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Liauw J, Foggin H, Socha P, Crane J, Joseph KS, Burrows J, Lacaze-Masmonteil T, Jain V, Boutin A, Hutcheon J. Technical Update No. 439: Antenatal Corticosteroids at Late Preterm Gestation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:445-457.e2. [PMID: 36572248 DOI: 10.1016/j.jogc.2022.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To update recommendations for administration of antenatal corticosteroids in the late preterm period. TARGET POPULATION Pregnant individuals at risk of preterm birth from 340 to 366 weeks gestation. OPTIONS Administration or non-administration of a single course of antenatal corticosteroids at 340 to 366 weeks gestation. OUTCOMES Neonatal morbidity (respiratory distress, hypoglycemia), long-term neurodevelopment, and other long-term outcomes (growth, cardiac/metabolic, respiratory). BENEFITS, HARMS, AND COSTS Administration of antenatal corticosteroids from 340 to 366 weeks gestation decreases the risk of neonatal respiratory distress but increases the risk of neonatal hypoglycemia. The long-term impacts of antenatal corticosteroid administration from 340 to 366 weeks gestation are uncertain. EVIDENCE For evidence on the neonatal effects of antenatal corticosteroid administration at late preterm gestation, we summarized evidence from the 2020 Cochrane review of antenatal corticosteroids and combined this with evidence from published randomized trials identified by searching Ovid MEDLINE from January 1, 2020, to May 11, 2022. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on neurodevelopmental outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on neurodevelopmental outcomes using the following sources: (1) the 2020 Cochrane review; and (2) evidence obtained by searching Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to January 5, 2022. We did not apply date or language restrictions. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on other long-term outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on other long-term outcomes by combining findings from the 2020 Cochrane review with evidence obtained by searching Ovid MEDLINE for observational studies related to long-term cardiometabolic, respiratory, and growth effects of antenatal corticosteroids from inception to October 22, 2021. We reviewed reference lists of included studies and relevant systematic reviews for additional references. See Appendix A for search terms and summaries. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Maternity care providers, including midwives, family physicians, and obstetricians. SUMMARY STATEMENTS RECOMMENDATIONS.
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Al-Jorani H, Jensen RC, Jonasson MTE, Birukov A, Schmedes AV, Christesen HT, Dreyer AF, Jensen TK, Glintborg D, Jensen BL, Andersen MS. Higher Maternal Cortisol Associated With Lower Blood Pressure in Offspring From 3 Months to 5 Years of Age in the Odense Child Cohort. Hypertension 2023; 80:828-836. [PMID: 36802792 DOI: 10.1161/hypertensionaha.122.20265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Synthetic glucocorticoid exposure in late pregnancy may be associated with higher blood pressure in offspring. We hypothesized that endogenous cortisol in pregnancy relates to offspring blood pressure (OBP). OBJECTIVE To investigate associations between maternal cortisol status in third trimester pregnancy and OBP. METHODS We included 1317 mother-child pairs from Odense Child Cohort, an observational prospective cohort. Serum (s-) cortisol and 24-hour urine (u-) cortisol and cortisone were assessed in gestational week 28. Offspring systolic blood pressure and diastolic blood pressure were measured at age 3, 18 months, and 3 and 5 years. Associations between maternal cortisol and OBP were examined by mixed effects linear models. RESULTS All significant associations between maternal cortisol and OBP were negative. In boys in pooled analyses, 1 nmol/L increase in maternal s-cortisol was associated with average decrease in systolic blood pressure (β=-0.003 mmHg [95% CI, -0.005 to -0.0003]) and diastolic blood pressure (β=-0.002 mmHg [95% CI, -0.004 to -0.0004]) after adjusting for confounders. At 3 months of age, higher maternal s-cortisol was significantly associated with lower systolic blood pressure (β=-0.01 mmHg [95% CI, -0.01 to -0.004]) and diastolic blood pressure (β=-0.010 mmHg [95% CI, -0.012 to -0.011]) in boys after adjusting for confounders, which remained significant after adjusting for potential intermediate factors. CONCLUSIONS We found temporal sex dimorphic negative associations between maternal s-cortisol levels and OBP, with significant findings in boys. We conclude that physiological maternal cortisol is not a risk factor for higher blood pressure in offspring up to 5 years of age.
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Affiliation(s)
- Hajir Al-Jorani
- Department of Endocrinology, Odense University Hospital, Odense, Denmark (H.A.-J., R.C.J., M.T.E.J., A.F.D., D.G., M.S.A.)
| | - Richard Christian Jensen
- Department of Endocrinology, Odense University Hospital, Odense, Denmark (H.A.-J., R.C.J., M.T.E.J., A.F.D., D.G., M.S.A.).,Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (R.C.J., T.K.J.), University of Southern Denmark, Odense, Denmark
| | - Mikaela T E Jonasson
- Department of Endocrinology, Odense University Hospital, Odense, Denmark (H.A.-J., R.C.J., M.T.E.J., A.F.D., D.G., M.S.A.)
| | - Anna Birukov
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany (A.B.)
| | - Anne Vibeke Schmedes
- Department of Biochemistry and Immunology, Lillebaelt Hospital, Vejle, Denmark (A.V.S.)
| | - Henrik Thybo Christesen
- Odense Child Cohort, Hans Christian Andersen Children's Hospital, Odense University Hospital, Denmark (H.T.C., T.K.J.)
| | - Anja F Dreyer
- Department of Endocrinology, Odense University Hospital, Odense, Denmark (H.A.-J., R.C.J., M.T.E.J., A.F.D., D.G., M.S.A.)
| | - Tina K Jensen
- Department of Clinical Pharmacology, Pharmacy and Environmental Medicine (R.C.J., T.K.J.), University of Southern Denmark, Odense, Denmark.,Odense Child Cohort, Hans Christian Andersen Children's Hospital, Odense University Hospital, Denmark (H.T.C., T.K.J.)
| | - Dorte Glintborg
- Department of Endocrinology, Odense University Hospital, Odense, Denmark (H.A.-J., R.C.J., M.T.E.J., A.F.D., D.G., M.S.A.)
| | - Boye L Jensen
- Institute for Molecular Medicine (B.L.J.), University of Southern Denmark, Odense, Denmark
| | - Marianne S Andersen
- Department of Endocrinology, Odense University Hospital, Odense, Denmark (H.A.-J., R.C.J., M.T.E.J., A.F.D., D.G., M.S.A.)
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Mise à jour technique no 439 : Corticothérapie prénatale en période de prématurité tardive. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 45:458-472.e2. [PMID: 36572247 DOI: 10.1016/j.jogc.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Karlsson L, Wallensteen L, Nordenström A, Krmar RT, Lajic S. Ambulatory Blood Pressure Monitoring in Children and Adults Prenatally Exposed to Dexamethasone Treatment. J Clin Endocrinol Metab 2022; 107:e2481-e2487. [PMID: 35148399 PMCID: PMC9113802 DOI: 10.1210/clinem/dgac081] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The clinical use of dexamethasone (DEX) prenatally to reduce virilization of external genitalia in female fetuses with congenital adrenal hyperplasia (CAH) is efficient but still controversial. It remains challenging to prevent the excessive exposure of DEX in unborn healthy babies during the first trimester of pregnancy. OBJECTIVE Since endogenous glucocorticoids contribute to the maintenance of blood pressure (BP) and since events during fetal life may program the fetus and affect future metabolic health, the aim of this study was to analyze ambulatory BP measurements in CAH-unaffected children and adults that were prenatally exposed to DEX treatment. METHODS Ambulatory BP measurements were analyzed in 33 (16 female) DEX-treated participants aged 5.1 to 26.3 years (19 participants aged ≤ 18 years) and in 54 (28 female) age- and sex-matched apparently healthy controls aged 5.5 to 25.3 years (27 participants aged ≤ 18 years) with ambulatory normotension. RESULTS Participants' age, height, weight, and body mass index were similar between the DEX-treated group and the control group. Heart rate, 24-hour BP, pulse pressure, and nighttime dipping did not statistically significantly differ between DEX-treated participants and controls. CONCLUSION Our study suggests that prenatal DEX treatment in CAH-unaffected children and adults does not appear to adversely affect ambulatory BP later in life. Our observations need to be confirmed in larger studies.
