive Environment Needed to
Implement ACS as Best Practice (2)
Provide in-service training on ACS administration for allhealthcare providers.
Strengthen antenatal screening to include information for
all women with conditions such as preterm uterine
contractions, preterm rupture of membranes, andsymptoms of pre-eclampsia.
Increase community awareness of the importance of
preterm birth prevention and the signs of threatened
preterm birth.
Support the provision of essential newborn care after
delivery and referrals for babies born prematurely.
USAID and MCHIP
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THANKS!