Antenatal Corticosteroids: Are we using them appropriately? - PowerPoint PPT Presentation

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Antenatal Corticosteroids: Are we using them appropriately? PowerPoint Presentation
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Antenatal Corticosteroids: Are we using them appropriately?

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  1. Antenatal Corticosteroids: Are we using them appropriately? Dr. C. Ohadike, Dr. E. Cadogan, Dr. P. Kanagaraj, Miss C. Rajagopalan, Miss S. Dhingra Background Aims, Standards, Methods, Results Results Discussions and Conclusions • All patients were given the correct dose and timing of steroids was appropriate as per RCOG guidelines. There were low rates of respiratory distress syndrome (11% of all babies admitted to the neonatal unit). • Steroids were most commonly given to Para 1, however this did not correlate with the previous birth having been preterm. The commonest indications were suspected preterm labour (22%) and pre-labour premature rupture of membranes (16%) and antepartum haemorrhage (11%). • Where fibronectin or actim partus were not performed this was an appropriate decision but where fibronectin was not appropriate actim partus was and this should be made available to staff. • 71% of patients had interval to delivery of greater than 14 days. Although in the majority of cases the indications of giving steroids was justified, in a small number the indication was unclear or unusual (21%). This may suggest that patient selection needs reviewing. There are potential cost implications and unclear short and long term medical effects of unnecessary steroid administration. • Learning points from the audit are as follows. Standardisation of care is planned in management of diabetic patients receiving steroids. Improvement is needed in documentation of indication of steroids. Increased awareness and use of actim partus and fibronectin tests amongst staff has been arranged. The selection of patients requiring steroids will be carefully assessed and individualised. We plan to update our local guidelines in line with the RCOG. Aims and Standards The aim of this audit is to review our current practice regarding the administration of antenatal corticosteroids against the standards set by the Royal College of Obstetricians and Gynaecologists (Green Top Guideline No. 7). Methods This was performed as a prospective audit. The target population was all antenatal women over 23 weeks gestation who receive corticosteroid. The patients were identified as they presented to the unit on delivery suite, antenatal ward, clinic and day unit. The notes assessed through the pregnancy and post delivery. A pro-forma was used to collect the following data: Demographic information, parity, multiplicity, gestational age at steroids, documented reason for steroids, grade of clinician deciding, type of steroid, dosing regime, fibronectin/actim partus test performed, diabetic, sliding scale/insulin regime changed, if the steroid course was repeated, earliest delivery, number of previous preterm deliveries, interval to delivery, gestation delivered, type of delivery, live birth or stillbirth, birth weight and neonatal unit admission. Results Sixty (60) patients were identified in total. There were 15 missing notes. Some data for patients with missing notes was pulled from the electronic system (PROTOS). The largest age group was 21-25 years old (32%) and the largest parity group were Para 1 (28%). The decision to administer steroids was made by a senior trainee or consultant in all cases. The reasons for steroid administration are highlighted in the chart below;‘Other’ indications were scar tenderness at 22 weeks gestation, elective caesarean for placenta praevia, absent end diastolic flow, polyhydramnios, rescue suture insertion, fetal growth restriction, a patient with recurrent late miscarriages, cervical incompetence and positive fetal fibronectin test. ‘Unusual’ indications for administering steroids included patient request after a fall, previous history of fetal growth restriction and previous history of stillbirth. The lowest gestation for steroids was 23+6 weeks in two cases; in one patient the indication was insertion of rescue stitch being performed. In the other patient, she had a history of two previous losses at 21 and 22 weeks and presented in this pregnancy with a positive fibronectin. The highest gestation for steroids was 37+2 weeks; the indication was caesarean section at 38 weeks for placenta praevia. The Royal College of Obstetricians and Gynaecologists released an updated version of the Green Top Guideline No. 7 – Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality in October 2010. The guideline describes the safety of antenatal corticosteroids and the effectiveness in reducing respiratory distress syndrome (RDS) and intraventricular haemorrhage (IVH). There is also an associated decrease in the neonatal mortality rate. A course of antenatal corticosteroids is defined as two doses of Betamethasone 12mg IM 24hrs apart OR four doses of Dexamethasone 6mg IM at 12 hourly intervals Antenatal corticosteroids are most effective in reducing RDS in pregnancies that deliver between 24 hours and 7 days after administration of the second dose of steroids therefore timing of administration is paramount to receive maximal effect. This is particularly so as a single course does not appear to be associated with any significant short term maternal or foetal adverse effects whereas there is insufficient evidence regarding the risks of multiple courses which may include reduced birth weight and behavioural disorders. Single rescue courses could however be considered at consultant level if the first course was given before 26 weeks gestation. There are no strict contraindications to antenatal corticosteroids although caution should be exercised in cases of systemic infection or chorioamnionitis. Suitable candidates to receive antenatal corticosteroid therapy include : . All women at risk of iatrogenic or spontaneous preterm birth up to 34+6 weeks . All women who are planned for an elective caesarean section prior to 38+6 weeks . Women with a multiple pregnancy who are at risk of imminent iatrogenic or spontaneous preterm delivery between 24+0 and 34+6 weeks . Women with fetal growth restriction between 24+0 and 35+6 weeks Women with diabetes in pregnancy are eligible to receive corticosteroids for similar indications as mentioned above. However this may induce maternal hyperglycaemia which may adversely affect foetal lung maturity and offset the initial intended benefit of the corticosteroid course. NICE guidance recommends that diabetic women receiving antenatal corticosteroids should have additional insulin according to an agreed protocol. Key and References REFERENCES RCOG Green Top Guideline No. 7 – Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality in October 2010 Miracle X et al. Guideline for the use of antenatal corticosteroids for fetal maturation. J. Perinatal. Med; 36 (2008): 191–196 KEY ABN CTG: Abnormal CTG APH: Antepartum Haemorrhage BM’S: Low blood glucose levels CONG ABN: congenital abnormality FEEDING: Problems with baby feeding IUGR: Fetal/intrauterine growth restriction MOD: mode of delivery ND: Not documented/ No data PTL: Preterm labour PET: Pre-eclampsia POS FIB/ACT: Positive fibronectin/actim partus PPROM: Prolonged pre-labour rupture of membranes PREM: Prematurity RESP: Respiratory problems