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Pei J, Chen J. The influence of prenatal dexamethasone administration before scheduled full-term cesarean delivery on short-term adverse neonatal outcomes: a retrospective single-center cohort study. Front Pediatr 2024; 11:1323097. [PMID: 38274470 PMCID: PMC10808727 DOI: 10.3389/fped.2023.1323097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/13/2023] [Indexed: 01/27/2024] Open
Abstract
Objective There has been a gradual increase in the prevalence of cesarean section deliveries and more healthcare professionals are considering the prophylactic use of corticosteroids before planned full-term cesarean sections. However, the association between dexamethasone administration before full-term cesarean delivery and short-term adverse neonatal outcomes is unclear. This study analyzed the disparities in short-term adverse neonatal effects in neonates born via full-term elective cesarean delivery with or without antenatal dexamethasone treatment. Study design This single-center retrospective cohort study involved neonates aged 37-39 weeks. The primary neonatal outcomes included various short-term adverse events, including neonatal admission to the neonatal intensive care unit, neonatal access to the special care baby unit, transient neonatal respiratory distress, respiratory distress syndrome, and the requirement of intravenous antibiotics or ventilatory support. Multiple logistic regression analysis was used to assess the association between these outcomes and dexamethasone exposure while adjusting for covariates. Results Of the 543 neonates included in the study, 121 (22.2%) had been exposed to prenatal dexamethasone. When compared with the control group, the dexamethasone-exposed group exhibited significantly higher rates of transient neonatal respiratory distress, respiratory distress syndrome, administration of intravenous antibiotics, the need for ventilatory support, and longer duration of neonatal hospitalization (P < 0.05). The association between dexamethasone exposure and short-term adverse neonatal outcomes remained significant after adjusting for potential confounders (odds ratio: 12.76, 95% confidence interval: 6.9-23.62, P < 0.001). Conclusion The dexamethasone-exposed group had a higher likelihood of experiencing short-term adverse outcomes when compared with non-exposed neonates, suggesting that dexamethasone may have detrimental effects on infants delivered at full term. This implies the importance of exercising caution when contemplating the use of antenatal corticosteroids.
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Affiliation(s)
| | - Jiao Chen
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Chengdu Medical College, Xindu District, Chengdu, Sichuan Province, China
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Räikkönen K, Gissler M, Kajantie E, Tapiainen T. Antenatal corticosteroid treatment and infectious diseases in children: a nationwide observational study. THE LANCET REGIONAL HEALTH. EUROPE 2023; 35:100750. [PMID: 37860637 PMCID: PMC10583166 DOI: 10.1016/j.lanepe.2023.100750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/21/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Abstract
Background Antenatal Corticosteroid Treatment (ACT) improves the outcome of preterm infants, but may influence immune system development and risk of immune-related diseases. We investigated whether ACT is associated with infectious diseases in children born at term (≥37 gestational weeks), and very-to-moderate (<34 gestational weeks), and late (34-36 completed gestational weeks) preterm. Methods All singleton live births in Finland between 01/01/2006 and 31/12/2021, were followed-up until 31/12/2021. Exposure was maternal ACT. Primary outcomes were numbers of inpatient treatment days, episodes, and specialized care outpatient visits with any infectious disease diagnoses between ages 0 and 4 years. We considered mother- and child-related covariates, and conducted term-born co-sibling comparisons. Findings Data comprised 855,234 children. Of the 20,858 (2.4%) treatment-exposed children, 5981 (28.2%) were very-to-moderate preterm-born, 5809 (27.9%) late preterm-born, and 9069 (43.5%) term-born. Of the 271,767 term-born co-sibling pairs, 5010 (1.8%) were treatment-exposure-discordant, and 266,522 (98.1%) nonexposure-concordant. Among the term- and late preterm-born, treatment-exposed children had more inpatient treatment days than nonexposed children (term: 0.87 vs. 0.56 day/y, adjusted mean difference [aMD] 0.19, 95% CI 0.17-0.28; late preterm: 1.35 vs. 1.00 days/y, aMD 0.31,0.13-0.31), more inpatient treatment episodes (term: 0.43 vs. 0.33 episodes/y, aMD 0.06, 0.06-0.11; late preterm: 0.55 vs. 0.48 episodes/y, aMD 0.12, 0.06-0.18), and specialized care treatment visits (term: 1.46 vs. 0.95 visits/y, aMD 0.38; 0.34-0.43; late preterm: 1.63 vs. 1.28 visits/y, aMD 0.22, 0.12-0.32). Treatment-exposed and nonexposed very-to-moderate preterm-born children were similar in these outcomes, though they had less inpatient treatment days and episodes at 3-4 years. Differences remained in term-born co-sibling comparisons. Interpretation These findings reinforce previous suggestions for careful consideration of risks and benefits of ACT. Funding Academy of Finland, HiLIFE Fellows-Programme.
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Affiliation(s)
- Katri Räikkönen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, THL Finnish Institute for Health and Welfare, Helsinki, Finland
- Research Centre for Child Psychiatry, University of Turku, Turku, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
| | - Eero Kajantie
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Department of Public Health Solutions, THL Finnish Institute for Health and Welfare, Helsinki and Oulu, Finland
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Terhi Tapiainen
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
- Department of Pediatrics and Adolescent Medicine, Medical Research Center, Oulu University Hospital, Oulu, Finland
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Van Noorden R. Medicine is plagued by untrustworthy clinical trials. How many studies are faked or flawed? Nature 2023; 619:454-458. [PMID: 37464079 DOI: 10.1038/d41586-023-02299-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
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Pergialiotis V, Rodolaki K, Nikolakea M, Antsaklis P, Stavros S, Panagopoulos P, Vrachnis N, Daskalakis G. Neonatal hypoglycemia following antenatal corticosteroid treatment prior to elective cesarean delivery during the early term period: a meta-analysis. AJOG GLOBAL REPORTS 2023; 3:100179. [PMID: 36923687 PMCID: PMC10009722 DOI: 10.1016/j.xagr.2023.100179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVE The necessity of administering antenatal corticosteroids in early-term neonates delivered by planned cesarean delivery remains arbitrary as their observed benefit addresses a few cases that may need pulmonary resuscitation. However, to date, whether the use of antenatal corticosteroids in the preterm period is associated with neonatal hypoglycemia, which is the most prominent neonatal side effect during this period, remains unknown. This study aimed to determine the effect of antenatal corticosteroids administered during the early term period on neonatal hypoglycemia rates. DATA SOURCES The databases of Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar were used. STUDY ELIGIBILITY CRITERIA Published clinical trials and observational studies were considered eligible. METHODS A modified data form that was based on the Cochrane data collection form for intervention reviews for randomized controlled trials and nonrandomized controlled trials was used. Meta-analysis was performed using RStudio (RStudio, Inc, Boston, MA). The quality of included studies was assessed with the Risk Of Bias In Non-randomized Studies of Interventions tool. Trial sequential analysis was performed to evaluate the sample size. RESULTS A total of 6 studies of moderate risk of bias were included in this systematic review consisting of 1273 parturients, of whom 537 received corticosteroids. The risk of neonatal hypoglycemia did not increase with the use of antenatal corticosteroids before early-term elective cesarean delivery (odds ratio, 1.80; 95% confidence interval, 0.45-7.25). Similarly, the risk of admission to the neonatal intensive care unit for respiratory distress syndrome or transient tachypnoea of the newborn was not affected by the use of corticosteroids (odds ratio, 0.61; 95% confidence interval, 0.19-1.99). CONCLUSION The use of antenatal corticosteroids did not seem to increase the risk of neonatal hypoglycemia. Given the quality and sample size of included studies, the effect size cannot be accounted for as definitive and cannot be directly applied in clinical practice. However, the provided information can be used as a guide for women participating in future trials.
