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Utilization of Antenatal Corticosteroids on premature babies of 27-34 weeks of gestational age born at SSRNH during 2003 PowerPoint Presentation
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Utilization of Antenatal Corticosteroids on premature babies of 27-34 weeks of gestational age born at SSRNH during 2003-2004. Dr S. Burahee Tutor: Dr (Miss) Soobadar. Introduction . Introduction.

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slide1

Utilization of Antenatal Corticosteroids on premature babies of 27-34 weeks of gestational age born at SSRNH during 2003-2004

Dr S. Burahee

Tutor: Dr (Miss) Soobadar

introduction
Introduction

ANS is a corticosteroid treatment given intramuscular to the pregnant mother at risk of premature delivery.

This corticosteroid will cross blood placental barrier and act upon premature lungs of fetus and help enhancing its maturity.

slide4
Premature newborns of 27-34 weeks gestation are at high risk of developing respiratory distress syndrome (RDS) due to lack of surfactant in their premature lung also called Hyaline membrane disease. (HMD)
slide5
Surfactant is a natural substance produced by pneumocytes II In the lungs.

It is a heterogenous mixture of lipids and proteins. Dipamitoyl phosphatidyl choline is the main component of the surfactant.

It spreads in the lung tissue- air interface

preventing alveolar collapse during

expiration, to open easily at next inspiration.

slide6
Hyaline Membrane Distress (HMD) occurs due to inadequate production of pulmonary surfactant in premature lung and is seen if labour occurs before 32-34 weeks of pregnancy.
slide7

Hyaline Membrane Disease

The alveolar wall collapses during expiration and each inspiration will require considerable effort.

This situation rapidly leads to fatigue, decreased respiratory effort, Hypoxia, cynosis, acidosis and eventually death, if not corrected by immediate treatment.

slide8
The steroids given IM to mothers passes across blood placental barrier and act upon the pneumocytes type II of lung, inducing production of surfactant and these help in preventing the HMD.
  • Steroids used are usually Betamethasone or Dexamethasone.
slide9
Antenatal Corticosteroid apart from reducing RDS (HMD) also reduce intraventricular hemorrhage and neonatal mortality.
indication of antenatal corticosteroid
Indication of Antenatal corticosteroid:

1. Indicated to all women pregnant of 24 to 34 weeks at risk of premature delivery within 7 days followed.

2. The women of 34-36 weeks can also be given ANS in certain critical condition

e.g. elective c.s for these clinical cases in 7 days following the ANC , e.g. gestational Diabetes mellitus, PIH, Placenta praevia

contra indication of antenatal corticosteroid
Contra indication of Antenatal corticosteroid :
  • woman suffering from systemic infection including T.B
  • Caution is advised if suspected chorioamnionitis is diagnosed.
dosage route of administration
Dosage & Route of administration:
  • Treatment of choice:

2 doses of Betamethasone 12mg given IM 24 hrs apart.

  • 2nd line of treatment:

-4 doses of dexamethasone 6mg given IM 12 hrs apart

-2 doses of 12 mg given IM 12 to 24 hrs apart.

slide13
Betamethasone is not available in public service in Mauritius.
  • Most extensively used regimen used in Mauritius:

2 doses of Dexamethasone 12mg IM 12 to 24 hrs apart

  • Most recently some doctors are using single dose of ANS in view of side effect of ANS.
the optimacy of treatment
The optimacy of treatment:
  • The optimal treatment- delivery interval for administration of ANS is more than 24 hrs but fewer than 7days after start of treatment.
history of ans therapy
History of ANS Therapy
  • Benefits are well known since 1972.
  • Liggins and Howic were the first who described the benefit of ANS in 1972.
  • Controlled trial of Betamethasone therapy was carried out in 282 mothers with threatened premature delivery before 37 weeks.
  • There was no death with HMD or IVH in infants of mother who had received Betamethasone at least 24 hrs before delivery.
justification for study on ans
Justification for study on ANS

In Mauritius, in years 70’s after independence day, IMR was very high due to very high neonatal and perinatal rates.

After the integration of MCH (Maternal & Child Health) programme, antenatal service improved at primary health centre ** and became easily accessible to all & hence mortality rates started decreasing.

slide19
For further improvement, NICU services started in Mauritius.

At Victoria Hospital, in 1999

At SSRN Hospital, in 2001

But the services are very costly & big economic

burden on Government.

ANS therapy decreases the risk of HMD, hence

decrease the need of NICU treatment & hence the

cost of treatment.

objective of study
Objective of Study

General Objective:

To describe the utilization of ANS in pregnancies of 27-34 weeks with high risk of premature deliveries.

