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Gosavi A, Amin Z, Carter SWD, Choolani MA, Fee EL, Milad MA, Jobe AH, Kemp MW. Antenatal corticosteroids in Singapore: a clinical and scientific assessment. Singapore Med J 2024; 65:479-487. [PMID: 36254928 DOI: 10.4103/singaporemedj.smj-2022-014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 07/13/2022] [Indexed: 01/28/2023]
Abstract
ABSTRACT Preterm birth (PTB; delivery prior to 37 weeks' gestation) is the leading cause of early childhood death in Singapore today. Approximately 9% of Singaporean babies are born preterm; the PTB rate is likely to increase given the increased use of assisted reproduction technologies, changes in the incidence of gestational diabetes/high body mass index and the ageing maternal population. Antenatal administration of dexamethasone phosphate is a key component of the obstetric management of Singaporean women who are at risk of imminent preterm labour. Dexamethasone improves preterm outcomes by crossing the placenta to functionally mature the fetal lung. The dexamethasone regimen used in Singapore today affords a very high maternofetal drug exposure over a brief period of time. Drawing on clinical and experimental data, we reviewed the pharmacokinetic profile and pharmacodynamic effects of dexamethasone treatment regimen in Singapore, with a view to creating a development pipeline for optimising this critically important antenatal therapy.
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Affiliation(s)
- Arundhati Gosavi
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Zubair Amin
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sean William David Carter
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Mahesh Arjandas Choolani
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Erin Lesley Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
| | - Mark Amir Milad
- Milad Pharmaceutical Consulting LLC, Plymouth, Michigan, USA
| | - Alan Hall Jobe
- Perinatal Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew Warren Kemp
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
- School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
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Pereira-Fantini PM, Tingay D, Lakshminrusimha S. A complex inflammatory mix: chorioamnionitis, antenatal steroids and early postnatal budesonide. Pediatr Res 2024:10.1038/s41390-024-03219-y. [PMID: 38724647 DOI: 10.1038/s41390-024-03219-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 06/12/2024]
Affiliation(s)
- Prue M Pereira-Fantini
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia.
| | - David Tingay
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
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Bashir HA, Lufting-Leeffrers D, Myat Min A, Htun Win H, Win Tun N, Gay Wah T, Ellen Gilder M, Kho Paw M, I. Carrara V, Meeyai A, Aderoba AK, Nosten F, Gross MM, McGready R. Antenatal corticosteroids reduce neonatal mortality in settings without assisted ventilatory support: a retrospective cohort study of early preterm births on the Thailand-Myanmar border. Wellcome Open Res 2024; 8:225. [PMID: 38779045 PMCID: PMC11109590 DOI: 10.12688/wellcomeopenres.19396.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 05/25/2024] Open
Abstract
Background Prematurity is the highest risk for under-five mortality globally. The aim of the study was to assess the effect of antenatal dexamethasone on neonatal mortality in early preterm in a resource-constrained setting without assisted ventilation. Methods This retrospective (2008-2013) cohort study in clinics for refugees/migrants on the Thai-Myanmar border included infants born <34 weeks gestation at home, in, or on the way to the clinic. Dexamethasone, 24 mg (three 8 mg intramuscular doses, every 8 hours), was prescribed to women at risk of preterm birth (28 to <34 weeks). Appropriate newborn care was available: including oxygen but not assisted ventilation. Mortality and maternal fever were compared by the number of doses (complete: three, incomplete (one or two), or no dose). A sub-cohort participated in neurodevelopmental testing at one year. Results Of 15,285 singleton births, 240 were included: 96 did not receive dexamethasone and 144 received one, two or three doses (56, 13 and 75, respectively). Of live-born infants followed to day 28, (n=168), early neonatal and neonatal mortality/1,000 livebirths (95%CI) with complete dosing was 217 (121-358) and 304 (190-449); compared to 394 (289-511) and 521 (407-633) with no dose. Compared to complete dosing, both incomplete and no dexamethasone were associated with elevated adjusted ORs 4.09 (1.39 to 12.00) and 3.13 (1.14 to 8.63), for early neonatal death. By contrast, for neonatal death, while there was clear evidence that no dosing was associated with higher mortality, adjusted OR 3.82 (1.42 to 10.27), the benefit of incomplete dosing was uncertain adjusted OR 1.75 (0.63 to 4.81). No adverse impact of dexamethasone on infant neurodevelopmental scores (12 months) or maternal fever was observed. Conclusions Neonatal mortality reduction is possible with complete dexamethasone dosing in pregnancies at risk of preterm birth in settings without capacity to provide assisted ventilation.
