Use Of Prenatal Corticosteroids Research Articles

Rectal and axillary admission temperature in preterm infants less than 32 weeks' gestation, a prospective study.

The purpose of this research was to evaluate the differences between rectal and axillary temperature measurements in preterm infants who were born less than 32 weeks' gestation using digital thermometers upon their admission to the Neonatal Intensive Care Unit (NICU). Prospective, observational, single centre study. Rectal and axillary temperatures measurements were performed using a digital thermometer. The study examined various maternal and neonatal factors to describe the study group, including the use of prenatal corticosteroids, the occurrence of maternal diabetes and hypertension, a history of maternal prolonged rupture of membranes (PROM), maternal chorioamnionitis, the mode of delivery, along with the neonate's gender, birth weight, and gestational age. The Pearson correlation coefficient (R) was calculated to ascertain the linear relationship between the temperatures taken at the rectal and axillary sites. The concordance between the two sets of temperature data was analyzed using the Bland-Altman method. Eighty infants with a mean gestational age of 28.4 weeks (SD = 2.9) and a mean birth weight of 1,229 g (SD = 456) were included in the study. The mean axillary temperature was 36.4 °C (SD = 0.7), which was lower than the mean rectal temperature of 36.6 °C (SD = 0.6) (p = 0.012). Rectal temperatures surpassed axillary measurements in 59% of instances, while the reverse was observed in 21% of cases. Rectal and axillary temperatures had a strong correlation (Pearson correlation coefficient of 0.915, p < 0.001). Bland-Altman plot showed a small mean difference of 0.1C between the two temperatures measurements but the limits of agreement were wide (+0.7 to -0.6 °C). For hypothermic infants, the mean difference between rectal and axillary temperatures was 0.27 °C, with a wide limit of agreement ranging from -0.5 °C to +1 °C. Conversely, for normothermic infants, the mean difference was smaller at 0.1 °C, with a narrower limit of agreement from -0.4 °C to +0.6 °C. While there is a good correlation between axillary and rectal temperatures, the wider limits of agreement indicate variability, particularly in hypothermic infants. For a more accurate assessment of core body temperature in hypothermic infants, clinicians should consider using rectal measurements to ensure effective thermal regulation and better clinical outcomes.

FIGO good practice recommendations on the use of prenatal corticosteroids to improve outcomes and minimize harm in babies born preterm.

For women with a singleton or a multiple pregnancy in situations where active neonatal care is appropriate, and for whom preterm birth is anticipated between 24 and 34weeks of gestation, one course of prenatal corticosteroids should ideally be offered 18 to 72h before preterm birth is expected to improve outcomes for the baby. However, if preterm birth is expected within 18h, prenatal corticosteroids should still be administered. One course of corticosteroids includes two doses of betamethasone acetate/phosphate 12mg IM 24h apart, or two doses of dexamethasone phosphate 12mg IM 24h apart. In women in whom preterm birth is expected within 72h and who have had one course of corticosteroids more than a week previously, one single additional course of prenatal corticosteroids could be given at risk of imminent delivery. Prenatal corticosteroids should not be offered routinely to women in whom late preterm birth between 34 and 36weeks is anticipated. In addition, prenatal corticosteroids should not be given routinely before cesarean delivery at term. Neither should prenatal corticosteroids be given "just in case". Instead, prenatal steroid administration should be reserved for women for whom preterm birth is expected within no more than 7days, based on the woman's symptoms or an accurate predictive test.

The Underlying Causes of Respiratory Distress in Late-Preterm and Full-Term Infants Are Different From Those of Early-Preterm Infants

