1
|
Prins LI, van de Meent M, Kooiman J, Pels A, Gordijn SJ, Lely T, Ganzevoort W. Practice variation in timing of antenatal corticosteroid administration in early-onset fetal growth restriction: A secondary analysis of the Dutch STRIDER study. Acta Obstet Gynecol Scand 2024; 103:77-84. [PMID: 37904620 PMCID: PMC10755118 DOI: 10.1111/aogs.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/21/2023] [Accepted: 09/12/2023] [Indexed: 11/01/2023]
Abstract
INTRODUCTION In early-onset fetal growth restriction the fetus fails to thrive in utero due to unmet fetal metabolic demands. This condition is linked to perinatal mortality and severe neonatal morbidity. Maternal administration of corticosteroids in high-risk pregnancies for preterm birth at a gestational age between 24 and 34 weeks has been shown to reduce perinatal mortality and morbidity. Practice variation exists in the timing of the administration of corticosteroids based on umbilical artery monitoring findings in early-onset fetal growth restriction. The aim of this study was to examine differences in neonatal outcomes when comparing different corticosteroid timing strategies. MATERIAL AND METHODS This was a post-hoc analysis of the Dutch STRIDER trial. We examined neonatal outcomes when comparing institutional strategies of early (umbilical artery pulsatility index >95th centile) and late (umbilical artery shows absent or reversed end-diastolic flow) administration of corticosteroids. The primary outcomes were neonatal mortality and a composite of neonatal mortality and neonatal morbidity, defined as bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis or retinopathy of prematurity. We also analyzed predictors for adverse neonatal outcomes, including gestational age at delivery, birthweight, maternal hypertensive disorders, and time interval between corticosteroids and birth. RESULTS A total of 120 patients matched our inclusion criteria. In 69 (57.5%) the early strategy was applied and in 51 (42.5%) patients the late strategy. Median gestational age at delivery was 28 4/7 (± 3, 3/7) weeks. Median birthweight was 708 (± 304) g. Composite primary outcome was found in 57 (47.5%) neonates. No significant differences were observed in the primary outcome between the two strategies (neonatal mortality adjusted odds ratio [OR] 1.22, 95% CI 0.44-3.38; composite primary outcome adjusted OR 1.05, 95% CI 0.42-2.64). Only gestational age at delivery was a significant predictor for improved neonatal outcome (adjusted OR 0.91, 95% CI 0.86-0.96). CONCLUSIONS No significant differences in neonatal outcomes were observed when comparing early and late strategy of antenatal corticosteroid administration on neonatal outcomes in pregnancies complicated by early-onset fetal growth restriction. We found no apparent risk contribution of interval between corticosteroid administration and delivery in multivariate analysis. Gestational age at delivery was found to be an important predictor of neonatal outcome.
Collapse
Affiliation(s)
- Leah I. Prins
- Department of Obstetrics and GynecologyAmsterdam University Medical Centers, University of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
| | - Mette van de Meent
- Department of Obstetrics and GynecologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Judith Kooiman
- Department of Obstetrics and GynecologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Anouk Pels
- Department of Obstetrics and GynecologyAmsterdam University Medical Centers, University of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
| | - Sanne J. Gordijn
- Department of Obstetrics and GynecologyUniversity Medical Center GroningenGroningenThe Netherlands
| | - Titia Lely
- Department of Obstetrics and GynecologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and GynecologyAmsterdam University Medical Centers, University of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
| |
Collapse
|
2
|
Heeling E, van de Kamer JB, Methorst M, Bruining A, van de Meent M, Vrancken Peeters MJTFD, Lok CAR, van der Ploeg IMC. The Safe Use of 125I-Seeds as a Localization Technique in Breast Cancer during Pregnancy. Cancers (Basel) 2023; 15:3229. [PMID: 37370839 DOI: 10.3390/cancers15123229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Some aspects of the treatment protocol for breast cancer during pregnancy (PrBC) have not been thoroughly studied. This study provides clarity regarding the safety of the use of 125I-seeds as a localization technique for breast-conserving surgery in patients with PrBC. METHODS To calculate the exposure to the fetus of one 125I-seed implanted in a breast tumor, we developed a model accounting for the decaying 125I-source, time to surgery, and the declining distance between the 125I-seed and the fetus. The primary outcome was the maximum cumulative fetal dose of radiation at consecutive gestational ages (GA). RESULTS The cumulative fetal dose remains below 1 mSv if a single 125I-seed is implanted at a GA of 26 weeks. After a GA of 26 weeks, the fetal dose can be at a maximum of 11.6 mSv. If surgery takes place within two weeks of implantation from a GA of 26 weeks, and one week above a GA of 32 weeks, the dose remains below 1 mSv. CONCLUSION The use of 125I-seeds is safe in PrBC. The maximum fetal exposure remains well below the threshold of 100 mSv, and therefore, does not lead to an increased risk of fetal tissue damage. Still, we propose keeping the fetal dose as low as possible, preferably below 1 mSv.
