Antenatal corticosteroid therapy: current strategies and identifying mediators and markers for response

Glycemic profile assessment during betamethasone administration in women with twin pregnancies after IVF with or without gestational diabetes

BACKGROUND AND AIMS

Betamethasone's effect on glycemia in twin pregnancies, with or without gestational diabetes mellitus, has not been adequately investigated.

METHODS

We assessed the glycemic profile of 30 women with twin pregnancies after in-vitro-fertilization who were given betamethasone.

RESULTS

The majority of women were treated eventually with insulin to maintain glycemia. In insulin-treated women the increase in insulin dosage was of 61.1%. Insulin use/dosage was not associated with betamethasone dose, age, gestational age, weight gain in pregnancy, or duration of hyperglycemia.

CONCLUSION

Post-betamethasone, twin pregnancies seem to follow the same glycemia pattern as singleton pregnancies.

Continuous but not pulsed low-dose fetal betamethasone exposures extend the durability of antenatal steroid therapy

Antenatal steroid (ANS) therapy is standard care for women at imminent risk of preterm labor. Despite extensive and long-standing use, 40-50% of babies exposed antenatally to steroids do not derive benefit; remaining undelivered 7d or more after ANS treatment is associated with a lack of treatment benefit, and increased risk of harms. We used a pregnant sheep model to evaluate the impact of continuous vs. pulsed ANS treatments on fetal lung maturation at an extended, eight-day treatment to delivery interval. Continuous low-dose ANS treatments for more than 72 hours in duration improved fetal lung maturation at eight days after treatment initiation. If fetal ANS exposure was interrupted, the beneficial ANS effect was lost. Truncated treatments, including that simulating the current clinical treatment regimen, did not improve lung function. Variable fetal lung maturation was correlated to the amount of saturated phosphatidylcholine present in the lung fluid. These data demonstrate that: i) the durability of ANS therapy may be enhanced by employing an extended, low-dose treatment regimen with reducing total dose; and ii) interrupting the continuity of fetal exposure by allowing it to fall below a minimal threshold was associated with comparably poor functional maturation of the preterm ovine lung.

Antenatal corticosteroids, maternal body mass index and infant morbidity within the ASTEROID trial

BACKGROUND

Antenatal corticosteroids (ACSs) administered to women before preterm birth improve neonatal health. Proportionately more women are obese or overweight in current obstetric populations than those who were included in the original trials of ACSs, and it remains uncertain if higher doses are required for such women.

AIM

Our aim was to assess the association between maternal body mass index (BMI) and infant morbidity after the administration of ACSs.

METHODS

In the secondary analysis of the ASTEROID trial cohort, women at risk of preterm birth at <34 weeks' gestation were randomised to betamethasone or dexamethasone. Infant outcomes were compared according to whether women were of normal weight (BMI < 25 kg/m² ), overweight (BMI 25-29.9 kg/m² ) or obese (BMI ≥ 30 kg/m² ).

RESULTS

Of 982 women with a singleton pregnancy and BMI data, 519 (52.9%) were of normal size, 241 (24.5%) were overweight and 222 (22.6%) were obese. Compared with infants born to women of normal weight, there was little or no difference in respiratory distress syndrome in infants born to women who were overweight (odds ratio (OR) = 0.92, 95% confidence interval (CI) 0.57, 1.49) or obese (OR = 1.44, 95% CI 0.90, 2.31). Similarly, there were no significant differences between infants born to women in the three BMI groups for other morbidities, including bronchopulmonary dysplasia, mechanical ventilation, intraventricular haemorrhage, retinopathy of prematurity, patent ductus arteriosus, necrotising enterocolitis, perinatal death or combined serious morbidity.

CONCLUSIONS

Maternal body size is not associated with infant morbidity after ACS exposure. Dose adjustment for women with higher BMI is not required.

Glycemia after Betamethasone in Pregnant Women without Diabetes-Impact of Marginal Values in the 75-g OGTT

Betamethasone (BM) administration in pregnancy has been shown to reduce the incidence and severity of neonatal respiratory distress syndrome. Its known diabetogenic impact, combined with placental insulin resistance, leads to a transient increase in glycemia. However, its effect on glucose homeostasis in pregnancy has not been adequately investigated. We closely monitored and assessed the glycemic profile of 83 pregnant women, with normal glucose metabolism, who were given BM during their hospitalization due to threatened premature labor. A significant change in the glycemic profile in most patients was noted, lasting 1.34 ± 1.05 days. Sixty-six of eighty-three women were eventually treated with insulin to maintain glycemia within acceptable limits. The mean ± SD insulin dosage was 12.25 ± 11.28 units/day. The need for insulin therapy was associated with higher BM doses and the presence of marginal values in the 75-g oral glucose tolerance test (OGTT) at 60 min. Our study demonstrates, following BM administration, the need for increased awareness and individualized monitoring/treatment of pregnant women with normal—yet marginal—values in the 75-g OGTT.

