The effect of glucocorticosteroid administration on fetal movements and biophysical profile scores in normal pregnancies

Effect of Steroids on the Biophysical Profile and Doppler Indices of Umbilical and Middle Cerebral Arteries in Preterm Fetuses

Introduction Preterm birth is a major cause of perinatal death and disability and emerges as an important global public health problem. The antenatal administration of corticosteroids for preventing neonatal death due to respiratory distress syndrome and the serious morbidities associated with preterm birth has become an accepted standard in worldwide obstetric practice since 1994. After administering corticosteroids, the biophysical score deteriorates transiently, leading to a high cesarean section rate. Thus, Doppler indices of the umbilical and middle cerebral arteries are taken into account before the termination of pregnancy in preterm labor. Materials and methods This is an interventional study conducted over a period of one year and six months among 59 eligible singleton pregnancies at risk for preterm delivery, i.e., at risk of preterm birth <34 weeks of gestation, having no contraindication to antenatal steroids, who were admitted to the labor room of the Srirama Chandra Bhanja (SCB) Medical College, Cuttack, India, from January 2014 to August 2015. The participants were prospectively recruited, after giving informed consent to participate in the study. The main indication for hospital admission and steroid use was preterm lower abdominal pain. Results Out of 59 eligible cases, 27 (45.8%) were <25 years of age, 26 (44.1%) were between 25 and 30 years of age, and six (10.2%) were >30 years of age. The range is 14 years (between 19 and 33 years). The mean age is 25.31 years, with a standard deviation of 3.74. The mean of the biophysical profile (BPP) score before steroid administration decreased from 9.19 ± 1.23 to 5.56 ± 1.05 after 48 hours of first dose of steroid. The p-value of this is <0.001, which is statistically significant. The results show that the administration of betamethasone decreased fetal movements by 78.6% and breathing by 71.8%. As a result, the BPP scores decreased significantly. However, the Doppler indices did not change significantly even after administering corticosteroids. Conclusion Doppler indices play an important role in differentiating between steroid-induced compromise in the fetus and real fetal distress. Thus, umbilical and middle cerebral artery (MCA) Doppler should always be done before the termination of pregnancy on the ground of fetal compromise after administering corticosteroids.

Neurological outcomes of antenatal corticosteroid therapy

AIM OF THE STUDY

The aim of the study was to investigate whether antenatal corticosteroid therapy (ACST) could impact neurological condition, as assessed through muscular tone, of prematurely born infants.

METHODS

All 82 patients at risk of preterm delivery treated and delivered over 12 months were divided into two equal groups regarding the use of ACST. The investigated parameters were pregnancy complications, biophysical profile, Apgar score, gestational age of delivery and all postpartum complications. Neurological development and muscular tone were evaluated at the 1st, 3rd, 6th and 12th months of life using Vojta's method, which classifies muscular tone as good, hypotonic or hypertonic.

RESULTS

After therapy, infants from the treated and control groups differed in biophysical profile, Apgar score, length of intensive care, occurrence of respiratory distress syndrome and intraventricular haemorrhage. During the follow-up, significantly more infants from the ACST group had good muscular tone when compared with those from the control group. Regression analysis showed that ASCT can significantly impact an infant's muscular tone. Still, the week of delivery and the complications such as diabetes mellitus, intrauterine growth restriction and respiratory distress syndrome, could change the association of ACST and infants' muscular tone.

CONCLUSION

ACST was associated with the positive neurological outcomes of prematurely born infants when assessed through their muscular tone.

Transplacental versus direct fetal corticosteroid treatment for accelerating fetal lung maturation where there is a risk of preterm birth

BACKGROUND

Despite major advances in medical technology, the incidence of preterm birth remains high. The use of antenatal corticosteroid administered transplacentally, by intramuscular injection to women at risk of preterm birth, has reduced the incidence of respiratory distress syndrome and increased the survival rates of preterm infants. However, this intervention also comes with its own risks and side effects. Animal studies and early studies in pregnant women at risk of preterm birth have reported the use of an alternative route of administration, by direct intramuscular injection of corticosteroid into the fetus under ultrasound guidance, in an attempt to minimise the side-effect profile. Direct fetal corticosteroid administration may have benefits over maternal administration in terms of safety and efficacy.

