Antenatal Steroids

Antenatal Antenatal corticosteroids to corticosteroids to

prevent prevent Respiratory Respiratory

Distress Distress SyndromeSyndromeDr. Ashraf Fouda

Damietta General Hospital

EVIDENCE BASED R.C.O.G. GUIDELINES

Revised February 2004

Preterm delivery rates vary from 6% to 15% of all deliveries, with the rate increasing in recent years.

Respiratory distress syndrome (RDS) causes significant mortality and morbidity in these babies.

RDS is known to affect 40–50% of babies born before 32 weeks. Evidence has been available

since 1972 that the antenatal administration of

corticosteroids prior to preterm delivery reduces the incidence

of RDS.

Effectiveness of antenatal Effectiveness of antenatal corticosteroid therapycorticosteroid therapy

Clinicians should offer antenatal Clinicians should offer antenatal corticosteroid treatment to women at corticosteroid treatment to women at

risk of preterm delivery because risk of preterm delivery because antenatal corticosteroids are antenatal corticosteroids are

associated with associated with a a significant reduction in rates of :significant reduction in rates of :

RDS, neonatal death and RDS, neonatal death and intraventricular haemorrhage.intraventricular haemorrhage. A

Healthcare organizations and services Healthcare organizations and services should have policies and protocols in should have policies and protocols in place for antenatal steroid treatment place for antenatal steroid treatment

because the cost and because the cost and duration of neonatal intensive care is duration of neonatal intensive care is

reduced following corticosteroid reduced following corticosteroid therapytherapy..

Effectiveness of antenatal Effectiveness of antenatal corticosteroid therapycorticosteroid therapy

B

The optimal treatment–delivery The optimal treatment–delivery interval for administration of interval for administration of antenatal corticosteroids is antenatal corticosteroids is

more than 24 hours but fewer more than 24 hours but fewer than seven days after the start than seven days after the start

of treatmentof treatment..

Effectiveness of antenatal Effectiveness of antenatal corticosteroid therapycorticosteroid therapy

A

The use of antenatal The use of antenatal corticosteroids in corticosteroids in

multiple pregnancies multiple pregnancies is recommendedis recommended, ,

but a significant reduction in rates but a significant reduction in rates of RDS has of RDS has not beennot been demonstrated. demonstrated.

Effectiveness of antenatal Effectiveness of antenatal corticosteroid therapycorticosteroid therapy

GPP

In preterm labour it is In preterm labour it is reasonable reasonable not not to use tocolytic drugsto use tocolytic drugs, , as there is no clear evidence as there is no clear evidence

that they improve outcome. that they improve outcome.

A

Effectiveness of antenatal Effectiveness of antenatal corticosteroid therapycorticosteroid therapy

However, clinicians should considerHowever, clinicians should consider the use of short-term tocolysisthe use of short-term tocolysis if the few days gained can be put to if the few days gained can be put to

good use, such as :good use, such as :

1.1. Completing a course of Completing a course of corticosteroids, or corticosteroids, or

2.2. In utero transfer.In utero transfer.

Effectiveness of antenatal Effectiveness of antenatal corticosteroid therapy corticosteroid therapy

A

If a tocolytic drug is used, If a tocolytic drug is used, ritodrine ritodrine no no longer seems to be the best choice. longer seems to be the best choice.

Atosiban or nifedipineAtosiban or nifedipine appear to be appear to be preferable, as they have fewer adverse preferable, as they have fewer adverse effects and seem to have comparable effects and seem to have comparable effectiveness.effectiveness.

AtosibanAtosiban is licensed for this usage in the is licensed for this usage in the UK but nifedipine is not.UK but nifedipine is not. A

Effectiveness of antenatal Effectiveness of antenatal corticosteroid therapycorticosteroid therapy

Corticosteroids after PROMCorticosteroids after PROM

Meta-analysis showed clear benefit for the use of antenatal corticosteroids after PPROM in reducing RDS.

Further studies, including a meta-analysis of RCT, have shown that a single course of corticosteroid therapy results in benefit without causing significant adverse effects such as neonatal sepsis.

A

SafetySafety

Women may be advised that the use Women may be advised that the use of a of a single coursesingle course of antenatal of antenatal

corticosteroids corticosteroids does not appeardoes not appear to to be associated with any significant be associated with any significant maternal or fetal adverse effects.maternal or fetal adverse effects.

