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Bashir HA, Lufting-Leeffrers D, Myat Min A, Htun Win H, Win Tun N, Gay Wah T, Ellen Gilder M, Kho Paw M, I. Carrara V, Meeyai A, Aderoba AK, Nosten F, Gross MM, McGready R. Antenatal corticosteroids reduce neonatal mortality in settings without assisted ventilatory support: a retrospective cohort study of early preterm births on the Thailand-Myanmar border. Wellcome Open Res 2024; 8:225. [PMID: 38779045 PMCID: PMC11109590 DOI: 10.12688/wellcomeopenres.19396.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 05/25/2024] Open
Abstract
Background Prematurity is the highest risk for under-five mortality globally. The aim of the study was to assess the effect of antenatal dexamethasone on neonatal mortality in early preterm in a resource-constrained setting without assisted ventilation. Methods This retrospective (2008-2013) cohort study in clinics for refugees/migrants on the Thai-Myanmar border included infants born <34 weeks gestation at home, in, or on the way to the clinic. Dexamethasone, 24 mg (three 8 mg intramuscular doses, every 8 hours), was prescribed to women at risk of preterm birth (28 to <34 weeks). Appropriate newborn care was available: including oxygen but not assisted ventilation. Mortality and maternal fever were compared by the number of doses (complete: three, incomplete (one or two), or no dose). A sub-cohort participated in neurodevelopmental testing at one year. Results Of 15,285 singleton births, 240 were included: 96 did not receive dexamethasone and 144 received one, two or three doses (56, 13 and 75, respectively). Of live-born infants followed to day 28, (n=168), early neonatal and neonatal mortality/1,000 livebirths (95%CI) with complete dosing was 217 (121-358) and 304 (190-449); compared to 394 (289-511) and 521 (407-633) with no dose. Compared to complete dosing, both incomplete and no dexamethasone were associated with elevated adjusted ORs 4.09 (1.39 to 12.00) and 3.13 (1.14 to 8.63), for early neonatal death. By contrast, for neonatal death, while there was clear evidence that no dosing was associated with higher mortality, adjusted OR 3.82 (1.42 to 10.27), the benefit of incomplete dosing was uncertain adjusted OR 1.75 (0.63 to 4.81). No adverse impact of dexamethasone on infant neurodevelopmental scores (12 months) or maternal fever was observed. Conclusions Neonatal mortality reduction is possible with complete dexamethasone dosing in pregnancies at risk of preterm birth in settings without capacity to provide assisted ventilation.
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Affiliation(s)
- Humayra Aisha Bashir
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | - Daphne Lufting-Leeffrers
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Midwifery Research and Education Unit, Hannover Medical School, Hannover, Germany
| | - Aung Myat Min
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Htun Htun Win
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Nay Win Tun
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Tha Gay Wah
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Mary Ellen Gilder
- Department of Family Medicine, Chiang Mai University, Chiang Mai, Chiang Mai, Thailand
| | - Moo Kho Paw
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Verena I. Carrara
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
- Institute of Global Health, Faculty of Medicine, Universite de Geneve, Geneva, Geneva, Switzerland
| | - Aronrag Meeyai
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | - Adeniyi Kolade Aderoba
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
- University of Medical Sciences Teaching Hospital, Akure, Ondo, Nigeria
| | - François Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | - Mechthild M. Gross
- Midwifery Research and Education Unit, Hannover Medical School, Hannover, Germany
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
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Panigrahi P. The neonatal gut microbiome and global health. Gut Microbes 2024; 16:2352175. [PMID: 38743045 PMCID: PMC11095572 DOI: 10.1080/19490976.2024.2352175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 05/02/2024] [Indexed: 05/16/2024] Open
Abstract
The role of gut microbiome in health, a century-old concept, has been on the center stage of medical research recently. While different body sites, disease conditions, and populations have been targeted, neonatal and early infancy appear to be the most suitable period for such interventions. It is intriguing to note that, unlike traditional use in diarrhea and maintenance of gastrointestinal health, microbiome-mediating therapies have now addressed the most serious medical conditions in young infants such as necrotizing enterocolitis and neonatal sepsis. Unfortunately, almost all new endeavors in this space have been carried out in the Western world leaving behind millions of neonates that can benefit from such manipulations while serving as a large resource for further learning. In this review, an attempt has been made to quantify the global burden of neonatal morbidity and mortality, examples presented on interventions that have failed as a result of drawing from studies conducted in the West, and a case made for manipulating the neonatal gut microbiome to address the biggest killers in early life. A brief comparative analysis has been made to demonstrate the differences in the gut microbiota of North and South and a large clinical trial of synbiotics conducted by our group in a South Asian setting has been presented. Although challenging, the value of conducting such global health research is introduced with an intent to invite medical scientists to engage in well-planned, scientifically robust research endeavors. This can bring about innovation while saving and serving the most vulnerable citizens now and protecting them from the negative health consequences in the later part of their lives, ultimately shaping a resilient and equitable world as pledged by 193 United Nations member countries in 2015.
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Affiliation(s)
- Pinaki Panigrahi
- Department of Pediatrics, Division of Neonatal Perinatal Medicine, International Microbiome Research, Georgetown University Medical Center, Georgetown, WA, USA
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3
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Usuda H, Fee EL, Carter S, Furfaro L, Takahashi T, Takahashi Y, Newnham JP, Milad MA, Saito M, Jobe AH, Kemp MW. Low-dose antenatal betamethasone treatment achieves preterm lung maturation equivalent to that of the World Health Organization dexamethasone regimen but with reduced endocrine disruption in a sheep model of pregnancy. Am J Obstet Gynecol 2022; 227:903.e1-903.e16. [PMID: 35792176 DOI: 10.1016/j.ajog.2022.06.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 06/08/2022] [Accepted: 06/28/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The intramuscular administration of antenatal steroids to women at risk of preterm delivery achieves high maternal and fetal plasma steroid concentrations, which are associated with adverse effects and may reduce treatment efficacy. We have demonstrated that antenatal steroid efficacy is independent of peak maternofetal steroid levels once exposure is maintained above a low threshold. OBJECTIVE This study aimed to test, using a sheep model of pregnancy, whether the low-dose antenatal steroid regimen proposed as part of the Antenatal Corticosteroids for Improving Outcomes in Preterm Newborns trial would achieve preterm lung maturation equivalent to that of the existing World Health Organization dexamethasone treatment regimen, but with reduced risk of adverse outcomes. STUDY DESIGN Following ethical review and approval, date-mated ewes with single fetuses received intramuscular injections of either (1) four 6-mg maternal intramuscular injections of dexamethasone phosphate every 12 hours (n=22), (2) 4 2-mg maternal intramuscular injections of betamethasone phosphate every 12 hours (n=21), or (3) 4 2-mL maternal intramuscular injections of saline every 12 hours (n=16). Of note, 48 hours after first injection, (124±1 day), lambs were delivered, ventilated for 30 minutes, and euthanized for sampling. Arterial blood gas, respiratory, hematological, and biochemical data were analyzed for between-group differences with analysis of variance according to distribution and variance, with P<.05 taken as significant. RESULTS After 30 minutes of ventilation, lambs from both steroid-treated groups had significant and equivalent improvements in lung function relative to saline control (P<.05). There was no significant difference in arterial blood pH, pO2, pCO2, lung compliance, ventilator efficiency index, or lung volume at necropsy with a static pressure of 40 cmH2O. The messenger RNA expression of surfactant protein (Sp)a, Spb, Spc, Spd, aquaporin (Aqp)1, Aqp5, and sodium channel epithelial 1 subunit beta (Scnn1b) was equivalent between both steroid groups. Maternal and fetal plasma neutrophil, glucose, and fetal plasma C-peptide levels were significantly elevated in the dexamethasone group, relative to the betamethasone group. Fetal plasma insulin-like growth factor 1 was significantly reduced in the dexamethasone group compared with the betamethasone group (P<0.05). Fetal adrenocorticotropic hormone (r=0.53), maternal glucose value (r=-0.52), and fetal glucose values (r=-0.42) were correlated with maternal weight in the betamethasone group (P<.05), whereas fetal pCO2 and pO2 were not correlated. There was no significant difference between male and female lamb outcomes in any groups for any of the items evaluated. CONCLUSION This study reported that in preterm lambs, a low-dose treatment regimen of 8 mg betamethasone achieves lung maturation equivalent to that of a 24-mg dexamethasone-based regimen, but with smaller perturbations to the maternofetal hypothalamic-pituitary-adrenal axis. These data suggested that given steroid pharmacokinetic differences between sheep and humans, a betamethasone dose of 2 mg may remain above the minimum dose necessary for robust maturation of the preterm lung. Maternal weight-adjusted betamethasone doses might also be a key to reducing perturbations to the maternofetal hypothalamic-pituitary-adrenal axis.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Erin L Fee
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Sean Carter
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Lucy Furfaro
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yuki Takahashi
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - John P Newnham
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; School of Veterinary and Life Sciences, Murdoch University, Western Australia, Australia
| | - Mark A Milad
- School of Veterinary and Life Sciences, Murdoch University, Western Australia, Australia
| | - Masatoshi Saito
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Alan H Jobe
- Milad Pharmaceutical Consulting LLC, Plymouth, MI
| | - Matthew W Kemp
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan; Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical School, Cincinnati, OH; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Queenstown, Singapore.
