Antenatal Corticosteroids PDF - Auckland DHB Guideline 2021

If printed, this document is only valid for the day of printing. Antenatal Corticosteroids to Improve Neonatal Outcomes Unique Identifier NMP200-SSM-078 – v03.00 Document Type Clinical Guideline Risk of non-compliance...

If printed, this document is only valid for the day of printing. Antenatal Corticosteroids to Improve Neonatal Outcomes Unique Identifier NMP200-SSM-078 – v03.00 Document Type Clinical Guideline Risk of non-compliance may result in significant harm to the patient/DHB Function Clinical Practice, Patient Care User Group(s) Auckland DHB only  Organisation(s) Auckland District Health Board  Directorate(s) Women’s Health  Department(s) Maternity  Used for which patients? All antenatal patients  Used by which staff? Clinicians and NWH access holders  Excluded Keywords Premature birth, fFN, fetal fibronectin, tocolysis, nifedipine, magnesium sulphate, corticosteroids, delayed cord clamping, preterm labour, preterm birth, PPROM Author Specialist - Maternal Fetal Medicine Authorisation  Owner Service Clinical Director – Secondary Maternity  Delegate / Issuer Sub Specialist – Maternal Fetal Medicine Edited by Document Control First issued 21 December 2009 This version issued 06 September 2021 - updated Review frequency 3 yearly Contents 1. Purpose of policy.......................................................................................................................... 2 2. Guideline management principles and goals............................................................................... 2 3. Background................................................................................................................................... 2 4. Definitions..................................................................................................................................... 3 5. Summary of guidelines................................................................................................................. 3 5.1 A. In a woman at risk of early preterm birth, use a two dose course of antenatal corticosteroids:..................................................................................................................... 3 5.2 B. Type and amount of corticosteroid to use for two dose course:..................................... 3 5.3 C. Use repeat antenatal corticosteroids in women still at risk of early preterm, imminent birth following an initial two dose course or single dose repeat of antenatal corticosteroids:..................................................................................................................... 4 5.4 D. Type and amount of corticosteroid to use for repeat dose:............................................ 5 5.5 E. Other indications and considerations for antenatal corticosteroid use (with best practice points):.................................................................................................................... 5 6. Flowchart...................................................................................................................................... 8 7. Supporting evidence..................................................................................................................... 9 8. Associated documents.................................................................................................................. 9 9. Disclaimer................................................................................................................................... 10 10. Corrections and amendments.................................................................................................... 10 Back to Contents Antenatal-Corticosteroids-to-Improve-Neonatal-Outcomes_2021-09-06.docx Page 1 of 10 If printed, this document is only valid for the day of printing. 1. Purpose of policy To provide recommendations for the use of antenatal corticosteroids in women prior to birth to improve neonatal outcomes. 2. Guideline management principles and goals Antenatal steroids are standard care for women at high risk of birth < 35 weeks gestation. A single repeat dose may be administered if still at risk of preterm birth, up to 32+6 weeks. 