Intraventricular Hemorrhage and Steroid Use in Very Low Birth Weight Infants
Abstract & Commentary
By John C. Hobbins, MD, Professor and Chief of Obstetrics, University of Colorado Health Sciences Center, Denver, is Associate Editor for OB/GYN Clinical Alert.
Dr. Hobbins reports no financial relationship to this field of study.
Synopsis: Complete course of antenatal corticosteroid therapy was independently associated with decreased risk for severe IVH in singleton and in multiple preterm VLBW infants
Source: Blickstein I, et al. Plurality-dependent risk of severe intraventricular hemorrhage among very low birth weight infants and antepartum corticosteroid treatment. Am J Obstet Gynecol. 2006;194:1329-1333.
After using steroids for many years, it is now clear from randomized trials that betamethasone/dexamethasone can stimulate pulmonic maturity in preterm fetuses. Also, it does seem that steroids can have an independent beneficial effect on the brains of very preterm babies (32 weeks or less) by protecting them against intraventricular hemorrhage (IVH).
A group from Israel published a study addressing the use of steroids to diminish IVH in multiple gestations—something we have been seeing a lot of lately. Blickstein et al culled data from the Israel National Very Low Birth Weight database involving 11,830 very preterm infants (between 24 and 32 weeks) born between 1995 and 2002. From this group, there were 5022 singletons, 1016 twin pairs, and 194 sets of triplets whose newborn special care unit courses were available for study.
Since the authors were predominantly interested in severe IVH, the end points of grade III and IV IVH were chosen. Also, since there has always been a question of whether a “partial dose” of steroids is effective, the authors classified each infant as having been exposed to 1) a full dose (betamethasone 12 mg q 24 h × 2, or dexamethasone 6 mg q 12 h × 4); 2) a partial dose (< 24 hours worth of steroids or > 1 week after steroids were administered); or 3) no steroid treatment.
The incidence of severe IVH was 12.6% and varied between 6.8% of singletons with a complete dose of steroids to 29.3% for triplets with no treatment. Most importantly, the twins and triplets having a complete steroid course fared as well as singletons with a complete course, 9.3%, 8.3%, and 6.8%, respectively. A partial steroid course resulted in an odds ratio for singletons for severe IVH of 1.6, and for twins and triplets, 1.9 and 2.3, respectively. Without steroids the chances of severe IVH more than doubled for singletons and twins and was four times higher for triplets.
The take-home message from this study is that steroids work in multiples, as well as in singletons infants born before 33 weeks gestation, and that, although “some” is not as good as a “full dose,” there does seem to be some protective effect if the infant delivers before a full dose can be administered.
Commentary
I wish that the authors had not included those who delivered after 1 week post-steroid treatment in the “partial” group, since there are data to indicate that repeating steroids after one week is not any more effective than a single dose, and may even be detrimental. Yes, there are data that may suggest a “rescue” dose might be useful if there has been a long interval since the first dose, but certainly the old regimen of weekly steroids should be abandoned.1,2
In any case, the same authors previously showed with the same investigative approach that a partial dose of steroids did not have a beneficial effect on lowering the incidence of respiratory distress syndrome (RDS) in singletons and twins, but, as opposed to another study, found that a full dose was effective in lowering the rate of RDS in multiple births.3,4
Here is the consensus feeling about the use of steroids today in preterm labor:5
- They diminish the incidence of RDS when a full dose is given at 34 weeks or less;
- They are of very questionable value after 34 weeks;
- In premature rupture of the membranes (PROM), they have little effect on the rate of RDS;
- Before 33 weeks of gestation they seem to have some protective effect against severe IVH, whether or not there is PROM (although not all studies have had uniform results6,7);
- Repetitive doses do not increase the efficacy of steroid therapy and may even negatively affect fetal growth, in general, and the fetal brain, in particular.
References
- Hamilton BE, et al. Births: preliminary data for 2003. Natl Vital Stat Rep. 2004;53:1-17.
- Murphy DJ, et al. Cohort study of the neonatal outcome of twin pregnancies that were treated with prophylactic or rescue antenatal corticosteroids. Am J Obstet Gynecol. 2002;187:483-488.
- Blickstein I, Keith LG. The decreased rates of triplet births: temporal trends and biologic speculations. Am J Obstet Gynecol. 2005;193:327-331.
- Blickstein I, et al. Plurality-dependent risk of respiratory distress syndrome among very-low-birth-weight infants and antepartum corticosteroid treatment. Am J Obstet Gynecol. 2005;192:360-364.
- Effect of corticosteroids for fetal maturation on perinatal outcomes. NIH Consensus Statement. 1994;12:1-24.
- Jobe AH. Antenatal steroids in twins. Am J Obstet Gynecol. 2003;188:856.
- Lee MJ, et al. Single versus weekly courses of antenatal corticosteroids in preterm premature rupture of membranes. Obstet Gynecol. 2004;103:274-281.
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