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Takahashi T, Jobe AH, Fee EL, Newnham JP, Schmidt AF, Usuda H, Kemp MW. The complex challenge of antenatal steroid therapy nonresponsiveness. Am J Obstet Gynecol 2022; 227:696-704. [PMID: 35932879 DOI: 10.1016/j.ajog.2022.07.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/01/2022]
Abstract
Antenatal steroid therapy is standard care for women at imminent risk of preterm delivery. When deliveries occur within 7 days of treatment, antenatal steroid therapy reduces the risk of neonatal death and improves preterm outcomes by exerting diverse developmental effects on the fetal organs, in particular the preterm lung and cardiovascular system. There is, however, sizable variability in antenatal steroid treatment efficacy, and an important percentage of fetuses exposed to antenatal steroid therapy do not respond sufficiently to derive benefit. Respiratory distress syndrome, for example, is a central metric of clinical trials to assess antenatal steroid outcomes. In the present analysis, we addressed the concept of antenatal steroid nonresponsiveness, and defined a failed or suboptimal response to antenatal steroids as death or a diagnosis of respiratory distress syndrome following treatment. For deliveries at 24 to 35 weeks' gestation, the number needed to treat to prevent 1 case of respiratory distress syndrome was 19 (95% confidence interval, 14-28). Reflecting gestation-dependent risk, for deliveries at >34 weeks' gestation the number needed to treat was 55 (95% confidence interval, 30-304), whereas for elective surgical deliveries at term this number was 106 (95% confidence interval, 61-421). We reviewed data from clinical and animal studies investigating antenatal steroid therapy to highlight the significant incidence of antenatal steroid therapy nonresponsiveness (ie, residual mortality or respiratory distress syndrome after treatment), and the potential mechanisms underpinning this outcome variability. The origins of this variability may be related to both the manner in which the therapy is applied (ie, the treatment regimen itself) and factors specific to the individual (ie, genetic variation, stress, infection). The primary aims of this review were: (1) to emphasize to the obstetrical and neonatal communities the extent of antenatal steroid response variability and its potential impact; (2) to propose approaches by which antenatal steroid therapy may be better applied to improve overall benefit; and (3) to stimulate further research toward the empirical optimization of this important antenatal therapy.
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Affiliation(s)
- Tsukasa Takahashi
- Division of Obstetrics and Gynaecology, University of Western Australia, Perth, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Alan H Jobe
- Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, University of Western Australia, Perth, Australia
| | - John P Newnham
- Division of Obstetrics and Gynaecology, University of Western Australia, Perth, Australia
| | | | - Haruo Usuda
- Division of Obstetrics and Gynaecology, University of Western Australia, Perth, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, University of Western Australia, Perth, Australia; Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan; School of Veterinary and Life Sciences, Murdoch University, Perth, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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5
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Lategan I, Price C, Rhoda NR, Zar HJ, Tooke L. Respiratory Interventions for Preterm Infants in LMICs: A Prospective Study From Cape Town, South Africa. Front Glob Womens Health 2022; 3:817817. [PMID: 35464776 PMCID: PMC9019119 DOI: 10.3389/fgwh.2022.817817] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/18/2022] [Indexed: 01/13/2023] Open
Abstract
Background Preterm birth is a global public health issue and complications of preterm birth result in the death of approximately 1 million infants each year, 99% of which are in low-and-middle income countries (LMIC). Although respiratory interventions such as continuous positive airway pressure (CPAP) and surfactant have been shown to improve the outcomes of preterm infants with respiratory distress, they are not readily available in low-resourced areas. The aim of this study was to report the respiratory support needs and outcomes of preterm infants in a low-resourced setting, and to estimate the impact of a lack of access to these interventions on neonatal mortality. Methods We conducted a six-month prospective observational study on preterm infants <1,801 g admitted at Groote Schuur Hospital and Mowbray Maternity Hospital neonatal units in Cape Town, South Africa. We extrapolated results from the study to model the potential outcomes of these infants in the absence of these interventions. Results Five hundred and fifty-two infants (552) <1,801 g were admitted. Three hundred (54.3%) infants received CPAP, and this was the initial respiratory intervention for most cases of respiratory distress syndrome. Surfactant was given to 100 (18.1%) infants and a less invasive method was the most common method of administration. Invasive mechanical ventilation was offered to 105 (19%) infants, of which only 57 (54.2%) survived until discharge from hospital. The overall mortality of the cohort was 14.1% and the hypothetical removal of invasive mechanical ventilation, surfactant and CPAP would result in an additional 157 deaths and increase the overall mortality to 42.5%. A lack of CPAP availability would have the largest impact on mortality and result in the largest number of additional deaths (109). Conclusion This study highlights the effect that access to key respiratory interventions has on preterm outcomes in LMICs. CPAP has the largest impact on neonatal mortality and improving its coverage should be the primary goal for low-resourced areas to save newborn lives.
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Affiliation(s)
- Ilse Lategan
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Caris Price
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Natasha Raygaan Rhoda
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Heather J. Zar
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council (SA-MRC) Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Lloyd Tooke
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- *Correspondence: Lloyd Tooke
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Wastnedge E, Waters D, Murray SR, McGowan B, Chipeta E, Nyondo-Mipando AL, Gadama L, Gadama G, Masamba M, Malata M, Taulo F, Dube Q, Kawaza K, Khomani PM, Whyte S, Crampin M, Freyne B, Norman JE, Reynolds RM. Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review. J Glob Health 2021; 11:04050. [PMID: 35003711 PMCID: PMC8709903 DOI: 10.7189/jogh.11.04050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required. METHODS A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted. RESULTS 179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions. CONCLUSIONS Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.