Antenatal Administration of Betamethasone Contributes to Intimal Thickening of the Rat Ductus Arteriosus

BACKGROUND

Antenatal betamethasone (BMZ) is a standard therapy for reducing respiratory distress syndrome in preterm infants. Recently, some reports have indicated that BMZ promotes ductus arteriosus (DA) closure. DA closure requires morphological remodeling; that is, intimal thickening (IT) formation; however, the role of BMZ in IT formation has not yet been reported. Methods and Results: First, DNA microarray analysis using smooth muscle cells (SMCs) of rat preterm DA on gestational day 20 (pDASMCs) stimulated with BMZ was performed. Among 58,717 probe sets, ADP-ribosyltransferase 3 (Art3) was markedly increased by BMZ stimulation. Quantitative reverse transcription polymerase chain reaction (RT-PCR) confirmed the BMZ-induced increase of Art3 in pDASMCs, but not in aortic SMCs. Immunocytochemistry showed that BMZ stimulation increased lamellipodia formation. BMZ significantly increased total paxillin protein expression and the ratio of phosphorylated to total paxillin. A scratch assay demonstrated that BMZ stimulation promoted pDASMC migration, which was attenuated byArt3-targeted siRNAs transfection. pDASMC proliferation was not promoted by BMZ, which was analyzed by a 5'-bromo-2'-deoxyuridine (BrdU) assay. Whether BMZ increased IT formation in vivo was examined. BMZ or saline was administered intravenously to maternal rats on gestational days 18 and 19, and DA tissues were obtained on gestational day 20. The ratio of IT to tunica media was significantly higher in the BMZ-treated group.

CONCLUSIONS

These data suggest that antenatal BMZ administration promotes DA IT through Art3-mediated DASMC migration.

Glycemic profile assessment during betamethasone administration in women with gestational diabetes mellitus

AIM

Betamethasone's effect on glucose homeostasis in the presence of gestational diabetes has not been adequately investigated.

MATERIALS-METHODS

We assessed the glycemic profile of 99 women with gestational diabetes (52 on insulin, 47 on medical nutrition therapy) who were given betamethasone during hospitalization for at risk pregnancies.

RESULTS

In insulin-treated women the increase in total daily insulin dose significantly linked to betamethasone dose (p = 0.014). In women on diet, the need for insulin was positively related to betamethasone dose, age and gestational age >34th week (all p < 0.05).

CONCLUSION

Parsimonious betamethasone use might still be beneficial with a milder effect on glycemia.

Impact of antenatal corticosteroids in preterm neonates based on maternal body mass index

OBJECTIVE

Impact of antenatal corticosteroid (ACS) in context of maternal body mass index (BMI) as it relates to neonatal outcomes remains unclear. We sought to evaluate effects of ACS on clinical outcomes of preterm infants based on maternal BMI.

METHODS

We performed a retrospective cohort study among neonates 23-33 weeks' GA at a tertiary neonatal intensive care unit from 2011 to 2015. Outcomes of neonates exposed to any ACS and pre-pregnancy maternal BMI ≥ 25 (N = 491) were compared with maternal BMI < 25 (N = 484). A priori planned subgroup analyses based on ACS exposure (partial ACS; complete ACS ≤ 7 days prior to delivery (PTD); and complete ACS > 7 days PTD) were conducted. Primary outcome was composite of mortality or any of moderate/severe bronchopulmonary dysplasia, severe neurologic injury, severe retinopathy of prematurity, necrotizing enterocolitis stage, or primary bloodstream infection.

RESULTS

Preterm neonates with maternal BMI ≥ 25 (exposed to any ACS) were not at increased risk of composite outcome vs. BMI < 25 (adjusted odd ratio (aOR) 1.03, 95% confidence interval (CI) 0.84-1.48), nor any individual neonatal morbidities. Similar findings were noted in subgroup analyses by type of ACS exposure.

CONCLUSION

Impact of ACS on neonatal outcomes do not appear to be influenced by maternal BMI based on data from this cohort. However, further research is required to definitively elucidate the impact of BMI on ACS with regards to pharmacokinetics and neonatal outcomes.

Antenatal corticosteroids beyond 34 weeks gestation: What do we do now?