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Affiliation(s)
- Leif Karlsson
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Wallensteen
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Rafael T Krmar
- Department of Physiology and Pharmacology, Biomedicum 5B, Karolinska Institutet, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
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McGoldrick E, Stewart F, Parker R, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2020; 12:CD004454. [PMID: 33368142 PMCID: PMC8094626 DOI: 10.1002/14651858.cd004454.pub4] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Respiratory morbidity including respiratory distress syndrome (RDS) is a serious complication of preterm birth and the primary cause of early neonatal mortality and disability. Despite early evidence indicating a beneficial effect of antenatal corticosteroids on fetal lung maturation and widespread recommendations to use this treatment in women at risk of preterm delivery, some uncertainty remains about their effectiveness particularly with regard to their use in lower-resource settings, different gestational ages and high-risk obstetric groups such as women with hypertension or multiple pregnancies. This updated review (which supersedes an earlier review Crowley 1996) was first published in 2006 and subsequently updated in 2017. OBJECTIVES To assess the effects of administering a course of corticosteroids to women prior to anticipated preterm birth (before 37 weeks of pregnancy) on fetal and neonatal morbidity and mortality, maternal mortality and morbidity, and on the child in later life. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (3 September 2020), ClinicalTrials.gov, the databases that contribute to the WHO International Clinical Trials Registry Platform (ICTRP) (3 September 2020), and reference lists of the retrieved studies. SELECTION CRITERIA We considered all randomised controlled comparisons of antenatal corticosteroid administration with placebo, or with no treatment, given to women with a singleton or multiple pregnancy, prior to anticipated preterm delivery (elective, or following rupture of membranes or spontaneous labour), regardless of other co-morbidity, for inclusion in this review. DATA COLLECTION AND ANALYSIS We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two review authors independently assessed trials for inclusion, assessed risk of bias, evaluated trustworthiness based on predefined criteria developed by Cochrane Pregnancy and Childbirth, extracted data and checked them for accuracy, and assessed the certainty of the evidence using the GRADE approach. Primary outcomes included perinatal death, neonatal death, RDS, intraventricular haemorrhage (IVH), birthweight, developmental delay in childhood and maternal death. MAIN RESULTS We included 27 studies (11,272 randomised women and 11,925 neonates) from 20 countries. Ten trials (4422 randomised women) took place in lower- or middle-resource settings. We removed six trials from the analysis that were included in the previous version of the review; this review only includes trials that meet our pre-defined trustworthiness criteria. In 19 trials the women received a single course of steroids. In the remaining eight trials repeated courses may have been prescribed. Fifteen trials were judged to be at low risk of bias, two had a high risk of bias in two or more domains and we ten trials had a high risk of bias due to lack of blinding (placebo was not used in the control arm. Overall, the certainty of evidence was moderate to high, but it was downgraded for IVH due to indirectness; for developmental delay due to risk of bias and for maternal adverse outcomes (death, chorioamnionitis and endometritis) due to imprecision. Neonatal/child outcomes Antenatal corticosteroids reduce the risk of: - perinatal death (risk ratio (RR) 0.85, 95% confidence interval (CI) 0.77 to 0.93; 9833 infants; 14 studies; high-certainty evidence; 2.3% fewer, 95% CI 1.1% to 3.6% fewer), - neonatal death (RR 0.78, 95% CI 0.70 to 0.87; 10,609 infants; 22 studies; high-certainty evidence; 2.6% fewer, 95% CI 1.5% to 3.6% fewer), - respiratory distress syndrome (RR 0.71, 95% CI 0.65 to 0.78; 11,183 infants; studies = 26; high-certainty evidence; 4.3% fewer, 95% CI 3.2% to 5.2% fewer). Antenatal corticosteroids probably reduce the risk of IVH (RR 0.58, 95% CI 0.45 to 0.75; 8475 infants; 12 studies; moderate-certainty evidence; 1.4% fewer, 95% CI 0.8% to1.8% fewer), and probably have little to no effect on birthweight (mean difference (MD) -14.02 g, 95% CI -33.79 to 5.76; 9551 infants; 19 studies; high-certainty evidence). Antenatal corticosteroids probably lead to a reduction in developmental delay in childhood (RR 0.51, 95% CI 0.27 to 0.97; 600 children; 3 studies; moderate-certainty evidence; 3.8% fewer, 95% CI 0.2% to 5.7% fewer). Maternal outcomes Antenatal corticosteroids probably result in little to no difference in maternal death (RR 1.19, 95% CI 0.36 to 3.89; 6244 women; 6 studies; moderate-certainty evidence; 0.0% fewer, 95% CI 0.1% fewer to 0.5% more), chorioamnionitis (RR 0.86, 95% CI 0.69 to 1.08; 8374 women; 15 studies; moderate-certainty evidence; 0.5% fewer, 95% CI 1.1% fewer to 0.3% more), and endometritis (RR 1.14, 95% CI 0.82 to 1.58; 6764 women; 10 studies; moderate-certainty; 0.3% more, 95% CI 0.3% fewer to 1.1% more) The wide 95% CIs in all of these outcomes include possible benefit and possible harm. AUTHORS' CONCLUSIONS Evidence from this updated review supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. Treatment with antenatal corticosteroids reduces the risk of perinatal death, neonatal death and RDS and probably reduces the risk of IVH. This evidence is robust, regardless of resource setting (high, middle or low). Further research should focus on variations in the treatment regimen, effectiveness of the intervention in specific understudied subgroups such as multiple pregnancies and other high-risk obstetric groups, and the risks and benefits in the very early or very late preterm periods. Additionally, outcomes from existing trials with follow-up into childhood and adulthood are needed in order to investigate any longer-term effects of antenatal corticosteroids. We encourage authors of previous studies to provide further information which may answer any remaining questions about the use of antenatal corticosteroids without the need for further randomised controlled trials. Individual patient data meta-analyses from published trials are likely to provide answers for most of the remaining clinical uncertainties.