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Affiliation(s)
- Elizabeth Wastnedge
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Donald Waters
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Sarah R Murray
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Brian McGowan
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Effie Chipeta
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- Department of Health Systems & Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luis Gadama
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gladys Gadama
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Martha Masamba
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Monica Malata
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Frank Taulo
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kondwani Kawaza
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Sonia Whyte
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Mia Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Bridget Freyne
- Malawi-Liverpool Wellcome Trust Research Program, Blantyre, Malawi
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK
| | - Jane E Norman
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Rebecca M Reynolds
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
- Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
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7
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Metaferia G, Abayneh M, Aynalem S, Demisse AG, Demtse AG, Eshetu B, Mekasha A, Worku B, Nigussie AK, McClure EM, Goldenberg RL, Muhe LM. Antenatal Steroid Utilization in Ethiopia. Glob Pediatr Health 2021; 8:2333794X21990344. [PMID: 33614845 PMCID: PMC7868499 DOI: 10.1177/2333794x21990344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 12/08/2020] [Accepted: 12/31/2020] [Indexed: 11/21/2022] Open
Abstract
Background. Administration of antenatal corticosteroids to pregnant mothers is one of the most effective interventions to decrease preterm neonatal mortality. In this study we assessed antenatal steroid utilization by the mother and its effect on preterm babies. Method. Two years prospective, multicenter, observational study was conducted in selected hospitals of Ethiopia. Significance of the study outcomes was tested by chi-square and binary logistic regression. Result. Out of 4919 participants, 1575 preterm babies whose gestational ages were below 35 weeks were included in the study. Use of antenatal dexamethasone was 37.5% among study participants. The risk of early onset neonatal sepsis 235 (40.4%) was higher in preterm babies whose mother took antenatal dexamethasone (P-value .002) than those who did not. Conclusion. Antenatal dexamethasone use in our study was comparable with other low and middle-income countries. Risk of early onset neonatal sepsis was higher among infants whose mother took antenatal dexamethasone.
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Affiliation(s)
- Gesit Metaferia
- St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mahlet Abayneh
- St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Sara Aynalem
- St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | | | | | | | | | | | | | | | | | - Lulu M Muhe
- Addis Ababa University, Addis Ababa, Ethiopia
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Tapia JL, Toso A, Vaz Ferreira C, Fabres J, Musante G, Mariani G, Herrera TI, D'Apremont I. The unfinished work of neonatal very low birthweight infants quality improvement: Improving outcomes at a continental level in South America. Semin Fetal Neonatal Med 2021; 26:101193. [PMID: 33478876 DOI: 10.1016/j.siny.2021.101193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Neonatal mortality rate varies between 4.2 and 18.6 per thousand by country in South America. There is little information regarding the outcomes of very low birth weight infants in the region and mortality rates are extremely variable ranging from 6% to over 50%. This group may represent up to 50-70% of the neonatal mortality and approximately 25-30% of infant mortality. Some initiatives, like the NEOCOSUR Network, have systematically collected and analyzed epidemiological information on VLBW infants' outcomes in the region. Over a 16-year period, survival without major morbidity improved from 37 to 44%. However, mortality has remained almost unchanged at approximately 27%, despite an increase in the implementation of the best available evidence in perinatal practices over time. Implementing quality improvement initiatives in the continent is particularly challenging but represents a great opportunity considering that there is a wide margin for progress in both care and outcomes.
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Affiliation(s)
- J L Tapia
- Department of Neonatology, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - A Toso
- Department of Neonatology, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - C Vaz Ferreira
- Department of Neonatology, Centro Hospitalario Pereira Rossell, Universidad de La República, Montevideo, Uruguay.
| | - J Fabres
- Department of Neonatology, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - G Musante
- Department of Maternal and Child Health, Hospital Universitario Austral, Pilar, Argentina.
| | - G Mariani
- Department of Pediatrics, Division of Neonatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - T I Herrera
- Department of Neonatology, Centro Hospitalario Pereira Rossell, Universidad de La República, Montevideo, Uruguay.
| | - I D'Apremont
- Department of Neonatology, Pontificia Universidad Católica de Chile, Santiago, Chile.
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9
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Jobe AH, Kemp M, Schmidt A, Takahashi T, Newnham J, Milad M. Antenatal corticosteroids: a reappraisal of the drug formulation and dose. Pediatr Res 2021; 89:318-325. [PMID: 33177675 PMCID: PMC7892336 DOI: 10.1038/s41390-020-01249-w] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 12/22/2022]
Abstract
We review the history of antenatal corticosteroid therapy (ACS) and present recent experimental data to demonstrate that this, one of the pillars of perinatal care, has been inadequately evaluated to minimize fetal exposure to these powerful medications. There have been concerns since 1972 that fetal exposures to ACS convey risk. However, this developmental modulator, with its multiple widespread biologic effects, has not been evaluated for drug choice, dose, or duration of treatment, despite over 30 randomized trials. The treatment used in the United States is two intramuscular doses of a mixture of 6 mg betamethasone phosphate (Beta P) and 6 mg betamethasone acetate (Beta Ac). To optimize outcomes with ACS, the goal should be to minimize fetal drug exposure. We have determined that the minimum exposure needed for fetal lung maturation in sheep, monkeys, and humans (based on published cord blood corticosteroid concentrations) is about 1 ng/ml for a 48-h continuous exposure, far lower than the concentration reached by the current dosing. Because the slowly released Beta Ac results in prolonged fetal exposure, a drug containing Beta Ac is not ideal for ACS use. IMPACT: Using sheep and monkey models, we have defined the minimum corticosteroid exposure for a fetal lung maturation. These results should generate new clinical trials of antenatal corticosteroids (ACS) at much lower fetal exposures to ACS, possibly given orally, with fewer risks for the fetus.