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Affiliation(s)
- Vasilios Pergialiotis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece (Drs Pergialiotis, Antsaklis, and Daskalakis).,Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens, Greece (Drs Pergialiotis, Rodolaki, and Nikolakea)
| | - Kalliopi Rodolaki
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens, Greece (Drs Pergialiotis, Rodolaki, and Nikolakea).,1st Department of Pediatrics, "Aghia Sophia" Children's Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece (Dr Rodolaki)
| | - Melina Nikolakea
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Athens, Greece (Drs Pergialiotis, Rodolaki, and Nikolakea)
| | - Panagiotis Antsaklis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece (Drs Pergialiotis, Antsaklis, and Daskalakis)
| | - Sofoklis Stavros
- 3rd Department of Obstetrics and Gynecology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece (Drs Stavros, Panagopoulos, and Vrachnis)
| | - Periklis Panagopoulos
- 3rd Department of Obstetrics and Gynecology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece (Drs Stavros, Panagopoulos, and Vrachnis)
| | - Nikolaos Vrachnis
- 3rd Department of Obstetrics and Gynecology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece (Drs Stavros, Panagopoulos, and Vrachnis)
| | - Georgios Daskalakis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece (Drs Pergialiotis, Antsaklis, and Daskalakis)
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Samouilidis A, Beltsios ET, Mavrovounis G, Adamou A, Belios I, Hadjivasilis A, Pantazopoulos I, Agouridis AP. The Use of Antenatal Dexamethasone in Late Preterm and Term Pregnancies to Improve Neonatal Morbidity and Mortality: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e27865. [PMID: 36110463 PMCID: PMC9462888 DOI: 10.7759/cureus.27865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 12/02/2022] Open
Abstract
There are no acceptable worldwide recommendations regarding the use of dexamethasone in late-preterm newborns delivered either vaginally or via cesarean section and term gestation that are performed via cesarean section. The present study aims to compare the effectiveness of antenatal intramuscular dexamethasone versus placebo/no-treatment in reducing neonatal respiratory complications in high-risk for imminent preterm birth in late preterm pregnancies and term pregnancies undergoing elective cesarean section. The PubMed, Scopus, and Cochrane Library databases were searched to assess the effectiveness of dexamethasone during late preterm and term gestation. The last literature search was performed on March 20th, 2022. Randomized controlled trials compared antenatal dexamethasone administration with placebo or no treatment. The outcomes of interest were: the incidence of Respiratory Distress Syndrome; Transient Tachypnea of the Newborn, Neonatal Intensive Care Unit admissions; and the need for ventilatory support or mechanical ventilation. A standardized data form and three independent investigators performed the data extraction. Ten RCTs fulfilled our inclusion criteria. No statistically significant difference was found regarding all of the outcomes in the 34th-36th gestational week group. In the >37th gestational week group, a statistically significant difference was found regarding the incidence of RDS [RR (95% CI); p-value: 0.56 (0.36, 0.87); 0.01], TTN [RR (95% CI); p-value: 0.54 (0.42, 0.71); <0.00001], need for ventilatory support [RR (95% CI); p-value: 0.71 (0.52, 0.96); 0.03] and need for mechanical ventilation [RR (95% CI); p-value: 0.56 (0.33, 0.95); 0.03]. To conclude, the antenatal administration of dexamethasone can be considered to prevent neonatal complications and reduce perinatal morbidity in term pregnancies.
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Arsad N, Abd Razak N, Omar MH, Shafiee MN, Kalok A, Cheah FC, Lim PS. Antenatal Corticosteroids to Asian Women Prior to Elective Cesarean Section at Early Term and Effects on Neonatal Respiratory Outcomes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5201. [PMID: 35564596 PMCID: PMC9104179 DOI: 10.3390/ijerph19095201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022]
Abstract
This exploratory study aimed to evaluate the effects of antenatal corticosteroids in singleton pregnancies of Asian women prior to elective cesarean section (CS) at early term on neonatal respiratory outcomes. METHODS This is a pilot and pragmatic randomized trial conducted at a university hospital in Malaysia. Women with singleton pregnancies planned for elective CS between 37+0 and 38+6 weeks gestation were randomly allocated into the intervention group, where they received two doses of IM dexamethasone 12 mg of 12 h apart, 24 h prior to surgery OR into the standard care, control group, and both groups received the normal routine antenatal care. The primary outcome measures were neonatal respiratory illnesses, NICU admission and length of stay. RESULTS A total of 189 patients were recruited, 93 women in the intervention group and 96 as controls. Between the steroid and control groups, the mean gestation at CS was similar, 266.1 ± 3.2 days (38 weeks) vs. 265.8 ± 4.0 days (37+6 weeks), p = 0.53. The mean birthweight of infants was 3.06 ± 0.41 kg vs. 3.04 ± 0.37 kg, p = 0.71. Infants with respiratory morbidities were primarily due to transient tachypnea of newborn (9.7% vs. 6.3%), and congenital pneumonia (1.1% vs. 3.1%) but none had respiratory distress syndrome. Only four infants required NICU admission (2.2% vs. 3.1%, p = 0.63). Their average length of stay was not statistically different; 3.5 ± 2.1 days vs. 5.7 ± 1.5 days, p = 0.27. CONCLUSIONS Elective CS at early term before 39 weeks was associated with a modest overall incidence of neonatal respiratory illness (10.1%) in this Asian population. Antenatal dexamethasone did not diminish infants needing respiratory support, NICU admission and length of stay.
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Affiliation(s)
- Noorazizah Arsad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (N.A.); (N.A.R.); (M.H.O.); (M.N.S.); (A.K.)
| | - Nurlina Abd Razak
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (N.A.); (N.A.R.); (M.H.O.); (M.N.S.); (A.K.)
| | - Mohd Hashim Omar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (N.A.); (N.A.R.); (M.H.O.); (M.N.S.); (A.K.)
| | - Mohamad Nasir Shafiee
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (N.A.); (N.A.R.); (M.H.O.); (M.N.S.); (A.K.)
| | - Aida Kalok
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (N.A.); (N.A.R.); (M.H.O.); (M.N.S.); (A.K.)
| | - Fook Choe Cheah
- Department of Pediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia;
| | - Pei Shan Lim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (N.A.); (N.A.R.); (M.H.O.); (M.N.S.); (A.K.)
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Madendağ Y, Sahin E, Col Madendag I, Eraslan Sahin M. Assessment of intrahepatic cholestasis in pregnancy and the effect of disease severity on transient tachypnea in the newborn in uncomplicated fetuses. J Perinat Med 2022; 50:87-92. [PMID: 34280960 DOI: 10.1515/jpm-2021-0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/09/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Considering the effects of bile-acid levels on fetal lungs and pulmonary surfactants, we hypothesized that in the presence of intrahepatic pregnancy cholestasis (ICP), poor neonatal respiratory problems are observed in relation to the severity of the disease. Delivery timing with the presence of ICP is scheduled during late-preterm and early term gestational weeks. The aim of this study was to assess ICP and disease severity effects on transient tachypnea of the newborn (TTN) in uncomplicated fetuses. METHODS This study comprised 1,097 singleton pregnant women who were separated into three groups-control, mild ICP, and severe ICP. The pregnant women diagnosed with ICP between January 2010 and September 2020 was investigated using the hospital's database. For the control group, healthy pregnant women who met the same exclusion criteria and were similar in terms of maternal age, gestational age at delivery, and mode of delivery were analyzed. RESULTS The TTN rate was 14.5% in the severe ICP group, 6.5% in the mild ICP group, and 6.2% in the control group. The TTN rate in the severe ICP group was significantly higher than that in the other groups (p<0.001). Similarly, the rate of admission to the neonatal intensive care unit was significantly higher in the severe ICP group than in the other groups (p<0.001). According to Pearson correlation analyses, maternal serum bile-acid levels were positively correlated with TTN (r=0.082; p=0.002). CONCLUSIONS Severe ICP, but not mild ICP, and serum bile-acid levels were positively correlated with increased TTN risk and reduced pulmonary surfactant levels.