OBJECTIVES

To assess if different routes of corticosteroid administration (maternal versus direct fetal) have effects on health outcomes for women and their babies.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (25 October 2017), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (25 October 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials comparing maternal with direct fetal routes of antenatal corticosteroid administration in women at risk of preterm birth.

DATA COLLECTION AND ANALYSIS

The two review authors independently assessed study eligibility. In future updates of this review, at least two review authors will extract data and assess the risks of bias in included studies. We will also assess the quality of the evidence using the GRADE approach.

MAIN RESULTS

We did not identify any eligible randomised controlled trials to include in this review.

AUTHORS' CONCLUSIONS

The available clinical studies carried out so far on animals and human have shown that direct intramuscular injection of corticosteroid into the fetus under ultrasound guidance is feasible, but data on health outcomes are lacking. Uncertainty therefore persists as to which method could provide better efficacy and safety. Randomised controlled trials are required focusing on the benefits and harms of transplacental versus direct fetal corticosteroid treatment. Until the uncertainties have been addressed, it is advisable to stay with the current standard of antenatal transplacental maternally-administered corticosteroid treatment.

Effects of betamethasone on fetoplacental and maternal hemodynamics in preterm pregnancies

OBJECTIVE

To evaluate the possible effects of prenatal steroid administration on Doppler parameters of the umbilical artery, uterine artery, middle cerebral artery, and ductus venosus, the cerebroplacental ratio, and the amniotic fluid index in preterm fetuses.

METHODS

The present prospective observational study was performed at the Perinatology Department of Trakya University, Edirne, Turkey, between June 1, 2015, and September 1, 2016. It included patients with healthy singleton pregnancies who had received betamethasone at 24-34 weeks of pregnancy. Doppler parameters were measured before (0 hours) and 24, 48, and 72 hours after the administration of betamethasone (two intramuscular doses of 12 mg each, administered 24 hours apart).

RESULTS

There were 68 patients included. Pairwise comparisons demonstrated that, at 72 hours after betamethasone administration, the umbilical artery resistance index (P=0.038), the middle cerebral artery systolic/diastolic velocity ratio (P=0.007), and the amniotic fluid index (P=0.017) were reduced, whereas the end-diastolic velocity of the middle cerebral artery was increased (P=0.012), compared with baseline values.

CONCLUSION

Betamethasone had favorable effects on fetal cerebral circulation, with increased end-diastolic velocity in the middle cerebral artery; this could represent a positive effect on cerebral blood circulation and decreased flow resistance in the umbilical artery.

Antenatal Surveillance in Twin Pregnancies Using the Biophysical Profile

Objectives-The nonstress test is currently the most widely used modality for antenatal surveillance in twin pregnancies, with a quoted false-positive rate of 11%-12%. Our objective was to report our experience with the sonographic portion of the biophysical profile in twin pregnancies as the primary screening modality.Methods-Women with twin pregnancies delivered by a single maternal-fetal medicine practice from 2005 to 2013 were included. We excluded monoamniotic twins. Twin pregnancies began weekly sonography for the biophysical profile starting at 32 to 33 weeks, or earlier if indicated. The nonstress test was performed if the sonographic biophysical profile score was less than 8 of 8. We reviewed biophysical profile scores and outcomes for all patients who delivered at 33 weeks or later to assess the false-positive rate for the biophysical profile, as well as the incidence of intrauterine fetal death (IUFD) after initiation of antenatal surveillance.Results-A total of 539 twin pregnancies were included. The incidence of IUFD per patient was 2 per 539 (0.4%; 95% confidence interval [CI], 0.1%-1.3%), and the incidence of IUFD per fetus was 2 per 1078 (0.19%; 95% CI, 0.05%-0.7%). The overall positive screen rate was 24 per 539 (4.45%; 95% CI, 3.0%-6.5%). The false-positive screen rate, defined as an abnormal biophysical profile that did not diagnose an IUFD or lead to delivery, was 10 per 539 (1.9%; 95% CI, 1.0%-3.4%).Conclusions-In twin pregnancies the use of the sonographic biophysical profile for routine antenatal surveillance has a low false-positive rate, with a very low incidence of IUFD. The sonographic biophysical profile should be considered as a primary mode for antenatal surveillance in twin pregnancies, with a reflex nonstress test for an abnormal score.