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Affiliation(s)
- Humayra Aisha Bashir
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | - Daphne Lufting-Leeffrers
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Midwifery Research and Education Unit, Hannover Medical School, Hannover, Germany
| | - Aung Myat Min
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Htun Htun Win
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Nay Win Tun
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Tha Gay Wah
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Mary Ellen Gilder
- Department of Family Medicine, Chiang Mai University, Chiang Mai, Chiang Mai, Thailand
| | - Moo Kho Paw
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Verena I. Carrara
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
- Institute of Global Health, Faculty of Medicine, Universite de Geneve, Geneva, Geneva, Switzerland
| | - Aronrag Meeyai
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | - Adeniyi Kolade Aderoba
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
- University of Medical Sciences Teaching Hospital, Akure, Ondo, Nigeria
| | - François Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | - Mechthild M. Gross
- Midwifery Research and Education Unit, Hannover Medical School, Hannover, Germany
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
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Baxter C, Crary I, Coler B, Marcell L, Huebner EM, Rutz S, Adams Waldorf KM. Addressing a broken drug pipeline for preterm birth: why early preterm birth is an orphan disease. Am J Obstet Gynecol 2023; 229:647-655. [PMID: 37516401 PMCID: PMC10818026 DOI: 10.1016/j.ajog.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/19/2023] [Accepted: 07/23/2023] [Indexed: 07/31/2023]
Abstract
Preterm birth remains one of the most urgent unresolved medical problems in obstetrics, yet only 2 therapeutics for preventing preterm birth have ever been approved by the United States Food and Drug Administration, and neither remains on the market. The recent withdrawal of 17-hydroxyprogesterone caproate (17-OHPC, Makena) marks a new but familiar era for obstetrics with no Food and Drug Administration-approved pharmaceuticals to address preterm birth. The lack of pharmaceuticals reflects a broad and ineffective pipeline hindered by extensive regulatory hurdles, soaring costs of performing drug research, and concerns regarding adverse effects among a particularly vulnerable population. The pharmaceutical industry has historically limited investments in research for diseases with similarly small markets, such as cystic fibrosis, given their rarity and diminished projected financial return. The Orphan Drug Act, however, incentivizes drug development for "orphan diseases", defined as affecting <200,000 people in the United States annually. Although the total number of preterm births in the United States exceeds this threshold annually, the early subset of preterm birth (<34 weeks' gestation) would qualify, which is predominantly caused by inflammation and infection. The scientific rationale for classifying preterm birth into early and late subsets is strong given that their etiologies differ, and therapeutics that may be efficacious for one subset may not work for the other. For example, antiinflammatory therapeutics would be expected to be highly effective for early but not late preterm birth. A robust therapeutic pipeline of antiinflammatory drugs already exists, which could be used to target spontaneous early preterm birth, in combination with antibiotics shown to sterilize the amniotic cavity. New applications for therapeutics targeting spontaneous early preterm birth could categorize as orphan disease drugs, which could revitalize the preterm birth therapeutic pipeline. Herein, we describe why drugs targeting early preterm birth should qualify for orphan status, which may increase pharmaceutical interest for this vitally important obstetrical condition.
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Affiliation(s)
- Carly Baxter
- School of Medicine, University of Washington, Seattle, WA
| | - Isabelle Crary
- School of Medicine, University of Washington, Seattle, WA
| | - Brahm Coler
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | - Lauren Marcell
- School of Medicine, University of Washington, Seattle, WA
| | | | - Sara Rutz
- School of Medicine, University of Washington, Seattle, WA
| | - Kristina M Adams Waldorf
- Departments of Obstetrics and Gynecology and Global Health, University of Washington, Seattle, WA.