Background: A diagnosis of neonatal respiratory distress syndrome (RDS) is common among newborns in China. Some late-preterm and full-term (LP/FT) infants with respiratory distress (RD) symptoms but not primary surfactant deficiency are also diagnosed with RDS and given exogenous surfactant replacement therapy (SRT). Objectives: An increasing number of neonatologists have proposed that RD etiologies should be specifically classified to guide clinical treatment. Methods: The therapeutic effects of SRT on infants of different gestational ages (GAs) were compared in a large retrospective multicenter cohort study performed at 26 Neonatal Intensive Care units in China. The cause of RD at different GAs was further analyzed by comparing the different risk factors closely related to RDS severity at different GAs. Results: Analysis of 1240 infants diagnosed with RDS showed that SRT was less effective in LP/FT infants than in early-preterm (EP) infants. GA &lt; 30 weeks and no prenatal corticosteroid use were closely related to RDS severity in EP infants, whereas perinatal infection- and perinatal hypoxia-associated risk factors and a high cesarean rate were closely related to RDS severity in LP/FT infants. Conclusions: The causes of RD might differ between LP/FT and EP infants, and the diagnosis of RDS might be overused in LP/FT infants. RD in LP/FT infants is more likely related to perinatal infection, perinatal hypoxia, elective cesarean and hereditary factors, which are important causes of neonatal pulmonary edema. New strategies for the treatment of refractory RD in LP/FT infants should concentrate more on pulmonary edema and neonatal ARDS.

Neonatal morbidity and mortality associated with low adherence to prenatal corticosteroids

IntroductionPrenatal corticosteroids reduce neonatal mortality and morbidity; however, there are few studies in developing countries, and with inconsistent results. The purpose of this study was to quantify the frequency of the use of prenatal corticosteroids and to estimate its effect on the morbidity and mortality of premature newborns. MethodsA retrospective cohort study was performed on premature newborns selected from a census conducted between January 2016 and August 2017. The use of corticosteroids was taken from the maternal records, and the dependent variables from the neonatal records. An analysis was made of the relationship using logistic regression, adjusted to gestational age and weight. ResultsThe study included 1083 premature infants of which 53.3% were male. The mean gestational age was 33.4 weeks. Corticosteroids were received by 42%, with latency ≥24h in 23.6% and ≥48h in 13.8%. Respiratory distress syndrome was observed in 35% (379/1083), early neonatal sepsis in 4.4% (48/1083), late neonatal sepsis in 10.7% (116/1083), intraventricular haemorrhage in 15.1% (137/908), chronic lung disease in 51.4% (165/321), and death in 22.3% (242/1083). Prenatal corticosteroids decreased the risk of death in children under 34 weeks (OR 0.63, 95% CI 0.40–0.98). The decrease was greater if they presented with latency ≥48h (OR 0.40, 95% CI 0.20–0.80). The rest of the dependent variables were not modified by the intervention. ConclusionsIn preterm infants, 42% received antenatal corticosteroids. In those with less than 34 weeks, there was a decrease in the risk of death without changes in morbidity.

Does the Use of Antenatal Corticosteroids Decrease Levels of Neonatal Hyperbilirubinemia in Preterm Infants? [15K

INTRODUCTION: The use of prenatal corticosteroids for pregnant women between 34-36 6/7 weeks of pregnancy is recommended to reducing the morbidity of late preterm infants. METHODS: This is a secondary analysis of a randomized clinical trial conducted to determine the effectiveness of corticosteroids in reducing respiratory disorders in infants born at 34-36 weeks' gestation Trial registration Clinical Trials NCT00675246. This study was approved by IRB and all participants signed an informed consent term. RESULTS: Of 245 preterm infants, the number of newborns with gestational age 34, 35 and 36 was 30 (12.2%), 110 (45.1%), and 105 (42.7%), respectively. Jaundice occurred in 150 (62.5%) newborns and 70 among them required phototherapy during hospitalization. Late preterm infants exposed to corticosteroids started treatment with lifetime of 61.2± 33.6 h vs. 48.3± 25.3 h (p = 0.03) with similar levels of bilirubin (12.1± 3.2 mg/dL vs. 12.8± 3.7 mg/dL, p = 0.38) when compared to the control group. They required less treatment compared to the placebo group (n = 27 vs. n = 42, p = 0.025), and spent less days on phototherapy (1.7± 1.7 vs. 2.6± 2.2, p = 0.05). CONCLUSION: Late preterm infants exposed to prenatal corticosteroids had less need for phototherapy and shorter treatment. Also, they developed elevated level of bilirubin later. This result suggests that prenatal corticosteroids decrease the levels of hyperbilirubinemia in late preterm infants.