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Affiliation(s)
- Alan H. Jobe
- grid.1012.20000 0004 1936 7910Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA Australia ,grid.24827.3b0000 0001 2179 9593Perinatal Institute, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH USA
| | - Matthew Kemp
- grid.1012.20000 0004 1936 7910Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA Australia ,grid.412757.20000 0004 0641 778XCentre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan ,grid.1025.60000 0004 0436 6763School of Veterinary and Life Sciences, Murdoch University, Perth, WA Australia
| | - Augusto Schmidt
- grid.26790.3a0000 0004 1936 8606Division of Neonatology, Department of Pediatrics, University of Miami, Miami, FL USA
| | - Tsukasa Takahashi
- grid.1012.20000 0004 1936 7910Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA Australia ,grid.412757.20000 0004 0641 778XCentre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - John Newnham
- grid.1012.20000 0004 1936 7910Division of Obstetrics and Gynecology, The University of Western Australia, Perth, WA Australia
| | - Mark Milad
- Milad Pharmaceutical Consulting, Plymouth, MI USA
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10
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Pusdekar YV, Patel AB, Kurhe KG, Bhargav SR, Thorsten V, Garces A, Goldenberg RL, Goudar SS, Saleem S, Esamai F, Chomba E, Bauserman M, Bose CL, Liechty EA, Krebs NF, Derman RJ, Carlo WA, Koso-Thomas M, Nolen TL, McClure EM, Hibberd PL. Rates and risk factors for preterm birth and low birthweight in the global network sites in six low- and low middle-income countries. Reprod Health 2020; 17:187. [PMID: 33334356 PMCID: PMC7745351 DOI: 10.1186/s12978-020-01029-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 12/15/2022] Open
Abstract
Background Preterm birth continues to be a major public health problem contributing to 75% of the neonatal mortality worldwide. Low birth weight (LBW) is an important but imperfect surrogate for prematurity when accurate assessment of gestational age is not possible. While there is overlap between preterm birth and LBW newborns, those that are both premature and LBW are at the highest risk of adverse neonatal outcomes. Understanding the epidemiology of preterm birth and LBW is important for prevention and improved care for at risk newborns, but in many countries, data are sparse and incomplete. Methods We conducted data analyses using the Global Network’s (GN) population-based registry of pregnant women and their babies in rural communities in six low- and middle-income countries (Democratic Republic of Congo, Kenya, Zambia, Guatemala, India and Pakistan). We analyzed data from January 2014 to December 2018. Trained study staff enrolled all pregnant women in the study catchment area as early as possible during pregnancy and conducted follow-up visits shortly after delivery and at 42 days after delivery. We analyzed the rates of preterm birth, LBW and the combination of preterm birth and LBW and studied risk factors associated with these outcomes across the GN sites. Results A total of 272,192 live births were included in the analysis. The overall preterm birth rate was 12.6% (ranging from 8.6% in Belagavi, India to 21.8% in the Pakistani site). The overall LBW rate was 13.6% (ranging from 2.7% in the Kenyan site to 21.4% in the Pakistani site). The overall rate of both preterm birth and LBW was 5.5% (ranging from 1.2% in the Kenyan site to 11.0% in the Pakistani site). Risk factors associated with preterm birth, LBW and the combination were similar across sites and included nulliparity [RR − 1.27 (95% CI 1.21–1.33)], maternal age under 20 [RR 1.41 (95% CI 1.32–1.49)] years, severe antenatal hemorrhage [RR 5.18 95% CI 4.44–6.04)], hypertensive disorders [RR 2.74 (95% CI − 1.21–1.33], and 1–3 antenatal visits versus four or more [RR 1.68 (95% CI 1.55–1.83)]. Conclusions Preterm birth, LBW and their combination continue to be common public health problems at some of the GN sites, particularly among young, nulliparous women who have received limited antenatal care services. Trial registration The identifier of the Maternal and Newborn Health Registry at ClinicalTrials.gov is NCT01073475.Trial registration: The identifier of the Maternal and Newborn Health Registry at ClinicalTrials.gov is NCT01073475.
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Affiliation(s)
| | - Archana B Patel
- Lata Medical Research Foundation, Nagpur, India.,Datta Meghe Institute of Medical Sciences, Wardha, India
| | | | | | | | - Ana Garces
- Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University School of Medicine, New York, NY, USA
| | - Shivaprasad S Goudar
- KLE Academy Higher Education and Research J N Medical College , Belagavi, Karnataka, India
| | | | | | | | | | - Carl L Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edward A Liechty
- Indiana School of Medicine, University of Indiana, Indianapolis, IN, USA
| | - Nancy F Krebs
- University of Colorado School of Medicine, Denver, CO, USA
| | | | | | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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11
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Schmidt AF, Kannan PS, Bridges J, Presicce P, Jackson CM, Miller LA, Kallapur SG, Chougnet CA, Jobe AH. Prenatal inflammation enhances antenatal corticosteroid-induced fetal lung maturation. JCI Insight 2020; 5:139452. [PMID: 33328385 PMCID: PMC7819743 DOI: 10.1172/jci.insight.139452] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 11/11/2020] [Indexed: 11/17/2022] Open
Abstract
Respiratory complicˆations are the major cause of morbidity and mortality among preterm infants, which is partially prevented by the administration of antenatal corticosteroids (ACS). Most very preterm infants are exposed to chorioamnionitis, but short- and long-term effects of ACS treatment in this setting are not well defined. In low-resource settings, ACS increased neonatal mortality by perhaps increasing infection. We report that treatment with low-dose ACS in the setting of inflammation induced by intraamniotic lipopolysaccharide (LPS) in rhesus macaques improves lung compliance and increases surfactant production relative to either exposure alone. RNA sequencing shows that these changes are mediated by suppression of proliferation and induction of mesenchymal cellular death via TP53. The combined exposure results in a mature-like transcriptomic profile with inhibition of extracellular matrix development by suppression of collagen genes COL1A1, COL1A2, and COL3A1 and regulators of lung development FGF9 and FGF10. ACS and inflammation also suppressed signature genes associated with proliferative mesenchymal progenitors similar to the term gestation lung. Treatment with ACS in the setting of inflammation may result in early respiratory advantage to preterm infants, but this advantage may come at a risk of abnormal extracellular matrix development, which may be associated with increased risk of chronic lung disease.
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Affiliation(s)
- Augusto F. Schmidt
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Paranthaman S. Kannan
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - James Bridges
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Pietro Presicce
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Courtney M. Jackson
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lisa A. Miller
- Department of Anatomy, Physiology and Cell Biology, School of Veterinary Medicine, UCD, Davis, California, USA
| | - Suhas G. Kallapur
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Claire A. Chougnet
- Division of Immunobiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alan H. Jobe
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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12
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Abstract
BACKGROUND Hyaline membrane disease contributes majorly to preterm mortality, particularly in the developing world. There are two animal-derived surfactants available in South Africa: poractant-alfa (120 mg/1.5 ml) and beractant (100 mg/4 ml). At equivalent doses, studies have shown no difference in mortality or morbidity, although there are limited data from the developing world. Both surfactants have been available for use at Groote Schuur Hospital in Cape Town but due to policy change, poractant-alfa was no longer available from November 2014. Due to weight-based dosing charts, infants who were given poractant-alfa received 20% higher dosages of phospholipid. METHODS A before-and-after policy change non-experimental study was performed including infants from 2013 to 2015. Infants weighing <1500 g were recruited by identifying them from the surfactant register and further data were obtained from patient records. Data fields included infant weight, gestation, respiratory support and outcomes. RESULTS Two hundred and eight infants were included. One hundred and eight received beractant and 100 received poractant-alfa. The mean birth weight was 1031 g and gestational age 28.8 weeks. Seventy-nine percent of the infants received surfactant via the INSURE (intubation, surfactant and extubation) method. The combined outcome for death or bronchopulmonary dysplasia was 35.3% in the beractant group and 36% in the poractant-alfa group (p = 0.902). All secondary outcomes including neonatal morbidities, oxygen at 28 days or length of ventilation were not statistically significant. CONCLUSION There were no significant differences in outcomes between the two groups of infants who received different surfactants at the dosages used in our unit. This is one of the few studies of this type performed in a low- and middle-income countries.