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Williamson C, Nana M, Poon L, Kupcinskas L, Painter R, Taliani G, Heneghan M, Marschall HU, Beuers U. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. J Hepatol 2023; 79:768-828. [PMID: 37394016 DOI: 10.1016/j.jhep.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 07/04/2023]
Abstract
Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.
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Frier EM, Lin C, Reynolds RM, Allegaert K, Been JV, Fraser A, Gissler M, Einarsdóttir K, Florian L, Jacobsson B, Vogel JP, Zoega H, Bhattacharya S, Krispin E, Henning Pedersen L, Roberts D, Kuhle S, Fahey J, Mol BW, Burgner D, Schuit E, Sheikh A, Wood R, Gyamfi-Bannerman C, Miller JE, Duhig K, Lahti-Pulkkinen M, Hadar E, Wright J, Murray SR, Stock SJ. Consortium for the Study of Pregnancy Treatments (Co-OPT): An international birth cohort to study the effects of antenatal corticosteroids. PLoS One 2023; 18:e0282477. [PMID: 36862657 PMCID: PMC9980789 DOI: 10.1371/journal.pone.0282477] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/15/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Antenatal corticosteroids (ACS) are widely prescribed to improve outcomes following preterm birth. Significant knowledge gaps surround their safety, long-term effects, optimal timing and dosage. Almost half of women given ACS give birth outside the "therapeutic window" and have not delivered over 7 days later. Overtreatment with ACS is a concern, as evidence accumulates of risks of unnecessary ACS exposure. METHODS The Consortium for the Study of Pregnancy Treatments (Co-OPT) was established to address research questions surrounding safety of medications in pregnancy. We created an international birth cohort containing information on ACS exposure and pregnancy and neonatal outcomes by combining data from four national/provincial birth registers and one hospital database, and follow-up through linked population-level data from death registers and electronic health records. RESULTS AND DISCUSSION The Co-OPT ACS cohort contains 2.28 million pregnancies and babies, born in Finland, Iceland, Israel, Canada and Scotland, between 1990 and 2019. Births from 22 to 45 weeks' gestation were included; 92.9% were at term (≥ 37 completed weeks). 3.6% of babies were exposed to ACS (67.0% and 77.9% of singleton and multiple births before 34 weeks, respectively). Rates of ACS exposure increased across the study period. Of all ACS-exposed babies, 26.8% were born at term. Longitudinal childhood data were available for 1.64 million live births. Follow-up includes diagnoses of a range of physical and mental disorders from the Finnish Hospital Register, diagnoses of mental, behavioural, and neurodevelopmental disorders from the Icelandic Patient Registers, and preschool reviews from the Scottish Child Health Surveillance Programme. The Co-OPT ACS cohort is the largest international birth cohort to date with data on ACS exposure and maternal, perinatal and childhood outcomes. Its large scale will enable assessment of important rare outcomes such as perinatal mortality, and comprehensive evaluation of the short- and long-term safety and efficacy of ACS.