Different Causes of Respiratory Distress in Neonates at Different Gestational Ages in China: A Retrospective Multi-Center Cohort Study

Background: Pulmonary surfactant replacement therapy (SRT) is currently the main treatment for neonatal respiratory distress syndrome (NRDS), but not all infants, particularly late-preterm and full-term (LP/FT) infants, with NRDS can achieve a satisfactory outcome despite intensive care and SRT in China. Few studies have been done to investigate the risk factors associated with respiratory distress at different gestational ages to guide clinical treatment. Methods: Therapeutic effects of SRT(conventional dose) in infants at different gestational ages (GAs) were compared in a large retrospective multicenter cohort study performed in 26 neonatal intensive care units in China. The cause of respiratory distress was further analyzed by comparing the different risk factors closely related to NRDS severity at different GAs. Results: The study of 1240 infants with NRDS showed that SRT in a conventional dose was less effective in LP/FT infants than in early-preterm infants. Further analysis of the risk factors of respiratory distress revealed that a GA less than 30 weeks and a lack of prenatal corticosteroid use were closely related to NRDS severity in early-preterm infants, whereas perinatal infection- and perinatal hypoxia-associated risk factors were closely related to NRDS severity in LP/FT infants. Conclusion: The cause of respiratory distress in LP/FT infants might differ from that in early-preterm infants in China. Respiratory distress in early-preterm infants is mostly due to primary surfactant deficiency. However, respiratory distress in LP/FT infants is more likely related to perinatal infection and perinatal hypoxia. Funding: This trial was designed, organized, and implemented by the first author and the corresponding author’s research center. Public funding was obtained from the Emergency Project of the National Science Foundation of China (No. 81741065) and Scientific Research Projects Unit of Chongqing (Project-cstc2016shms-ztzx13001) (Project-cstc2015shmszx1201114). Declaration of Interest: None of the authors have conflicts of interest to disclose. Ethical Approval: The ethics committee of Daping Hospital approved the study protocols, according to the Chinese regulations for clinical investigation.

Different Causes of Respiratory Distress in Neonates at Different Gestational Ages

Background: Surfactant replacement therapy has been widely used for the treatment of neonatal respiratory distress syndrome (NRDS). However, not all infants, especially near-term and term infants, with respiratory distress can achieve a satisfactory outcome despite intensive care and surfactant replacement therapy. Few studies have attempted to distinguish and analyze the causes of respiratory distress according to gestational age. Methods: A retrospective multicenter study was performed in 26 neonatal intensive care units (NICU) in China from 2011 to 2016. The therapeutic effect of surfactant therapy in infants at different gestational ages was compared. By comparing the differences in risk factors that are closely related to the severity of NRDS at different gestational ages, the cause of respiratory distress at different gestational ages was further analyzed. Results: In total, 1240 infants with NRDS were included in this study. Surfactant therapy was less effective in the near-term and term infants than that in the early preterm infants. Further analysis of the causes of respiratory distress at different gestational ages revealed that a gestational age of less than 30 weeks and a lack of prenatal corticosteroid use were closely related to the severity of NRDS in the early preterm infants. However, perinatal infection- and perinatal hypoxia-associated risk factors were closely related to the severity of NRDS in the near-term and term infants. Conclusion: The cause of respiratory distress in near-term and term infants differs from that in early preterm infants. Some newborn infants with respiratory distress may not have NRDS. Respiratory distress in early preterm infants is mostly due to primary surfactant deficiency, which belongs in the category of NRDS. However, respiratory distress in near-term and term infants is more likely related to perinatal infection and perinatal hypoxia and may belong to the category of NARDS. Trial Registration Number: NCT03385863 Funding: This trial was designed, organized and implemented by the first author and the corresponding author’s research center. Public funding was obtained from the Emergency Project of the National Science Foundation of China (No. 81741065) and Scientific Research Projects Unit of Chongqing (Project-cstc2016shms-ztzx13001) (Project-cstc2015shmszx1201114) Conflict of Interest: None of the authors have conflicts of interest to disclose. Ethical Approval Statement: See link in PDF.

Providers' compliance with practice guidelines of prenatal and neonatal care to reduce neonatal mortality: 2004 versus 2012.