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Affiliation(s)
- Lize Boshoff Coyles
- Division of Neonatal Medicine, Department of Paediatrics, University of Cape Town, Groote Schuur Hospital, Cape Town, 7925, South Africa
| | - Yaseen Joolay
- Division of Neonatal Medicine, Department of Paediatrics, University of Cape Town, Groote Schuur Hospital, Cape Town, 7925, South Africa
| | - Lloyd Tooke
- Division of Neonatal Medicine, Department of Paediatrics, University of Cape Town, Groote Schuur Hospital, Cape Town, 7925, South Africa
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13
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Rohwer AC, Oladapo OT, Hofmeyr GJ. Strategies for optimising antenatal corticosteroid administration for women with anticipated preterm birth. Cochrane Database Syst Rev 2020; 5:CD013633. [PMID: 32452555 PMCID: PMC7387231 DOI: 10.1002/14651858.cd013633] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Preterm birth is a serious and common pregnancy complication. The burden is particularly high in low- and middle-income countries where available care is often inadequate to ensure preterm newborn survival. Administration of antenatal corticosteroids (ACS) is recommended as the standard care for the management of women at risk of imminent preterm birth but its coverage varies globally. Efforts to improve preterm newborn survival have largely been focused on optimising the coverage of ACS use. However, the benefits and harms of such strategies are unclear. OBJECTIVES To determine the relative benefits and risks of individual patient protocols, health service policies, educational interventions or other strategies which aim to optimise the use of ACS for anticipated preterm birth. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs), randomised at individual or cluster level, and quasi-randomised trials that assessed strategies to optimise (either by increasing or restricting) the administration of ACS compared with usual care amongst women at risk of preterm birth. Our primary outcomes were perinatal death and a composite outcome of offspring mortality and early or late neurodevelopmental morbidity. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion. All three review authors independently extracted data and assessed risk of bias. We used narrative synthesis to analyse results, as we were unable to pool data from the included studies. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS We included three cluster-RCTs, all assessing the effects of a multifaceted strategy aiming to promote the use of ACS among women at risk of preterm birth. We did not identify any trials assessing strategies to restrict the use of ACS versus usual care. Two of the included trials assessed use of ACS in high-resource hospital settings. The third trial, the Antenatal Corticosteroid Trial (ACT) was a multi-site trial conducted in rural and semi-urban settings of six low- and middle-income countries in South Asia, sub-Saharan Africa and Central and South America. In two trials, promoting the use of ACS resulted in increased use of ACS, whereas one trial did not find a difference in the rate of ACS administration compared to usual care. Whilst we included three studies, we were unable to pool the data in meta-analysis due to outcomes not being reported across all studies, or outcome results being reported in different ways. The main source of data in this review is from the ACT trial. We assessed the ACT trial as high risk for performance and selective reporting bias. In the protocol for this review, we planned to report all settings and subgroup by low-middle versus high-income countries; these planned analyses were not possible in this version of the review, although adding further studies in future updates may allow us to carry out planned subgroup analyses. The ACT trial was conducted in low-resource settings and reported data on appropriate ACS treatment and inappropriate ACS treatment. Although a strategy of promoting the administration of ACS compared to routine care may increase appropriate ACS treatment (RR 4.34, 95%CI 3.59 to 5.25; 1 study; n = 4389; low-certainty evidence), it may also increase inappropriate ACS treatment (RR 9.11 95%CI 8.04 to 10.33, 1 study, n = 89,237; low-certainty evidence). In low-resource settings, a strategy of promoting the administration of ACS probably increases population level perinatal death by 3 per 1000 infants (risk ratio (RR) 1.11, 95% confidence interval (CI) 1.04 to 1.19; 1 study; n = 100,705; moderate-certainty evidence); stillbirth by 2 per 1000 infants (RR 1.11, 95% CI 1.02 to 1.21; 1 study; n = 100,705; moderate-certainty evidence); and neonatal death before 28 days by 2 per 1000 infants (RR 1.12, 95% CI 1.02 to 1.23; 1 study; n = 100,705; moderate-certainty evidence); may increase the risk for 'suspected' maternal infection or inflammation (RR 1.49, 95% CI 1.32 to 1.68; 1 study; n = 99,742; low-certainty evidence); and make little or no difference to the risk of maternal mortality (RR 1.11, 95% CI 0.64 to 1.92; 1 study; n = 99,742; low-certainty evidence) compared to routine care. Included trials did not report on the composite outcomes offspring mortality, early neurodevelopmental morbidity or late neurodevelopmental morbidity; and offspring mortality or severe neonatal morbidity. AUTHORS' CONCLUSIONS In low-resource settings, a strategy of actively promoting the use of ACS in women at risk of preterm birth may increase ACS use in the target population, but may also carry a substantial risk of unnecessary exposure of ACS to women in whom ACS is not indicated. At the population level, these effects are probably associated with increased risks of stillbirth, perinatal death, neonatal death before 28 days, and maternal infection. The findings of this review support a more conservative approach to clinical protocols and clinical decision-making particularly in low-resource settings, along the lines of the World Health Organization's ACS 2015 recommendations, which take into account both the established clinical efficacy of ACS when used in the correct situation and context, and the possibility of important adverse effects when certain conditions are not met. Given the unanticipated results of the ACT trial, further research on strategies to optimise the use of ACS in low-resource settings is justified.
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Affiliation(s)
- Anke C Rohwer
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - G Justus Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand/Fort Hare, East London, South Africa; Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; and, University of Botswana, Gaborone, Botswana
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14
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Wastnedge E, Vogel J, Been JV, Bannerman-Gyamfi C, Schuit E, Roberts D, Reynolds RM, Stock S. An evaluation of the benefits and harms of antenatal corticosteroid treatment for women at risk of imminent preterm birth or prior to elective Caesarean-section: Study protocol for an individual participant data meta-analysis. Wellcome Open Res 2020; 5:38. [PMID: 32529039 PMCID: PMC7268149 DOI: 10.12688/wellcomeopenres.15661.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Antenatal corticosteroid treatment (ACT) has been widely accepted as a safe, beneficial treatment which improves outcomes following preterm birth. It has been shown to reduce respiratory distress syndrome and neonatal mortality and is commonly used in threatened or planned preterm delivery, as well as prior to elective Caesarean-section at term. There are some concerns however, that in some cases, ACT is used in patients where clinical benefit has not been established, or may potentially increase harm. Many women who receive ACT do not deliver preterm and the long-term consequences of ACT treatment are unclear. This study aims to evaluate the benefits and harms of ACT using latest trial evidence to allow refinement of current practice. Methods: This study will compare ACT with placebo or non-treatment. Inclusion criteria are: Randomised Controlled Trials (RCT) comparing ACT vs. no ACT (with or without placebo) in all settings. Exclusion criteria are: non-randomised or quasi-randomised studies and studies comparing single vs. multiple courses of ACT. Main outcomes are to evaluate, for women at risk of preterm birth or undergoing planned Caesarean- section, the benefits and harms of ACT, on maternal, fetal, newborn, and long-term offspring health outcomes. The individual participant data (IPD) of identified RCTs will be collected and consecutively synthesised using meta-analysis with both a one-stage model where all IPD is analysed together and a two-stage model where treatment effect estimates are calculated for each trial individually first and thereafter pooled in a meta-analysis. Sub-group analysis will be performed to identify heterogeneous effects of ACT across predefined risk groups. Discussion: Co-opt is the Consortium for the Study of Pregnancy Treatments and aims to complete a robust evaluation of the benefits and harms of ACT. This IPD meta-analysis will contribute to this by allowing detailed interrogation of existing trial datasets. PROSPERO registration: CRD42020167312 (03/02/2020).