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Affiliation(s)
- Emily M. Frier
- MRC Centre for Reproductive Health, The Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, United Kingdom
- * E-mail:
| | - Chun Lin
- Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Rebecca M. Reynolds
- MRC Centre for Reproductive Health, The Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, United Kingdom
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, United Kingdom
| | - Karel Allegaert
- Department of Development and Regeneration & Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jasper V. Been
- Division of Neonatology, Department of Paediatrics / Department of Obstetrics and Gynaecology / Department of Public Health, Erasmus MC Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Abigail Fraser
- Population Health Sciences, Bristol Medical School and MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, United Kingdom
| | - Mika Gissler
- THL Finnish Institute for Health and Welfare, Department of Knowledge Brokers, Helsinki, Finland
- Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Kristjana Einarsdóttir
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Lani Florian
- Moray House School of Education and Sport, University of Edinburgh, Edinburgh, United Kingdom
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Genetics and Bioinformatics, Domain of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
| | - Joshua P. Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
| | - Helga Zoega
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
- School of Population Health, Faculty of Medicine & Health, University of New South Wales, Sydney, Australia
| | - Sohinee Bhattacharya
- Aberdeen Centre for Women’s Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Eyal Krispin
- Boston Children’s Hospital, Harvard University, Boston, Massachusetts, United States of America
| | - Lars Henning Pedersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Devender Roberts
- Family Health Division, Liverpool Women’s Hospital, Liverpool, United Kingdom
| | - Stefan Kuhle
- Departments of Pediatrics and Obstetrics & Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John Fahey
- Reproductive Care Program of Nova Scotia, IWK Health, Halifax, Nova Scotia, Canada
| | - Ben W. Mol
- Aberdeen Centre for Women’s Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
- Ritchie Centre, Monash University, Clayton, Australia
| | - David Burgner
- Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, Melbourne University, Parkville, Victoria, Australia
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Aziz Sheikh
- Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Rachael Wood
- Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
- Public Health Scotland, Edinburgh, United Kingdom
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology and Reproductive Sciences, UC San Diego Health Sciences, La Jolla, California, United States of America
| | - Jessica E. Miller
- Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, Melbourne University, Parkville, Victoria, Australia
| | - Kate Duhig
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, United Kingdom
| | - Marius Lahti-Pulkkinen
- MRC Centre for Reproductive Health, The Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, United Kingdom
- THL Finnish Institute for Health and Welfare, Department of Knowledge Brokers, Helsinki, Finland
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - John Wright
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Sarah R. Murray
- MRC Centre for Reproductive Health, The Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Sarah J. Stock
- Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
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Ekhaguere OA, Okonkwo IR, Batra M, Hedstrom AB. Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022. Front Pediatr 2022; 10:961509. [PMID: 35967574 PMCID: PMC9372546 DOI: 10.3389/fped.2022.961509] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/30/2022] [Indexed: 01/19/2023] Open
Abstract
The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.
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Affiliation(s)
- Osayame A. Ekhaguere
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ikechukwu R. Okonkwo
- Department of Pediatrics, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Maneesh Batra
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
| | - Anna B. Hedstrom
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
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Mwita S, Kamala BA, Konje E, Ambrose EE, Izina A, Chibwe E, Kongola G, Dewey D. Association between antenatal corticosteroids use and perinatal mortality among preterm singletons and twins in Mwanza, Tanzania: an observational study. BMJ Open 2022; 12:e059030. [PMID: 35393329 PMCID: PMC8991063 DOI: 10.1136/bmjopen-2021-059030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To examine the association between antenatal corticosteroids (ACS) use and perinatal mortality in singletons and twins delivered before 35 weeks of gestation. DESIGN Secondary analysis of data from an observational prospective chart review study that investigated if exposure to ACS was associated with lower rates of perinatal mortality in preterm infants. SETTING This study was conducted in four hospitals located in Mwanza region, Tanzania. PARTICIPANTS The study population included all preterm singletons and twins delivered at these hospitals between 24 weeks 0 days and 34 weeks 6 days of gestation from July 2019 to February 2020. OUTCOME MEASURES The primary outcome was perinatal mortality; the secondary outcome was respiratory distress syndrome (RDS). RESULTS The study included 844 singletons and 210 twin infants. Three hundred and fourteen singletons (37.2%) and 52 twins (24.8%) were exposed to at least one dose of ACS. Adjusted multivariate analyses revealed that among singletons' exposure to ACS was significantly associated with a lower likelihood of perinatal mortality, adjusted relative risk (aRR) 0.30 (95% CI 0.22 to 0.40) and RDS, aRR 0.92 (95% CI 0.87 to 0.97). In twin infants, exposure to ACS was associated with a reduced risk of RDS only, aRR 0.87 (95% CI 0.78 to 0.98). CONCLUSION The use of ACS between 24 weeks 0 days and 34 weeks 6 days of gestation in both singletons and twins in low-resource settings is associated with positive infant outcomes. No adverse effects were noted. Further research that examines the benefits of ACS for twin infants is needed.