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Affiliation(s)
- Emma McGoldrick
- Obstetrics Directorate, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Fiona Stewart
- Cochrane Children and Families Network, c/o Cochrane Pregnancy and Childbirth, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Roses Parker
- Musculoskeletal, Oral, Skin and Sensory Network, Oxford University Hospitals NHS Foundation Trust Second Floor, OUH Cowley Unipart House Business Centre, Oxford, UK
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
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Hrabalkova L, Takahashi T, Kemp MW, Stock SJ. Antenatal Corticosteroids for Fetal Lung Maturity - Too Much of a Good Thing? Curr Pharm Des 2020; 25:593-600. [PMID: 30914016 DOI: 10.2174/1381612825666190326143814] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/22/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Between 5-15% of babies are born prematurely worldwide, with preterm birth defined as delivery before 37 completed weeks of pregnancy (term is at 40 weeks of gestation). Women at risk of preterm birth receive antenatal corticosteroids as part of standard care to accelerate fetal lung maturation and thus improve neonatal outcomes in the event of delivery. As a consequence of this treatment, the entire fetal organ system is exposed to the administered corticosteroids. The implications of this exposure, particularly the long-term impacts on offspring health, are poorly understood. AIMS This review will consider the origins of antenatal corticosteroid treatment and variations in current clinical practices surrounding the treatment. The limitations in the evidence base supporting the use of antenatal corticosteroids and the evidence of potential harm to offspring are also summarised. RESULTS Little has been done to optimise the dose and formulation of antenatal corticosteroid treatment since the first clinical trial in 1972. International guidelines for the use of the treatment lack clarity regarding the recommended type of corticosteroid and the gestational window of treatment administration. Furthermore, clinical trials cited in the most recent Cochrane Review have limitations which should be taken into account when considering the use of antenatal corticosteroids in clinical practice. Lastly, there is limited evidence regarding the long-term effects on the different fetal organ systems exposed in utero, particularly when the timing of corticosteroid administration is sub-optimal. CONCLUSION Further investigations are urgently needed to determine the most safe and effective treatment regimen for antenatal corticosteroids, particularly regarding the type of corticosteroid and optimal gestational window of administration. A clear consensus on the use of this common treatment could maximise the benefits and minimise potential harms to offspring.
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Affiliation(s)
- Lenka Hrabalkova
- Tommy's Centre for Maternal and Fetal Health at the MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Matthew W Kemp
- Tohoku University Hospital, Sendai, Miyagi, Japan.,Division of Obstetrics and Gynaecology, University of Western Australia, Perth, Australia
| | - Sarah J Stock
- Tommy's Centre for Maternal and Fetal Health at the MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
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Jobe AH. Antenatal Corticosteroids-A Concern for Lifelong Outcomes. J Pediatr 2020; 217:184-188. [PMID: 31606149 DOI: 10.1016/j.jpeds.2019.09.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/05/2019] [Accepted: 09/10/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Alan H Jobe
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH.
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Jobe AH, Goldenberg RL. Antenatal corticosteroids: an assessment of anticipated benefits and potential risks. Am J Obstet Gynecol 2018; 219:62-74. [PMID: 29630886 DOI: 10.1016/j.ajog.2018.04.007] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 12/20/2022]
Abstract
Antenatal corticosteroids are standard of care for pregnancies at risk of preterm delivery between 24-34 weeks' gestational age. Recent trials demonstrate modest benefits from antenatal corticosteroids for late preterm and elective cesarean deliveries, and antenatal corticosteroids for periviable deliveries should be considered with family discussion. However, many women with threatened preterm deliveries receive antenatal corticosteroids but do not deliver until >34 weeks or at term. The net effect is that a substantial fraction of the delivery population will be exposed to antenatal corticosteroids. There are gaps in accurate assessments of benefits of antenatal corticosteroids because the randomized controlled trials were performed prior to about 1990 in pregnancies generally >28 weeks. The care practices for the mother and infant survival were different than today. The randomized controlled trial data also do not strongly support the optimal interval from antenatal corticosteroid treatment to delivery of 1-7 days. Epidemiology-based studies using large cohorts with >85% of at-risk pregnancies treated with antenatal corticosteroids probably overestimate the benefits of antenatal corticosteroids. Although most of the prematurity-associated mortality is in low-resource environments, the efficacy and safety of antenatal corticosteroids in those environments remain to be evaluated. The short-term benefits of antenatal corticosteroids for high-risk pregnancies in high-resource environments certainly justify antenatal corticosteroids as few risks have been identified over many years. However, cardiovascular and metabolic abnormalities have been identified in large animal models and cohorts of children exposed to antenatal corticosteroids that are consistent with fetal programming for adult diseases. These late effects of antenatal corticosteroids suggest caution for the expanded use of antenatal corticosteroids beyond at-risk pregnancies at 24-34 weeks. A way forward is to develop noninvasive fetal assessments to identify pregnancies across a wider gestational age that could benefit from antenatal corticosteroids.
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Magann EF, Haram K, Ounpraseuth S, Mortensen JH, Spencer HJ, Morrison JC. Use of antenatal corticosteroids in special circumstances: a comprehensive review. Acta Obstet Gynecol Scand 2017; 96:395-409. [DOI: 10.1111/aogs.13104] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 01/20/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Everett F. Magann
- Department of Obstetrics and Gynecology; Department of Biostatistics; University of Arkansas for the Medical Sciences; Little Rock AR USA
| | - Kjell Haram
- Haukeland University Hospital; Department of Public and Primary Care; University of Bergen; Bergen Norway
| | - Songthip Ounpraseuth
- Department of Obstetrics and Gynecology; Department of Biostatistics; University of Arkansas for the Medical Sciences; Little Rock AR USA
| | - Jan H. Mortensen
- Haukeland University Hospital; Department of Public and Primary Care; University of Bergen; Bergen Norway
| | - Horace J. Spencer
- Haukeland University Hospital; Department of Public and Primary Care; University of Bergen; Bergen Norway
| | - John C. Morrison
- Department of Obstetrics and Gynecology; University of Mississippi Medical Center; Jackson MS USA
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Roberts D, Brown J, Medley N, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2017; 3:CD004454. [PMID: 28321847 PMCID: PMC6464568 DOI: 10.1002/14651858.cd004454.pub3] [Citation(s) in RCA: 451] [Impact Index Per Article: 64.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Respiratory morbidity including respiratory distress syndrome (RDS) is a serious complication of preterm birth and the primary cause of early neonatal mortality and disability. While researching the effects of the steroid dexamethasone on premature parturition in fetal sheep in 1969, Liggins found that there was some inflation of the lungs of lambs born at gestations at which the lungs would be expected to be airless. Liggins and Howie published the first randomised controlled trial in humans in 1972 and many others followed. OBJECTIVES To assess the effects of administering a course of corticosteroids to the mother prior to anticipated preterm birth on fetal and neonatal morbidity and mortality, maternal mortality and morbidity, and on the child in later life. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (17 February 2016) and reference lists of retrieved studies. SELECTION CRITERIA We considered all randomised controlled comparisons of antenatal corticosteroid administration (betamethasone, dexamethasone, or hydrocortisone) with placebo, or with no treatment, given to women with a singleton or multiple pregnancy, prior to anticipated preterm delivery (elective, or following spontaneous labour), regardless of other co-morbidity, for inclusion in this review. Most women in this review received a single course of steroids; however, nine of the included trials allowed for women to have weekly repeats. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS This update includes 30 studies (7774 women and 8158 infants). Most studies are of low or unclear risk for most bias domains. An assessment of high risk usually meant a trial had potential for performance bias due to lack of blinding. Two trials had low risks of bias for all risk of bias domains.Treatment with antenatal corticosteroids (compared with placebo or no treatment) is associated with a reduction in the most serious adverse outcomes related to prematurity, including: perinatal death (average risk ratio (RR) 0.72, 95% confidence interval (CI) 0.58 to 0.89; participants = 6729; studies = 15; Tau² = 0.05, I² = 34%; moderate-quality); neonatal death (RR 0.69, 95% CI 0.59 to 0.81; participants = 7188; studies = 22), RDS (average RR 0.66, 95% CI 0.56 to 0.77; participants = 7764; studies = 28; Tau² = 0.06, I² = 48%; moderate-quality); moderate/severe RDS (average RR 0.59, 95% CI 0.38 to 0.91; participants = 1686; studies = 6; Tau² = 0.14, I² = 52%); intraventricular haemorrhage (IVH) (average RR 0.55, 95% CI 0.40 to 0.76; participants = 6093; studies = 16; Tau² = 0.10, I² = 33%; moderate-quality), necrotising enterocolitis (RR 0.50, 95% CI 0.32 to 0.78; participants = 4702; studies = 10); need for mechanical ventilation (RR 0.68, 95% CI 0.56 to 0.84; participants = 1368; studies = 9); and systemic infections in the first 48 hours of life (RR 0.60, 95% CI 0.41 to 0.88; participants = 1753; studies = 8).There was no obvious benefit for: chronic lung disease (average RR 0.86, 95% CI 0.42 to 1.79; participants = 818; studies = 6; Tau² = 0.38 I² = 65%); mean birthweight (g) (MD -18.47, 95% CI -40.83 to 3.90; participants = 6182; studies = 16; moderate-quality); death in childhood (RR 0.68, 95% CI 0.36 to 1.27; participants = 1010; studies = 4); neurodevelopment delay in childhood (RR 0.64, 95% CI 0.14 to 2.98; participants = 82; studies = 1); or death into adulthood (RR 1.00, 95% CI 0.56 to 1.81; participants = 988; studies = 1).Treatment with antenatal corticosteroids does not increase the risk of chorioamnionitis (RR 0.83, 95% CI 0.66 to 1.06; participants = 5546; studies = 15; moderate-quality evidence) or endometritis (RR 1.20, 95% CI 0.87 to 1.63; participants = 4030; studies = 10; Tau² = 0.11, I² = 28%; moderate-quality). No increased risk in maternal death was observed. However, the data on maternal death is based on data from a single trial with two deaths; four other trials reporting maternal death had zero events (participants = 3392; studies = 5; moderate-quality).There is no definitive evidence to suggest that antenatal corticosteroids work differently in any pre-specified subgroups (singleton versus multiple pregnancy; membrane status; presence of hypertension) or for different study protocols (type of corticosteroid; single course or weekly repeats).GRADE outcomes were downgraded to moderate-quality. Downgrading decisions (for perinatal death, RDS, IVH, and mean birthweight) were due to limitations in study design or concerns regarding precision (chorioamnionitis, endometritis). Maternal death was downgraded for imprecision due to few events. AUTHORS' CONCLUSIONS Evidence from this update supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. A single course of antenatal corticosteroids could be considered routine for preterm delivery. It is important to note that most of the evidence comes from high income countries and hospital settings; therefore, the results may not be applicable to low-resource settings with high rates of infections.There is little need for further trials of a single course of antenatal corticosteroids versus placebo in singleton pregnancies in higher income countries and hospital settings. However, data are sparse in lower income settings. There are also few data regarding risks and benefits of antenatal corticosteroids in multiple pregnancies and other high-risk obstetric groups. Further information is also required concerning the optimal dose-to-delivery interval, and the optimal corticosteroid to use.We encourage authors of previous studies to provide further information, which may answer any remaining questions about the use of antenatal corticosteroids in such pregnancies without the need for further randomised controlled trials. Individual patient data meta-analysis from published trials is likely to answer some of the evidence gaps. Follow-up studies into childhood and adulthood, particularly in the late preterm gestation and repeat courses groups, are needed. We have not examined the possible harmful effects of antenatal corticosteroids in low-resource settings in this review. It would be particularly relevant to explore this finding in adequately powered prospective trials.
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Affiliation(s)
- Devender Roberts
- Liverpool Women's NHS Foundation TrustObstetrics DirectorateCrown StreetLiverpoolUKL8 7SS
| | - Julie Brown
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
| | - Nancy Medley
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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11
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Schmitz T. Prévention des complications de la prématurité par l’administration anténatale de corticoïdes. ACTA ACUST UNITED AC 2016; 45:1399-1417. [DOI: 10.1016/j.jgyn.2016.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 10/20/2022]
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Haram K, Mortensen JH, Magann EF, Morrison JC. Antenatal corticosteroid treatment: factors other than lung maturation. J Matern Fetal Neonatal Med 2016; 30:1437-1441. [DOI: 10.1080/14767058.2016.1219716] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Prospective evaluation of associations between prenatal cortisol and adulthood coronary heart disease risk: the New England family study. Psychosom Med 2015; 77:237-45. [PMID: 25768844 PMCID: PMC4965800 DOI: 10.1097/psy.0000000000000164] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Increasing evidence suggests that early life factors may influence coronary heart disease (CHD) risk; however, little is known about the contributions of prenatal cortisol. Objectives were to prospectively assess the associations of maternal cortisol levels during pregnancy with offspring's 10-year CHD risk during middle age. METHODS Participants were 262 mother-offspring dyads from the New England Family Study. Maternal free cortisol was assessed in third-trimester maternal serum samples. Ten-year CHD risk was calculated in offspring at a mean age of 42 years, using the validated Framingham risk algorithm incorporating diabetes, systolic and diastolic blood pressure, total and high-density lipoprotein cholesterol, smoking, age, and sex. RESULTS In multivariable-adjusted linear regression analyses adjusted for age and race/ethnicity, high versus low maternal cortisol tertile was associated with 36.7% (95% confidence interval [CI] = 8.4% to 72.5%) greater mean 10-year CHD risk score in women. There was no association in men (-2.8%, 95% CI = -23.8% to 24.0%). Further adjustment for in utero socioeconomic position showed 26.1% (95% CI = -0.5% to 59.9%) greater CHD risk in women. Adjustment for maternal age and size for gestational age had little effect on findings. CONCLUSIONS Maternal prenatal cortisol levels were positively associated with 10-year CHD risk among female, and not male, offspring. Adjusting for socioeconomic position during pregnancy reduced effect size in women, suggesting that it may be a common prior factor in both maternal cortisol and CHD risk. These findings provide evidence that targeting mothers who have elevated prenatal cortisol levels, including elevated cortisol in the setting of low socioeconomic position, may potentially reduce long-term CHD risk in their offspring.
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14
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Abstract
Since their introduction more than forty years ago, antenatal glucocorticoids have become a cornerstone in the management of preterm birth and have been responsible for substantial reductions in neonatal mortality and morbidity. Clinical trials conducted over the past decade have shown that these benefits may be increased further through administration of repeat doses of antenatal glucocorticoids in women at ongoing risk of preterm and in those undergoing elective cesarean at term. At the same time, a growing body of experimental animal evidence and observational data in humans has linked fetal overexposure to maternal glucocorticoids with increased risk of cardiovascular, metabolic and other disorders in later life. Despite these concerns, and somewhat surprisingly, there has been little evidence to date from randomized trials of longer-term harm from clinical doses of synthetic glucocorticoids. However, with wider clinical application of antenatal glucocorticoid therapy there has been greater need to consider the potential for later adverse effects. This paper reviews current evidence for the short- and long-term health effects of antenatal glucocorticoids and discusses the apparent discrepancy between data from randomized clinical trials and other studies.
