The 2016 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists is ongoing from May 14 to May 17 at the Washington Convention
Center in Washington, DC.
Recent
clinical trials have led to two important changes in recommendations by ACOG
and SMFM on management of preterm births. Steroids are recommended at 23 weeks
and at 34-36 weeks to reduce the risks associated with preterm delivery.
Dr. Uma
Reddy, MD, MPH, Pregnancy and Perinatology Branch of the Eunice Kennedy Shriver
National Institute of Child Health and Human Development at the National
Institutes of Health said “All of these changes in practice
recommendations will have a real impact on preterm birth.” “We have
already seen a significant decrease in preterm births since a high of 12.8
percent in 2006,” she added. “Preterm birth fell to 11.4 percent in 2013, the
last year for which we have complete data. We have had a positive impact in
reducing preterm birth.”
The latest recommendations
were discussed at Saturday clinical seminar at ACOG annual conference on Saturday
May 14, 2016.
ACOG
and the Society for Maternal-Fetal Medicine (SMFM) is now suggesting a single
course of steroids for pregnant women starting at 23 weeks who are at risk for
preterm birth within seven days. This recommendation is based on a cohort study
involving US top 23 academic pediatric centers. It was seen that infants born
at 23 to 25 weeks who received antenatal steroids had lower rates of death and
lower rates of neurodevelopmental impairment at 18 to 22 months.
The second
important recommendation was based on results of the Antenatal Later Preterm Steroids (ALPS) trial reported earlier this year by the Maternal-Fetal Medicine
Units Network. A single course of betamethasone in singleton pregnancies
between 34 and 36 weeks in women at risk for preterm birth should be given.
The trial
showed reduction in the need for respiratory support, reduction in severe
respiratory complications, decreased transient tachypnea(TTN), bronchopulmonary
dysplasia, and the need for postnatal surfactant. There was no increase in
neonatal sepsis, chorioamnionitis, or endometritis, but hypoglycemia was more
common in infants exposed to betamethasone.
These new recommendations
are in addition to old recommendations that suggest that all pregnant women between
24 and 34 weeks who are at risk for preterm delivery within seven days receive
a single course of corticosteroids. A single rescue course should be considered
if a prior course was given at least seven days earlier and the woman remains
at risk for preterm birth before 34 weeks.
In summary:
- With the release of this new data and until further guidance is released, administration of betamethasone may be considered in women with a singleton pregnancy between 34 0/7 and 36 6/7 weeks gestation at imminent risk of preterm birth within 7 days.
- For women in active labor, it is advised to wait for cervical dilatation up-to 3 cm or 75% effacement before administering betamethasone.
- Tocolysis should not be used in order to delay delivery to allow for administration of late preterm antenatal corticosteroids, nor should an indicated late preterm delivery (such as for preeclampsia with severe features) be postponed for steroid administration.
- All hospitals should utilize standard guidelines for management of hypoglycemia in late preterm newborns.
- Late preterm antenatal corticosteroid administration should not be used in women diagnosed with chorioamnionitis.
- Administration of late preterm antenatal corticosteroids should not be given if the pregnancy was already exposed to antenatal corticosteroids.
- Because the ALPS trial excluded pregnant women with diabetes, multifetal gestations, previous exposure to steroids during pregnancy, or pregnancies with major non-lethal fetal malformations, ACOG is reviewing these topics and will issue any updated clinical guidance as appropriate.
References:
http://www.nejm.org/doi/full/10.1056/NEJMoa1516783?af=R&rss=currentIssue
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