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Affiliation(s)
| | - Joshua Vogel
- Maternal and Child Health Program, Burnet Institute, Melbourne, Australia
| | - Jasper V. Been
- Division of Neonatology, Department of Paediatrics, Division of Obstetrics and Gynaecology and Department of Publisc Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Ewoud Schuit
- Julian Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Rebecca M. Reynolds
- Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Sarah Stock
- Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Co_Opt collaboration
- Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- Maternal and Child Health Program, Burnet Institute, Melbourne, Australia
- Division of Neonatology, Department of Paediatrics, Division of Obstetrics and Gynaecology and Department of Publisc Health, Erasmus MC, Rotterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Columbia University, New York, USA
- Julian Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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15
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Barnes KI, Canario JA, Vernekar SS, Goudar SS, Espinal R, Merson L, Cheah PY. Equitable data sharing: challenges and suggestions for ways forward. Wellcome Open Res 2019. [DOI: 10.12688/wellcomeopenres.15425.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Data sharing is increasingly mandated by health research funders and publishers. In the context of data collected in low-resource settings, concerns have been raised regarding inequitable opportunities to engage in secondary use of data between researchers in well-resourced and resource-limited settings. In this context, we present three case studies and their issues related to equity: the multicountry Antenatal Corticosteroid Trial, health research in the Dominican Repulic and the WorldWide Antimalarial Resistance Network. These case studies were discussed at the 2018 Global Forum for Bioethics in Research in South Africa, focussing on the theme “The ethics of data sharing and biobanking in health research”. The case studies provide concrete examples of real challenges such as lack of prior consent for data sharing, potential for misinterpretation of data by secondary users and limited capacity of researchers in low-resource settings to conduct secondary analyses. We conclude by suggesting ways forward. We stress the importance of capacity building and investments in data management and data science skills, and in data sharing platforms supporting poverty-related disease research. In addition, we recommend that there should be incentives to promote data sharing and that research groups and institutions establish their own data sharing policies tailored to their context, data and community while persuing harmonization with existing policies as much as possible. We also think that international guidelines on authorship criteria should be revisited. For new studies, researchers should obtain consent for sharing of participants’ data with secondary users. Lastly we recommend that community and stakeholder engagement be conducted to improve the consent process and identify what might be sensitive data to mitigate any potential harms to data subjects and their communities.
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16
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Neonatal morbidity and mortality associated with low adherence to prenatal corticosteroids. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.anpede.2018.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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17
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Abstract
Antenatal corticosteroids (ACS) are sporadically used in low and middle income countries (LMIC), although their use is considered by the World Health Organization (WHO) as essential for decreasing infant mortality. Presently the WHO recommends the use of ACS only when gestational age is known, delivery is imminent, and the delivery will be in a facility that can provide care for the mother and the infant. We review uncertainties about ACS in high income countries that are underappreciated for anticipating their effectiveness in LMIC. We discuss the implications of a large RCT that evaluated the use of ACS in LMIC and found no benefit for presumed preterm infants and increased mortality in larger infants. The treatment schedules for ACS have not been optimized and more is now known about how to improve treatment strategies to hopefully decrease risks such as neonatal hypoglycemia in LMIC. The benefits from ACS may depend on the patient populations and health care environment in which the therapy is used. Further trials are needed to evaluate the safety and efficacy of ACS in LMIC.
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Affiliation(s)
- Alan H Jobe
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 7029, Cincinnati, OH 45248, USA; University of Western Australia, Perth, Australia.
| | - Matthew W Kemp
- University of Western Australia, Perth, Australia; Tohoku University Hospital, Sendai, Japan; Murdock University, Perth, Australia
| | - Beena Kamath-Rayne
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 7029, Cincinnati, OH 45248, USA
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18
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Dosing and formulation of antenatal corticosteroids for fetal lung maturation and gene expression in rhesus macaques. Sci Rep 2019; 9:9039. [PMID: 31227752 PMCID: PMC6588577 DOI: 10.1038/s41598-019-45171-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/15/2019] [Indexed: 02/07/2023] Open
Abstract
Antenatal corticosteroids (ANS) are the major intervention to decrease respiratory distress syndrome and mortality from premature birth and are standard of care. The use of ANS is expanding to include new indications and gestational ages, although the recommended dosing was never optimized. The most widely used treatment is two intramuscular doses of a 1:1 mixture of betamethasone-phosphate (Beta-P) and betamethasone-acetate (Beta-Ac) - the clinical drug. We tested in a primate model the efficacy of the slow release Beta-Ac alone for enhancing fetal lung maturation and to reduce fetal corticosteroid exposure and potential toxic effects. Pregnant rhesus macaques at 127 days of gestation (80% of term) were treated with either the clinical drug (0.25 mg/kg) or Beta-Ac (0.125 mg/kg). Beta-Ac alone increased lung compliance and surfactant concentration in the fetal lung equivalently to the clinical drug. By transcriptome analyses the early suppression of genes associated with immune responses and developmental pathways were less affected by Beta-Ac than the clinical drug. Promoter and regulatory analysis prediction identified differentially expressed genes targeted by the glucocorticoid receptor in the lung. At 5 days the clinical drug suppressed genes associated with neuronal development and differentiation in the fetal hippocampus compared to control, while low dose Beta-Ac alone did not. A low dose ANS treatment with Beta-Ac should be assessed for efficacy in human trials.
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19
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Abstract
Treatment with antenatal corticosteroids (ACS) is standard of care for women at risk of preterm birth between 24 and 34 weeks' gestation. ACS are increasingly used for other indications, including threated or indicated late preterm birth, elective cesarean, and in at-risk pregnancies for periviable gestations. However, the various drugs and doses being used worldwide have not been rigorously evaluated to optimize clinical responses and to minimize potential risks. Translational research in animal models indicate that a constant, low concentration fetal exposure to ACS is sufficient for lung maturation, resulting in lower fetal exposures. Clinical trials to develop dosing strategies with inexpensive and widely available drugs could promote greater use in low resource environments.
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Affiliation(s)
- Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia.
| | - Augusto F Schmidt
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue
- MLC 7029, Cincinnati, OH, 45229, USA.
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue
- MLC 7029, Cincinnati, OH, 45229, USA.
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20
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Pérez-Ramírez RO, Lona-Reyes JC, Ochoa-Meza CA, Gómez-Ruiz LM, Ramos-Gutiérrez RY, Camarena-Pulido EE, Gallegos-Marín JA. [Neonatal morbidity and mortality associated with low adherence to prenatal corticosteroids]. An Pediatr (Barc) 2019; 91:105-111. [PMID: 30612910 DOI: 10.1016/j.anpedi.2018.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/15/2018] [Accepted: 11/21/2018] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Prenatal corticosteroids reduce neonatal mortality and morbidity; however, there are few studies in developing countries, and with inconsistent results. The purpose of this study was to quantify the frequency of the use of prenatal corticosteroids and to estimate its effect on the morbidity and mortality of premature newborns. METHODS A retrospective cohort study was performed on premature newborns selected from a census conducted between January 2016 and August 2017. The use of corticosteroids was taken from the maternal records, and the dependent variables from the neonatal records. An analysis was made of the relationship using logistic regression, adjusted to gestational age and weight. RESULTS The study included 1083 premature infants of which 53.3% were male. The mean gestational age was 33.4 weeks. Corticosteroids were received by 42%, with latency ≥24hours in 23.6% and ≥48hours in 13.8%. Respiratory distress syndrome was observed in 35% (379/1083), early neonatal sepsis in 4.4% (48/1083), late neonatal sepsis in 10.7% (116/1083), intraventricular haemorrhage in 15.1% (137/908), chronic lung disease in 51.4% (165/321), and death in 22.3% (242/1083). Prenatal corticosteroids decreased the risk of death in children under 34 weeks (OR 0.63, 95% CI 0.40-0.98). The decrease was greater if they presented with latency ≥48hours (OR 0.40, 95% CI 0.20-0.80). The rest of the dependent variables were not modified by the intervention. CONCLUSIONS In preterm infants, 42% received antenatal corticosteroids. In those with less than 34 weeks, there was a decrease in the risk of death without changes in morbidity.