The practice of antenatal corticosteroid administration in pregnancies of 24-34 weeks of gestation that are at risk of preterm delivery was adopted over 20 years after the first randomized clinical trial in humans. It is biologically plausible that antenatal corticosteroid in pregnancies beyond 34 weeks of gestation would reduce rates of respiratory morbidity and neonatal intensive care admission. Mostly guided by the results of a large multicenter randomized trial of antenatal corticosteroid in late preterm infants, the Antenatal Late Preterm Steroids Trial, the American Congress of Obstetricians and Gynecologists has released a practice advisory that the "administration of betamethasone may be considered in women with a singleton pregnancy between 34 0/7 and 36 6/7 weeks of gestation at imminent risk of preterm birth within 7 days." However, many unanswered questions about the risks and benefits of antenatal corticosteroids in this population remain and should be considered with the adoption of this treatment recommendation. This review of the literature indicates that the greatest effect is in the reduction of transient tachypnea of the newborn infant, which is a mostly self-limited condition. This benefit must be weighed against unanticipated outcomes, such as neonatal hypoglycemia, and unknowns about long-term neurodevelopmental follow up and metabolic risks. Amelioration of respiratory morbidity in late preterm infants does not preclude these infants from having other complications that are related to prematurity that require intensive care. Other possible morbidities of prematurity may be magnified if these babies no longer have respiratory symptoms. Conversely, if these late preterm babies no longer exhibit respiratory symptoms and "look good," they may be discharged before other morbidities of prematurity have resolved and be at risk for readmission. Furthermore, it is also important to ensure that unintended consequences are avoided to achieve a minor benefit. Some of these consequences may include treatment with multiple steroid courses or "treatment creep" in women at 34 to <37 weeks of gestation who do not meet the inclusion/exclusion criteria of the Antenatal Late Preterm Steroids Trial, particularly when a high percentage of women do not receive antenatal corticosteroid within 7 days of delivery. Finally, we believe that caution should be exercised before wide-scale universal adoption of antenatal corticosteroid for pregnancies that are at risk of preterm birth at 34 to <37 weeks of gestation, when it is unclear whether there are long-term effects. For a more balanced rationale for the decision to use antenatal corticosteroid treatment in pregnancies at >34 weeks of gestation, we urge for ongoing research into the risks and benefits of antenatal corticosteroid use in preterm infants overall, for better prediction of preterm birth so that antenatal corticosteroid can be administered within the ideal time frame, and for long-term neurodevelopmental follow-up of the participants in the large randomized Antenatal Late Preterm Steroids Trial.

Surgical treatment of melanoma in pregnancy: a practical guideline

A tumor primarily requiring surgical treatment, newly diagnosed or preexisting melanoma during pregnancy is a clinical rarity. In such cases, the surgeon faces the challenge of having to decide on the appropriate therapeutic course of action. Based on our clinical experience and a review of the literature, we herein provide a guideline on how to practically deal with this rare clinical conundrum. In our experience, pregnant melanoma patients require thorough counseling with respect to their therapeutic options. They naturally tend to put their unborn child first, and are hesitant to consent to necessary surgery despite a potentially life-threatening diagnosis. It is therefore crucial to clearly inform these patients that - based on existing medical experience - pregnancy by itself is no reason to hold off on any type of necessary melanoma surgery. However, various parameters such as preoperative imaging procedures, positioning on the operating table, monitoring, anesthesia, and perioperative medication require certain adjustments in order to comply with this special situation.

Chirurgische Behandlung von Melanomen in der Schwangerschaft: eine praktische Anleitung

Als ein Tumor, der primär eine chirurgische Behandlung erfordert, ist ein neu diagnostiziertes oder vorbestehendes Melanom in der Schwangerschaft eine klinische Rarität. In solchen Fällen steht der Chirurg vor der Herausforderung, ein geeignetes therapeutisches Vorgehen festlegen zu müssen. Auf der Grundlage unserer klinischen Erfahrung und einer Übersicht über die Literatur geben wir in der vorliegenden Arbeit eine Anleitung für das praktische Vorgehen bei dieser seltenen klinischen Konstellation. Unserer Erfahrung nach müssen schwangere Melanom-Patientinnen im Hinblick auf ihre therapeutischen Optionen ausführlich beraten werden. Naturgemäß setzen sie ihr ungeborenes Kind an die erste Stelle und zögern, der erforderlichen Operation zuzustimmen, obwohl bei ihnen eine möglicherweise lebensbedrohliche Erkrankung diagnostiziert worden ist. Daher ist es entscheidend, diese Patientinnen klar darüber zu informieren, dass, wie die vorliegenden medizinischen Erfahrungen zeigen, eine Schwangerschaft per se kein Grund ist, eine notwendige Melanom-Operation aufzuschieben. Jedoch müssen bei einigen Parametern wie den präoperativen Bildgebungsverfahren, der Positionierung auf dem Operationstisch, der Überwachung, Anästhesie und der perioperativen Medikation bestimmte Anpassungen vorgenommen werden, um der speziellen Situation Rechnung zu tragen.