Controversies in antenatal corticosteroid treatment

Clinical course and management of COVID-19 in the era of widespread population immunity

The clinical implications of COVID-19 have changed since SARS-CoV-2 first emerged in humans. The current high levels of population immunity, due to prior infection and/or vaccination, have been associated with a vastly decreased overall risk of severe disease. Some people, particularly those with immunocompromising conditions, remain at risk for severe outcomes. Through the course of the pandemic, variants with somewhat different symptom profiles from the original SARS-CoV-2 virus have emerged. The management of COVID-19 has also changed since 2020, with the increasing availability of evidence-based treatments in two main classes: antivirals and immunomodulators. Selecting the appropriate treatment(s) for patients with COVID-19 requires a deep understanding of the evidence and an awareness of the limitations of applying data that have been largely based on immune-naive populations to patients today who most likely have vaccine-derived and/or infection-derived immunity. In this Review, we provide a summary of the clinical manifestations and approaches to caring for adult patients with COVID-19 in the era of vaccine availability and the dominance of the Omicron subvariants, with a focus on the management of COVID-19 in different patient groups, including immunocompromised, pregnant, vaccinated and unvaccinated patients.

Pregnant women with diabetes and their clinician's experience of participating in a pilot randomised controlled trial of corticosteroid administration in late pregnancy: A qualitative study

BACKGROUND

Little research exists to support the administration of corticosteroids to pregnant women with diabetes. Pregnant women are often excluded from clinical trials due to concerns of harm to the foetus.

AIM

This study aimed to understand the experiences of women and clinicians of participating in the Prevention of neonatal Respiratory distress with antenatal corticosteroids before Elective Caesarean section in women with Diabetes pilot randomised controlled trial to determine the acceptability of the study protocol.

METHODS

Women and clinicians participating in the pilot trial were invited to complete a telephone interview regarding their experiences of participating. Qualitative data were collected and subsequently analysed using thematic analysis.

RESULTS

A total of 13 women and nine clinicians were recruited between June 2020 and May 2022 for a telephone interview. Participating in the study was deemed acceptable by women and clinicians. Women chose to participate in the study due to the perceived low risk of harm associated with the intervention and for altruistic reasons. The high level of clinical support and information provided for the duration of the pilot trial was valued by women and clinicians. All clinicians highlighted the importance of conducting the trial to inform evidence-based practice.

CONCLUSIONS

Pregnant women are more likely to participate in clinical trials when perceived risks are low and they are well-informed during decision-making. Clinicians will support clinical trials when they perceive a benefit to practice and feel assured that women receive extensive monitoring and support. Incorporating these factors into study protocols is more likely to be successful in recruiting pregnant women and maintaining the engagement of clinical staff for the duration of clinical trials.

PATIENT OR PUBLIC CONTRIBUTIONS

Patients were invited to be participants in this study. A consumer has been included in the planning and oversite of the large multicentre trial.

Antenatal corticosteroid administration-to-birth interval and neonatal outcomes in very preterm infants: A secondary analysis based on a prospective cohort study

INTRODUCTION

Despite the prevalent use of antenatal corticosteroids (ACS) to prevent preterm infants' adverse neonatal complications, there is currently no consensus on administration-to-birth intervals of ACS. International guidelines broadly agree that the administration of antenatal corticosteroids should be within 7 days prior to preterm birth. However, there is little evidence to support narrower optimal ACS administration-to-birth interval time. This study was undertaken to investigate the association between the administration-to-birth interval of ACS which is bounded by 48 hours and neonatal outcomes in very preterm infants.

MATERIALS AND METHODS

This is a single-center prospective observational study. Data were collected prospectively from eligible infants from January 2008 to April 2014 at the Santa Clara Valley Medical Center, neonatal outcomes were compared between two groups based on the interval of antenatal corticosteroid administration-to-birth: the interval of <48h, and the interval of >48h. It was noted that the entire study was completed by Dongli Song et al., and uploaded the data to the DATADRYAD website. The author only used this data for secondary analysis.

RESULTS

After adjusting potential confounders (gestational age, sex, birth weight, duration of cord clamping and delivery mode), the interval of >48h group compared to the interval of <48h group had significant reductions in mortality (OR: 0.17; 95% CI: 0.05-0.59), any retinopathy of prematurity (OR: 0.36; 95% CI: 0.16-0.82), severe retinopathy of prematurity (OR: 0.07; 95% CI: 0.01-0.45), any intubation (OR: 0.39; 95% CI: 0.20-0.75) and higher 1 min Apgar (β: 0.56; 95% CI: 0.10-1.02).

CONCLUSION

This study shows that in very preterm infants, compared with the interval of ACS<48h, the interval of ACS>48 hours has a significant health promotion effect.

Association of maternal body composition and diet on breast milk hormones and neonatal growth during the first month of lactation

INTRODUCTION

Preterm birth is associated with altered growth patterns and an increased risk of cardiometabolic diseases, with breast milk (BM) being a counteracting factor. Preterm infants also show alterations in adipokines and gut hormones influencing appetite and metabolism. Since these hormones are present in BM, it is possible that their levels may equilibrate deficiencies improving infant growth. We aimed to assess 1) the BM levels of ghrelin, resistin, leptin, insulin, peptide YY, and the gastrointestinal peptide in women with preterm and term labor; 2) the relationship between BM hormones and neonatal growth; and 3) the influence of maternal body composition and diet on these BM hormones.