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Affiliation(s)
- Rene O Pérez-Ramírez
- Hospital Civil de Guadalajara Dr. Juan I. Menchaca, División de Pediatría, Guadalajara, Jalisco, México
| | - Juan Carlos Lona-Reyes
- Hospital Civil de Guadalajara Dr. Juan I. Menchaca, División de Pediatría, Guadalajara, Jalisco, México; Centro Universitario de Tonalá, Universidad de Guadalajara, Tonalá, Jalisco, México.
| | - Cesar A Ochoa-Meza
- Hospital Civil de Guadalajara Dr. Juan I. Menchaca, División de Pediatría, Guadalajara, Jalisco, México
| | - Larissa M Gómez-Ruiz
- Hospital Civil de Guadalajara Dr. Juan I. Menchaca, División de Pediatría, Guadalajara, Jalisco, México
| | - Ruth Y Ramos-Gutiérrez
- Hospital Civil de Guadalajara Dr. Juan I. Menchaca, División de Pediatría, Guadalajara, Jalisco, México
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21
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Morsi A, DeFranco D, Witchel SF. The Hypothalamic-Pituitary-Adrenal Axis and the Fetus. Horm Res Paediatr 2018; 89:380-387. [PMID: 29874660 DOI: 10.1159/000488106] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 02/28/2018] [Indexed: 11/19/2022] Open
Abstract
Glucocorticoids (GCs), cortisol in humans, influence multiple essential maturational events during gestation. In the human fetus, fetal hypothalamic-pituitary-adrenal (HPA) axis function, fetal adrenal steroidogenesis, placental 11β- hydroxysteroid dehydrogenase type 2 activity, maternal cortisol concentrations, and environmental factors impact fetal cortisol exposure. The beneficial effects of synthetic glucocorticoids (sGCs), such as dexamethasone and betamethasone, on fetal lung maturation have significantly shifted the management of preterm labor and threatened preterm birth. Accumulating evidence suggests that exposure to sGCs in utero at critical developmental stages can alter the function of organ systems and that these effects may have sequelae that extend into adult life. Maternal stress and environmental influences may also impact fetal GC exposure. This article explores the vulnerability of the fetal HPA axis to endogenous GCs and exogenous sGCs.
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Affiliation(s)
- Amr Morsi
- Division of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Donald DeFranco
- Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Selma F Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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22
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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: 99] [Impact Index Per Article: 16.5] [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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Fogarty M, Osborn DA, Askie L, Seidler AL, Hunter K, Lui K, Simes J, Tarnow-Mordi W. Delayed vs early umbilical cord clamping for preterm infants: a systematic review and meta-analysis. Am J Obstet Gynecol 2018; 218:1-18. [PMID: 29097178 DOI: 10.1016/j.ajog.2017.10.231] [Citation(s) in RCA: 292] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 10/25/2017] [Accepted: 10/26/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The effects of delayed cord clamping of the umbilical cord in preterm infants are unclear. OBJECTIVE We sought to compare the effects of delayed vs early cord clamping on hospital mortality (primary outcome) and morbidity in preterm infants using Cochrane Collaboration neonatal review group methodology. STUDY DESIGN We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Chinese articles, cross-referencing citations, expert informants, and trial registries to July 31, 2017, for randomized controlled trials of delayed (≥30 seconds) vs early (<30 seconds) clamping in infants born <37 weeks' gestation. Before searching the literature, we specified that trials estimated to have cord milking in >20% of infants in any arm would be ineligible. Two reviewers independently selected studies, assessed bias, and extracted data. Relative risk (ie, risk ratio), risk difference, and mean difference with 95% confidence intervals were assessed by fixed effects models, heterogeneity by I2 statistics, and the quality of evidence by Grading of Recommendations, Assessment, Development, and Evaluations. RESULTS Eighteen randomized controlled trials compared delayed vs early clamping in 2834 infants. Most infants allocated to have delayed clamping were assigned a delay of ≥60 seconds. Delayed clamping reduced hospital mortality (risk ratio, 0.68; 95% confidence interval, 0.52-0.90; risk difference, -0.03; 95% confidence interval, -0.05 to -0.01; P = .005; number needed to benefit, 33; 95% confidence interval, 20-100; Grading of Recommendations, Assessment, Development, and Evaluations = high, with I2 = 0 indicating no heterogeneity). In 3 trials in 996 infants ≤28 weeks' gestation, delayed clamping reduced hospital mortality (risk ratio, 0.70; 95% confidence interval, 0.51-0.95; risk difference, -0.05; 95% confidence interval, -0.09 to -0.01; P = .02, number needed to benefit, 20; 95% confidence interval, 11-100; I2 = 0). In subgroup analyses, delayed clamping reduced the incidence of low Apgar score at 1 minute, but not at 5 minutes, and did not reduce the incidence of intubation for resuscitation, admission temperature, mechanical ventilation, intraventricular hemorrhage, brain injury, chronic lung disease, patent ductus arteriosus, necrotizing enterocolitis, late onset sepsis or retinopathy of prematurity. Delayed clamping increased peak hematocrit by 2.73 percentage points (95% confidence interval, 1.94-3.52; P < .00001) and reduced the proportion of infants having blood transfusion by 10% (95% confidence interval, 6-13%; P < .00001). Potential harms of delayed clamping included polycythemia and hyperbilirubinemia. CONCLUSION This systematic review provides high-quality evidence that delayed clamping reduced hospital mortality, which supports current guidelines recommending delayed clamping in preterm infants. This review does not evaluate cord milking, which may also be of benefit. Analyses of individual patient data in these and other randomized controlled trials will be critically important in reliably evaluating important secondary outcomes.