To evaluate providers' compliance with practice guidelines of prenatal and neonatal care in order to reduce neonatal mortality. Uncontrolled before-and-after study designed to evaluate changes that occurred between 2004 and 2012, after the interventions proposed by the Municipality Committee of Research on Child Deaths, Foetal and Maternal Death (COMAI) on the frequency of the process indicators for perinatal assistance improvement. A total of 254 patients were studied in 2004 and 259 patients in 2012. During the study period, there was an increase of 65% in the use of prenatal corticosteroids among pregnant women in preterm labor with gestational age of ≤ 34 weeks (rate of use of 38.0 and 62.8% in 2004 and 2012, respectively; p < 0.001), 35% of increase in the use of surfactant among newborns with ≤ 34 weeks of gestational age (41.3 and 55.6% in 2004 and 2012, respectively; p = 0.025) and a reduction of 16% in the prevalence of hypothermia (70.8 and 59.4% in 2004 and 2012, respectively; p = 0.009) at the neonatal intensive care unit admission. Prenatal and neonatal care practices improved between 2004 and 2012. At the end of the study period, rates of use of antenatal steroids and surfactant were lower than figures reported internationally. Similarly, the frequency of hypothermia at the neonatal intensive care unit admission was higher than the occurrence observed in developed countries.

Antenatal Dexamethasone For Women at Risk af Preterm Birth and Intraventricular Haemorrhage: What is the Truth?

Administration of antenatal corticosteroids to pregnant women with imminent delivery of a newborn at 24 to 34 weeks of gestation represents one of the most important advances in perinatal medicine in the past 25 years (1, 2). A single course of antenatal steroid has been associated with a decrease in acute neonatal systemic morbidity and mortality after preterm birth reducing the risk of respiratory distress syndrome and intraventricular haemorrhage (IVH) (2, 3). Currently, the only corticosteroids that are used for such prophylactic therapy are betamethasone administered intramuscularly as two doses of 12 mg each 24 h apart or four doses of 6 mg of dexamethasone given intramuscularly 12 h apart (1, 2). Both readily cross the placenta in their active form with nearly identical biological impact1. Both are devoid of mineralcorticoid activity and have relatively weak immunosuppressive actions with short term use in comparison to other forms of steroids (1, 2 and 4). However, there is conflicting evidence on efficacy and safety of these agents to prevent adverse outcomes in preterm babies for what concerns IVH in particular (1-3). To date, considerable disparity exists between physician beliefs and actual practice habits in worldwide Obstetrics Units lacking sufficient data to recommend one steroid regimen over the other (1-3). IVH is the most common neurological complication of prematurity (6). It has emerged as a global health problem in relation to the increasing incidence of preterm birth (6). No therapy of IVH is currently available and the use of prenatal corticosteroids in women in preterm labor represents the only widely practiced preventive strategy (1, 2 and 6). IVH typically initiates in the germinal matrix (5). It has been suggested that prenatal corticosteroids reduce the propensity of germinal matrix to hemorrhage through its vasculature stabilization (5). Dexamethasone treatment has been shown to reduce the rate of IVH more than betamethasone (1, 3). In contrast, others found that dexamethasone may be neurologically detrimental when compared with betamethasone (2-4). It has been observed that there is abundance of apoptotic neuronal cells and neuronal degeneration after exposure to prenatal glucocorticoids with marked discrepancy among the human, rabbits and sheep fetuses (5). Betamethasone has been found to be safer and more protective for the immature brain than dexamethasone (6). On the contrary, dexamethasone has been related to a higher risk of persistent brain parenchymal hyperechogenicity in comparison to betamethasone (7). It has been demonstrated that dexamethasone down-regulate survivin expression (8, 9). Survivin is the smallest member of the inhibitors of apoptosis gene family that plays an essential role in vascular cell responses to ischemia in brain (10-14). It has been highlighted that survivin mediates the antiapoptic effects of ischemic preconditioning via phosphatidylinositol 3'–kinase/AKT(PI3K/AKT) pathways (15). Concordantly, dexamethasone causes a significant down-regulation of PI3K/AKT signaling pathway resulting in increases in indices of cell apoptosis in brain (11, 15). The signaling interaction between survivin and PI3K/AKT has also been described to be essential for endothelial progenitor cells (EPCs) proliferation that are the major source of cells in endothelial repair after vascular injury (15, 16). A variety of studies not only has proposed a role for survivin in the extent of vascularization of the infarct but also has suggested the notion for treatment of brain injury by up-regulation of surviving (10-12). Dexamethasone has also been linked to over-expression of MAPK phosphatase-1 (MKP-1) which antagonizes the activity of mitogen-activated protein-kinases (MAPKs) (13). Intriguingly, the activity of MAPKs has been described as a signal transduction pathway upstream of surviving (14). With respect to the above, we advance the hypothesis that prenatal dexamethasone exposure may not protect preterm infants against IVH down-regulating the expression of survivin that plays a key role in the protection of brain cells against insult-induced apoptosis. Research studies are needed to better define whether antenatal betamethasone may be the best alternative therapy for antenatal prevention of IVH and whether dexamethasone may sensitize immature brain to IVH involving dose timing and treatment regimen.