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Affiliation(s)
- Yusuf Madendağ
- Depertmant of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Erdem Sahin
- Depertmant of Obstetrics and Gynecology, Erciyes University Medicine Faculty, Kayseri, Turkey
| | - Ilknur Col Madendag
- Department of Obstetrics and Gynecology, Kayseri City Hospital, Kayseri, Turkey
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Sotiriadis A, McGoldrick E, Makrydimas G, Papatheodorou S, Ioannidis JP, Stewart F, Parker R. Antenatal corticosteroids prior to planned caesarean at term for improving neonatal outcomes. Cochrane Database Syst Rev 2021; 12:CD006614. [PMID: 34935127 PMCID: PMC8692259 DOI: 10.1002/14651858.cd006614.pub4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Infants born at term by elective caesarean section are more likely to develop respiratory morbidity than infants born vaginally. Prophylactic corticosteroids in singleton preterm pregnancies accelerate lung maturation and reduce the incidence of respiratory complications. It is unclear whether administration at term gestations, prior to caesarean section, improves the respiratory outcomes for these babies without causing any unnecessary morbidity to the mother or the infant. OBJECTIVES The objective of this review was to assess the effect of prophylactic corticosteroid administration before elective caesarean section at term, as compared to usual care (which could be placebo or no treatment), on fetal, neonatal and maternal morbidity. We also assessed the impact of the treatment on the child in later life. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov (20 January 2021) and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials comparing prophylactic antenatal corticosteroid administration (betamethasone or dexamethasone) with placebo or with no treatment, given before elective caesarean section at term (at or after 37 weeks of gestation). Quasi-randomised and cluster-randomised controlled trials were also eligible for inclusion. DATA COLLECTION AND ANALYSIS We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two review authors independently assessed trials for inclusion, assessed risk of bias, evaluated trustworthiness (based on predefined criteria developed by Cochrane Pregnancy and Childbirth), extracted data and checked them for accuracy and assessed the certainty of the evidence using the GRADE approach. Our primary outcomes were respiratory distress syndrome (RDS), transient tachypnoea of the neonate (TTN), admission to neonatal special care for respiratory morbidity and need for mechanical ventilation. We planned to perform subgroup analyses for the primary outcomes according to gestational age at randomisation and type of corticosteroid (betamethasone or dexamethasone). We also planned to perform sensitivity analysis, including only studies at low risk of bias. MAIN RESULTS We included one trial in which participants were randomised to receive either betamethasone or usual care. The trial included 942 women and 942 neonates recruited from 10 UK hospitals between 1995 and 2002. This review includes only trials that met predefined criteria for trustworthiness. We removed three trials from the analysis that were included in the previous version of this review. The risk of bias was low for random sequence generation, allocation concealment and incomplete outcome data. The risk of bias for selective outcome reporting was unclear because there was no published trial protocol, and therefore it is unclear whether all the planned outcomes were reported in full. Due to a lack of blinding we judged there to be high risk of performance bias and detection bias. We downgraded the certainty of the evidence because of concerns about risk of bias and because of imprecision due to low event rates and wide 95% confidence intervals (CIs), which are consistent with possible benefit and possible harm Compared with usual care, it is uncertain if antenatal corticosteroids reduce the risk of RDS (relative risk (RR) 0.34 95% CI 0.07 to 1.65; 1 study; 942 infants) or TTN (RR 0.52, 95% CI 0.25 to 1.11; 1 study; 938 infants) because the certainty of evidence is low and the 95% CIs are consistent with possible benefit and possible harm. Antenatal corticosteroids probably reduce the risk of admission to neonatal special care for respiratory complications, compared with usual care (RR 0.45, 95% CI 0.22 to 0.90; 1 study; 942 infants; moderate-certainty evidence). The proportion of infants admitted to neonatal special care for respiratory morbidity after treatment with antenatal corticosteroids was 2.3% compared with 5.1% in the usual care group. It is uncertain if antenatal steroids have any effect on the risk of needing mechanical ventilation, compared with usual care (RR 4.07, 95% CI 0.46 to 36.27; 1 study; 942 infants; very low-certainty evidence). The effect of antenatal corticosteroids on the maternal development of postpartum infection/pyrexia in the first 72 hours is unclear due to the very low certainty of the evidence; one study (942 women) reported zero cases. The included studies did not report any data for neonatal hypoglycaemia or maternal mortality/severe mortality. AUTHORS' CONCLUSIONS Evidence from one randomised controlled trial suggests that prophylactic corticosteroids before elective caesarean section at term probably reduces admission to the neonatal intensive care unit for respiratory morbidity. It is uncertain if administration of antenatal corticosteroids reduces the rates of respiratory distress syndrome (RDS) or transient tachypnoea of the neonate (TTN). The overall certainty of the evidence for the primary outcomes was found to be low or very low, apart from the outcome of admission to neonatal special care (all levels) for respiratory morbidity, for which the evidence was of moderate certainty. Therefore, there is currently insufficient data to draw any firm conclusions. More evidence is needed to investigate the effect of prophylactic antenatal corticosteroids on the incidence of recognised respiratory morbidity such as RDS. Any future trials should assess the balance between respiratory benefit and potential immediate adverse effects (e.g. hypoglycaemia) and long-term adverse effects (e.g. academic performance) for the infant. There is very limited information on maternal health outcomes to provide any assurances that corticosteroids do not pose any increased risk of harm to the mother. Further research should consider investigating the effectiveness of antenatal steroids at different gestational ages prior to caesarean section. There are nine potentially eligible studies that are currently ongoing and could be included in future updates of this review.
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Affiliation(s)
- Alexandros Sotiriadis
- Second Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Emma McGoldrick
- Obstetrics Directorate, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - George Makrydimas
- Department of Obstetrics and Gynaecology, University Hospital of Ioannina, Ioannina, Greece
| | | | - John Pa Ioannidis
- Stanford Prevention Research Center, Department of Medicine and Department of Health Research and Policy, Palo Alto, California, USA
| | - Fiona Stewart
- c/o Cochrane Incontinence, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- c/o Cochrane Pregnancy and Childbirth, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Roses Parker
- Cochrane MOSS Network, c/o Cochrane Pain Palliative and Supportive Care Group, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Anthoulakis C, Mamopoulos A, Rousso D, Karagiannis A, Athanasiadis A, Grimbizis G, Athyros V. Arterial Stiffness as a Cardiovascular Risk Factor for the Development of Preeclampsia and Pharmacopreventive Options. Curr Vasc Pharmacol 2021; 20:52-61. [PMID: 34615450 DOI: 10.2174/1570161119666211006114258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/08/2021] [Accepted: 08/18/2021] [Indexed: 11/22/2022]
Abstract
Arterial stiffness (AS) describes the rigidity of the arterial walls. Epidemiological studies have shown that increased AS is an independent predictive marker of cardiovascular (CV) morbidity and mortality in both pregnant and non-pregnant women. Preeclampsia (PE), a form of pregnancy-induced hypertension, affects approximately 5% of pregnancies worldwide. Preeclamptic women have a higher risk of CV disease (CVD), mainly because PE damages the heart's ability to relax between contractions. Different pharmacological approaches for the prevention of PE have been tested in clinical trials (e.g. aspirin, enoxaparin, metformin, pravastatin, and sildenafil citrate). In current clinical practice, only low-dose aspirin is used for PE pharmacoprevention. However, low-dose aspirin does not prevent term PE, which is the most common form of PE. Compromised vascular integrity precedes the onset of PE and therefore, AS assessment may constitute a promising predictive marker of PE. Several non-invasive techniques have been developed to assess AS. Compared with normotensive pregnancies, both carotid-femoral pulse wave velocity (cfPWV) and augmentation index (AIx) are increased in PE. In view of simplicity, reliability, and reproducibility, there is an interest in oscillometric AS measurements in pregnancies complicated by PE.
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Affiliation(s)
- Christos Anthoulakis
- First Department of Obstetrics & Gynecology, "Papageorgiou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Apostolos Mamopoulos
- Third Department of Obstetrics & Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - David Rousso
- Third Department of Obstetrics & Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Asterios Karagiannis
- Second Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Apostolos Athanasiadis
- Third Department of Obstetrics & Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Grigoris Grimbizis
- First Department of Obstetrics & Gynecology, "Papageorgiou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Vasilios Athyros
- Second Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
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Czamara D, Dieckmann L, Röh S, Kraemer S, Rancourt RC, Sammallahti S, Kajantie E, Laivuori H, Eriksson JG, Räikkönen K, Henrich W, Plagemann A, Binder EB, Braun T, Entringer S. Betamethasone administration during pregnancy is associated with placental epigenetic changes with implications for inflammation. Clin Epigenetics 2021; 13:165. [PMID: 34446099 PMCID: PMC8393766 DOI: 10.1186/s13148-021-01153-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/12/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Glucocorticoids (GCs) play a pivotal role in fetal programming. Antenatal treatment with synthetic GCs (sGCs) in individuals in danger of preterm labor is common practice. Adverse short- and long-term effects of antenatal sGCs have been reported, but their effects on placental epigenetic characteristics have never been systematically studied in humans. RESULTS We tested the association between exposure to the sGC betamethasone (BET) and placental DNA methylation (DNAm) in 52 exposed cases and 84 gestational-age-matched controls. We fine-mapped associated loci using targeted bisulfite sequencing. The association of placental DNAm with gene expression and co-expression analysis on implicated genes was performed in an independent cohort including 494 placentas. Exposure to BET was significantly associated with lower placenta DNAm at an enhancer of FKBP5. FKBP5 (FK506-binding protein 51) is a co-chaperone that modulates glucocorticoid receptor activity. Lower DNAm at this enhancer site was associated with higher expression of FKBP5 and a co-expressed gene module. This module is enriched for genes associated with preeclampsia and involved in inflammation and immune response. CONCLUSIONS Our findings suggest that BET exposure during pregnancy associates with few but lasting changes in placental DNAm and may promote a gene expression profile associated with placental dysfunction and increased inflammation. This may represent a pathway mediating GC-associated negative long-term consequences and health outcomes in offspring.
