ACOG updates the committee opinion and expands antenatal corticosteroids recommendations for late preterm births.

American College of Obstetricians and Gynecologists (ACOG) recently updated its committee opinion for administration of prenatal corticosteroids and expanded it to high risk women for late preterm birth (34 0/7 - 36 6/7 weeks).

“Providing women’s health care providers with evidence-based techniques to successfully manage instances of preterm birth is a top priority for ACOG,” said one of the Committee Opinion authors, 

Dr. Yasser El-Sayed, MD, FACOG. “Through the new committee opinion we are expanding an existing therapy, based on recent data, to improve outcomes in more clinical settings. It’s an important step in getting more mothers and babies the care they need to be healthy.”[1]

This new Committee Opinion replaces ACOG’s Practice Advisory on Antenatal Corticosteroid Administration in the Late Preterm Period, originally issued on April 4, 2016.[2]

These recommendations follow the results of significant Antenatal Late PretermSteroids (ALPS) trial, published earlier this year.[3] The committee opinion now includes recommendations that support the administration of antenatal corticosteroids in certain populations during the late preterm birth period, or between 34 and 37 weeks of gestation.

The recommendation also holds good in multiple gestation.

Corticosteroids given late preterm significantly reduced the rate of neonatal respiratory complications like transient tachypnea of the newborn, surfactant use, and bronchopulmonary dysplasia. Studies also show lower rates of intracranial hemorrhage, necrotizing enterocolitis, and mortality. The only side effect is neonatal hypoglycemia which should be monitored closely.

As per the news release “The document also re-emphasizes ACOG’s recommendation to consider antenatal corticosteroids for pregnant women at risk of preterm delivery starting at 23 weeks of gestation, based on a family’s decision regarding resuscitation.”

The ACOG recommendations in the October issue of journal of Obstetrics and Gynecology[4]: It states: 

• A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation, including for those with ruptured membranes and multiple gestations. It may be considered for women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family’s decision regarding resuscitation. 
• A single course of betamethasone is recommended for pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation at risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids.
• Treatment should consist of either two 12-mg doses of betamethasone given intramuscularly 24 hours apart or four 6-mg doses of dexamethasone administered intramuscularly every 12 hours.
• Scheduled repeat course or serial courses are not recommended.
• A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who have an imminent risk of preterm delivery within the next 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario.
• Evidence is insufficient at present for giving a rescue or repeat course in patients with preterm pre labor rupture of membranes (PROM), hence no recommendation is made.
• ACOG advocates continuous long term monitoring of patients who received corticosteroids.  

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[1]http://www.acog.org/About-ACOG/News-Room/News-Releases/2016/ACOG-Improves-Outcomes-for-Preterm-Births

[2] http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Antenatal-Corticosteroid-Administration-in-the-Late-Preterm-Period

[3] http://www.nejm.org/doi/full/10.1056/NEJMoa1516783#t=article

[4] http://journals.lww.com/greenjournal/Fulltext/2016/10000/Committee_Opinion_No_677___Antenatal.62.aspx

Updates on management of Preterm Births- News from ACOG Annual Clinical and Scientific Meeting 2016.

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.acogdailynews.com/latest-trials-change-preterm-birth-guidance/

http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Antenatal-Corticosteroid-Administration-in-the-Late-Preterm-Period

http://www.nejm.org/doi/full/10.1056/NEJMoa1516783?af=R&rss=currentIssue