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24
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Low-dose betamethasone-acetate for fetal lung maturation in preterm sheep. Am J Obstet Gynecol 2018; 218:132.e1-132.e9. [PMID: 29138038 PMCID: PMC5759749 DOI: 10.1016/j.ajog.2017.11.560] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/20/2017] [Accepted: 11/07/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Antenatal steroids are standard of care for women who are at risk of preterm delivery; however, antenatal steroid dosing and formulation have not been evaluated adequately. The standard clinical 2-dose treatment with betamethasone-acetate+betamethasone-phosphate is more effective than 2 doses of betamethasone-phosphate for the induction of lung maturation in preterm fetal sheep. We hypothesized that the slowly released betamethasone-acetate component induces similar lung maturation to betamethasone-phosphate+betamethasone-acetate with decreased dose and fetal exposure. OBJECTIVE The purpose of this study was to investigate pharmacokinetics and fetal lung maturation of antenatal betamethasone-acetate in preterm fetal sheep. STUDY DESIGN Groups of 10 singleton-pregnant ewes received 1 or 2 intramuscular doses 24 hours apart of 0.25 mg/kg/dose of betamethasone-phosphate+betamethasone-acetate (the standard of care dose) or 1 intramuscular dose of 0.5 mg/kg, 0.25 mg/kg, or 0.125 mg/kg of betamethasone-acetate. Fetuses were delivered 48 hours after the first injection at 122 days of gestation (80% of term) and ventilated for 30 minutes, with ventilator settings, compliance, vital signs, and blood gas measurements recorded every 10 minutes. After ventilation, we measured static lung pressure-volume curves and sampled the lungs for messenger RNA measurements. Other groups of pregnant ewes and fetuses were catheterized and treated with intramuscular injections of betamethasone-phosphate 0.125 mg/kg, betamethasone-acetate 0.125 mg/kg, or betamethasone-acetate 0.5 mg/kg. Maternal and fetal betamethasone concentrations in plasma were measured for 24 hours. RESULTS All betamethasone-treated groups had increased messenger RNA expression of surfactant proteins A, B, and C, ATP-binding cassette subfamily A member 3, and aquaporin-5 compared with control animals. Treatment with 1 dose of intramuscular betamethasone-acetate 0.125mg/kg improved dynamic and static lung compliance, gas exchange, and ventilation efficiency similarly to the standard treatment of 2 doses of 0.25 m/kg of betamethasone-acetate+betamethasone-phosphate. Betamethasone-acetate 0.125 mg/kg resulted in lower maternal and fetal peak plasma concentrations and decreased fetal exposure to betamethasone compared with betamethasone-phosphate 0.125 mg/kg. CONCLUSION A single dose of betamethasone-acetate results in similar fetal lung maturation as the 2-dose clinical formulation of betamethasone-phosphate+betamethasone-acetate with decreased fetal exposure to betamethasone. A lower dose of betamethasone-acetate may be an effective alternative to induce fetal lung maturation with less risk to the fetus.
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Affiliation(s)
| | - William Stones
- Malawi College of MedicineDepartments of Public Health and Obstetrics & GynaecologyBlantyreMalawi
- St George's, University of LondonUK
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Wang ME, Patel AB, Hansen NI, Arlington L, Prakash A, Hibberd PL. Risk factors for possible serious bacterial infection in a rural cohort of young infants in central India. BMC Public Health 2016; 16:1097. [PMID: 27760543 PMCID: PMC5070173 DOI: 10.1186/s12889-016-3688-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/20/2016] [Indexed: 11/13/2022] Open
Abstract
Background Possible serious bacterial infection (PBSI) is a major cause of neonatal mortality worldwide. We studied risk factors for PSBI in a large rural population in central India where facility deliveries have increased as a result of a government financial assistance program. Methods We studied 37,379 pregnant women and their singleton live born infants with birth weight ≥ 1.5 kg from 20 rural primary health centers around Nagpur, India, using data from the 2010–13 population-based Maternal and Newborn Health Registry supported by NICHD’s Global Network for Women’s and Children’s Health Research. Factors associated with PSBI were identified using multivariable Poisson regression. Results Two thousand one hundred twenty-three infants (6 %) had PSBI. Risk factors for PSBI included nulliparity (RR 1.13, 95 % CI 1.03–1.23), parity > 2 (RR 1.30, 95 % CI 1.07–1.57) compared to parity 1–2, first antenatal care visit in the 2nd/3rd trimester (RR 1.46, 95 % CI 1.08–1.98) compared to 1st trimester, administration of antenatal corticosteroids (RR 2.04, 95 % CI 1.60–2.61), low birth weight (RR 3.10, 95 % CI 2.17–4.42), male sex (RR 1.20, 95 % CI 1.10–1.31) and lack of early initiation of breastfeeding (RR 3.87, 95 % CI 2.69–5.58). Conclusion Infants who are low birth weight, born to mothers who present late to antenatal care or receive antenatal corticosteroids, or born to nulliparous women or those with a parity > 2, could be targeted for interventions before and after delivery to improve early recognition of signs and symptoms of PSBI and prompt referral. There also appears to be a need for a renewed focus on promoting early initiation of breastfeeding following delivery in facilities. Trial registration This trial is registered at ClinicalTrials.gov (NCT01073475). Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3688-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marie E Wang
- Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Boston, MA, USA. .,Division of Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA.
| | - Archana B Patel
- Lata Medical Research Foundation, Nagpur, Maharashtra, India
| | | | - Lauren Arlington
- Department of Global Health, Boston University School of Public Health, Boston University, Boston, MA, USA
| | - Amber Prakash
- Lata Medical Research Foundation, Nagpur, Maharashtra, India
| | - Patricia L Hibberd
- Department of Global Health, Boston University School of Public Health, Boston University, Boston, MA, USA
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27
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McClure EM, Goldenberg RL, Jobe AH, Miodovnik M, Koso-Thomas M, Buekens P, Belizan J, Althabe F. Reducing neonatal mortality associated with preterm birth: gaps in knowledge of the impact of antenatal corticosteroids on preterm birth outcomes in low-middle income countries. Reprod Health 2016; 13:61. [PMID: 27221397 PMCID: PMC4877818 DOI: 10.1186/s12978-016-0180-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 05/04/2016] [Indexed: 12/29/2022] Open
Abstract
The Global Network's Antenatal Corticosteroids Trial (ACT), was a multi-country, cluster-randomized trial to improve appropriate use of antenatal corticosteroids (ACS) in low-resource settings in low-middle income countries (LMIC). ACT substantially increased ACS use in the intervention clusters, but the intervention failed to show benefit in the targeted < 5th percentile birth weight infants and was associated with increased neonatal mortality and stillbirth in the overall population. In this issue are six papers which are secondary analyses related to ACT that explore potential reasons for the increase in adverse outcomes overall, as well as site differences in outcomes. The African sites appeared to have increased neonatal mortality in the intervention clusters while the Guatemalan site had a significant reduction in neonatal mortality, perhaps related to a combination of ACS and improving obstetric care in the intervention clusters. Maternal and neonatal infections were increased in the intervention clusters across all sites and increased infections are a possible partial explanation for the increase in neonatal mortality and stillbirth in the intervention clusters, especially in the African sites. The analyses presented here provide guidance for future ACS trials in LMIC. These include having accurate gestational age dating of study subjects and having care givers who can diagnose conditions leading to preterm birth and predict which women likely will deliver in the next 7 days. All study subjects should be followed through delivery and the neonatal period, regardless of when they deliver. Clearly defined measures of maternal and neonatal infection should be utilized. Trials in low income country facilities including clinics and those without newborn intensive care seem to be of the highest priority.
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Affiliation(s)
- Elizabeth M McClure
- Social, Statistical and Environmental Health Sciences, RTI International, 3040 Cornwallis Road, Durham, NC, USA.
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Alan H Jobe
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Menachem Miodovnik
- Eunice Kennedy Shriver National Institute of Child and Human Development, Bethesda, MD, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child and Human Development, Bethesda, MD, USA
| | - Pierre Buekens
- Tulane University School of Tropical Medicine and Hygiene, New Orleans, LA, USA
| | - Jose Belizan
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Fernando Althabe
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
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