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Affiliation(s)
- Darina Czamara
- Department of Translational Research in Psychiatry, Max-Planck-Institute of Psychiatry, 80804 Munich, Germany
| | - Linda Dieckmann
- Department of Translational Research in Psychiatry, Max-Planck-Institute of Psychiatry, 80804 Munich, Germany
- International Max Planck Research School for Translational Psychiatry, München, Germany
| | - Simone Röh
- Department of Translational Research in Psychiatry, Max-Planck-Institute of Psychiatry, 80804 Munich, Germany
| | - Sarah Kraemer
- Institute of Medical Psychology, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health (BIH), Luisenstr. 57, 10117 Berlin, Germany
| | - Rebecca C. Rancourt
- Department of Experimental Obstetrics, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health (BIH), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Sara Sammallahti
- Department of Child and Adolescent Psychiatry, Erasmus MC, Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Eero Kajantie
- Finnish Institute for Health and Welfare, Helsinki, Finland
- Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Faculty of Medicine, PEDEGO Research Unit, MRC Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hannele Laivuori
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Obstetrics and Gynecology, Tampere University Hospital and Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Johan G. Eriksson
- Department of General Practice and Primary Care, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Department of Obstetrics and Gynaecology and Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Katri Räikkönen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Wolfgang Henrich
- Department of Obstetrics, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health (BIH), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Andreas Plagemann
- Department of Experimental Obstetrics, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health (BIH), Augustenburger Platz 1, 13353 Berlin, Germany
- Department of Obstetrics, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health (BIH), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Elisabeth B. Binder
- Department of Translational Research in Psychiatry, Max-Planck-Institute of Psychiatry, 80804 Munich, Germany
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA 30329 USA
| | - Thorsten Braun
- Department of Experimental Obstetrics, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health (BIH), Augustenburger Platz 1, 13353 Berlin, Germany
- Department of Obstetrics, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health (BIH), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Sonja Entringer
- Institute of Medical Psychology, Charité − Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health (BIH), Luisenstr. 57, 10117 Berlin, Germany
- Development, Health, and Disease Research Program, University of California, Irvine, Orange, CA USA
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Medina Poma SL, González-Andrade F. Differences between preterm infants receiving a dose for lung maturation and those receiving an additional rescue dose of corticosteroids. BIONATURA 2021. [DOI: 10.21931/rb/2021.06.03.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
it is unknown if there is a difference between preterm infants with a history of receiving pulmonary corticosteroid maturation or using an additional rescue dose of corticosteroid. This paper aims to determine the difference between infants with pulmonary maturation and infants who received a rescue dose of corticosteroid.
We performed an epidemiological, observational, and cross-sectional study. We analyzed time of stay, the requirement of mechanical ventilation, the use of surfactant, and neurological complications in newborns hospitalized in Neonatology of the Isidro Ayora Gyneco-Obstetric Hospital, 2019. We analyzed 204 preterm infants of 28-37 weeks who received a total lung maturation dose versus an added rescue dose. We analyzed the information with the statistical program SPSS v 22.0. With rescue dose the stay time was 28.4±21.6 days (p <0.05), days of invasive mechanical ventilation 3±5.7 days (p <0.05); Surfactant use 33.3% (p>0.05). We found neurological complications in 6.9% of patients (p> 0.05). In group 2 with not rescue dose use, the stay time was 21.5±16.6 days (p<0.05), days of invasive mechanical ventilation 1.8 ± 4.1 days (p <0.05). Surfactant use was 24.5% (p>0.05), and neurological complications 2% (p> 0.05). Preterm males weighing <1000 g from 30 to 32 weeks, who used rescue doses of corticosteroids, showed an increase in intraventricular hemorrhage (13.7%), seizures (6.9%), and leukomalacia (13.7%), associated with the fact that in the group with rescue dose they are younger and had lower weight.
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Affiliation(s)
- Sandra Liliana Medina Poma
- Universidad San Francisco de Quito USFQ, Colegio Ciencias de la Salud, calle Diego de Robles s/n y Pampite, 170901, Quito, Ecuador
| | - Fabricio González-Andrade
- Universidad San Francisco de Quito USFQ, Colegio Ciencias de la Salud, calle Diego de Robles s/n y Pampite, 170901, Quito, Ecuador Universidad Central del Ecuador, Facultad de Ciencias Médicas, Unidad de Medicina Traslacional, Iquique N14-121 y Sodiro-Itchimbía, 170403, Quito, Ecuador
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12
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Arruda A, Ormonde M, Stokreef S, Fraga B, Franco C, Dâmaso C, Lima A. Is there a Role for Antenatal Corticosteroids in Term Infants before Elective Cesarean Section? REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:283-290. [PMID: 33979889 PMCID: PMC10183905 DOI: 10.1055/s-0041-1726055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE Cesarean section (CS) delivery, especially without previous labor, is associated with worse neonatal respiratory outcomes. Some studies comparing neonatal outcomes between term infants exposed and not exposed to antenatal corticosteroids (ACS) before elective CS revealed that ACS appears to decrease the risk of respiratory distress syndrome (RDS), transient tachypnea of the neonate (TTN), admission to the neonatal intensive care unit (NICU), and the length of stay in the NICU. METHODS The present retrospective cohort study aimed to compare neonatal outcomes in infants born trough term elective CS exposed and not exposed to ACS. Outcomes included neonatal morbidity at birth, neonatal respiratory morbidity, and general neonatal morbidity. Maternal demographic characteristics and obstetric data were analyzed as possible confounders. RESULTS A total of 334 newborns met the inclusion criteria. One third of the population study (n = 129; 38.6%) received ACS. The present study found that the likelihood for RDS (odds ratio [OR] = 1.250; 95% confidence interval [CI]: 0.454-3.442), transient TTN (OR = 1.,623; 95%CI: 0.556-4.739), and NIUC admission (OR = 2.155; 95%CI: 0.474-9.788) was higher in the ACS exposed group, although with no statistical significance. When adjusting for gestational age and arterial hypertension, the likelihood for RDS (OR = 0,732; 95%CI: 0.240-2.232), TTN (OR = 0.959; 95%CI: 0.297-3.091), and NIUC admission (OR = 0,852; 95%CI: 0.161-4.520) become lower in the ACS exposed group. CONCLUSION Our findings highlight the known association between CS-related respiratory morbidity and gestational age, supporting recent guidelines that advocate postponing elective CSs until 39 weeks of gestational age.
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Affiliation(s)
- Augusta Arruda
- Pediatrics Department, Hospital Divino Espírito Santo, Ponta Delgada, Portugal
| | - Mariana Ormonde
- Obstetrics & Gynecology Department, Hospital Divino Espírito Santo, Ponta Delgada, Portugal
| | - Sarah Stokreef
- Pediatrics Department, Hospital Divino Espírito Santo, Ponta Delgada, Portugal
| | - Beatriz Fraga
- Pediatrics Department, Hospital Divino Espírito Santo, Ponta Delgada, Portugal
| | - Catarina Franco
- Pediatrics Department, Hospital Divino Espírito Santo, Ponta Delgada, Portugal
| | - Catarina Dâmaso
- Pediatrics Department, Hospital Divino Espírito Santo, Ponta Delgada, Portugal
| | - Ana Lima
- Obstetrics & Gynecology Department, Hospital Divino Espírito Santo, Ponta Delgada, Portugal
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Mwita S, Jande M, Katabalo D, Kamala B, Dewey D. Reducing neonatal mortality and respiratory distress syndrome associated with preterm birth: a scoping review on the impact of antenatal corticosteroids in low- and middle-income countries. World J Pediatr 2021; 17:131-140. [PMID: 33389692 DOI: 10.1007/s12519-020-00398-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The most common cause of death among preterm infants in low- and middle-income countries is respiratory distress syndrome. The purpose of this review was to assess whether antenatal corticosteroids given to women at risk of preterm birth at ≤ 34 weeks of gestation reduce rates of neonatal mortality and respiratory distress syndrome in low- and middle-income countries. METHODS Two reviewers independently searched four databases including MEDLINE (through PubMed), CINAHL, Embase, and Cochrane Libraries. We did not apply any language or date restrictions. All publications up to April 2020 were included in this search. RESULTS The search yielded 71 articles, 10 of which were included in this review (3 randomized controlled trials, 7 observational studies, 36,773 neonates). The majority of studies reported associations between exposure to antenatal corticosteroids and lower rates of neonatal mortality and respiratory distress syndrome. However, a few studies reported that antenatal corticosteroids were not associated with improved preterm birth outcomes. CONCLUSIONS Most of the studies in low- and middle-income countries showed that use of antenatal corticosteroids in hospitals with high levels of neonatal care was associated with lower rates of neonatal mortality and respiratory distress syndrome. However, the findings are inconclusive because some studies in low-resource settings reported that antenatal corticosteroids had no benefit in reducing rates of neonatal mortality or respiratory distress syndrome. Further research on the impact of antenatal corticosteroids in resource-limited settings in low-income countries is a priority.
