Antenatal corticosteroid therapy for foetal maturation in women with eclampsia and severe pre-eclampsia in a rural hospital in Western Tanzania

Effectiveness of antenatal dexamethasone in reducing respiratory distress syndrome and mortality in preterm neonates: a nested case control study

BACKGROUND

Respiratory distress syndrome (RDS) is a significant cause of preterm neonatal morbidity and mortality globally. Measures like the use of antenatal corticosteroids (ACS) and immediate resuscitation of the newborn after birth are taken to abate preterm related complications. Most studies that evidenced the benefit of ACS were done in high resource settings. Therefore, this study was conducted to assess the effectiveness of ACS in reducing RDS and neonatal mortality in preterm neonates in resource-limited settings.

METHODS

A three months prospective nested case-control study (1:2 unmatched) was conducted at Muhimbili National Hospital and Amana regional referral hospital in Dar es salaam, Tanzania. Neonates delivered at 28 to 34 gestational weeks were enrolled and followed up until discharge. Data analysis was done using the statistical package of social sciences version 23. Logistic regression analysis was used to determine the effect of ACS on the RDS and mortality in the cohort, controlling for important maternal and neonatal variables. All tests were considered statistically significant at p < 0.05.

RESULTS

Out of 330 preterm neonates enrolled, 110 were cases and 220 were controls. The median gestational age at delivery was 30 weeks and 6 days (IQR 4.68) among cases and 33 weeks (IQR 3) among controls. One-minute APGAR score of < 7 (AOR: 3.11; 95% CI 1.54-6.30), and neonatal birth weight (AOR: 0.998; 95% CI 0.997-0.999) were significantly associated with RDS. No significant association was observed between ACS exposure and RDS occurrence (AOR: 1.65; 95% CI 0.86 - 3.15). The overall mortality rate was 9 per 1000 neonates. Neonatal mortality occurred only among cases whereby, a unit increase in gestational age was associated with a 30% reduction in neonatal mortality (Adjusted hazard ratio, AHR: 0.70, 95% CI: 0.5-0.92, p = 0.011).

CONCLUSION

Decrease in gestational age, one minute APGAR score of < 7 and decreasing birth weight were associated with RDS among preterm neonates. ACS was not associated with reduced RDS occurrence and neonatal mortality rates. Moreover, increase in gestation age was the only factor found to be protective against preterm neonatal mortality.

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

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.

Neonatal mortality rates and association with antenatal corticosteroids at Kamuzu Central Hospital

OBJECTIVE

Malawi has one of the highest child mortality rates in the world, and neonates account for nearly half of all under-five mortality. No previous study has reported neonatal outcomes in Malawi over 12 months. We aimed to evaluate outcomes in the neonatal intensive care unit (NICU) at Kamuzu Central Hospital (KCH) and to determine if there was an association between increased survival and antenatal corticosteroid (ACS) exposure.

STUDY DESIGN

We introduced a prospective, observational electronic database to collect 122 de-identified variables related to neonatal outcomes for all neonates admitted to the KCH NICU over 12 months. Patients with congenital anomalies were excluded. We compared neonatal mortality rates in neonates who were exposed to ACS compared to those who were not. Statistical methodology included the Wilcoxon rank sum test, Fisher's exact test, and logistic regression.

RESULTS

Of 2051 neonates admitted to the KCH NICU, the overall neonatal mortality rate was 23.1% and remained similar across 12 months. Mortality was inversely related to birth weight, and outborn neonates referred to KCH had the highest mortality rate (29%). After controlling for confounding covariates, inborn infants exposed to ACS had significantly lower odds of death compared to those without exposure to ACS (adjusted odds ratio = 0.46, 95% confidence interval: 0.24-0.88, p = 0.020).

CONCLUSION

Lower birth weight, outborn, and no ACS exposure were associated with increased mortality. ACS was associated with a 54% reduction in odds of mortality in inborn neonates highlighting the need for further evaluations of ACS use in resource-limited settings.