Antenatal corticosteroid use in preterm birth at Kenyatta National Hospital

Abstract

Background: Preterm birth causes about 75% of neonatal deaths that are not attributable to congenital malformations. Antenatal corticosteroids (ACS) given to mothers at risk of preterm birth reduce the incidence/severity of RDS, intraventricular haemmorhage, necrotizing enterocolitis and neonatal deaths. The WHO recommends use of antenatal steroids for all pregnant women 26-34 weeks gestation at risk of preterm delivery and after 34 weeks gestation only if there is evidence of fetal pulmonary immaturity. Despite this, ACS are widely used locally
across all gestational periods.
Objective: To determine the frequency of administration and impact of ACS in reducing the morbidity and mortality in preterm neonates born 28- 37 weeks gestation at Kenyatta National Hospital.
Design: This was a hospital-based retrospective cohort study.
Setting: Kenyattah National Hospital labour ward, antenatal wards, NBU, NICU.
Methods: The study compared the neonatal outcomes of mothers with preterm birth who received antenatal steroids and those who did not receive. The study populations were mothers with preterm birth due to preterm labor, PPROM and severe pre eclampsia and their neonates. Mothers who met the inclusion criteria were recruited immediately after delivery, interviewed, medical records scrutinized and information obtained entered into a questionnaire. Neonates were followed until discharge/death/ 7^th day whichever came earlier. The outcome measures considered were the occurrence and severity of RDS, NBU admissions and neonatal deaths.
Results: Two hundred and six mother/neonate pairs were recruited. Overall 35% of mothers/neonates were exposed to ACS. Forty six percent of those who delivered <34 weeks received ACS compared to 26% of those who delivered >34 weeks. Only 3% of mothers received a complete course of ACS. ACS significantly reduced the
occurrence and severity of RDS in preterm neonates up to 34 weeks gestation. Sixty eight percent of neonates delivered before 34 weeks and not exposed to ACS developed RDS compared to 38% of those exposed (RR 0.6, 95% CI 0.4-0.9, P= 0.005). Exposure to ACS >34 weeks gestation did not reduce occurrence and severity of RDS. Forty percent of those exposed to ACS developed RDS compared to 37% of those not exposed (RR 1.2 95% CI 0.7-1.8, P =0.755). ACS reduced neonatal mortality across all gestational ages. The neonatal mortality within 7 days of life was 26% among those exposed to ACS <34 weeks compared to 38% among those not exposed (RR1.2, 95% CI 0.9-1.6, p=0.224). for those delivered after 34 weeks mortality was 3.3% in the exposed group compared to 9.2% in the non exposed group (RR 1.1 95%CI 1.0-1.2 p=0.443). ACS did not reduce NBU/NICU admissions across all gestational ages. Eighty five percent of neonates exposed to ACS before 34 weeks were admitted to NBU compared to 71% of those not exposed (RR1.2, 95% CI 1-2.1, p=0.113). Fifty percent of neonates exposed to ACS after 34 weeks were admitted to NBU compared to 32.2% of those not exposed (RR 1.3
95% CI 0.9-2.1, p=0.225).
Conclusions: ACS are underutilized. ACS significantly reduce the incidence/severity of neonatal RDS and mortality <34 weeks gestation.
Recommendations: There is need to upscale the utilization of ACS. The study provides local evidence to discourage routine use of ACS >34 weeks.