Describe the outcome of premature babies in 3 groups according to ANS:

  • With no ANS treatment
  • With ANS incomplete or suboptimal treatment
  • With complete & optimal ANS therapy

Specific Objective:

methodology
Methodology
  • It is a retrospective descriptive observational study on premature babies of 27-34 weeks born at SSRN Hospital during Jan 2003 to Dec 2004.
  • Though we know that best technique for this study would be the randomised clinical trial, but it was not possible due to existing circumstances and ethical reasons.
slide22
Total premature babies born alive during

2003-2004 =421

Selected for study=112

Criteria of inclusion:

Babies of gestational age 27-34 weeks born at

SSRNH only including inutero transfer

Criteria of exclusion:

Premature babies with congenital malformation, infant

of diabetic mother, multiple pregnancies

slide23
Subdivided our population of study in 3 groups:
  • Group of babies with suboptimal ANS therapy (no=29)
  • Group of babies with optimal ANS therapy (no=49)
  • Group of babies with no ANS (no=34)

Group suboptimal whose mothers had

Incomplete course of ANS with short interval

between therapy and delivery, i.e. less than 24 hrs.

Group optimal whose mothers had complete

course of ANS at least 24 hrs before delivery

grading of prematurity
Grading of prematurity
  • Extreme premature: G.A of 26-32 weeks

no=5

  • Severe premature: 28-31 weeks

no=55

  • Mild premature: 32-34 weeks

no=52

criteria of diagnosis of severity of rds
Criteria of diagnosis of severity of RDS
  • According to clinical conditions
  • Chest X Ray
  • Need of treatment

Mild RDS X Ray chest result, need of

O2 less than 30% fiO2, NO need of surfactant

& less tachypnia

Severe RDS X Ray result, severe tachypnia,

need of O2 more than 30% even with respiratory

Support, need of surfactant

results
Results

Percentage of antenatal corticotherapy

slide28
About 30% of the eligible women couldn’t get ANS.

Main reason:

Very rapid delivery of baby; i.e. within 24 hrs of

hospitalization 26/34 (76.4%) delivered rapidly

slide29

NUMBER OF CASES

Incidence of severe RDS (HMD)

30

25

HMD

20

Mild

15

Severe

NIL

10

5

0

SUBOPTIMAL

OPTIMAL

NIL

CORTICOTHERAPY

  • 44% (13 / 29 ) in group sub optimal treatment
  • 41.1% (14 / 34 ) in NO ANS group
  • 10.2% (5 / 49 ) in group optimal
slide30
On comparison among 3 different groups:
  • Significant difference between optimal & sub optimal group (P=0.0012)
  • Significant difference between optimal & NO ANS (P=0.0023)
  • No difference between group sub optimal & group NO ANS.
slide33
It is costly when we use surfactant & ventilation.
  • Optimal ANS will help in decreasing the cost of treatment.
duration of stay in nicu
Duration of stay in NICU

No significant difference in duration of stay in NICU (P-value=0.476)

total stay in hospital
Total stay in hospital

No significant difference among the 3 groups (P value=0.89)

slide36
2 principle reasons for no significant difference in

duration of stay among the 3 groups:

  • Very high rates of nosocomial infections in our units
  • Slow weight gain
morbidity
Morbidity

No significant difference among the 3 groups

in occurrence of:

1. Patent ductus arteriosus

2. Intra ventricular hemorrhage

3. Broncho pulmonary dysplasia

This result is due to small size of our sample.

mortality
Mortality

No significant difference among the 3

groups in results of mortality

Reason:

1. Nosocomial infections are the main cause of neonatal mortality

2. Short duration of study

It suggests to do study on long duration and compile more datas.

recommendations
Recommendations
  • We propose more aggressive campaign of sensiblisation and education of pregnant women about regular follow up of antenatal clinics, its advantage.
  • Informing these mothers of the signs and symptoms of complication of pregnancy which provoked premature labour.
recommendations41
Recommendations
  • Informing doctors conducting ANC at LHC (most often generalists) about:
    • problems of premature labour
    • Antenatal steroid protocol so that they can always start treatment without delaying as dexamethasone is easily available at LHC.
recommendations42
Recommendations
  • We recommend to start use Betamethasone as drug of choice due to:
    • simplicity of application & better patient compliance
    • superiority on Dexamethasone- decreased risk of cystic peri ventricular leucomalacia among premature infant born at 24th to 31 week G.A
conclusion
Conclusion
  • It is very important to give ANS at right time with right doses to achieve maximum effect.
  • In future, a randomised clinical trial should be done between single dose therapy and conventional treatment so that we can establish better protocol without increasing any harm to baby or mother.