university medical center, utrecht, the nl update on ...€¦ · impact of corticosteroids on the...
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University Medical Center, Utrecht, the NL
Gerard H.A.Visser
Chair FIGO Committee Safe Motherhood & Newborn Health
Update on antenatal
corticosteroids
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Antenatal Corticosteroids
• How it all began
• Positive effects
• Side-effects
• Repeated courses
• Steroids after 34 wks of gestation
• Unresolved issues
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Sir Graham Liggins
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Serendipity
Lambs born preterm were more
viable after antenatal glucocorticoid
administration
(Liggins, 1969)
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Antenatal corticosteroids
1969 – Liggins
1972 – first RCT ( Liggins & Howie)
1994 – 15 RCT
2006 – 21 RCT
2017 - 27 RCT
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So there is a case to give corticosteroids in women at risk of preterm
delivery between 24 weeks and 34 weeks
Betamethasone is more effective than dexamethasone; but be aware of its
effects on FHR variation and movements
(Roberts and Dalziel, Cochrane, 2006)
1970s 1980s 1990s
RDS 0.55 0.71 0.69
PVH 0.50 0.61 0.53
Neonatal death 0.73 0.98 0.50
Antenatal steroids: RCT’s over the decades
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Cochrane Systematic Review, 2006
• No consistency in benefit for infants < 26 wks
• Data relate to very few fetuses < 26 wks ( n=49 out of
which 22 were stillborn)
• Doubts as to effectivity because of immature lung
development ( canalicular stage of development; type II pneumocytes)
Roberts & Dalziel, Cochrane 2006
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Retrospective cohort study, infants born at 23 wks
• Data from 3 tertiary centers; in total 181 neonates
• Stillbirths, voluntary terminations, parental elected non-
resuscitations excluded
• Death OR 0.32 (CI 0.12-0.84)
• Death, completed course CS 0.18 (CI 0.06-0.54)
• Severe IVH: 21 versus 57% (p=0.17)
Hayes et al, Obstet Gynecol 2008;111: 921-6; data from 1998-2007
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Retrospective cohort study, 24- 26 wks gestation
• 82 treated with antenatal CSs before 24 wks, 35 controls
• All infants treated with prophylactic surfactant at birth
Steroid treated Controls
N 82 35
5-min Apgar<7 (%) 30% 51%*
Death 29% 63%*
IVH grade 3 or 4 17% 36%*
Abbasi et al, Am J Perinat.2010, 27:61-66; data from 1998-2008; * sign differences
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Population based study; Trent region UK
Wks Steroids YES Steroid NO p
N N Mort (%) N Mort (%)
• 23 102 81 (79) 84 75 (89) 0.07
• 24 330 203 (62) 123 99 (80) 0.0001
• 25 458 169 (37) 120 68 (57) 0.0001
• 26 650 185 (28) 132 60 (46) 0.0001
• 27 741 130 (18) 162 44 (27) 0.005
10 to 20% improved survival; no difference in duration of respiratory support or
CLD; beneficial effects due to effects on tissues outside the lung??
Mantlelow et al, Arch Child Fetal Neonatal Ed 2010, 95: F95-F98; data 1993-2007
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Antenatal corticosteroids at
the threshold of viability
Yes, they seem to work
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Antenatal CSs in low to middle income countries(Argentina,Guatemala, India, Kenya, Pakistan, Zambia)
Althabe et al, Lancet Febr 14, 2015
• Implementation program of Cs in case of threatened
preterm birth versus standard care (n=98.000)
• Proxi for preterm birth: birthweight< 5th centile (36-
37wks)
• Intervention group CS in 45%, in control group 10%
• Neonatal mortality (<28d; <5th c group): RR 0.96 (0.87-1.06)
• Total mortality : RR 1.12 (1.02-1.22)
• Maternal infections : RR 1.45 (1.33-1.58)
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Antenatal CSs in low to middle income countries(Argentina,Guatemala, India, Kenya, Pakistan, Zambia)
Althabe et al, Lancet Febr 14, 2015
• 87% of CS were given to infants weighing> 2000-
2500g, where there is no evidence of its usefulness
• With risks of known steroid side-effects such as
reduced fetal/placental growth, apoptosis in the
brain, CP and maternal infection, which may explain
the overall poorer outcome
• These data stress the importance of adequate dating of
the pregnancy and of identifying women at real risk
of preterm birth (Visser & DiRenzo, correspondence Lancet, 2015)
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Corticosteroids are potent drugs, but potent
drug also have potent side-effects
• Reduced placental weight ( human)
• Reduced fetal weight and height ( animals
and human)
• Reduced head circumference, with dominant
effects in the hippocampus area ( animals;
human)
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Apoptosis versus cell proliferation
Noorlander et al, 2013; similar findings pren/neon exposure: Zuloaga et al, 2011; Chun-I Sze et
al, 2013
controls
birth
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Morris water maze:Hippocampus dependent
learning and memory task
No difference in swimming speed
Behavioural analysis
02468
1012141618
1 2 3 4 5Time (days)
Velo
cit
y (
cm
/sec)
SalineDexamethasone
Camera
Visual Cue
Light
Hidden
Platform
Morris water maze
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*
*
*
Hidden platform
*
*
**
Impaired learning and memory after dexamethasone treatment
0
20
40
60
80
100
1 2 3 4 5
Late
ncy (
sec)
0
20
40
60
80
100
1 2 3
0
400
800
1,200
1,600
1 2 3 4 5
Time (days)
Dis
tan
ce s
wu
m (
cm
)
1 2 3
Visible platform
Behavioural analysis
SalineDexamethasone
SalineDexamethasone
SalineDexamethasone
SalineDexamethasone
Time (days)
Late
ncy (
sec)
0
400
800
1,200
1,600
Dis
tan
ce s
wu
m (
cm
)
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Pericentral areas of fibrosis that extends to portal fields
Saline Dexamethasone
Peripheral analysis: Liver
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Dexamethasone
Peripheral analysis: Heart
Saline
Myocytes → thin layer of collagen, indicating
degeneration of myocytes replaced by fibrous tissue
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corticosteroids induce precocious
aging and reduced lifespan in mice
Implications for the human…?