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Rog-Zielinska EA, Richardson RV, Denvir MA, Chapman KE. Glucocorticoids and foetal heart maturation; implications for prematurity and foetal programming. J Mol Endocrinol 2014; 52:R125-35. [PMID: 24299741 DOI: 10.1530/jme-13-0204] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Glucocorticoids are steroid hormones, essential in mammals to prepare for life after birth. Blood levels of glucocorticoids (cortisol in most mammals including humans; corticosterone in rats and mice) rise dramatically shortly before birth. This is mimicked clinically in the routine administration of synthetic glucocorticoids to pregnant women threatened by a preterm birth or to preterm infants to improve neonatal survival. Whilst effects on lung are well documented and essential for postnatal survival, those on heart are less well known. In this study, we review recent evidence for a crucial role of glucocorticoids in late gestational heart maturation. Either insufficient or excessive glucocorticoid exposure before birth may alter the normal glucocorticoid-regulated trajectory of heart maturation with potential life-long consequences.
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Affiliation(s)
- Eva A Rog-Zielinska
- Queen's Medical Research Institute, Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK
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16
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Braun T, Challis JR, Newnham JP, Sloboda DM. Early-life glucocorticoid exposure: the hypothalamic-pituitary-adrenal axis, placental function, and long-term disease risk. Endocr Rev 2013; 34:885-916. [PMID: 23970762 DOI: 10.1210/er.2013-1012] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
An adverse early-life environment is associated with long-term disease consequences. Adversity early in life is hypothesized to elicit developmental adaptations that serve to improve fetal and postnatal survival and prepare the organism for a particular range of postnatal environments. These processes, although adaptive in their nature, may later prove to be maladaptive or disadvantageous if the prenatal and postnatal environments are widely discrepant. The exposure of the fetus to elevated levels of either endogenous or synthetic glucocorticoids is one model of early-life adversity that contributes substantially to the propensity of developing disease. Moreover, early-life glucocorticoid exposure has direct clinical relevance because synthetic glucocorticoids are routinely used in the management of women at risk of early preterm birth. In this regard, reports of adverse events in human newborns have raised concerns about the safety of glucocorticoid treatment; synthetic glucocorticoids have detrimental effects on fetal growth and development, childhood cognition, and long-term behavioral outcomes. Experimental evidence supports a link between prenatal exposure to synthetic glucocorticoids and alterations in fetal development and changes in placental function, and many of these alterations appear to be permanent. Because the placenta is the conduit between the maternal and fetal environments, it is likely that placental function plays a key role in mediating effects of fetal glucocorticoid exposure on hypothalamic-pituitary-adrenal axis development and long-term disease risk. Here we review recent insights into how the placenta responds to changes in the intrauterine glucocorticoid environment and discuss possible mechanisms by which the placenta mediates fetal hypothalamic-pituitary-adrenal development, metabolism, cardiovascular function, and reproduction.
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Affiliation(s)
- Thorsten Braun
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, 1280 Main Street West, HSC 4H30A, Hamilton, Ontario, Canada L8S 4K1.
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Shaltout HA, Rose JC, Chappell MC, Diz DI. Angiotensin-(1-7) deficiency and baroreflex impairment precede the antenatal Betamethasone exposure-induced elevation in blood pressure. Hypertension 2012; 59:453-8. [PMID: 22215705 DOI: 10.1161/hypertensionaha.111.185876] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Betamethasone is administered to accelerate lung development and improve survival of premature infants but may be associated with hypertension later in life. In a sheep model of fetal programming resulting from exposure at day 80 of gestation to Betamethasone (Beta-exposed), adult sheep at 6 to 9 months or 1.8 years of age have elevated mean arterial pressure (MAP) and attenuated spontaneous baroreflex sensitivity (sBRS) for control of heart rate compared to age-matched controls associated with imbalances in angiotensin (Ang) II vs Ang-(1-7) tone. At 6 weeks of age, evoked BRS is already low in the Beta-exposed animals. In this study, we assessed the potential contribution of the renin-angiotensin system to the impaired sBRS. Female lambs (6 weeks old) with Beta exposure in utero had similar MAP to control lambs (78±2 vs 77±2 mm Hg, n=4-5 per group), but lower sBRS (8±1 vs 16±3 ms/mm Hg; P<0.05) and impaired heart rate variability. Peripheral AT1 receptor blockade using candesartan lowered MAP in both groups (≈10 mm Hg) and improved sBRS and heart rate variability in Beta-exposed lambs to a level similar to control. AT7 receptor blockade by infusion of D-ala Ang-(1-7) (700 ng/kg/min for 45 minutes) reduced sBRS 46%±10% in Beta-exposed vs in control lambs (P<0.15) and increased MAP in both groups (≈6±2 mm Hg). Our data reveal that Beta exposure impairs sBRS and heart rate variability at a time point preceding the elevation in MAP via mechanisms involving an imbalance in the Ang II/Ang-(1-7) ratio consistent with a progressive loss in Ang-(1-7) function.
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Affiliation(s)
- Hossam A Shaltout
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Hanes Building, 6th floor, Medical Center Boulevard, Winston-Salem, NC 27157-1032, USA.
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Diz DI, Arnold AC, Nautiyal M, Isa K, Shaltout HA, Tallant EA. Angiotensin peptides and central autonomic regulation. Curr Opin Pharmacol 2011; 11:131-7. [PMID: 21367658 DOI: 10.1016/j.coph.2011.02.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 02/08/2011] [Indexed: 10/18/2022]
Abstract
Aging, hypertension, and fetal-programmed cardiovascular disease are associated with a functional deficiency of angiotensin (Ang)-(1-7) in the brain dorsomedial medulla. The resulting unrestrained activity of Ang II in brainstem regions negatively impacts resting mean arterial pressure, sympathovagal balance, and baroreflex sensitivity for control of heart rate. The differential effects of Ang II and Ang-(1-7) may be related to the cellular sources of these peptides as well as different precursor pathways. Long-term alterations of the brain renin-angiotensin system may influence signaling pathways including phosphoinositol-3-kinase and mitogen-activated protein kinase and their downstream mediators, and as a consequence may influence metabolic function. Differential regulation of signaling pathways in aging and hypertension by Ang II versus Ang-(1-7) may contribute to the autonomic dysfunction accompanying these states.
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Affiliation(s)
- Debra I Diz
- The Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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19
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Hovi P, Andersson S, Räikkönen K, Strang-Karlsson S, Järvenpää AL, Eriksson JG, Pesonen AK, Heinonen K, Pyhälä R, Kajantie E. Ambulatory blood pressure in young adults with very low birth weight. J Pediatr 2010; 156:54-59.e1. [PMID: 19796771 DOI: 10.1016/j.jpeds.2009.07.022] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 06/15/2009] [Accepted: 07/08/2009] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We hypothesized that, as compared with a matched control group born at term, young adults with very low birth weight (VLBW <1.5 kg) would have higher 24-hour ambulatory blood pressure. STUDY DESIGN We studied 118 18- to 27-year-old subjects born with VLBW within the greater Helsinki area and 120 term-born control subjects with similar age, sex, and birth hospital. The mean birth weight for VLBW subjects was 1.1 kg (standard deviation [SD], 0.2) and for controls, 3.6 kg (SD, 0.5). Gestational ages were 29.2 (SD, 2.3) and 40.1 (SD, 1.0) weeks. Current education of higher-educated parents served as an indicator of childhood socioeconomic status. Ambulatory blood pressure was measured during a 24-hour period with an oscillometric device (Spacelabs 90207). RESULTS VLBW subjects had, with sex, age, and body mass index adjustment, a 2.4 mm Hg (95% confidence interval, 0.2 to 4.6) higher 24-hour systolic pressure. We found hypertension in 11 VLBW subjects and in 3 term-born subjects, giving an adjusted odds ratio of 4.0 (1.1 to 14.8). When socioeconomic status was taken into account, results remained unchanged. CONCLUSIONS Higher rates of hypertension and higher 24-hour blood pressure among young adults with VLBW may indicate higher risk for adverse cardiovascular outcomes.
