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האיגוד הישראלי לניאונטולוגיה
Antenatal Steroid Use: Drilling down on the audit process

To           Manny, Ido and Adina

CC           Shmuel

Subj:      Antenatal Steroid Use: Drilling down on the audit process

Date:     May 30, 2019

 

Well this started out for me as a simple self-imposed task:  how do our ANS use rates compare with others? And How do others conduct their audits to better understand the challenges of improving these rates.  To my great delight and interest, I was pleased that others had pushed beyond the simple audit forms we first introduced 20 years ago and that some very creative thinking has been addressing this topic more recently.  The headline for this report is that:  THE GOAL POSTS HAVE BEEN MOVED!   (Not sure how this  American football saying gets best translated into the Hebrew context—maybe they have moved the basketball goal and made it higher!)

In particular:

  1.  “Complete ANS” now is being transformed into ANS dosing >48 h and < 7d  and, when appropriate, a “rescue” dose given.
  2. Audits and care planning aids should ideally identify and address the varied scenarios which confront the clinicians, e.g.

Levin et al:  Major Findings:  For the majority of women in this cohort, ACS timing was

suboptimal. In particular, two groups of women who ultimately

delivered preterm were unlikely to have optimally

timed steroids: (1) women who were asymptomatic but

received steroids for increased risk for spontaneous preterm

birth based on a positive fetal fibronectin, short ultrasound

cervical length or asymptomatic cervical dilation; and (2)

women presenting with abruption and/or vaginal bleeding.

Patients with hypertensive disorders were most likely to

receive optimally timed steroids, although this was not statistically

significant in the adjusted analysis. In addition to

optimal timing rates varying across different indications,

the timing of suboptimal administration —early or late—

was different across groups. Asymptomatic women at

increased risk for spontaneous preterm birth and women

with abruption/bleeding were much more likely to receive

steroids administered early, rather than late. Patients with

hypertensive disorders and preterm labour had a relatively

higher percentage of suboptimal timing cases due to late

administration (<24-hour interval to delivery) rather than

early administration (≥7 days).

How might this apply to the proposed breakout session?  Several of these articles start from the raw material of hundreds of ANS audits, a situation we have not reached yet in our project work.  Thus, you may want to pose two or three of these clinical scenarios to attendees as “how would you implement a “Plan/Do/Study/Act” cycle that would improve ANS preparation for patients presenting with each of these scenarios.

Oh by the way, below is the TABLE that compares “old” versus “new” ANS performance table.

 

 

Ref_au

Ref_Journal

Site

Number

NO ANS

  ANY    ANS

PARTIAL

COMPLETE ANS

 

 

 

 

 

 

 

"OLD"

OPTIMAL

 

 

 

 

 

 

<24 hr  PTD

2 DOSES OVER 24hr

2 DOSES 1-7d PTD

2 DOSES > 48 h < 7d PTD

RESCUE DOSE > 7d

Melamed

ACOG_2015

CANADA

2126

15.2

85

21.6

63.1

45.8

 

17.3

 

 

 

 

 

 

 

 

 

 

 

Travers

AJOG 2018

NICHD

2282*

6.6

93.4

22.7

70.8

na

na

na

 

 

 

 

 

 

 

 

 

 

 

Levin

BJPG 2015

NEW YORK

630

7

93

?

?

na

37.8

13.8

 

 

 

 

 

 

 

 

 

 

 

PMB Project

Draft Report yr 01

ISRAEL

140

12

88

22.5

65.5

7.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*24-28wksGA

 

 

 

 

 

 

Ok ,  that’s it.  My rough notes follow and the articles are also attached in the email.

David

 

 

 

 

 

DW on preliminary inquiry of ANS results in Israel—

 

1st cut of unverified Isr entries to PMB dataset showed 144 records in which ANS status was noted. (3 without).  Of these, 130 (90%  showed “ANY ANS”, 93 reported as “complete” courses (73%) and 32 (25%) “as incomplete”

 

 

 

 

 

 

 

 

 

 

t participating centers of the National Institute of Child Health and Human

Development Neonatal Research Network between January 2006 and December 2011

 

Re-iterates importance of ANS—not relevant here

Association of Neurodevelopmental Outcomes

and Neonatal Morbidities of Extremely Premature Infants

With Differential Exposure to Antenatal Steroids

Sanjay Chawla JAMA peds 2016

 

 

 