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Affiliation(s)
- Stanley Mwita
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania.
| | - Mary Jande
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
| | - Deogratias Katabalo
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
| | - Benjamin Kamala
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
| | - Deborah Dewey
- School of Pharmacy, Catholic University of Health and Allied Sciences, Bugando Area, PO Box 1464, Mwanza, Tanzania
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Ali H, Salama H, Robertson N, Olukade T, Al-Obaidly S, Al-Qubaisi M, Al Rifai H. Antenatal corticosteroids and short-term neonatal outcomes in term and near-term infants of diabetic mothers. Analysis of the Qatar PEARL-peristat registry. J Perinat Med 2021; 49:377-382. [PMID: 33098633 DOI: 10.1515/jpm-2020-0249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 10/02/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES A recent discussion surrounding the extension of antenatal corticosteroid (ACS) use beyond 34 weeks of gestation did not include the subgroup of infants of diabetic mothers (IDM). We aimed to examine the association between ACS exposure and outcomes in neonates born at term and at near-term gestation in a large cohort of IDMs. METHODS We selected 13976 eligible near-term and term infants who were included in the PEARL-Peristat Perinatal Registry Study (PPS). We assessed the association of ACS exposure with neonatal outcomes in a multivariate regression model that controlled for diabetes mellitus (DM) and other perinatal variables. RESULTS The incidence of DM was 28% (3,895 of 13,976) in the cohort. Caesarean section was performed in one-third of the study population. The incidence of ACS exposure was low (1.8%) and typically occurred>2 weeks before delivery. The incidence rates of respiratory distress syndrome (RDS)/ transient tachypnoea of newborns (TTN), all-cause neonatal intensive care unit (NICU) admissions, NICU admissions for hypoglycaemia, and low 5-min Apgar scores were 3.5, 8.8, 1.3, and 0.1%, respectively. In a multivariate regression model, ACS was associated with a slight increase in NICU admissions (OR: 1.44; 95% CI: 1.04-2.03; p=0.028), but not with RDS/TTN. CONCLUSIONS Although the low exposure rate was a limitation, ACS administration did not reduce respiratory morbidity in near-term or term IDMs. It was independently associated with an increase in NICU admissions. Randomized controlled trials are required to assess the efficacy and safety of ACS administration in diabetic mothers at late gestation.
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Affiliation(s)
- Haytham Ali
- Sidra Medical and Research Center, Doha, Qatar
| | - Husam Salama
- Department of Neonatalogy, Hamad Medical Corp, Doha, Qatar
| | - Nicola Robertson
- Department of Obstetrics and Gynaeocology, University College Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Tawa Olukade
- Department of Obstetrics and Gynecology, Hamad Medical Corp, Doha, Qatar
| | - Sawsan Al-Obaidly
- Department of Obstetrics and Gynecology, Hamad Medical Corp, Doha, Qatar
| | - Mai Al-Qubaisi
- Department of Obstetrics and Gynecology, Hamad Medical Corp, Doha, Qatar
| | - Hilal Al Rifai
- Department of Neonatology, Hamad Medical Corp, Doha, Qatar
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15
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Uggioni MLR, Colonetti T, Grande AJ, Cruz MVB, da Rosa MI. Corticosteroids in Pregnancy for Preventing RDS: Overview of Systematic Reviews. Reprod Sci 2021; 29:54-68. [PMID: 33624258 DOI: 10.1007/s43032-020-00425-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/06/2020] [Indexed: 11/25/2022]
Abstract
The objective of this study was to analyze the available evidence of systematic reviews that evaluated the efficacy of antenatal corticosteroids in order to contribute to a reduction in magnitude and transcendence of respiratory distress syndrome of the newborn (RDS). Thus, an overview was conducted including all systematic reviews of randomized controlled trials (RCTs) that evaluated women who received corticosteroid treatment during pregnancy to prevent RDS. Therefore, a search strategy was developed using the terms "respiratory distress syndrome, newborn," "corticosteroids," "perinatal death," "neonatal death," "neonate," and "pregnancy." The electronic databases searched were MEDLINE, EMBASE, Cochrane Library, LILACS, and Google Scholar, for studies published until June 2020. We identified 354 references, 38 of which were relevant after the initial screening. Ten systematic reviews met the inclusion criteria. For RDS, 1522 cases occurred in the control group composed of 8716 participants, while in the intervention group was 1088 in 8740 participants (RR = 0.67, 95% CI 0.60-0.75). For neonatal death, 343 cases occurred in 5248 participants of the control group, while in the intervention group, there were 227 cases in 5246 participants (RR = 0.66, 95% CI 0.56-0.78). For perinatal death, there were 344 cases in 3345 participants in the control group, while in the intervention group, the number of cases was 264 in 3384 participants (RR = 0.72, 95% CI 0.58-0.89). Thus, the use of corticosteroids during pregnancy in women at risk of preterm birth is effective for the prevention of RDS in neonates and reducing the number of neonatal and perinatal deaths in preterm. PROSPERO protocol no: CRD42017074604.
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Affiliation(s)
| | - Tamy Colonetti
- Translational Biomedicine Laboratory, University of the Extreme South of Santa Catarina, Criciúma, SC, Brazil
| | - Antonio José Grande
- Evidence-Based Health Laboratory, State University of Mato Grosso do Sul, Campo Grande, MS, Brazil
| | | | - Maria Inês da Rosa
- Translational Biomedicine Laboratory, University of the Extreme South of Santa Catarina, Criciúma, SC, Brazil
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Wellmann S, Manegold-Brauer G, Fischer T, Schäffer L, Gaertner VD, Malfertheiner SF, Burkhardt T. Improving Neonatal and Maternal Outcome by Inducing Mild Labor before Elective Cesarean Section: The Lacarus Randomized Controlled Trial. Neonatology 2021; 118:116-121. [PMID: 33472211 DOI: 10.1159/000512752] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/09/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Newborns delivered by elective cesarean section (CS) are at higher respiratory risk than those delivered vaginally or by CS proceeded by labor (secondary CS). The oxytocin challenge test (OCT) induces uterine contractions that trigger the release of fetal hormones regulating lung fluid clearance during transition from the uterine to an air-breathing environment. OBJECTIVES The aim is to summarize current evidence and outline the Lacarus trial protocol. METHODS Literature review informed the design of a randomized placebo-controlled multicenter trial of OCT preceding elective CS in 1,450 women with a singleton pregnancy due for CS at >35 weeks gestation, without preceding contractions, rupture of the membranes, or antenatal steroids. OCT comprises the infusion of oxytocin 5 IU/500 mL Ringer lactate at a rate of 12 mL/h, doubling every 10 min until inducing 5 uterine contractions per 15-min interval. The primary endpoint is the occurrence of neonatal respiratory morbidity within 24 h after birth. Secondary endpoints include biochemical and physiological parameters of fetal and maternal well-being, such as breastfeeding rate and fetal plasma copeptin concentrations. CONCLUSION This is the first trial to test the hypothesis that oxytocin-induced contractions before elective CS is a promising application of physiologic principles gleaned from natural birth to improve neonatal and maternal outcomes.