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Affiliation(s)
- Petteri Hovi
- Department of Chronic Disease Prevention, National Institute for Health and Welfare, Helsinki, Finland.
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20
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Antenatal corticosteroid treatment: what's happened since Drs Liggins and Howie? Am J Obstet Gynecol 2009; 200:448-57. [PMID: 19318156 DOI: 10.1016/j.ajog.2008.12.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Revised: 11/07/2008] [Accepted: 12/05/2008] [Indexed: 11/23/2022]
Abstract
In 1972, Drs Liggins and Howie published a landmark article demonstrating that antenatal corticosteroids significantly reduced the frequency of respiratory distress syndrome and neonatal mortality. A single course of antenatal corticosteroids has become standard of care for pregnant women at risk for preterm birth. Recent studies have suggested weekly courses of antenatal corticosteroids result in improvement in the acute neonatal condition but have not supported long-term benefit. With greater understanding of the beneficial actions of corticosteroids on the fetal lung, the role for this therapy may expand. In addition to increased surfactant production and secretion, corticosteroids facilitate clearance of fetal lung fluid, as well as other maturational effects. Thus, antenatal corticosteroids may prove valuable in the late preterm period and before elective cesarean delivery at term.
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21
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Morrison JL, Orgeig S. Review: Antenatal Glucocorticoid Treatment of The Growth-restricted Fetus: Benefit or Cost? Reprod Sci 2009; 16:527-38. [DOI: 10.1177/1933719109332821] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Janna L. Morrison
- Sansom Institute, University of South Australia, Adelaide, South Australia, Australia, , Early Origins of Adult Health Research Group, University of South Australia, Adelaide, South Australia, Australia
| | - Sandra Orgeig
- Sansom Institute, University of South Australia, Adelaide, South Australia, Australia
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22
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Huh SY, Andrew R, Rich-Edwards JW, Kleinman KP, Seckl JR, Gillman MW. Association between umbilical cord glucocorticoids and blood pressure at age 3 years. BMC Med 2008; 6:25. [PMID: 18755017 PMCID: PMC2533350 DOI: 10.1186/1741-7015-6-25] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Accepted: 08/28/2008] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Animal data show that decreased activity of placental 11-beta-hydroxysteroid dehydrogenase type 2 (11beta-HSD2), which potently inactivates glucocorticoids (e.g. cortisol) to inert forms (cortisone), allows increased access of maternal glucocorticoids to the fetus and 'programs' hypertension. Data in humans are limited. We examined in humans the association between venous umbilical cord blood glucocorticoids, a potential marker for placental 11beta-HSD2 enzyme activity, and blood pressure at age 3 years. METHODS Among 286 newborns in Project Viva, a prospective pre-birth cohort study based in eastern Massachusetts, we measured cortisol (F) and cortisone (E) in venous cord blood and used the ratio of F/E as a marker for placental 11beta-HSD2 activity. We measured blood pressure (BP) when the offspring reached age 3 years. Using mixed effects regression models to control for BP measurement conditions, maternal and child characteristics, we examined the association between the F/E ratio and child BP. RESULTS At age 3 years, each unit increase in the F/E ratio was associated with a 1.6 mm Hg increase in systolic BP (95% CI 0.0 to 3.1). The F/E ratio was not associated with diastolic blood pressure or birth weight for gestational age z-score. CONCLUSION A higher F/E ratio in umbilical venous cord blood, likely reflecting reduced placental 11beta-HSD2 activity, was associated with higher systolic blood pressure at age 3 years. Our data suggest that increased fetal exposure to active maternal glucocorticoids may program later systolic blood pressure.
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Affiliation(s)
- Susanna Y Huh
- Division of Gastroenterology and Nutrition, Children's Hospital Boston, Boston, MA, USA.
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De Matteo R, Stacy V, Probyn ME, Brew N, Blasch N, Harding R. Does moderate preterm birth lead to altered arterial pressure? Studies in sheep. Clin Exp Pharmacol Physiol 2008; 35:1426-32. [PMID: 18671717 DOI: 10.1111/j.1440-1681.2008.05014.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
1. Low birth weight (LBW) is associated with an increased risk of cardiovascular disease. Preterm birth is a major determinant of LBW and has been shown to result in elevated arterial pressure (AP) in humans, but few studies have investigated the effects of preterm birth in the absence of potentially confounding factors. Our aim was to determine whether moderately preterm birth per se alters the postnatal development of AP in lambs. 2. Preterm lambs were delivered approximately 14 days before term (i.e. approximately 133 days of gestation); controls were born at term (approximately 147 days). Mean arterial pressure (MAP), heart rate (HR), blood composition and indices of growth were measured at 4 and 8 weeks post term-equivalent age (PTEA). We also studied a separate cohort of preterm and term sheep as young adults (approximately 1.1 years). 3. Preterm lambs had significantly lower birth weights than term lambs, but bodyweights were not significantly different by Day 12 PTEA. In addition, MAP, HR and most blood variables did not differ between term and preterm lambs at 4 or 8 weeks PTEA. Preterm birth per se did not alter MAP or HR in young adult sheep. 4. Low birth weight due to preterm birth does not result in an altered AP during early postnatal life or at maturity. Moderate intrauterine growth restriction (IUGR) due to twinning, which further reduces birth weight, does not affect MAP in preterm lambs. Other factors, such as the degree of prematurity or IUGR, exposure to corticosteroids or postnatal nutrition, may be important in the later development of elevated AP.
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Affiliation(s)
- Robert De Matteo
- Department of Anatomy and Developmental Biology, Monash University, Clayton, Victoria, Australia.
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24
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Abstract
Cardiopulmonary diseases dominate the early days after birth for very preterm babies, but most survive these disorders. However, a minority who survive remain oxygen-dependent for a prolonged period, including after discharge. For the remaining very preterm survivors, cardiopulmonary problems are not major health issues in early childhood, apart from higher rates of hospital readmission for respiratory illnesses in the first few years after the primary hospitalization. However, as they progress through childhood and into adulthood, it is clear that very preterm survivors have reduced lung function, higher blood pressure, and other cardiovascular abnormalities that may lead to adverse cardiopulmonary outcomes much earlier in adult life than would normally be expected. The contribution of these cardiopulmonary problems in early adulthood to morbidity in middle and old ages needs to be determined.
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Affiliation(s)
- Lex W Doyle
- The Royal Women's Hospital, University of Melbourne, Murdoch Childrens Research Institute, Melbourne, Australia.
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de Boo HA, Harding JE. The developmental origins of adult disease (Barker) hypothesis. Aust N Z J Obstet Gynaecol 2008; 46:4-14. [PMID: 16441686 DOI: 10.1111/j.1479-828x.2006.00506.x] [Citation(s) in RCA: 395] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Many studies have provided evidence for the hypothesis that size at birth is related to the risk of developing disease in later life. In particular, links are well established between reduced birthweight and increased risk of coronary heart disease, diabetes, hypertension and stroke in adulthood. These relationships are modified by patterns of postnatal growth. The most widely accepted mechanisms thought to underlie these relationships are those of fetal programming by nutritional stimuli or excess fetal glucocorticoid exposure. It is suggested that the fetus makes physiological adaptations in response to changes in its environment to prepare itself for postnatal life. These changes may include epigenetic modification of gene expression. Less clear at this time are the relevance of fetal programming phenomena to twins and preterm babies, and whether any of these effects can be reversed after birth. Much current active research in this field will be of direct relevance to future obstetric practice.
