Title: Utilization of Antenatal Corticosteroids on premature babies of 2734 weeks of gestational age born a
1Utilization 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
2Introduction
3Introduction
- 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.
7Hyaline 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.
10Indication 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
11Contra indication of Antenatal corticosteroid
- woman suffering from systemic infection including
T.B - Caution is advised if suspected chorioamnionitis
is diagnosed.
12Dosage 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.
14The 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.
15History 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.
16Justification 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.
17Comparison between African countries in 2000
18Comparison 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.
20Objective 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
21Methodology
- 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
24Grading of prematurity
- Extreme premature G.A of 26-32 weeks
- no5
- Severe premature 28-31 weeks
- no55
- Mild premature 32-34 weeks
- no52
25Criteria 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
26Results
27Results
- 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.
31Utilization of surfactant on Premature babies in
different groups
32Need for artificial ventilation
33- It is costly when we use surfactant
ventilation. - Optimal ANS will help in decreasing the cost of
treatment.
34Duration of stay in NICU
No significant difference in duration of stay in
NICU (P-value0.476)
35Total 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
37Morbidity
- 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.
38Mortality
- 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.
39Recommendation
40Recommendations
- 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.
41Recommendations
- 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.
42Recommendations
- 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
43Conclusion
- 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.
44Thanks