3. Background Maternal administration of a single course of intramuscular corticosteroids prior to preterm birth has a major role in reducing mortality and major morbidity (including respiratory distress syndrome, intraventricular haemorrhage and necrotising enterocolitis) in babies born very and moderately preterm and is now considered the standard of care for women at high risk of birth < 35 weeks gestation (Crowley, 1990). Evidence from meta-analyses assessing the use of repeat corticosteroids, demonstrates neonatal benefit from repeat dose(s) of corticosteroids to women at on-going risk of preterm birth greater than seven days (and less than 14 days) after the initial course of corticosteroids, with no evidence of adverse effect in follow-up studies of children up to school age (Crowther, 2011; McKinlay 2015). The evidence lacks clarity regarding the best type, dose, frequency and mode of administration of corticosteroid. There is no evidence of benefit for routes of administration other than intramuscular. Many have extended the use of antenatal corticosteroids in attempts to improve neonatal outcomes for other groups considered at increased risk of neonatal respiratory morbidity including for late preterm birth at 35-37 weeks gestation, prior to elective caesarean section, in women with diabetes, and in women with multiple pregnancy. In 2015 the Antenatal Corticosteroids Given to Women Prior to Birth to Improve Fetal, Infant, Child and Adult Health: Clinical Practice Guidelines were released. These bi-national guidelines were developed by a multidisciplinary clinical practice guideline panel including several Auckland DHB representatives with all relevant data systematically reviewed and considered. The extensive guideline document provides the best evidence-based recommendations to guide decision-making in clinical practice also highlighting areas of uncertainty requiring further research. National Women’s Health has elected to follow these guidelines for all antenatal corticosteroid use. The full document can be accessed at: http://www.ligginstrials.org/ANC_CPG/ This document provides a summary of the guidelines highlighting practice points of interest. This document should be read in conjunction with:  Preterm Labour (PTL) - Management of Threatened and Active PTL guideline (see associated Auckland documents) for women at risk of spontaneous preterm birth and Back to Contents Antenatal-Corticosteroids-to-Improve-Neonatal-Outcomes_2021-09-06.docx Page 2 of 10 If printed, this document is only valid for the day of printing.  Magnesium Sulphate for Pre-eclampsia and for Neuroprotection in Pre-Term Births 37+0 weeks. However, the GRADE quality of evidence was low (Sotiriadis 2018) indicating that the true effect of corticosteroids may be substantially different than the estimate of effect given, and no trials >37+0 weeks included neonatal hypoglycaemia as an outcome, hence the potential for harm is unknown. Until further evidence is available to guide practice, avoid routine use of corticosteroids for women undergoing elective CS ≥35+0 weeks gestation. The C*STEROID Feasibility Study has been undertaken at ADHB and the multicentre C*STEROID Trial is being planned by Auckland investigators as a New Zealand-wide randomised placebo- controlled trial of betamethasone prior to planned CS at 35+0 to 39+6 weeks assessing both neonatal benefit and harm. All women meeting inclusion criteria should be offered the opportunity to participate and all healthcare professionals should encourage and endorse participation whilst the trial is active. https://www.auckland.ac.nz/en/liggins/in-the- community/clinical-studies/clinical-studies-pregnancy/c-steroid-feasibility-study/c-steroid- information-for-clinicians-and-midwives.html In women with diabetes in pregnancy including gestational diabetes:  Single course and repeat doses of corticosteroids should be given to patients at risk of preterm birth as per guidelines for general use  Patients with diabetes receiving corticosteroids will require blood glucose monitoring and management of any subsequent hyperglycaemia. This should be done in consultation with the Obstetric Physician service  Patients with diabetes receiving corticosteroids should be monitored for puerperal sepsis  There is insufficient evidence to support use of corticosteroids in patients with diabetes greater ≥35+0 weeks gestation, regardless of mode of delivery. In women with multiple pregnancy:  Single course and repeat doses of corticosteroids should be given to patients at risk of preterm birth as per guidelines for general use  Do not use single course and repeat doses of corticosteroids in women with a multiple pregnancy where there is no other identified risk of preterm birth  Use adjunct prediction tests to identify those most likely to deliver in 48 hours/next seven days (eg for spontaneous preterm labour use fetal fibronectin or transvaginal cervical length, refer to Preterm Labour (PTL) - Management of Threatened and Active PTL guideline in associated Auckland DHB documents. Back to Contents Antenatal-Corticosteroids-to-Improve-Neonatal-Outcomes_2021-09-06.docx Page 6 of 10 If printed, this document is only valid for the day of printing. At gestational age 23+0 – 23+6 weeks:  Single course of corticosteroids should be considered in women when preterm birth is planned or expected within the next seven days, even if birth is likely within 24 hours, only once a full review has been made and if a plan has been made for ‘active intervention’ (Refer to section 12 (Threatened and active PTL at