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Affiliation(s)
- Hendrina A de Boo
- Liggins Institute, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Crowther CA, Doyle LW, Haslam RR, Hiller JE, Harding JE, Robinson JS. Outcomes at 2 years of age after repeat doses of antenatal corticosteroids. N Engl J Med 2007; 357:1179-89. [PMID: 17881750 DOI: 10.1056/nejmoa071152] [Citation(s) in RCA: 187] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We previously reported the results of a randomized, controlled trial showing that repeat doses of antenatal corticosteroids reduced the risk of respiratory distress syndrome and serious neonatal morbidity. However, data have not been available regarding longer-term effects of this treatment. METHODS Women who had received an initial course of corticosteroid treatment 7 or more days previously were randomly assigned to receive an intramuscular injection of corticosteroid (11.4 mg of betamethasone) or saline placebo; the dose was repeated weekly if the mother was still considered to be at risk for preterm delivery and the duration of gestation was less than 32 weeks. We assessed survival free of major neurosensory disability and body size of the children at 2 years of corrected age. RESULTS Of the 1085 children who were alive at 2 years of age, 1047 (96.5%) were seen for assessment (521 exposed to repeat-corticosteroid treatment and 526 exposed to placebo). The rate of survival free of major disability was similar in the repeat-corticosteroid and placebo groups (84.4% and 81.0%, respectively; adjusted relative risk, 1.04, 95% confidence interval, 0.98 to 1.10; adjusted P=0.20). There were no significant differences between the groups in body size, blood pressure, use of health services, respiratory morbidity, or child behavior scores, although children exposed to repeat doses of corticosteroids were more likely than those exposed to placebo to warrant assessment for attention problems (P=0.04). CONCLUSIONS Administration of repeat doses of antenatal corticosteroids reduces neonatal morbidity without changing either survival free of major neurosensory disability or body size at 2 years of age. (Current Controlled Trials number, ISRCTN48656428 [controlled-trials.com].).
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Affiliation(s)
- Caroline A Crowther
- Disciplines of Obstetrics and Gynaecology, University of Adelaide, Women's and Children's Hospital, Adelaide, Australia.
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Baud O, Sola A. Corticosteroids in perinatal medicine: how to improve outcomes without affecting the developing brain? Semin Fetal Neonatal Med 2007; 12:273-9. [PMID: 17376752 DOI: 10.1016/j.siny.2007.01.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Antenatal glucocorticoid therapy remains one of the most striking successes in the perinatal management of complicated pregnancies that result in premature birth. The anti-inflammatory and maturative properties of fluorocorticoids are such that all women at risk of preterm delivery before 34weeks gestation should be treated. Betamethasone is preferred to dexamethasone and no more than two courses, 2weeks apart, should be given until the evidence from further controlled trials on repeated doses becomes available. In particular, the early use of postnatal dexamethasone should be avoided in preterm infants because of the deleterious effects on neurological development, including not only cerebral palsy but also cognitive function and psychiatric-related behavior. Treatment with other steroids should be restricted to the context of randomized controlled trials.
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Affiliation(s)
- Olivier Baud
- NICU and Neonatal Medicine, INSERM U676, Robert Debré Children's Hospital, 48 Bd Sérurier, Paris, France.
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Dalziel SR, Parag V, Rodgers A, Harding JE. Cardiovascular risk factors at age 30 following pre-term birth. Int J Epidemiol 2007; 36:907-15. [PMID: 17468503 DOI: 10.1093/ije/dym067] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Recent epidemiological evidence has shown increased rates of cardiovascular mortality and associated risk factors in those born small. However, scarce information exists concerning cardiovascular risk factors in adulthood following pre-term birth, or distinguishing the relative contributions of length of gestation and fetal growth to small size at birth. METHODS Prospective follow-up of 458 30-year-olds whose mothers took part in a randomized controlled trial of antenatal betamethasone for the prevention of neonatal respiratory distress syndrome (147 born at term, 311 born pre-term). Follow-up assessments included anthropometry, blood pressure, blood lipids, early morning cortisol levels and 75 g oral glucose tolerance test. RESULTS Gestational age at birth, pre-term birth, and birth weight z-score were not associated with serum cholesterol, triglyceride or cortisol at age 30 (P > 0.1 for all). However, pre-term birth was associated with increased systolic blood pressure (3.5 mmHg, 95% CI 0.9-6.1 mmHg, P = 0.009) and insulin resistance at age 30 [Log (Insulin area under the curve) = 0.17, 95% CI 0.05-0.28, P = 0.006]. Low gestational age at birth was also associated with these outcomes, whereas birth weight, adjusted for gestational age, was not. CONCLUSIONS Adults who were born moderately pre-term have increased blood pressure and insulin resistance at 30 years of age. Pre-term birth rather than poor fetal growth is the major determinant of this association. As both the incidence of pre-term birth and survival amongst those born pre-term are increasing, this group may contribute an increasing proportion to overall cardiovascular disease burden.
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Affiliation(s)
- Stuart R Dalziel
- Clinical Trials Research Unit, The University of Auckland, Auckland, New Zealand
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Abstract
The effect of antenatal steroids on blood pressure in humans remains an unresolved question. Here we report the effects of prenatal exposure to clinically relevant doses of betamethasone on endothelial and/or vascular smooth muscle function. Pregnant sheep were randomly treated with betamethasone (0.17 mg/kg) or vehicle at 80 and 81 d of gestation. We studied arterial segments (4th-5th generation) of the right brachial artery obtained at 1-2 y of age under general anesthesia. We demonstrate that in brachial arteries of steroid exposed offspring: KCl induced contraction is increased after endothelium removal or incubation with inhibitors of nitric oxide synthase or cyclooxygenase; acetylcholine-induced relaxation is increased; sensitivity to endothelin-1 (ET-1) is increased and this effect is decreased by the ETB antagonist BQ-788. These data suggest that, in sheep treated with clinically relevant doses of betamethasone at a gestational stage when human fetuses are routinely exposed to glucocorticoids, there is a dual effect of betamethasone on the adult sheep brachial artery, i.e. endothelial dysfunction with an impairment of endothelin-1 ETB receptor-induced release of nitric oxide and an increased contribution of the ETB receptor in smooth muscle to the contractile effects of ET-1.