Collapse
Affiliation(s)
- Eva Heeling
- Department of Surgical Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Jeroen B van de Kamer
- Department of Radiation Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Michelle Methorst
- Department of Gynaecologic Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Annemarie Bruining
- Department of Radiology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Mette van de Meent
- Department of Obstetrics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | | | - Christianne A R Lok
- Department of Gynaecologic Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Iris M C van der Ploeg
- Department of Surgical Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| |
Collapse
|
3
|
van de Meent M, Kleuskens DG, Ganzevoort W, Gordijn SJ, Kooi EMW, Onland W, van Rijn BB, Duvekot JJ, Kornelisse RF, Al-Nasiry S, Jellema RK, Knol HM, Manten GTR, Mulder-de Tollenaer SM, Derks JB, Groenendaal F, Bekker MN, Schuit E, Lely AT, Kooiman J. OPtimal TIming of antenatal COrticosteroid administration in pregnancies complicated by early-onset fetal growth REstriction (OPTICORE): study protocol of a multicentre, retrospective cohort study. BMJ Open 2023; 13:e070729. [PMID: 36931680 PMCID: PMC10030622 DOI: 10.1136/bmjopen-2022-070729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
INTRODUCTION Early-onset fetal growth restriction (FGR) requires timely, often preterm, delivery to prevent fetal hypoxia causing stillbirth or neurologic impairment. Antenatal corticosteroids (CCS) administration reduces neonatal morbidity and mortality following preterm birth, most effectively when administered within 1 week preceding delivery. Optimal timing of CCS administration is challenging in early-onset FGR, as the exact onset and course of fetal hypoxia are unpredictable. International guidelines do not provide a directive on this topic. In the Netherlands, two timing strategies are commonly practiced: administration of CCS when the umbilical artery shows (A) a pulsatility index above the 95thh centile and (B) absent or reversed end-diastolic velocity (a more progressed disease state). This study aims to (1) use practice variation to compare CCS timing strategies in early-onset FGR on fetal and neonatal outcomes and (2) develop a dynamic tool to predict the time interval in days until delivery, as a novel timing strategy for antenatal CCS in early-onset FGR. METHODS AND ANALYSIS A multicentre, retrospective cohort study will be performed including pregnancies complicated by early-onset FGR in six tertiary hospitals in the Netherlands in the period between 2012 and 2021 (estimated sample size n=1800). Main exclusion criteria are multiple pregnancies and fetal congenital or genetic abnormalities. Routinely collected data will be extracted from medical charts. Primary outcome for the comparison of the two CCS timing strategies is a composite of perinatal, neonatal and in-hospital mortality. Secondary outcomes include the COSGROVE core outcome set for FGR. A multivariable, mixed-effects model will be used to compare timing strategies on study outcomes. Primary outcome for the dynamic prediction tool is 'days until birth'. ETHICS AND DISSEMINATION The need for ethical approval was waived by the Ethics Committee (University Medical Center Utrecht). Results will be published in open-access, peer-reviewed journals and disseminated by presentations at scientific conferences. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT05606497.
Collapse
Affiliation(s)
- Mette van de Meent
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Dianne G Kleuskens
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, location AMC, Amsterdam, Netherlands
| | - Sanne J Gordijn
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, Groningen, Netherlands
| | - Elisabeth M W Kooi
- Department of Pediatrics, University Medical Center Groningen, Groningen, Netherlands
| | - Wes Onland
- Department of Pediatrics, Amsterdam University Medical Center, location AMC, Amsterdam, Netherlands
- Amsterdam Reproduction and Development, Amsterdam, Netherlands
| | - Bas B van Rijn
- Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, Netherlands
| | | | - Salwan Al-Nasiry
- Department of Obstetrics and Gynaecology, Maastricht UMC+, Maastricht, Netherlands
| | - Reint K Jellema
- Department of Pediatrics, Maastricht UMC+, Maastricht, Netherlands
| | - H Marieke Knol
- Department of Obstetrics and Gynaecology, Isala Zwolle, Zwolle, Netherlands
| | | | | | - Jan B Derks
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Floris Groenendaal
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Mireille N Bekker
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - A Titia Lely
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Judith Kooiman
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, Netherlands
| |
Collapse
|