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Utilization of Antenatal Corticosteroids on premature babies of 2734 weeks of gestational age born a

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Title: Utilization of Antenatal Corticosteroids on premature babies of 2734 weeks of gestational age born a


1
Utilization of Antenatal Corticosteroids on
premature babies of 27-34 weeks of gestational
age born at SSRNH during 2003-2004
  • Dr S. Burahee
  • Tutor Dr (Miss) Soobadar

2
Introduction
3
Introduction
  • ANS is a corticosteroid treatment given
    intramuscular to the pregnant mother at risk of
    premature delivery.
  • This corticosteroid will cross blood placental
    barrier and act upon premature lungs of fetus and
    help enhancing its maturity.

4
  • Premature newborns of 27-34 weeks gestation are
    at high risk of developing respiratory distress
    syndrome (RDS) due to lack of surfactant in their
    premature lung also called Hyaline membrane
    disease. (HMD)

5
  • Surfactant is a natural substance produced by
    pneumocytes II In the lungs.
  • It is a heterogenous mixture of lipids and
    proteins. Dipamitoyl phosphatidyl choline is the
    main component of the surfactant.
  • It spreads in the lung tissue- air interface
  • preventing alveolar collapse during
  • expiration, to open easily at next inspiration.

6
  • Hyaline Membrane Distress (HMD) occurs due to
    inadequate production of pulmonary surfactant in
    premature lung and is seen if labour occurs
    before 32-34 weeks of pregnancy.

7
Hyaline Membrane Disease
  • The alveolar wall collapses during expiration
    and each inspiration will require considerable
    effort.
  • This situation rapidly leads to fatigue,
    decreased respiratory effort, Hypoxia, cynosis,
    acidosis and eventually death, if not corrected
    by immediate treatment.

8
  • The steroids given IM to mothers passes across
    blood placental barrier and act upon the
    pneumocytes type II of lung, inducing production
    of surfactant and these help in preventing the
    HMD.
  • Steroids used are usually Betamethasone or
    Dexamethasone.

9
  • Antenatal Corticosteroid apart from reducing RDS
    (HMD) also reduce intraventricular hemorrhage and
    neonatal mortality.

10
Indication of Antenatal corticosteroid
  • 1. Indicated to all women pregnant of 24 to 34
    weeks at risk of premature delivery within 7 days
    followed.
  • 2. The women of 34-36 weeks can also be given ANS
    in certain critical condition
  • e.g. elective c.s for these clinical cases in 7
    days following the ANC , e.g. gestational
    Diabetes mellitus, PIH, Placenta praevia

11
Contra indication of Antenatal corticosteroid
  • woman suffering from systemic infection including
    T.B
  • Caution is advised if suspected chorioamnionitis
    is diagnosed.

12
Dosage Route of administration
  • Treatment of choice
  • 2 doses of Betamethasone 12mg given IM 24 hrs
    apart.
  • 2nd line of treatment
  • -4 doses of dexamethasone 6mg given IM 12 hrs
    apart
  • -2 doses of 12 mg given IM 12 to 24 hrs apart.

13
  • Betamethasone is not available in public service
    in Mauritius.
  • Most extensively used regimen used in Mauritius
  • 2 doses of Dexamethasone 12mg IM 12 to 24 hrs
    apart
  • Most recently some doctors are using single dose
    of ANS in view of side effect of ANS.

14
The optimacy of treatment
  • The optimal treatment- delivery interval for
    administration of ANS is more than 24 hrs but
    fewer than 7 days after start of treatment.

15
History of ANS Therapy
  • Benefits are well known since 1972.
  • Liggins and Howic were the first who described
    the benefit of ANS in 1972.
  • Controlled trial of Betamethasone therapy was
    carried out in 282 mothers with threatened
    premature delivery before 37 weeks.
  • There was no death with HMD or IVH in infants of
    mother who had received Betamethasone at least 24
    hrs before delivery.

16
Justification for study on ANS
In Mauritius, in years 70s after independence
day, IMR was very high due to very high neonatal
and perinatal rates. After the integration of
MCH (Maternal Child Health) programme,
antenatal service improved at primary health
centre and became easily accessible to all
hence mortality rates started decreasing.
17
Comparison between African countries in 2000
18
Comparison with developed countries Reunion
Island in 2000
19
  • For further improvement, NICU services started in
    Mauritius.
  • At Victoria Hospital, in 1999
  • At SSRN Hospital, in 2001
  • But the services are very costly big economic
  • burden on Government.
  • ANS therapy decreases the risk of HMD, hence
  • decrease the need of NICU treatment hence the
  • cost of treatment.