MANAGEMENT OF REDUCED FETAL MOVEMENTS

Reduced fetal movement (RFM) is commonly defined as any reduction in maternal perception of fetal activity. Perceived fetal activity may be movement of limbs, trunk or head movement, but excludes fetal hiccoughs (as this is involuntary movement). The perception of fetal movement by an expectant mother is the first, and ongoing, non-sonographic indicator of fetal viability. The “normal” pattern of fetal movements varies from pregnancy to pregnancy, and often does not become established until 28 weeks’ gestation. Many babies have particularly active periods of the day, usually corresponding to periods of maternal rest and inactivity (which may in itself reflect increased maternal awareness of fetal movement). A variable percentage of sonographically observed fetal movements are perceived by prospective mothers (commonly 30–40%, although some studies report rates as high as 80%).

Transplacental versus direct fetal corticosteroid treatment for accelerating fetal lung maturation where there is a risk of preterm birth

BACKGROUND

Despite major advances in medical technology, the incidence of preterm birth remains high. The use of antenatal corticosteroid administered transplacentally, by intramuscular injection to women at risk of preterm birth, has reduced the incidence of respiratory distress syndrome and increased the survival rates of preterm infants. However, this intervention also comes with its own risks and side effects. Animal studies and early studies in pregnant women at risk of preterm birth have reported the use of an alternative route of administration, by direct intramuscular injection of corticosteroid into the fetus under ultrasound guidance, in an attempt to minimise the side effects profile. Direct fetal corticosteroid administration may have benefits over maternal administration in terms of safety and efficacy.

OBJECTIVES

To assess if different routes of corticosteroid administration (maternal versus direct fetal) have effects on maternal health, and the risk of stillbirth, neonatal, perinatal, infant and child mortality and morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (16 June 2011) and the WHO International Clinical Trials Registry Platform (ICTRP) (16 June 2011).

SELECTION CRITERIA

Randomised controlled trials comparing maternal with direct fetal routes of antenatal corticosteroid administration in women at risk of preterm birth.

DATA COLLECTION AND ANALYSIS

We did not perform any data collection or analyses.

MAIN RESULTS

We did not identify any eligible randomised controlled trials to include in this review.

AUTHORS' CONCLUSIONS

The available clinical studies carried out so far on animals and human have shown that direct intramuscular injection of corticosteroid into the fetus under ultrasound guidance is feasible, but data on health outcomes are lacking. Therefore, uncertainty persists as to which method could provide better efficacy and safety profile. Randomised controlled trials are required focusing on the benefits and harms of transplacental versus direct fetal corticosteroid treatment. Until the uncertainties have been answered, it is advisable to stay with the current standard of antenatal transplacental maternally administered corticosteroid treatment.

Does diurnal rhythm have an impact on fetal biophysical profile?

OBJECTIVES

To investigate whether parameters in fetal biophysical profile (BPP) testing exhibit a diurnal rhythm and to discuss the probable factors associated with these variables.

METHODS

Thirty healthy primigravid patients carrying pregnancies between 35 and 40 completed weeks were enrolled for the study. Fetal BPP testing was performed for each patient both in the early morning (08:00-10:00 am) and in the late evening (08:00-10:00 pm), and the scoring parameters were compared between morning and evening tests.

RESULTS

BPP scores in the evening were significantly higher than that in the morning (p < 0.05). Deepest vertical amniotic pocket measurements and fetal breathing absence in the morning mostly contributed to this variation (p < 0.001). Fetal movement counts were also significantly lower in the morning tests (p < 0.001).

CONCLUSIONS

The parameters of BPP exhibit circadian variations in healthy fetuses, which may be associated with many factors such as fetomaternal hormones. It is essential for the clinician to be aware of these changes when interpreting the results, as interventions based on false-positive results may have deleterious effects on both the mother and her fetus.

The uses and limitations of the fetal biophysical profile

In the second half of the twentieth century, true antepartum fetal assessment became possible, mainly due to the advent of real-time ultrasound. Initially, the most widely used form of antepartum fetal assessment was electronic fetal heart rate monitoring, through the nonstress test or the oxytocin-induced contraction stress test. It was soon realized, however, that these forms of monitoring had significant limitations. The biophysical profile allows a more thorough evaluation of fetal well-being and has the potential to significantly reduce the false-positive rate of the nonstress test/contraction stress test.

