Monday, May 15, 2017

Antenatal Corticosteroids administration just few hours before preterm delivery improves survival and health gains for the infants.

Genesis Research Trust.

Imminent preterm labor, with no time to give antenatal corticosteroids? Still give it says the result of a large population based study.

Antenatal corticosteroids given few hours before an imminent delivery is effective in improving survival says results of a large population-based study of 4594 European infants born before 32 weeks’ gestation. This study was published on line today in JAMA Pediatrics.

The interval between steroids administration and birth varies, and so does the benefits achieved by the preterm infant. When women at risk for preterm delivery receive antenatal corticosteroids(ANS) 1 to 7 days before delivery, it reduces respiratory distress syndrome by 34%, necrotizing enterocolitis by 54%, intraventricular hemorrhage by 46%, and reduces Infant mortality by nearly 30%.

According to recent Cochrane Review “a single course of a corticosteroids, given to the mother in preterm labor and before the baby is born, helps to develop the baby's lungs and reduces complications such as breathing problems.”

Use of corticosteroid within the 24 hours’ window before delivery has been labelled as ‘partial’ or’ suboptimal’ according to Mikael Norman, MD, PhD, of Karolinska Institutet in Stockholm, Sweden, and the lead investigator of this study.

In fact, the latest timing of corticosteroids administration has never been investigated till now.

But this study “challenge current thinking about the optimal timing” of antenatal corticosteroids and encourage “a more proactive management of women at risk for imminent preterm birth, which may help reduce infant mortality and severe neonatal brain injury,” said Mikael Norman.

The Effective Perinatal Intensive Care in Europe (EPICE) study, a population-based prospective cohort study, gathered data from 19 regions in 11 European countries in 2011 and 2012 on 4594 singleton infants with gestational ages between 24 and 31 weeks, without severe anomalies and unexposed to repeated courses of ANS.

The study also evaluated the effects of  3 other evidence based practices: delivery in a maternity unit with appropriate level of neonatal care; prevention of hypothermia (temperature on admission to neonatal unit ≥36°C); surfactant used within two hours of birth or early nasal continuous positive airway pressure.

Nearly 55% were boys and the mean (SD) gestational age was 28.5 (2.2) weeks and mean (SD) birth weight was 1213 (400) g.

The cohort was divided into 4 categories depending upon the timing of corticosteroids given: no injections (662 infants, or 14.4% of the study population), first injection at less than 24 hours before birth (1,111 infants, or 24.2%), first injection at the recommended 1-7 days before birth (1,871 infants, or 40.7%), and first injection more than 7 days before birth (950 infants, or 20.7%).

The study results show that:

Receiving ANS at any time before delivery is associated with significant reduction in neonatal morbidity as compared to receiving no steroids.
The largest benefit (> 50%) was achieved in group which received them at the recommended interval of 1-7 days before delivery.
Nearly 20% of the infants in the study received ANS more than 7 days before and showed an increased mortality by 40% as compared to women who received them in the recommended window of period.

Using this information on timing of administration and benefits derived, the investigators created a simulation model for 661 infants who did not received any corticosteroids. The model predicts that if these infants had received treatment at least 3 hours before delivery, overall mortality would have decreased by 26%; 3-5 hours before delivery, mortality would have decreased by 37%; and if received treatment at 6-12 hours before delivery it would have decreased by 51%.

The authors concluded that “Encouraging administration of antenatal corticosteroids when delivery is very imminent could result in substantial survival and health gains for very preterm infants.”

A current project Screening to Improve Health in Very Preterm Infants in Europe (SHIPS) is about follow-up programmes for children born preterm. The project builds on the EPICE cohort to follow them to pick up any early problem and is currently ongoing in all the 11 countries.

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