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Antenatal dex treatment in Rh monkeys (Uno et
al, 19990 and 1994)
• Reduced n pyramidal neurons
and granular neurons in CA
and dendrate regions of
hippocampus, resp. ( at birth)
• Higher plasma cortisol ( at 9m
of age)
• 30% reduction in hippocampus
size ( at 20 months)
• Dose dependent effects
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Follow-up after one course of
corticosteroids is reassuring
(McArthur et al, 1990; Smolders – de Haas et al, 1990; Schmand et al 1990;
Dessens et al, 2000; Dalziel et al, 2005 (2x),Karemaker 2006)
• no impairment at the age of 6 (maybe some
impaired visual memory)
. normal behaviour and motor function at 7-10 years
• normal physical and psychological development at
the age of 12 and 20 years
• normal cardiovascular and psychological development at
the age of 30 years (apart from increased insulin resistance)
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Impact of corticosteroids on the density of
large neurons in the human hippocampus
(22 infants, 25–32 weeks, who died <4 days after delivery; Thijsseling et al, PLoS One 2012)
Density of neurons Antenatal CS No antenatal CS
High (4) 1 6
Moderate (3) 4 3
Moderate/low (2) 6 2
Low (1) 0 0
Total n of neonates 11 11 (p<0.02)
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(data from 19 RCT; Halliday, 2001)
Early neonatal treatment with corticosteroids
• 14 more extubated by 7 days
• 11 less have CLD
• 7 less will die
• 14 avoid late CS treatment
• 6 more have GI bleeding
• 4 more have GI perforation
• 12 have cerebral palsy
• 14 have abnormal
neurological development
at follow-up
For every 100 babies treated…
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Early neonatal treatment with corticosteroids
GOOD
BAD
Doyle, Halliday et al, Cochrane 2014
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Potent drugs may have potent side effects
0.05–0.20 mg/day for 2 days
0.5 mg/kg/day for many days
Fetal versus neonatal dose
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In 40% of 420 European Centres >3 courses will
be given (Eurail, 2001)
37%
22%
14%
0
20
40
60
80
100
120
140
160
1 2 3 4 5 6 7 8 9 10 11 12 20
Number of courses, Europe 2000
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It all relates to the fact, that
• Women want to be treated
• And doctors want to treat
• but……………………..
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Direct side effects 3 as compared to one course
MACS, Lancet December 2008
Decreased birth weight and head circumference
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Single vs repeated corticosteroids
studies
NRR CI
RDS
Severe RDS
Comp sev morb
Use postn ster
8; 3206
6;4826
7;5094
3;3931
0.83
0.80
0.84
1.38
0.75-0.91
0.56-1.14
0.71-0.94
0.99-1.93
IVH
IVH grade 3/4
Peri V Leucom
Patent Duct Art
Chron Lung D
6;3065
6;4819
7;4888
6;4356
8;5393
0.94
1.13
0.77
0.80
1.06
0.75-1.18
0.69-1.86
0.43-1.37
0.64-0.98
0.87-1.30
M birth weight
M head circ
M length
Weight childh
9;5626
9;5626
6;4550
-76g
-0.32 cm
-0.56 cm
-0.03 or -0.20g*
-118, -34
-0.49, -0.15
-0.89, -0.23
Crowther et al, Cochrane, July 5, 2015
No differences in total deaths and/or survival free of any or major
disability or serious outcome
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Authors’ conclusions, (Crowther et al, Cochrane, 2015)
The short-term benefits for babies of less respiratory distress and fewer serious
health problems in the first few weeks after birth support the use of repeat
dose(s) of prenatal corticosteroids for women still at risk of preterm birth seven
days or more after an initial course. These benefits were associated with a
small reduction in size at birth. The current available evidence reassuringly
shows no significant harm in early childhood, although no benefit.