METHODS

BM from 48 women (30 term and 18 preterm labor) was collected at days 7, 14, and 28 of lactation. Maternal body composition was evaluated by bioimpedance, and neonate anthropometric parameters were collected from medical records. The maternal dietary pattern was assessed by a 72-h dietary recall at days 7 and 28 of lactation. BM hormones were analyzed by the U-Plex Ultra-sensitive method. Data were analyzed using linear regression models. BM from women with preterm labor had lower ghrelin levels, with the other hormones being significantly higher compared to women with term delivery.

RESULTS

In premature infants, growth was positively associated with BM ghrelin, while, in term infants, it was positively associated with insulin and negatively with peptide YY. In the first week of lactation, women with preterm labor had higher body fat compared to women with term labor. In this group, ghrelin levels were positively associated with maternal body fat and with fiber and protein intake. In women with term labor, no associations between anthropometric parameters and BM hormones were found, and fiber intake was negatively associated with peptide YY.

DISCUSSION

Preterm labor is a factor influencing the levels of BM adipokines and gut hormones, with BM ghrelin being a relevant hormone for premature infant growth. Since ghrelin is lower in BM from women with preterm labor and the levels are associated with maternal fat storage and some dietary components, our data support the importance to monitor diet and body composition in women who gave birth prematurely to improve the BM hormonal status.

Diagnosis and management of covid-19 in pregnancy

Pregnant women with covid-19 are at greater risk of severe disease than their non-pregnant peers, and yet they are frequently denied investigations or treatments because of unfounded concerns about risk to the fetus. The basic principles of diagnosing and managing covid-19 are the same as for non-pregnant patients, and a multidisciplinary, expert team approach is essential to ensure optimal care. During pregnancy, treatment with corticosteroids should be modified to use non-fluorinated glucocorticoids. Il-6 inhibitors and monoclonal antibodies, together with specific antiviral therapies, may also be considered. Prophylaxis against venous thromboembolism is important. Women may require respiratory support with oxygen, non-invasive ventilation, ventilation in a prone position (either awake or during invasive ventilation), intubation and ventilation, and extracorporeal membrane oxygenation (ECMO). Pregnancy is not a contraindication for any of these supportive therapies, and the criteria for providing them are the same as in the general population. Decisions regarding timing, place, and mode of delivery should be taken with a multidisciplinary team including obstetricians, physicians, anesthetists, and intensivists experienced in the care of covid-19 in pregnancy. Ideally these decisions should take place in consultation with centers that have experience and expertise in all these specialties.

How can obstetricians improve outcomes for infants born extremely preterm?

Prematurity remains a leading cause of perinatal morbidity and mortality, and also has significant implications for long-term health. Obstetricians have a key role to play in improving outcomes for infants born at extremely preterm gestations. This review explores the evidence for interventions available to obstetricians caring for women at risk of birthing at extremely preterm gestations, including antenatal corticosteroids, magnesium sulfate, tocolysis and antibiotics. It also addresses the importance of strategies to facilitate safe in-utero transfer, to maximise the chance of extremely preterm births occurring in tertiary centers, and the clinical value of strategies by which preterm birth can be predicted. The paper concludes with an appraisal of evidence for different modes of birth at extremely preterm gestations, and for delayed cord clamping.

Association of antenatal corticosteroids with morbidity and mortality among preterm multiple gestations: meta-analysis of observational studies

OBJECTIVE

This meta-analysis aimed to assess the efficacy of antenatal corticosteroids (ACS) on morbidity and mortality among preterm multiple pregnancies.

METHODS

The PubMed, Embase, Web of Science and Cochrane Library databases were searched for studies investigating the outcomes among preterm multiple gestations following to ACS, from their inception to 1 November 2020. Two authors independently performed the study selection, risk of bias assessment and data extraction. The primary outcomes were respiratory distress syndrome (RDS) and mortality and secondary outcomes included intraventricular haemorrhage (IVH), periventricular leukomalacia (PVL), necrotising enterocolitis, retinopathy of prematurity and bronchopulmonary dysplasia. Pooled ORs were obtained using random effects models. Subgroup analyses were performed to explain heterogeneity by ACS completeness, administration-to-delivery intervals (≤7 days) and single or multicentre.

RESULTS

A total of 16 observational studies with 36 973 newborns were included in the meta-analysis. ACS treatment was associated with a reduction in RDS (OR 0.66; 95% CI 0.54 to 0.82; I2=91.4%; p<0.001), mortality (OR 0.64; 95% CI 0.50 to 0.81; I2=85.9%; p<0.001), IVH (OR 0.67; 95% CI 0.54 to 0.83; I2=77.4%; p<0.001) and PVL (OR 0.65; 95% CI 0.47 to 0.92; I2=75.5%; p<0.001). Subgroup analyses showed ACS completeness, administration-to-delivery interval and multicentre study affected these associations.

DISCUSSION

ACS may be beneficial for reducing the risks of RDS, mortality, IVH and PVL among preterm multiple gestations. The efficacy of ACS could be affected by ACS completeness and administration-to-delivery. More robust evidence on the efficacy of ACS treatment among multiple gestations is warranted.