Postnatal Steroids and Febrile Seizure Susceptibility in Preterm Children.

To investigate risk factors, seizure characteristics, and outcomes of febrile seizure (FS) in children born very preterm. This study used a prospective registry data set of 844 preterm infants (birth weight <1500 g and gestational age <32 weeks) admitted to NICUs from 2001 to 2009 in southern Taiwan. We investigated the prevalence, risks, seizure patterns, and outcomes of FS in children aged 5 years. Among 575 children (follow-up rate, 85.8%) followed up for 5 years, 35 (6.1%) developed FS. The FS and non-FS groups were comparable regarding their mean gestational age, birth weight, 5-minute Apgar score <6, and prenatal and postnatal complications. No difference was observed in the use of prenatal corticosteroids between the 2 groups. The FS group had a significantly higher rate of postnatal corticosteroid treatment than the non-FS group, even after adjusting for confounding factors (odds ratio, 5.4 [95% confidence interval, 1.9-15.8]; P = .006). No differences were observed in IQs or subsequent epilepsy rates between the 2 groups. Although no difference was observed in the age of FS onset or neurodevelopmental outcomes between the 2 groups, children with FS who received postnatal corticosteroid treatment had a significantly lower mean body temperature during the first FS attack compared with those who did not receive postnatal corticosteroid treatment (38.6 ± 0.4°C vs 39.2 ± 0.6°C; P = .034). Children born very preterm have a higher rate of FS, and postnatal corticosteroid treatment was associated with FS susceptibility in these children.

Factors associated with the use of prenatal corticosteroids in the management of preterm delivery in Chinese hospitals

ObjectiveTo assess the prevalence of the use of prenatal corticosteroids (PCS) in the management of preterm delivery and the factors associated with PCS administration. MethodsA secondary analysis was performed of a cross-sectional study conducted in 21 Chinese healthcare facilities between November 2010 and January 2011. The medical records of women who delivered preterm were reviewed. Associations between PCS administration and individual and organizational-level factors were determined. ResultsThe study population comprised 659 women who delivered at 20 facilities. PCS were given to 158 (68.1%) of 232 women delivering after 27–34weeks of pregnancy and 119 (27.9%) of 427 delivering after 35–36weeks. Teenaged girls were less likely to receive PCS after 27–34weeks than were women aged 20–35years (odds ratio [OR] 0.22; 95% confidence interval [CI] 0.07–0.70). Among women who delivered after 35–36weeks, the odds of receiving PCS were lower in urban hospitals than in periurban or rural hospitals (OR 0.04; 95% CI 0.00–0.44), and there was significant hospital-level variance with regard to the administration of PCS (P<0.05). ConclusionGenerally, PCS were underprescribed to women at risk of preterm delivery and many women received the treatment after 35–36weeks of pregnancy, when it might not have been effective.