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Affiliation(s)
- Sven Wellmann
- University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany.,Division of Neonatology, University of Basel Children's Hospital (UKBB), Basel, Switzerland
| | | | - Tina Fischer
- Department of Obstetrics, Community Hospital St. Gallen, St. Gallen, Switzerland
| | - Leonhard Schäffer
- Department of Obstetrics, Community Hospital Baden, Baden, Switzerland
| | - Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Sara Fill Malfertheiner
- University Department of Obstetrics and Gynecology at the Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Tilo Burkhardt
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland,
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McGoldrick E, Stewart F, Parker R, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2020; 12:CD004454. [PMID: 33368142 PMCID: PMC8094626 DOI: 10.1002/14651858.cd004454.pub4] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Respiratory morbidity including respiratory distress syndrome (RDS) is a serious complication of preterm birth and the primary cause of early neonatal mortality and disability. Despite early evidence indicating a beneficial effect of antenatal corticosteroids on fetal lung maturation and widespread recommendations to use this treatment in women at risk of preterm delivery, some uncertainty remains about their effectiveness particularly with regard to their use in lower-resource settings, different gestational ages and high-risk obstetric groups such as women with hypertension or multiple pregnancies. This updated review (which supersedes an earlier review Crowley 1996) was first published in 2006 and subsequently updated in 2017. OBJECTIVES To assess the effects of administering a course of corticosteroids to women prior to anticipated preterm birth (before 37 weeks of pregnancy) on fetal and neonatal morbidity and mortality, maternal mortality and morbidity, and on the child in later life. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (3 September 2020), ClinicalTrials.gov, the databases that contribute to the WHO International Clinical Trials Registry Platform (ICTRP) (3 September 2020), and reference lists of the retrieved studies. SELECTION CRITERIA We considered all randomised controlled comparisons of antenatal corticosteroid administration with placebo, or with no treatment, given to women with a singleton or multiple pregnancy, prior to anticipated preterm delivery (elective, or following rupture of membranes or spontaneous labour), regardless of other co-morbidity, for inclusion in this review. DATA COLLECTION AND ANALYSIS We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two review authors independently assessed trials for inclusion, assessed risk of bias, evaluated trustworthiness based on predefined criteria developed by Cochrane Pregnancy and Childbirth, extracted data and checked them for accuracy, and assessed the certainty of the evidence using the GRADE approach. Primary outcomes included perinatal death, neonatal death, RDS, intraventricular haemorrhage (IVH), birthweight, developmental delay in childhood and maternal death. MAIN RESULTS We included 27 studies (11,272 randomised women and 11,925 neonates) from 20 countries. Ten trials (4422 randomised women) took place in lower- or middle-resource settings. We removed six trials from the analysis that were included in the previous version of the review; this review only includes trials that meet our pre-defined trustworthiness criteria. In 19 trials the women received a single course of steroids. In the remaining eight trials repeated courses may have been prescribed. Fifteen trials were judged to be at low risk of bias, two had a high risk of bias in two or more domains and we ten trials had a high risk of bias due to lack of blinding (placebo was not used in the control arm. Overall, the certainty of evidence was moderate to high, but it was downgraded for IVH due to indirectness; for developmental delay due to risk of bias and for maternal adverse outcomes (death, chorioamnionitis and endometritis) due to imprecision. Neonatal/child outcomes Antenatal corticosteroids reduce the risk of: - perinatal death (risk ratio (RR) 0.85, 95% confidence interval (CI) 0.77 to 0.93; 9833 infants; 14 studies; high-certainty evidence; 2.3% fewer, 95% CI 1.1% to 3.6% fewer), - neonatal death (RR 0.78, 95% CI 0.70 to 0.87; 10,609 infants; 22 studies; high-certainty evidence; 2.6% fewer, 95% CI 1.5% to 3.6% fewer), - respiratory distress syndrome (RR 0.71, 95% CI 0.65 to 0.78; 11,183 infants; studies = 26; high-certainty evidence; 4.3% fewer, 95% CI 3.2% to 5.2% fewer). Antenatal corticosteroids probably reduce the risk of IVH (RR 0.58, 95% CI 0.45 to 0.75; 8475 infants; 12 studies; moderate-certainty evidence; 1.4% fewer, 95% CI 0.8% to1.8% fewer), and probably have little to no effect on birthweight (mean difference (MD) -14.02 g, 95% CI -33.79 to 5.76; 9551 infants; 19 studies; high-certainty evidence). Antenatal corticosteroids probably lead to a reduction in developmental delay in childhood (RR 0.51, 95% CI 0.27 to 0.97; 600 children; 3 studies; moderate-certainty evidence; 3.8% fewer, 95% CI 0.2% to 5.7% fewer). Maternal outcomes Antenatal corticosteroids probably result in little to no difference in maternal death (RR 1.19, 95% CI 0.36 to 3.89; 6244 women; 6 studies; moderate-certainty evidence; 0.0% fewer, 95% CI 0.1% fewer to 0.5% more), chorioamnionitis (RR 0.86, 95% CI 0.69 to 1.08; 8374 women; 15 studies; moderate-certainty evidence; 0.5% fewer, 95% CI 1.1% fewer to 0.3% more), and endometritis (RR 1.14, 95% CI 0.82 to 1.58; 6764 women; 10 studies; moderate-certainty; 0.3% more, 95% CI 0.3% fewer to 1.1% more) The wide 95% CIs in all of these outcomes include possible benefit and possible harm. AUTHORS' CONCLUSIONS Evidence from this updated review supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. Treatment with antenatal corticosteroids reduces the risk of perinatal death, neonatal death and RDS and probably reduces the risk of IVH. This evidence is robust, regardless of resource setting (high, middle or low). Further research should focus on variations in the treatment regimen, effectiveness of the intervention in specific understudied subgroups such as multiple pregnancies and other high-risk obstetric groups, and the risks and benefits in the very early or very late preterm periods. Additionally, outcomes from existing trials with follow-up into childhood and adulthood are needed in order to investigate any longer-term effects of antenatal corticosteroids. We encourage authors of previous studies to provide further information which may answer any remaining questions about the use of antenatal corticosteroids without the need for further randomised controlled trials. Individual patient data meta-analyses from published trials are likely to provide answers for most of the remaining clinical uncertainties.
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Affiliation(s)
- Emma McGoldrick
- Obstetrics Directorate, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Fiona Stewart
- Cochrane Children and Families Network, c/o Cochrane Pregnancy and Childbirth, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Roses Parker
- Musculoskeletal, Oral, Skin and Sensory Network, Oxford University Hospitals NHS Foundation Trust Second Floor, OUH Cowley Unipart House Business Centre, Oxford, UK
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
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Słabuszewska-Jóźwiak A, Szymański JK, Ciebiera M, Sarecka-Hujar B, Jakiel G. Pediatrics Consequences of Caesarean Section-A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8031. [PMID: 33142727 PMCID: PMC7662709 DOI: 10.3390/ijerph17218031] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cesarean section is a surgical procedure, which is the most frequently performed in gynecology and obstetrics. It is commonly believed that an operative delivery is a less painful and safer mode of delivery, which translates into an increasing number of the procedures performed without medical indications. The maternal sequelae of cesarean sections are well elucidated and widely discussed in the literature, while long-term neonatal consequences still remain the issue of research and scientific dispute. The aim of the present paper was to perform a systematic review of current literature regarding pediatrics consequences of cesarean section. METHODS We reviewed available data from PubMed, Science Direct as well as Google Scholar bases concerning early and long-term neonatal sequelae of operative deliveries. The following key words were used: "cesarean section", "caesarean section", "neonatal outcomes", "respiratory disorders", "asthma", "obesity", "overweight", and "neurological disorders". A total of 1636 papers were retrieved out of which 27 were selected for the final systematic review whereas 16 articles provided data for meta-analysis. Statistical analyses were performed using RevMan 5.4. To determine the strength of association between the caesarean section and respiratory tract infections, asthma, diabetes type 1 as well as obesity the pooled odds ratios (OR) with the 95% confidence intervals (CI) were calculated. RESULTS Conducted meta-analyses revealed that caesarean section is a risk factor for respiratory tract infections (pooled OR = 1.30 95%CI 1.06-1.60, p = 0.001), asthma (pooled OR = 1.23 95%CI 1.14-1.33, p < 0.00001) as well as obesity (pooled OR = 1.35 95%CI 1.29-1.41, p < 0.00001) in offspring. CONCLUSIONS The results of the studies included indicated that children delivered by cesarean section more commonly developed respiratory tract infections, obesity and the manifestations of asthma than children delivered vaginally. The risk of developing diabetes mellitus type 1 or neurological disorders in offspring after caesarean section is still under discussion.
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Affiliation(s)
- Aneta Słabuszewska-Jóźwiak
- First Department of Obstetrics and Gynaecology, Centre of Postgraduate Medical Education, Żelazna 90 Street, 01-004 Warsaw, Poland; (J.K.S.); (G.J.)
| | - Jacek Krzysztof Szymański
- First Department of Obstetrics and Gynaecology, Centre of Postgraduate Medical Education, Żelazna 90 Street, 01-004 Warsaw, Poland; (J.K.S.); (G.J.)
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynaecology, Centre of Postgraduate Medical Education, Cegłowska 80 Street, 01-809 Warsaw, Poland;
| | - Beata Sarecka-Hujar
- Department of Basic Biomedical Science, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Kasztanowa 3 Street, 41-200 Sosnowiec, Poland;
| | - Grzegorz Jakiel
- First Department of Obstetrics and Gynaecology, Centre of Postgraduate Medical Education, Żelazna 90 Street, 01-004 Warsaw, Poland; (J.K.S.); (G.J.)