A

The use of antenatal The use of antenatal corticosteroids in pregnancies corticosteroids in pregnancies

complicated by complicated by maternal diabetes maternal diabetes mellitus is recommendedmellitus is recommended, ,

but a significant but a significant reduction in rates of RDS has not reduction in rates of RDS has not

been demonstrated. been demonstrated.

SafetySafety

GPP

Indications for antenatal Indications for antenatal corticosteroid therapy corticosteroid therapy

Every effort should be made to initiate Every effort should be made to initiate antenatal corticosteroid therapy in women antenatal corticosteroid therapy in women between 24 and 34 weeks of gestation with any between 24 and 34 weeks of gestation with any of the following:of the following:

1.1. Threatened preterm labourThreatened preterm labour

2.2. Antepartum haemorrhageAntepartum haemorrhage

3.3. Preterm rupture of membranesPreterm rupture of membranes

4.4. Any condition requiring elective preterm Any condition requiring elective preterm delivery.delivery.

A

Between 35 to 36 weeksBetween 35 to 36 weeks obstetricians might want to obstetricians might want to consider antenatal steroid consider antenatal steroid use although the numbers use although the numbers

needed to treat will increase needed to treat will increase significantly.significantly.

Indications for antenatal Indications for antenatal corticosteroid therapycorticosteroid therapy

A

Contraindications and Contraindications and precautionsprecautions

Corticosteroid therapy is Corticosteroid therapy is contraindicated if a woman contraindicated if a woman suffers from suffers from systemic infectionsystemic infection including including tuberculosis.tuberculosis.

Caution is advised if suspected Caution is advised if suspected chorioamnionitischorioamnionitis is diagnosed. is diagnosed.

GPP

Dose and route of administrationDose and route of administration

BetamethasoneBetamethasone is the steroid of is the steroid of choice to enhance lung maturity. choice to enhance lung maturity.

Recommended therapy involves Recommended therapy involves two dosestwo doses of betamethasone of betamethasone 12 mg12 mg, given intramuscularly , given intramuscularly 24 hours apart24 hours apart..

B

The most extensively studied regimens of corticosteroid treatment for the prevention of RDS are:

1. Two doses of betamethasone 12 mg, given intramuscularly 24 hours apart and

2. Four doses of dexamethasone 6 mg, given intramuscularly 12 hours apart. C

Antenatal exposure to betamethasone, but not dexamethasone, is associated with a decreased risk of cystic periventricular leucomalacia among premature infants born at 24–31 weeks of gestation.

The RCOG recommends that betamethasone is the steroid of choice to enhance lung maturation.

C

Comparison of oral versus intramuscular dexamethasone suggests no difference in the frequency of RDS between the two modes of drug delivery but neonatal sepsis and intraventricular haemorrhage were significantly higher in the neonates of women receiving oral dexamethasone.

So, oral administration of steroids cannot be recommended for routine clinical use at present.

C

Repeated dosesRepeated doses

If repeat courses of antenatal If repeat courses of antenatal corticosteroids are contemplated corticosteroids are contemplated

then senior opinion should be then senior opinion should be sought as, at present, sought as, at present,

there is a lack of evidence to show there is a lack of evidence to show significant benefit.significant benefit.

A

Animal studies and observational studies in humans have suggested that multiple courses

of steroids may lead to;

Possible harmful effects including: 1. Growth delay, 2. Brain developmental delay, 3. Lung development problems, 4. Necrotizing enterocolitis, 5. Maternal and neonatal sepsis, 6. Adrenal gland insufficiency and 7. Placental infarction. C

Obstetricians should consider Obstetricians should consider enrolling their patients in enrolling their patients in

randomized controlled trials randomized controlled trials if repeat corticosteroid if repeat corticosteroid

therapy is contemplated.therapy is contemplated.A

Repeated dosesRepeated doses

Effectiveness of Effectiveness of thyrotrophin-releasing thyrotrophin-releasing

hormonehormone

The use of thyrotrophin-The use of thyrotrophin-releasing hormone releasing hormone is is not recommendednot recommended in in combination with antenatal combination with antenatal

corticosteroids.corticosteroids.A