Antenatal corticosteroid therapy: short-term effects on fetal behaviour and haemodynamics

Antenatal corticosteroid therapy to enhance fetal lung maturity in threatened preterm delivery has a number of non-pulmonary side-effects, both beneficial and undesirable. This review focuses on the short-term (transient) effects of betamethasone and dexamethasone on aspects of fetal circulation and behaviour which are used clinically as markers of fetal well-being. We summarise the effects observed, discuss the proposed underlying mechanisms, and emphasise the consequences for clinical decision-making. Recommendations are given to optimise medical care and to minimise the risk of unwarranted iatrogenic preterm delivery.

Caring for pregnant and postnatal women in intensive care: what do we know?

Critically ill pregnant and postnatal women admitted to intensive care units (ICUs) require highly specialised care, components of which many critical care nurses are unfamiliar with. There are no specialist critical care obstetric centres in Australia, with critically ill obstetric patients admitted to general ICUs. There are no published guidelines and little research that assist critical care nurses to care for such women. Furthermore, the admission of pregnant or postnatal women to ICUs is likely to increase with emerging childbearing patterns in Australia. It is therefore timely to review what we know about caring for critically ill pregnant and postnatal women. This paper analyses the literature on intensive care utilisation by obstetric patients and provides an overview regarding which pregnant and postpartum women require intensive care. The key areas of providing mechanical ventilation to pregnant women and assessment of fetal wellbeing are explored in detail. The most frequent conditions and their treatment, preeclampsia and obstetric haemorrhage, are also reviewed. The establishment of lactation is also considered as the critical carenurse is commonly involved in supporting the woman's endeavour to breastfeed.

Doppler, Cardiotocography, and Biophysical Profile Changes in Growth-Restricted Fetuses

OBJECTIVE

To assess from diagnosis to delivery the Doppler studies of the umbilical artery, middle cerebral artery, umbilical vein, ductus venosus, and amniotic fluid index of fetuses with idiopathic growth restriction.

METHODS

A total of 145 singleton growth-restricted fetuses with abnormal umbilical artery pulsatility indexes were studied. Cesarean delivery was performed because of abnormal biophysical profile or nonreassuring fetal heart rate pattern.

RESULTS

There were 4 fetal and 50 neonatal deaths. Two growth-restricted groups were identified: Group A (n = 44) included fetuses in whom all measures became abnormal preceding an abnormal biophysical profile or nonreassuring nonstress test. Group B (n = 101) included fetuses in whom 1 or more measures were normal at the time of cesarean delivery. There was no statistically significant difference in perinatal morbidity and mortality between the 2 groups. Neonatal death was increased in fetuses with umbilical artery reversed flow (odds ratio 2.34, 95% confidence interval 1.16-4.73; P < .05) and ductus venosus reversed flow (odds ratio 4.18, 95% confidence interval 2.01-8.69; P < .05). A significant correlation was also found between low birth weight and adverse perinatal outcome.

CONCLUSION

In fetuses with idiopathic growth restriction, 1) low birth weight, 2) umbilical artery reversed flow, and 3) ductus venosus absent or reversed flow are associated with an increased perinatal morbidity and mortality.

Decreased fetal movements: background, assessment, and clinical management

A reduction or cessation of fetal movements (FMs) is frequently reported by pregnant women and causes concern and anxiety. However, the clinical significance of a history of reduced FMs remains unclear, and the assessment and management of these pregnancies is controversial. This article is a review of the literature on decreased FMs found in medline and the cochrane library using the search phrases: decreased FMs, perinatal outcome, FM monitoring, and fetal assessment. Formal counting of FMs by the pregnant woman could possibly identify the fetuses, which are at risk of compromise, thus allowing for appropriate action. However, the benefit of this intervention has not been definitely proven. Cardiotocography, umbilical/uterine artery Doppler velocimetry, and ultrasonography have been used for antepartum fetal assessment in pregnancies with decreased FMs, but the evidence of a clinical benefit is limited. The effects of fetal assessment with vibroacoustic stimulation and biophysical profile are unknown and should be further evaluated. Present recommendations on the management of pregnancies with decreased FMs are based on limited and inconsistent scientific evidence. There is a need for further well-designed studies in order to provide evidence-based guidelines in the future.