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Antoine C, Young BK. Cesarean section one hundred years 1920-2020: the Good, the Bad and the Ugly. J Perinat Med 2020; 49:5-16. [PMID: 32887190 DOI: 10.1515/jpm-2020-0305] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/10/2020] [Indexed: 12/15/2022]
Abstract
In present-day obstetrics, cesarean delivery occurs in one in three women in the United States, and in up to four of five women in some regions of the world. The history of cesarean section extends well over four centuries. Up until the end of the nineteenth century, the operation was avoided because of its high mortality rate. In 1926, the Munro Kerr low transverse uterine incision was introduced and became the standard method for the next 50 years. Since the 1970's, newer surgical techniques gradually became the most commonly used method today because of intraoperative and postpartum benefits. Concurrently, despite attempts to encourage vaginal birth after previous cesareans, the cesarean delivery rate increased steadily from 5 to 30-32% over the last 10 years, with a parallel increase in costs as well as short- and long-term maternal, neonatal and childhood complications. Attempts to reduce the rate of cesarean deliveries have been largely unsuccessful because of the perceived safety of the operation, short-term postpartum benefits, the legal climate and maternal request in the absence of indications. In the United States, as the cesarean delivery rate has increased, maternal mortality and morbidity have also risen steadily over the last three decades, disproportionately impacting black women as compared to other races. Extensive data on the prenatal diagnosis and management of cesarean-related abnormal placentation have improved outcomes of affected women. Fewer data are available however for the improvement of outcomes of cesarean-related gynecological conditions. In this review, the authors address the challenges and opportunities to research, educate and change health effects associated with cesarean delivery for all women.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Bruce K Young
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
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20
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Does the Caesarean Section Impact on 11β HSD2 and Fetal Cortisol? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155566. [PMID: 32752242 PMCID: PMC7432821 DOI: 10.3390/ijerph17155566] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 01/09/2023]
Abstract
Purpose: Comparison of the activity of 11beta-hydroxysteroid dehydrogenase type 2 in the placenta and the umbilical cord blood cortisol level between caesarean sections with or without uterine contraction and vaginal delivery groups. Cortisol is the main stress hormone responsible for the normal adaptation of the neonate to extrauterine life. The disorders resulting from a dysfunction of the 11β-HSD 2–cortisol system can explain the higher risk of developing diseases in children born by caesarean section. Methods: 111 healthy, pregnant women in singular pregnancy at term of delivery were included into the study. The study comprised 11β-HSD 2 in placental tissue from 49 pregnant women delivering by elective caesarean section and 46 pregnant women delivering by vagina. In 16 cases of the elective caesarean section, regular uterine contractions were declared. Cortisol level was estimated in umbilical cord blood directly after delivery. Results: We found no statistically significant differences in the activity of 11β-HSD 2 in placentas delivered via caesarean sections (29.61 on average in elective caesarean sections and 26.65 on average in intrapartum caesarean sections) compared to vaginal deliveries (31.94 on average, p = 0.381), while umbilical cord blood cortisol in the elective caesarean sections group was significantly lower (29.86 on average) compared to the vaginal deliveries (55.50 on average, p < 0.001) and intrapartum caesarean sections (52.27 on average, p < 0.001). Conclusions: The model of placental 11β-HSD 2 activity and umbilical cord blood cortisol concentration seems to be significant in conditions of stress associated with natural uterine contractions in labour.
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Parnell L, Ayuk P. Prophylactic antenatal corticosteroids for fetal lung maturity: Known unknowns and unknown unknowns. Case Rep Womens Health 2020; 28:e00242. [PMID: 32874928 PMCID: PMC7451617 DOI: 10.1016/j.crwh.2020.e00242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Laura Parnell
- ST6 Obstetrics Registrar, Department of Obstetrics, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, United Kingdom
| | - Paul Ayuk
- Consultant Obstetrician, Department of Obstetrics, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, United Kingdom
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22
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Al Riyami N, Al Hadhrami A, Al Lawati T, Pillai S, Abdellatif M, Jaju S. Respiratory Distress Syndrome in Neonates Delivered at Term-gestation by Elective Cesarean Section at Tertiary Care Hospital in Oman. Oman Med J 2020; 2020:e133. [PMID: 32607253 PMCID: PMC7315520 DOI: 10.5001/omj.2020.51] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 05/13/2020] [Indexed: 11/29/2022] Open
Abstract
Objectives We sought to assess the relationship between respiratory distress syndrome (RDS) in neonates delivered by elective cesarean section at term gestation with and without corticosteroids cover. We also aimed to determine other neonatal complications such as sepsis, hypoglycemia, and hyperbilirubinemia. Methods We conducted a retrospective descriptive study from January 2010 to December 2015 on all Omani women who delivered by elective cesarean section at Sultan Qaboos University Hospital between 37+0 and 38+6 weeks gestation. Results Among 650 patients included in the study, 20.8% (n = 135) received corticosteroids antenatally and 79.2% did not. RDS was found in 16 out of 650 neonates, making the prevalence of RDS 2.5%. Higher gravidity and parity and a mean gestational age of less than 37.6 weeks, were associated with a significant risk of RDS. Administration of antenatal corticosteroids did not change the respiratory morbidity in the newborns (p = 0.340). A mean birth weight of 2.9 kg was associated with a significant risk of RDS (p = 0.043). All 16 newborns required neonatal intensive care unit admission and ventilator support. The most common ventilatory support used was continuous positive airway pressure (56.2%). The most common secondary complication in neonates diagnosed with RDS was transient tachypnea of the newborn (53.8%). Conclusions The prevalence of RDS was low. Giving antenatal corticosteroids for patients with planned elective cesarean at term did not seem to have a beneficial effect on neonatal respiratory morbidity. Further studies with larger sample size including multiple centers is recommended.
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Affiliation(s)
- Nihal Al Riyami
- Department of Obstetrics and Gynecology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Abeer Al Hadhrami
- Obstetrics and Gynecology Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
| | - Tuqa Al Lawati
- Obstetrics and Gynecology Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
| | - Silja Pillai
- Department of Obstetrics and Gynecology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Mohamed Abdellatif
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
| | - Sanjay Jaju
- Epidemiology and Biostatistics Section, Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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Rohwer AC, Oladapo OT, Hofmeyr GJ. Strategies for optimising antenatal corticosteroid administration for women with anticipated preterm birth. Cochrane Database Syst Rev 2020; 5:CD013633. [PMID: 32452555 PMCID: PMC7387231 DOI: 10.1002/14651858.cd013633] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Preterm birth is a serious and common pregnancy complication. The burden is particularly high in low- and middle-income countries where available care is often inadequate to ensure preterm newborn survival. Administration of antenatal corticosteroids (ACS) is recommended as the standard care for the management of women at risk of imminent preterm birth but its coverage varies globally. Efforts to improve preterm newborn survival have largely been focused on optimising the coverage of ACS use. However, the benefits and harms of such strategies are unclear. OBJECTIVES To determine the relative benefits and risks of individual patient protocols, health service policies, educational interventions or other strategies which aim to optimise the use of ACS for anticipated preterm birth. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs), randomised at individual or cluster level, and quasi-randomised trials that assessed strategies to optimise (either by increasing or restricting) the administration of ACS compared with usual care amongst women at risk of preterm birth. Our primary outcomes were perinatal death and a composite outcome of offspring mortality and early or late neurodevelopmental morbidity. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion. All three review authors independently extracted data and assessed risk of bias. We used narrative synthesis to analyse results, as we were unable to pool data from the included studies. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS We included three cluster-RCTs, all assessing the effects of a multifaceted strategy aiming to promote the use of ACS among women at risk of preterm birth. We did not identify any trials assessing strategies to restrict the use of ACS versus usual care. Two of the included trials assessed use of ACS in high-resource hospital settings. The third trial, the Antenatal Corticosteroid Trial (ACT) was a multi-site trial conducted in rural and semi-urban settings of six low- and middle-income countries in South Asia, sub-Saharan Africa and Central and South America. In two trials, promoting the use of ACS resulted in increased use of ACS, whereas one trial did not find a difference in the rate of ACS administration compared to usual care. Whilst we included three studies, we were unable to pool the data in meta-analysis due to outcomes not being reported across all studies, or outcome results being reported in different ways. The main source of data in this review is from the ACT trial. We assessed the ACT trial as high risk for performance and selective reporting bias. In the protocol for this review, we planned to report all settings and subgroup by low-middle versus high-income countries; these planned analyses were not possible in this version of the review, although adding further studies in future updates may allow us to carry out planned subgroup analyses. The ACT trial was conducted in low-resource settings and reported data on appropriate ACS treatment and inappropriate ACS treatment. Although a strategy of promoting the administration of ACS compared to routine care may increase appropriate ACS treatment (RR 4.34, 95%CI 3.59 to 5.25; 1 study; n = 4389; low-certainty evidence), it may also increase inappropriate ACS treatment (RR 9.11 95%CI 8.04 to 10.33, 1 study, n = 89,237; low-certainty evidence). In low-resource settings, a strategy of promoting the administration of ACS probably increases population level perinatal death by 3 per 1000 infants (risk ratio (RR) 1.11, 95% confidence interval (CI) 1.04 to 1.19; 1 study; n = 100,705; moderate-certainty evidence); stillbirth by 2 per 1000 infants (RR 1.11, 95% CI 1.02 to 1.21; 1 study; n = 100,705; moderate-certainty evidence); and neonatal death before 28 days by 2 per 1000 infants (RR 1.12, 95% CI 1.02 to 1.23; 1 study; n = 100,705; moderate-certainty evidence); may increase the risk for 'suspected' maternal infection or inflammation (RR 1.49, 95% CI 1.32 to 1.68; 1 study; n = 99,742; low-certainty evidence); and make little or no difference to the risk of maternal mortality (RR 1.11, 95% CI 0.64 to 1.92; 1 study; n = 99,742; low-certainty evidence) compared to routine care. Included trials did not report on the composite outcomes offspring mortality, early neurodevelopmental morbidity or late neurodevelopmental morbidity; and offspring mortality or severe neonatal morbidity. AUTHORS' CONCLUSIONS In low-resource settings, a strategy of actively promoting the use of ACS in women at risk of preterm birth may increase ACS use in the target population, but may also carry a substantial risk of unnecessary exposure of ACS to women in whom ACS is not indicated. At the population level, these effects are probably associated with increased risks of stillbirth, perinatal death, neonatal death before 28 days, and maternal infection. The findings of this review support a more conservative approach to clinical protocols and clinical decision-making particularly in low-resource settings, along the lines of the World Health Organization's ACS 2015 recommendations, which take into account both the established clinical efficacy of ACS when used in the correct situation and context, and the possibility of important adverse effects when certain conditions are not met. Given the unanticipated results of the ACT trial, further research on strategies to optimise the use of ACS in low-resource settings is justified.