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Affiliation(s)
- Stanley Mwita
- School of Pharmacy, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
| | - Benjamin Anathory Kamala
- Department of Research, Haydom Lutheran Hospital, Mbulu, Manyara, United Republic of Tanzania
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Eveline Konje
- Department of Epidemiology and Biostatistics, Catholic University of Health and Allied, Mwanza, United Republic of Tanzania
| | - Emmanuela Eusebio Ambrose
- Department of Peadiatrics and Child Health, Bugando Medical Centre, Mwanza, United Republic of Tanzania
| | - Angelina Izina
- Department of Radiology, Bugando Medical Centre, Mwanza, United Republic of Tanzania
| | - Elieza Chibwe
- Department of Obstetrics and Gynaecology, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
| | - Gilbert Kongola
- Department of Pharmacology, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
| | - Deborah Dewey
- Owerko Centre at the Alberta Children's Hospital Research Institute and Departments of Pediatrics and Community Health Sciences, The University of Calgary, Calgary, Alberta, Canada
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Lategan I, Price C, Rhoda NR, Zar HJ, Tooke L. Respiratory Interventions for Preterm Infants in LMICs: A Prospective Study From Cape Town, South Africa. Front Glob Womens Health 2022; 3:817817. [PMID: 35464776 PMCID: PMC9019119 DOI: 10.3389/fgwh.2022.817817] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/18/2022] [Indexed: 01/13/2023] Open
Abstract
Background Preterm birth is a global public health issue and complications of preterm birth result in the death of approximately 1 million infants each year, 99% of which are in low-and-middle income countries (LMIC). Although respiratory interventions such as continuous positive airway pressure (CPAP) and surfactant have been shown to improve the outcomes of preterm infants with respiratory distress, they are not readily available in low-resourced areas. The aim of this study was to report the respiratory support needs and outcomes of preterm infants in a low-resourced setting, and to estimate the impact of a lack of access to these interventions on neonatal mortality. Methods We conducted a six-month prospective observational study on preterm infants <1,801 g admitted at Groote Schuur Hospital and Mowbray Maternity Hospital neonatal units in Cape Town, South Africa. We extrapolated results from the study to model the potential outcomes of these infants in the absence of these interventions. Results Five hundred and fifty-two infants (552) <1,801 g were admitted. Three hundred (54.3%) infants received CPAP, and this was the initial respiratory intervention for most cases of respiratory distress syndrome. Surfactant was given to 100 (18.1%) infants and a less invasive method was the most common method of administration. Invasive mechanical ventilation was offered to 105 (19%) infants, of which only 57 (54.2%) survived until discharge from hospital. The overall mortality of the cohort was 14.1% and the hypothetical removal of invasive mechanical ventilation, surfactant and CPAP would result in an additional 157 deaths and increase the overall mortality to 42.5%. A lack of CPAP availability would have the largest impact on mortality and result in the largest number of additional deaths (109). Conclusion This study highlights the effect that access to key respiratory interventions has on preterm outcomes in LMICs. CPAP has the largest impact on neonatal mortality and improving its coverage should be the primary goal for low-resourced areas to save newborn lives.