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Affiliation(s)
- Victor M Pulgar
- Center for Research in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
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30
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Gillman MW, Rich-Edwards JW, Huh S, Majzoub JA, Oken E, Taveras EM, Rifas-Shiman SL. Maternal corticotropin-releasing hormone levels during pregnancy and offspring adiposity. Obesity (Silver Spring) 2006; 14:1647-53. [PMID: 17030976 PMCID: PMC1899091 DOI: 10.1038/oby.2006.189] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Animal models suggest that fetal exposure to glucocorticoids can program adiposity, especially central adiposity, later in life. We examined associations of maternal corticotropin-releasing hormone (CRH) levels in the late 2nd trimester of pregnancy, a marker of fetal glucocorticoid exposure, with child adiposity at age 3 years. RESEARCH METHODS AND PROCEDURES We analyzed data from 199 participants in Project Viva, a prospective cohort study of pregnant women and their children, At age 3 years, the main outcomes were age-sex-specific BMI z score and the sum of subscapular (SS) and triceps (TR) skinfold thicknesses to represent overall adiposity, and ratio of SS to TR (SS:TR) to represent central adiposity. RESULTS Mean (standard deviation) maternal 2nd trimester log CRH was 4.94 (0.56) pg/mL. At age 3, mean (standard deviation) for BMI z score was 0.52 (1.02); for SS + TR, 16.51 (3.94) mm; and for SS:TR, 0.67 (0.17). Log CRH was mildly inversely correlated with birth weight (r = -0.08), chiefly because of its association with length of gestation (r = -0.21) rather than fetal growth (r = -0.004). After adjustment for sociodemographic factors, maternal smoking, BMI, and gestational weight gain, fetal growth, length of gestation, breastfeeding duration, and (for SS:TR only) child's 3-year BMI, each increment of 1 unit of log CRH was associated with a reduction in BMI z score [-0.43; 95% confidence interval (CI), -0.73, -0.14; p = 0.004] and possible reduction in SS + TR (-1.10; 95% CI, -2.33, 0.14; p = 0.08). In contrast, log CRH was associated with higher SS:TR (0.07; 95% CI, 0.02, 0.13; p = 0.007). DISCUSSION Fetal exposure to glucocorticoids, although associated with an overall decrease in body size, may cause an increase in central adiposity.
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Affiliation(s)
- Matthew W Gillman
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA 02215, USA.
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Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2006:CD004454. [PMID: 16856047 DOI: 10.1002/14651858.cd004454.pub2] [Citation(s) in RCA: 740] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Respiratory distress syndrome (RDS) is a serious complication of preterm birth and the primary cause of early neonatal mortality and disability. OBJECTIVES To assess the effects on fetal and neonatal morbidity and mortality, on maternal mortality and morbidity, and on the child in later life of administering corticosteroids to the mother before anticipated preterm birth. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 October 2005). SELECTION CRITERIA Randomised controlled comparisons of antenatal corticosteroid administration (betamethasone, dexamethasone, or hydrocortisone) with placebo or with no treatment given to women with a singleton or multiple pregnancy, expected to deliver preterm as a result of either spontaneous preterm labour, preterm prelabour rupture of the membranes or elective preterm delivery. DATA COLLECTION AND ANALYSIS Two review authors assessed trial quality and extracted data independently. MAIN RESULTS Twenty-one studies (3885 women and 4269 infants) are included. Treatment with antenatal corticosteroids does not increase risk to the mother of death, chorioamnionitis or puerperal sepsis. Treatment with antenatal corticosteroids is associated with an overall reduction in neonatal death (relative risk (RR) 0.69, 95% confidence interval (CI) 0.58 to 0.81, 18 studies, 3956 infants), RDS (RR 0.66, 95% CI 0.59 to 0.73, 21 studies, 4038 infants), cerebroventricular haemorrhage (RR 0.54, 95% CI 0.43 to 0.69, 13 studies, 2872 infants), necrotising enterocolitis (RR 0.46, 95% CI 0.29 to 0.74, eight studies, 1675 infants), respiratory support, intensive care admissions (RR 0.80, 95% CI 0.65 to 0.99, two studies, 277 infants) and systemic infections in the first 48 hours of life (RR 0.56, 95% CI 0.38 to 0.85, five studies, 1319 infants). Antenatal corticosteroid use is effective in women with premature rupture of membranes and pregnancy related hypertension syndromes. AUTHORS' CONCLUSIONS The evidence from this new review supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. A single course of antenatal corticosteroids should be considered routine for preterm delivery with few exceptions. Further information is required concerning optimal dose to delivery interval, optimal corticosteroid to use, effects in multiple pregnancies, and to confirm the long-term effects into adulthood.
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Affiliation(s)
- D Roberts
- Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, Merseyside, UK L8 7SS.
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Murphy VE, Smith R, Giles WB, Clifton VL. Endocrine regulation of human fetal growth: the role of the mother, placenta, and fetus. Endocr Rev 2006; 27:141-69. [PMID: 16434511 DOI: 10.1210/er.2005-0011] [Citation(s) in RCA: 411] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The environment in which the fetus develops is critical for its survival and long-term health. The regulation of normal human fetal growth involves many multidirectional interactions between the mother, placenta, and fetus. The mother supplies nutrients and oxygen to the fetus via the placenta. The fetus influences the provision of maternal nutrients via the placental production of hormones that regulate maternal metabolism. The placenta is the site of exchange between mother and fetus and regulates fetal growth via the production and metabolism of growth-regulating hormones such as IGFs and glucocorticoids. Adequate trophoblast invasion in early pregnancy and increased uteroplacental blood flow ensure sufficient growth of the uterus, placenta, and fetus. The placenta may respond to fetal endocrine signals to increase transport of maternal nutrients by growth of the placenta, by activation of transport systems, and by production of placental hormones to influence maternal physiology and even behavior. There are consequences of poor fetal growth both in the short term and long term, in the form of increased mortality and morbidity. Endocrine regulation of fetal growth involves interactions between the mother, placenta, and fetus, and these effects may program long-term physiology.
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Affiliation(s)
- Vanessa E Murphy
- Mothers and Babies Research Centre, and Department of Respiratory and Sleep Medicine, Hunter Medical Research Institute, University of Newcastle, New South Wales, Australia
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Stutchfield PR, Whitaker R. Giving steroids before elective caesarean section: authors respond to editorial. BMJ 2005; 331:1475. [PMID: 16357001 PMCID: PMC1315707 DOI: 10.1136/bmj.331.7530.1475-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- P R Stutchfield
- Conwy and Denbighshire NHS Trust, Glan Clwyd Hospital, Rhyl, Denbighshire LL18 5UJ
| | - R Whitaker
- Institute of Medical and Social Care Research, University of Wales Bangor LL57 2PX
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Figueroa JP, Rose JC, Massmann GA, Zhang J, Acuña G. Alterations in fetal kidney development and elevations in arterial blood pressure in young adult sheep after clinical doses of antenatal glucocorticoids. Pediatr Res 2005; 58:510-5. [PMID: 16148065 DOI: 10.1203/01.pdr.0000179410.57947.88] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Epidemiologic studies have yielded controversial information regarding an association between antenatal steroid administration and elevations in arterial blood pressure (BP). The aim of the study was to determine whether antenatal administration of a clinically relevant dose of steroids at a time when fetal nephrogenesis is at its highest results in abnormal kidney development and adult hypertension. Pregnant sheep were treated with either vehicle or betamethasone. Maternal injections were given 24 h apart at 80 d of gestational age (dGA; 0.55 of gestation). Animals were studied either as fetuses or as immature adults. Fetuses were delivered by cesarean section at 135 dGA. Adults were studied at 6 mo of age. Betamethasone administration did not induce premature labor or intrauterine growth restriction. In the betamethasone-exposed group, we found at 135 dGA a 25.5% decrease in the number of glomeruli with no differences in fetal kidney weight. In adults, mean, systolic, and diastolic arterial BPs were significantly higher, whereas there were no significant differences in heart rate over the same study period. The major finding of this study is that a single course of antenatal steroids alters renal development and is associated with elevations in arterial BP in lambs at 6 mo of age. We conclude that antenatal glucocorticoid administration under the National Institutes of Health consensus guidelines may alter human fetal renal development.
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Affiliation(s)
- Jorge P Figueroa
- Center for Research in Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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