Authors MACS trail ( comment in Cochrane, 2015, p205)“Although the short term neonatal benefits of repeated courses of antenatal
corticosteroids support their use, long-term benefits have not been
demonstrated and long-term adverse effects have not been ruled out. The
adverse effect of repeated doses of antenatal corticosteroids on birth weight and
weight at early childhood follow-up is a concern. Caution should therefore be
exercised to ensure that only those women who are at particularly high risk of
very early preterm birth are offered treatment with repeated courses of antenatal
corticosteroids.”
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Should steroids be repeated?
• If you think so (Crowther et al), than give only a single repeat course ( WHO, August 2015)
• And only before 32 weeks of gestation
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RCT Steroids before elective CS<39wks
Stutchfield et al, BMJ 2005; n=1000
RR in intervention group
• RDS 0.21 (0.03-1.32)
• Transient Tachypnea NICU 0.54 (0.26-1.12)
• RDS NICU admission 0.46 (0.23-0.93)
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Arch Dis Child
Fetal Neonatal
2013
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RCT Steroids before elective CS<39wks
Stutchfield et al, BMJ
2005
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Steroids before elective CS<39 wks
• Why do we give these potent drugs with potent side-
effects instead of waiting for 39 wks
• Or, why don’t we first determine fetal lung maturation by
amniocentesis
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NEJM Febr 4, 2016
RCT, n=2.800
Betam. Placebo
• N 1429 1402
• CPAP/Oxygen,Mech Vent 11.6% 14.4% 0.80(0.66-0.97)
• ECMO - -
• Stillbirth/neon d<72h - -
• RDS 5.5% 6.4% 0.87(0.65-1.17)
• Comp RDS/Tachypnea/apnea 13.9% 17.8% 0.87(0.66-0.93)
• Hypoglycemia<2.2mmol/l 24% 15% 1.60(1.37-1.87)
34-37 wks
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Steroids for women at risk for late preterm birth
• Implemented in the USA
However,
• It will result in more than doubling of steroid use.
Uncertain if positive effects prevail over long term side
effects?
• Improved morbidity at all ages or only at 34-35 wks ?
• No follow-up data yet.
• So, what is wise ??
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French College of O&G: NO
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Antenatal corticosteroids
Poison with some positive side effects
And I would also suggest to wait
with implementation, until more
information is obtained
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The future
Co-treatment to prevent steroid induced
side-effects ??
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The future
Co-treatment with statins, which improve
NO bioavailability
• Paravastatin prevents alterations of
cardiovascular system and brain
development (volume, cortical and hypocampal neuronal numbers,
GFAP-positive astrocyte density in the white matter) in rat pups
treated neonatally
Thijsseling, PhD Utrecht, January 2014; in collaboration with D Giussani,
Cambridge. Thijsseling et al, Ped Res 2013
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The future
• Co-treatment with allo-pregnanolone (AP); a
neurosteroid and GABAA receptor antagonist
that influences fetal brain development and has
neuroprotective properties.
• Co-administration of AP prevented changes in
the n of myelinating cells in subcortical white
matter, in fetal sheep
Yawno et al, Neuropharmacology 2014
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But, in the meantime we have to find out
• The optimal dose
• If correction for maternal BMA is necessary
• And if steroids are useful in IUGR fetuses
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So, with steroids it remains an unfinished story
![Page 47: University Medical Center, Utrecht, the NL Update on ...€¦ · Impact of corticosteroids on the density of large neurons in the human hippocampus (22 infants, 25–32 weeks, who](https://reader034.vdocuments.us/reader034/viewer/2022042302/5ecd9e8fde70ab26557c30dc/html5/thumbnails/47.jpg)
Finally,
• Use of corticosteroids should be reduced by a better
identification of women who really are at increased risk of late
preterm delivery (CL measurement, fibronectin)
• 24-34 wks, preterm contractions n=665, PTD 12%; Van Baaren et al, O&G 2014
n PTD<1wk
• CL >30mm 255 2 0.7%
• CL 15-30mm 297 25 8 %• CL 15-30 FN- 139 4 3 %
• CL 15-30 FN+ 148 21 14 %
• CL < 15 mm 113 53 47 %
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Corticosteroids; poison with some
positive side-effects.
So, only use it with wisdom and
only if really indicated
Women want to be treated and
doctors want to treat,
But doctors should know better
THANK YOU