Thyrotropin-releasing hormone added to corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease

Thyrotropin-releasing hormones (TRH) added to prenatal corticosteroids has been suggested as a way to further reduce breathing problems and neonatal lung disease in infants born preterm. To assess the effects of giving prenatal TRH in addition to corticosteroids to women at risk of preterm birth for the prevention of neonatal respiratory disease. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013) and reference lists of retrieved studies. We also contacted trial authors. Randomised controlled trials in women at sufficient risk of preterm birth to warrant the use of prenatal corticosteroids to promote lung maturity. TRH and corticosteroids were compared with corticosteroids, with or without placebo. All assessments of trial eligibility, risk of bias and data extractions were independently carried out by at least two review authors. Over 4600 women were recruited into the 15 trials included in the review, however two trials did not contribute any outcome data to the review. The trials had a moderate risk of bias. Overall, prenatal TRH, in addition to corticosteroids, did not reduce the risk of death prior to hospital discharge (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.86 to 1.27, six trials, 3694 infants), neonatal respiratory distress syndrome (average RR 1.05, 95% CI 0.91 to 1.22, nine trials, 3833 infants), or chronic lung disease (RR 1.01, 95% CI 0.85 to 1.19, five trials, 2511 infants), and did not improve any of the secondary fetal, neonatal or childhood outcomes assessed by intention-to-treat analyses.Indeed, the data showed prenatal TRH to have adverse effects for women and their infants. All side effects reported (nausea, vomiting, light headedness, urgency of micturition, facial flushing) were significantly more likely to occur in women receiving TRH. In the infants, prenatal TRH increased the risk of needing respiratory support (RR 1.16, 95% CI 1.03 to 1.29, three trials, 1969 infants), and of having a low Apgar score at five minutes (RR 1.48, 95% CI 1.14 to 1.92, three trials, 1969 infants). Only three trials provided data on childhood follow-up, and while one trial suggested poorer outcomes for infants who were exposed to prenatal TRH, the other two trials, that assessed infants using an established developmental instrument, showed no clear differences between groups in follow-up outcomes.Sensitivity analyses by trial quality, or subgroups with differing times from entry to birth, or different dose regimens of TRH, did not change these findings. Prenatal TRH in addition to corticosteroids, given to women at risk of preterm birth, does not improve infant outcomes and can cause maternal side effects.

Manejo perinatal en el límite de la viabilidad. Propuestas de abordaje en un hospital terciario

This article aims to provide a clinical practice guideline on perinatal management in fetuses/neonates at the threshold of viability (below a gestational age of 256/7 weeks). We reviewed the main literature published in the last few years. On the basis of outcomes in morbidity and mortality in our hospital and consensus with neonatologists, we established a management protocol in our center. We propose a protocol in which, gestational age or, in its absence, birth weight are used to determine the kind of prenatal care provided, the need for neonatal transport, use of prenatal corticosteroids, mode of delivery and neonatal resuscitation. This protocol is applied in close collaboration with neonatologists and with parents’ participation in the decision to treat.

A conference report on prenatal corticosteroid use in low- and middle-income countries

Objective To evaluate the evidence for prenatal corticosteroid use in low- and middle-income countries and to make recommendations regarding implementation and further research. Methods Studies and meta-analyses on prenatal corticosteroids relevant to low- and middle-income countries were identified and reviewed at the Maternal and Child Health Integrated Project (MCHIP) Antenatal Corticosteroid Conference held in Washington on October 19, 2010. Results There is strong evidence regarding the effectiveness of prenatal corticosteroid use in hospitals in high- and middle-income countries, usually in settings with high-level newborn care. For births occurring in hospitals in low-income countries without high-level neonatal care or for births outside hospitals, no studies have been conducted to evaluate prenatal corticosteroid use. The efficacy and safety of prenatal corticosteroid use in these settings must be evaluated. Conclusions The conference working group recommended expanding the use of prenatal corticosteroids in hospitals with high-level newborn care in low-income countries. For other low-income country settings, further research regarding efficacy and safety should precede the widespread introduction of prenatal corticosteroids.

Estrategias para Mejorar la Sobrevida del Prematuro Extremo

Introduction: Biomedical advances have not decreased the number of premature deliveries. Newborns under 32 weeks constitute the most significant portion of infant mortality in developed countries. Objective: a literature review that identifies risk factors associated to premature labor and highlight strategies that increase survival. Results: Prenatal factor associated to early delivery include Black descent, maternal age, history of premature delivery, socioeconomic stratus, multiple deliveries and infections. Mortality is increased with earlier gestational age and lower fetal weight. Factors associated to increased survival include area of residence and place of birth, uterine transfer, variable levels of neonatal care, use of prenatal corticosteroids to accelerate pulmonary maturation, proactive management during childbirth, use of artificial surfactant and avoid use of steroids after delivery. Neonatal networks improve survival by potentiating best practices. Conclusions: Survival among these patients is enhanced by identification of risk factors for early delivery, knowing strategies that improve survival and planning for delivery in sites where best practices are offered.