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Affiliation(s)
- Anke C Rohwer
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - G Justus Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand/Fort Hare, East London, South Africa; Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; and, University of Botswana, Gaborone, Botswana
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Wynne K, Rowe C, Delbridge M, Watkins B, Brown K, Addley J, Woods A, Murray H. Antenatal corticosteroid administration for foetal lung maturation. F1000Res 2020; 9. [PMID: 32269758 PMCID: PMC7111495 DOI: 10.12688/f1000research.20550.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2020] [Indexed: 01/27/2023] Open
Abstract
Antenatal corticosteroids are an essential component in the management of women at risk for preterm labour. They promote lung maturation and reduce the risk of other preterm neonatal complications. This narrative review discusses the contentious issues and controversies around the optimal use of antenatal corticosteroids and their consequences for both the mother and the neonate. The most recent evidence base is presented.
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Affiliation(s)
- Katie Wynne
- Department of Diabetes & Endocrinology, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia.,Mothers and Babies, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Christopher Rowe
- Department of Diabetes & Endocrinology, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia.,Mothers and Babies, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Matthew Delbridge
- School of Medicine and Public Health, University of New England, Armidale, NSW, 2351, Australia
| | - Brendan Watkins
- School of Medicine and Public Health, University of New England, Armidale, NSW, 2351, Australia
| | - Karina Brown
- School of Medicine and Public Health, University of New England, Armidale, NSW, 2351, Australia
| | - Jordan Addley
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Andrew Woods
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.,Department of Obstetrics, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia
| | - Henry Murray
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.,Department of Obstetrics, John Hunter Hospital, New Lambton Heights, NSW, 2305, Australia
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25
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Bruschettini M, Moresco L, Calevo MG, Romantsik O. Postnatal corticosteroids for transient tachypnoea of the newborn. Cochrane Database Syst Rev 2020; 3:CD013222. [PMID: 32180216 PMCID: PMC7076329 DOI: 10.1002/14651858.cd013222.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Transient tachypnoea of the newborn (TTN) is characterized by tachypnoea and signs of respiratory distress. Transient tachypnoea typically appears within the first two hours of life in term and late preterm newborns. The administration of corticosteroids might compensate for the impaired hormonal changes which occur when infants are delivered late preterm, or at term but before the onset of spontaneous labour (elective caesarean section). Corticosteroids might improve the clearance of liquid from the lungs, thus reducing the effort required to breathe and improving respiratory distress. OBJECTIVES The objective of this review is to assess whether postnatal corticosteroids - compared to placebo, no treatment or any other drugs administered to treat TTN - are effective and safe in the treatment of TTN in infants born at 34 weeks' gestational age or more. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2), MEDLINE (1996 to 19 February 2019), Embase (1980 to 19 February 2019) and CINAHL (1982 to 19 February 2019). We applied no language restrictions. We searched clinical trial registries for ongoing studies. SELECTION CRITERIA We included randomized controlled trials, quasi-randomized controlled trials and cluster-randomized trials comparing postnatal corticosteroids versus placebo or no treatment or any other drugs administered to infants born at 34 weeks' gestational age or more and less than three days of age with TTN. DATA COLLECTION AND ANALYSIS For each of the included trials, two review authors independently extracted data (e.g. number of participants, birth weight, gestational age, duration of oxygen therapy, need for continuous positive airway pressure, need for mechanical ventilation, duration of mechanical ventilation, etc.) and assessed the risk of bias (e.g. adequacy of randomization and blinding, completeness of follow-up). The primary outcomes considered in this review were need for nasal continuous positive airway pressure and need for mechanical ventilation. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS One trial, which included 49 infants, met the inclusion criteria. The trial compared the use of inhaled corticosteroids (budesonide) with placebo. We found no differences between groups in terms of need for nasal continuous positive airway pressure (risk ratio (RR) 1.27, 95% confidence interval (CI) 0.65 to 2.51; 1 study, 49 participants) and need for mechanical ventilation (RR 0.52, 95% CI 0.05 to 5.38; 1 study, 49 participants). The type of mechanical ventilation used in the included study was high-frequency oscillation. Tests for heterogeneity were not applicable for any of the analyses as only one study was included. Out of the secondary outcomes we deemed to be of greatest importance to patients, the study only reported on duration of hospital stay, which was no different between groups. The quality of the evidence is very low, due to the imprecision of the estimates and indirectness. We identified no ongoing trials. AUTHORS' CONCLUSIONS Given the paucity and very low quality of the available evidence, we are unable to determine the benefits and harms of postnatal administration of either inhaled or systemic corticosteroids for the management of TTN.
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Affiliation(s)
- Matteo Bruschettini
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
- Skåne University HospitalCochrane SwedenWigerthuset, Remissgatan 4, first floorroom 11‐221LundSweden22185
| | - Luca Moresco
- Ospedale San PaoloPediatric and Neonatology UnitSavonaItaly
| | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics Unit, IRCCSGenoaItaly16147
| | - Olga Romantsik
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
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Tuohy JF, Bloomfield FH, Harding JE, Crowther CA. Patterns of antenatal corticosteroid administration in a cohort of women with diabetes in pregnancy. PLoS One 2020; 15:e0229014. [PMID: 32106249 PMCID: PMC7046227 DOI: 10.1371/journal.pone.0229014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/28/2020] [Indexed: 01/13/2023] Open
Abstract
Antenatal corticosteroids administered to the mother prior to birth decrease the risk of mortality and major morbidity in infants born at less than 35 weeks’ gestation. However, the evidence relating to women with diabetes in pregnancy is limited. Clinical guidelines for antenatal corticosteroid administration recommend that women with diabetes in pregnancy are treated in the same way as women without diabetes, but there are no recent descriptions of whether contemporary practice complies with this guidance. This study is a retrospective review of antenatal corticosteroid administration at a New Zealand tertiary hospital in women with diabetes in pregnancy. We found that in this cohort, for both an initial course at less than 35 weeks’ gestation and repeat courses at less than 33 weeks’, the administration of antenatal corticosteroid to women with diabetes in pregnancy is largely consistent with current Australian and New Zealand recommendations. However, almost 25% of women received their last dose of antenatal corticosteroid at or beyond the latest recommended gestation of 35 weeks’ gestation. Pre-existing diabetes and planned caesarean section were independently associated with an increased rate of antenatal corticosteroid administration. We conclude that diabetes in pregnancy does not appear to be a deterrent to antenatal corticosteroid administration. The high rates of administration at gestations beyond recommendations, despite the lack of evidence of benefit in this group of women, highlights the need for further research into the risks and benefits of antenatal corticosteroid administration to women with diabetes in pregnancy, particularly in the late preterm and early term periods.
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Affiliation(s)
- Jeremy F. Tuohy
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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27
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Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GHA, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update. Neonatology 2019; 115:432-450. [PMID: 30974433 PMCID: PMC6604659 DOI: 10.1159/000499361] [Citation(s) in RCA: 654] [Impact Index Per Article: 130.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.
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Affiliation(s)
- David G Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, United Kingdom,
| | - Virgilio Carnielli
- Department of Neonatology, Polytechnic University of Marche, and Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Pediatrics and Adolescence, Oulu University Hospital, and PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan Te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C Roehr
- Department of Paediatrics, University of Oxford, Medical Sciences Division, Newborn Services, John Radcliffe Hospitals, Oxford, United Kingdom
| | - Ola D Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
| | - Umberto Simeoni
- Division of Pediatrics, CHUV & University of Lausanne, Lausanne, Switzerland
| | - Christian P Speer
- Department of Pediatrics, University Children's Hospital, Würzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerhard H A Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, United Kingdom
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