Antenatal corticosteroid use in preterm delivery at Kenyatta National Hospital

Abstract

Preterm birth is the cause of at least 75% of neonatal deaths that are not attributable to congenital malformations. Antenatal corticosteroids given to mothers at risk of preterm birth between 24 and 34 weeks reduce the incidence and severity of respiratory distress syndrome, intraventricular haemmorhage, necrotizing enterocolitis and neonatal deaths. The World Health Organization recommends the use of one course of antenatal steroids for all pregnant women between 26 and 35 weeks of gestation who are at risk of preterm delivery within 7 days while both the American College of Obstetricians and Gynaecologists and the Royal College of Obstetricians and Gynaecologists recommend their use between 24 and 34 weeks of gestation. The use of ACS after 34 or 35 weeks of gestation is not recommended unless there is evidence of fetal pulmonary immaturity. Despite this. ACS are widely used locally across all gestational periods. Objective To determine the frequency of adminstration and impact of ACS in reducing the incidence and severity of RDS, NBU admissions and neonatal deaths i.n preterm neonates 28- 37 weeks gestation. born to women. with PTL PPROM or severe preeclampsia at KNI-1. Methods The study was conducted in Labour ward, NBU and the postnatal wards of Kenyatta National Hospital. It was a hospital-based cross sectional study with a descriptive and comparative design that compared the neonatal outcomes of mothers with preterm birth who received antenatal steroids and those who did not receive the steroids. The study population were mothers with preterm birth between 28-37 weeks gestation and their neonates. The women who met the inclusion criteria and consented for the study were recruited sequentially immediately after delivery. Themothers were interviewed and the information obtained entered into a questionnaire. Maternal and neonatal medical records were scrutinized and information gathered tilled in a structured questionnaire. The neonates were followed up until discharge/death or the 7th day, whichever came earlier. The outcome measures included occurrence of RDS, severity . of RDS (use of and duration of oxygen therapy, admission to NICU and use of mechanical ventilation), neonatal NBU admissions and neonatal deaths. The outcomes were compared for gestational age. Results Two hundred and six (206) women who met the inclusion criteria were recruited: 114 had spontaneous pretenn labour, 53 PPROM and 39 severe Pre- eclampsia. The overall frequency of antenatal steroid use at KNH was 35%. Forty six percent of those who delivered before 34weeks received ACS while 26% of those who delivered after 34 weeks received ACS. Dexamethasone was the only ACS used at KNH. Only 3 % (nee2) of the mothers received a complete course of ACS. ACS significantly reduced the occurrence and severity of RDS in preterm neonates up to 34 weeks gestation with 69% of neonates not exposed to ACS developing RDS compared to 38% of those who were exposed. ACS reduced neonatal mortality of preterm neonates across all gestational ages. However, the impact was more in those delivered before 34weeks (11.5% reduction in mortality) compared to those delivered > 34 weeks (5.8% reduction in mortality). ACS did not reduce the prevalence of ]\iBU and NICU admissions.

Conclusions ACS is effective In reducing the incidence and severity of neonatal RDS and mortality. The effect is significant in those born <34 weeks gestation. Recommendations There is urgent need to upscale the utilization of ACS at KNH. Measures should be put in place to ensure that patients get a complete course of ACS. There is need to standardize the dose of dexamethasone. The study provides local evidence to discourage the routine use of ACS after 34 weeks.