Use of prenatal corticosteroids for preterm birth in three Latin American countries

Objective To determine the prevalence of the use of prenatal corticosteroids in women who delivered prematurely in 3 Latin American counties and to evaluate the maternal characteristics associated with use. Methods A multicenter, prospective, descriptive study was conducted in 4 hospitals in Ecuador, 5 in Uruguay, and 3 in El Salvador between 2004 and 2008. Women who had delivered between 24 and 34 weeks of pregnancy responded to a questionnaire assessing sociodemographic characteristics, obstetric history, prenatal care, women's attitudes to health services and knowledge of preterm risk factors, prenatal corticosteroid administration, and characteristics of the delivery and neonate. The association between the prenatal corticosteroid use and the study variables was evaluated through a logistic regression analysis based on a hierarchical model. Results A total of 1062 women who had a preterm birth were included in the study. Prenatal corticosteroid use was 34.8% (95% CI, 29.9%–39.9%) in Ecuador, 54.6% (95% CI, 49.6%–59.6%) in El Salvador, and 71.0% (95% CI, 65.3%–76.2%) in Uruguay. Hospital admission-to-delivery time was associated with the use of prenatal corticosteroids in all 3 countries. Conclusion The study revealed a varied pattern of use of prenatal corticosteroids across the 3 countries, and a diversity of influencing factors.

Prenatal Corticosteroid Prophylaxis for Women Delivering at Late Preterm Gestation

We studied patterns of prenatal corticosteroid use, respiratory distress syndrome, and associated mortality rates to assess the congruence between knowledge and clinical practice related to such prophylaxis. We used data on all live births in the United States (for the years 1989-1991, 1995-1997, and 2002-2004) and Nova Scotia, Canada (for the years 1988-2007). Gestational age-specific temporal trends in infant deaths resulting from respiratory distress syndrome were quantified in the United States, and gestational age-specific temporal trends in corticosteroid use and morbidity (respiratory distress syndrome and intraventricular hemorrhage) were quantified in Nova Scotia. In the United States, infant deaths associated with respiratory distress syndrome decreased by 48% (95% confidence interval: 46%-50%) from 1989-1991 to 1995-1997 and then decreased by another 18% (95% confidence interval: 15%-22%) by 2002-2004. The latter mortality reduction was evident at 28 to 32 weeks but not 33 to 36 weeks of gestation. Corticosteroid use at 28 to 32 weeks was high in Nova Scotia and increased from 30.7% in 1988-1989 to 50.0% in 1996-1997 and to 52.9% in 2006-2007, whereas rates of use at 33 to 36 weeks were much lower (eg, 6.7%, 17.0%, and 15.7% at 34 weeks in the 3 periods). Increased corticosteroid use at 33 and 34 weeks was estimated to reduce respiratory distress syndrome substantially. Addressing the knowledge-practice gap in corticosteroid use at 33 to 34 weeks should reduce infant morbidity and mortality rates.

Chronic lung disease of prematurity: A short history

Chronic lung disease of prematurity (CLD) is commonly considered to be a consequence of assisted ventilation. However, prior to the description in 1967 of bronchopulmonary dysplasia (BPD), following ventilator therapy for respiratory distress syndrome, Wilson-Mikity syndrome (WMS) had been described in very preterm infants on minimal oxygen supplementation. In the 1970s and 1980s, many infants treated with assisted ventilation required prolonged mechanical ventilation after developing radiographic features of coarse infiltrates, severe hyperinflation, and microcystic changes, associated with hypercarbemia and the need for increased inspired oxygen concentrations. Some infants died and showed evidence of pulmonary fibrosis, obstructive bronchiolitis, and dysplastic change. The role of supplemental oxygen, positive pressure ventilation, and the immaturity of the lung have long been considered important in the etiology of CLD/BPD. More recently, the role of inflammation (particularly antenatal exposure to cytokines) and individual susceptibility (genetic predisposition) have assumed greater etiologic importance. The historical setting into which corticosteroid treatment for BPD was introduced is also discussed. After the licensing of exogenous surfactant to treat RDS in the early 1990s and more widespread use of prenatal corticosteroids in the mid-1990s, severe BPD became an unusual event. Gradually, the diagnosis of CLD, still often referred to as BPD, was based on an oxygen requirement at 36 weeks postmenstrual age. However, it is not clear that this 'new BPD' is substantially different from WMS. It is difficult to make prognostications about long-term lung function of these infants based on oxygen 'requirement' at 36 weeks, since supplemental oxygen is frequently used unnecessarily.