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Affiliation(s)
- Ilse Lategan
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Caris Price
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Natasha Raygaan Rhoda
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Heather J. Zar
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council (SA-MRC) Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Lloyd Tooke
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- *Correspondence: Lloyd Tooke
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Magee LA, Brown MA, Hall DR, Gupte S, Hennessy A, Karumanchi SA, Kenny LC, McCarthy F, Myers J, Poon LC, Rana S, Saito S, Staff AC, Tsigas E, von Dadelszen P. The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2022; 27:148-169. [DOI: 10.1016/j.preghy.2021.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
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Kankaria A, Duggal M, Chauhan A, Sarkar D, Dalpath S, Kumar A, Dhanjal GS, Kumar V, Suri V, Kumar R, Kumar P, Litch JA. Readiness to Provide Antenatal Corticosteroids for Threatened Preterm Birth in Public Health Facilities in Northern India. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:575-589. [PMID: 34593583 PMCID: PMC8514043 DOI: 10.9745/ghsp-d-20-00716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 05/13/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In 2014, the Government of India (GOI) released operational guidelines on the use of antenatal corticosteroids (ACS) in preterm labor. However, without ensuring the quality of childbirth and newborn care at facilities, the use of ACS in low- and middle-income countries is potentially harmful. This study assessed the readiness to provide ACS at primary and secondary care public health facilities in northern India. METHODS A cross-sectional study was conducted in 37 public health facilities in 2 districts of Haryana, India. Facility processes and program implementation for ACS delivery were assessed using pretested study tools developed from the World Health Organization (WHO) quality of care standards and WHO guidelines for threatened preterm birth. RESULTS Key gaps in public health facilities' process of care to provide ACS for threatened preterm birth were identified, particularly concerning evidence-based practices, competent workforce, and actionable health information system. Emphasis on accurate gestational age estimation, quality of childbirth care, and quality of preterm care were inadequate. Shortage of trained staff was widespread, and a disconnect was found between knowledge and attitudes regarding ACS use. ACS administration was provided only at district or subdistrict hospitals, and these facilities did not uniformly record ACS-specific indicators. All levels lacked a comprehensive protocol and job aids for identifying and managing threatened preterm birth. CONCLUSIONS ACS operational guidelines were not widely disseminated or uniformly implemented. Facilities require strengthened supervision and standardization of threatened preterm birth care. Facilities need greater readiness to meet required conditions for ACS use. Increasing uptake of a single intervention without supporting it with adequate quality of maternal and newborn care will jeopardize improvement in preterm birth outcomes. We recommend updating and expanding the existing GOI ACS operational guidelines to include specific actions for the safe and effective use of ACS in line with recent scientific evidence.
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Affiliation(s)
- Ankita Kankaria
- Post Graduate Institute of Medical Education and Research Chandigarh, India.,All India Institute of Medical Sciences, Bathinda, Punjab, India
| | - Mona Duggal
- Post Graduate Institute of Medical Education and Research Chandigarh, India
| | - Anshul Chauhan
- Post Graduate Institute of Medical Education and Research Chandigarh, India
| | - Debarati Sarkar
- Post Graduate Institute of Medical Education and Research Chandigarh, India
| | | | - Akash Kumar
- Post Graduate Institute of Medical Education and Research Chandigarh, India
| | | | - Vijay Kumar
- Survival for Women and Children (SWACH) Foundation, Panchkula, Haryana, India
| | - Vanita Suri
- Post Graduate Institute of Medical Education and Research Chandigarh, India
| | - Rajesh Kumar
- Post Graduate Institute of Medical Education and Research Chandigarh, India
| | - Praveen Kumar
- Post Graduate Institute of Medical Education and Research Chandigarh, India
| | - James A Litch
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), Lynnwood, WA, 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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Shukla V, Mwenechanya M, Carlo WA. Dealing with neonatal emergencies in low-resource settings. Semin Fetal Neonatal Med 2019; 24:101028. [PMID: 31744767 DOI: 10.1016/j.siny.2019.101028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We describe the development and delivery of neonatal care including trends and impacts of major interventions on neonatal mortality particularly in low-resource settings. Low- and middle-income countries continue to be major contributors to neonatal mortality. Although there has been progress in reducing neonatal mortality, neonatal deaths are contributing an increasing percentage of childhood mortality. Several interventions targeting neonatal care such as neonatal resuscitation and essential newborn care have contributed to improved outcomes. However, there are still many neonatal deaths that are preventable with known effective interventions. This review addresses interventions proven effective in reducing neonatal mortality, challenges to implement them, and future directions of implementing these interventions in low- and middle-income countries.
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Affiliation(s)
- Vivek Shukla
- University of Alabama at Birmingham, Division of Neonatology, Suite 9380 WIC, 1700 6th Avenue South, Birmingham, AL, 35249, USA
| | - Musaku Mwenechanya
- University Teaching Hospital- Children's Hospital, Nationalist Road, Lusaka, Zambia
| | - Waldemar A Carlo
- University of Alabama at Birmingham, Division of Neonatology, Suite 9380 WIC, 1700 6th Avenue South, Birmingham, AL, 35249, USA.
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