20
Objective of Study
General Objective
  • To describe the utilization of ANS in
    pregnancies of 27-34 weeks with high risk of
    premature deliveries.
  • Describe the outcome of premature babies in 3
    groups according to ANS
  • With no ANS treatment
  • With ANS incomplete or suboptimal treatment
  • With complete optimal ANS therapy

Specific Objective
21
Methodology
  • It is a retrospective descriptive observational
    study on premature babies of 27-34 weeks born at
    SSRN Hospital during Jan 2003 to Dec 2004.
  • Though we know that best technique for this study
    would be the randomised clinical trial, but it
    was not possible due to existing circumstances
    and ethical reasons.

22
  • Total premature babies born alive during
  • 2003-2004 421
  • Selected for study112
  • Criteria of inclusion
  • Babies of gestational age 27-34 weeks born at
  • SSRNH only including inutero transfer
  • Criteria of exclusion
  • Premature babies with congenital malformation,
    infant
  • of diabetic mother, multiple pregnancies

23
  • Subdivided our population of study in 3 groups
  • Group of babies with suboptimal ANS therapy
    (no29)
  • Group of babies with optimal ANS therapy (no49)
  • Group of babies with no ANS (no34)
  • Group suboptimal whose mothers had
  • Incomplete course of ANS with short interval
  • between therapy and delivery, i.e. less than 24
    hrs.
  • Group optimal whose mothers had
    complete
  • course of ANS at least 24 hrs before delivery

24
Grading of prematurity
  • Extreme premature G.A of 26-32 weeks
  • no5
  • Severe premature 28-31 weeks
  • no55
  • Mild premature 32-34 weeks
  • no52

25
Criteria of diagnosis of severity of RDS
  • According to clinical conditions
  • Chest X Ray
  • Need of treatment
  • Mild RDS X Ray chest result, need of
  • O2 less than 30 fiO2, NO need of surfactant
  • less tachypnia
  • Severe RDS X Ray result, severe
    tachypnia,
  • need of O2 more than 30 even with respiratory
  • Support, need of surfactant

26
Results
27
Results
  • Percentage of antenatal corticotherapy

28
  • About 30 of the eligible women couldnt get ANS.
  • Main reason
  • Very rapid delivery of baby i.e. within 24 hrs
    of
  • hospitalization 26/34 (76.4) delivered rapidly

29
  • Incidence of severe RDS (HMD)

NUMBER OF CASES
30
25
HMD
20
Mild
15
Severe
NIL
10
5
0
SUBOPTIMAL
OPTIMAL
NIL
CORTICOTHERAPY
44 (13 / 29 ) in group sub optimal treatment
41.1 (14 / 34 ) in NO ANS group 10.2 (5 / 49 )
in group optimal
30
  • On comparison among 3 different groups
  • Significant difference between optimal sub
    optimal group (P0.0012)
  • Significant difference between optimal NO ANS
    (P0.0023)
  • No difference between group sub optimal group
    NO ANS.

31
Utilization of surfactant on Premature babies in
different groups
32
Need for artificial ventilation
33
  • It is costly when we use surfactant
    ventilation.
  • Optimal ANS will help in decreasing the cost of
    treatment.

34
Duration of stay in NICU
No significant difference in duration of stay in
NICU (P-value0.476)
35
Total stay in hospital
No significant difference among the 3 groups (P
value0.89)
36
  • 2 principle reasons for no significant difference
    in
  • duration of stay among the 3 groups
  • Very high rates of nosocomial infections in our
    units
  • Slow weight gain

37
Morbidity
  • No significant difference among the 3 groups
  • in occurrence of
  • 1. Patent ductus arteriosus
  • 2. Intra ventricular hemorrhage
  • 3. Broncho pulmonary dysplasia
  • This result is due to small size of our sample.

38
Mortality
  • No significant difference among the 3
  • groups in results of mortality
  • Reason
  • 1. Nosocomial infections are the main cause of
    neonatal mortality
  • 2. Short duration of study
  • It suggests to do study on long duration and
    compile more datas.

39
Recommendation
40
Recommendations
  • We propose more aggressive campaign of
    sensiblisation and education of pregnant women
    about regular follow up of antenatal clinics, its
    advantage.
  • Informing these mothers of the signs and
    symptoms of complication of pregnancy which
    provoked premature labour.

41
Recommendations
  • Informing doctors conducting ANC at LHC (most
    often generalists) about
  • problems of premature labour
  • Antenatal steroid protocol so that they can
    always start treatment without delaying as
    dexamethasone is easily available at LHC.

42
Recommendations
  • We recommend to start use Betamethasone as drug
    of choice due to
  • simplicity of application better patient
    compliance
  • superiority on Dexamethasone- decreased risk of
    cystic peri ventricular leucomalacia among
    premature infant born at 24th to 31 week G.A

43
Conclusion
  • It is very important to give ANS at right time
    with right doses to achieve maximum effect.
  • In future, a randomised clinical trial should be
    done between single dose therapy and conventional
    treatment so that we can establish better
    protocol without increasing any harm to baby or
    mother.

44
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