Using Intensive Care Technology in the Delivery Room: A New Concept for the Resuscitation of Extremely Preterm Neonates

Despite dramatic improvements in survival rates of preterm infants over the last 50 years, there have been no significant further improvements in survival or morbidity rates over the most recent 10 years.1,2 Survival rates among infants with a birth weight of 500 to 1500 g in participating centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network of the United States were 84% in 1995–1996 and 85% in 1997–2002; the survival rate without major neonatal morbidity (which included bronchopulmonary dysplasia [BPD], intraventricular hemorrhage, and necrotizing enterocolitis) was unchanged (70%) between these 2 time periods.1 Similar findings were observed in epidemiologic data from Norway and Germany, which were published almost coincidentally.2,3 New paradigms for addressing care of extremely preterm infants may be necessary to achieve further improvements in outcome. Before the last decade, increased survival rates of preterm infants had been attributed to regionalization of high-risk pregnancies, use of prenatal corticosteroids, and an aggressive approach to perinatal therapy.4 Birth in a high-risk perinatal center with a higher level of neonatal care is associated with better survival rates than birth in a center that provides a lower level of care,5 and mortality and morbidity rates are increased for the most immature infants who require transport after birth.6 Some of the major morbidities associated with extreme prematurity such as BPD and intraventricular/periventricular hemorrhage could potentially be affected by management in the first minutes of life. However, the principles of care that occur in the NICU are not always used in the delivery room (DR). Care of the smallest preterm infants in the DR has received very little attention in newborn-resuscitation protocols. It is only with the most recent edition of the Neonatal Resuscitation Program textbook7 … Address correspondence to Maximo Vento, PhD, MD, Hospital Universitario Materno Infantil La Fe, Neonatal Research Unit, Division of Neonatology, Avenida de Campanar, 21, E46009 Valencia, Spain. E-mail: maximo.vento{at}uv.es or maximovento{at}telefonica.net

Prenatal Corticosteroids

After completing this article, readers should be able to: 1. Describe the standard of care for prenatal corticosteroids for women in preterm labor prior to 34 weeks’ gestation. 2. Describe the effects of prenatal corticosteroids on the fetus. 3. List the preferred corticosteroid for prenatal treatments. 4. Explain the recommendation regarding not using repetitive courses of prenatal corticosteroids. Prenatal glucocorticoids are standard of care for women at high risk of preterm delivery prior to 34 weeks’ gestation because randomized, controlled trials and extensive meta-analyses demonstrate decreased death and improved outcomes, primarily related to less respiratory distress syndrome (RDS) and a decreased incidence of intraventricular hemorrhages (IVH) (Fig. 1). (1) However, it is worth remembering that the benefits of prenatal corticosteroids initially were demonstrated in 1972, and most of the trials were completed before 1985. Most infants in the trials were delivered after 28 weeks’ gestation and in the presurfactant era, when mortality rates for infants whose birthweights were less than 1 kg were high and when obstetric management differed from current practice. Maternal corticosteroid therapy is validated practice, but care strategies proven to be effective may lose effectiveness as other aspects of care change and the target population most likely to benefit changes. This review asks a series of questions to frame the overriding question of how antenatal corticosteroids should be used in 2006. Figure 1. Meta-analysis of randomized controlled trials of prenatal corticosteroids. Adapted from Crowley. (1) The current recommendations come from the 1994 National Institutes of Health (NIH) Consensus Conference and were reinforced by a second NIH Consensus Conference in 2000. (2) The key points from the guidelines are: 1. The benefits of prenatal corticosteroids outweigh any risks that have been identified. The benefits include decreased death and decreased incidence of RDS and IVH. 2. All fetuses at 24 to 34 weeks’ gestation are candidates …