Among the no, partial, and complete ANS groups, there were significant differences in the rates of mortality (43.1%, 29.6%, and 25.2%, respectively), severe intracranial hemorrhage among survivors (23.3%, 19.1%, and 11.7%), death or necrotizing enterocolitis (48.1%, 37.1%, and 32.5%), and death or bronchopulmonary dysplasia (74.9%, 68.9%, and 65.5%). Additionally, death or neurodevelopmental impairment occurred in 68.1%, 54.4%, and 48.1% of patients in the no, partial, and complete ANS groups, respectively

Results

Between 2006 and 2011, 8847 infants with a GA of 27 weeks

or less were born at NRN centers. Of these, 700 infants died

within 12 hours without receiving aggressive neonatal care. A

total of 2026 infants were not eligible for follow-up; 79 had

weights greater than 1000 g, 1574 had Gas more than 26 weeksfor infants born after 2007, 372 were outborn, and 1 had an unknown status. Follow-up data were available for 3892 of 4284eligible extremely low GA neonates (90.8%) (Figure)

 

 

 

 

 

 

 

 

24 0/7 and 33 6/7

weeks of gestation and admitted to tertiary neonatal

units in Canada during 2010–2012 were obtained from

the Canadian Neonatal Network

Melamed Lee Canadian Network ACOG 2015

No Antenatal

Corticosteroids

324

 

Gestational age 28 wk or less

ANS

Less Than 24 Hours

460

 

 

Gestational age 28 wk or less

ANS

1–7 Days

 

974

 

Gestational age 28 wk or less

ANS

Greater Than 7

Days

368

 

Gestational age 28 wk or less

Of 6,870 eligible neonates, 1,378 (20%)

received no antenatal corticosteroids; 1,473 (21%) received partial antenatal corticosteroids; 2,721 (40%) received antenatal corticosteroids 1–7 days before

birth; and 1,298 (19%) received antenatal corticosteroids greater than 7 days before birth

 

 

 

 

 

CANADA--2010-2012

 

 

 

No Corticosteroids

Less Than 24 Hours

1–7 Days

Greater Than 7 d

 

15.2%

21.6%

45.8%

17.3%

 

Non-Optimal

 

OptimaL

 

54.2%

 

45.8%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mortality and pulmonary outcomes of extremely preterm infants exposed to antenatal corticosteroids.

 

Travers  NICHD Am J Obstet Gynecol. 2018

1,022 infants 22 0/7 to 28 6/7 weeks' gestational age with a birthweight of ≥401 g born from Jan. 1, 2006, through Dec. 31, 2014, were analyzed

 

 

 

Infants exposed to any antenatal corticosteroids had a lower rate of death (2193/9670 [22.7%]) compared to infants without exposure (540/1302 [41.5%]) (adjusted relative risk, 0.71; 95% confidence interval, 0.65-0.76; P < .0001). Infants exposed to a partial course of antenatal corticosteroids also had a lower rate of death (654/2520 [26.0%]) compared to infants without exposure (540/1302 [41.5%]); (adjusted relative risk, 0.77; 95% confidence interval, 0.70-0.85; P < .0001)…

This study was

also designed to determine if exposure to

a partial or a complete course of

antenatal corticosteroids is associated

with improved survival and pulmonary

outcomes in extremely preterm infants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Variability of Very Low Birth Weight

Infant Outcome and Practice in

Swiss and US Neonatal Units

Mark Adam  peds 2018

 

 

Has vlbw inf  and crude percentage .. not really useful

 

We observed a wide variability in

some of the obstetric, DR, NICU, and

nutritional practices between the SNN

and US-VON. After adjustment for

case mix and indirect standardization

using US-VON infants as reference,

the SNN had a higher than expected

use of antenatal steroids, a practice

well-known to improve outcome.‍

33

In the DR, stabilization on continuous

positive airway pressure rather than

intubation was higher in the SNN, for

which recent large trials reveal a lower

risk of CLD or death.‍

34 On the ward,

the SNN also used less

 

 

 

 

 

 

 

 

 

WONG  Antenatal corticosteroids administration: are we giving them

at the right time?  Arch on GYN 2018

Overall, our antenatal corticosteroids administration

rate is comparable to that attained by centres in other

developed countries. It is difficult but important to discriminate

women who will benefit from this timely intervention

 

 

24  Levin HI, Ananth CV, Benjamin-Boamah C, Siddiq Z, Son M,

Friedman AM (2016) Clinical indication and timing of antenatal

corticosteroid administration at a single centre. BJOG

123(3):409–414

Amongst the preterm deliveries, 50.3% women had presented

at gestation age ≤ 34+6 to the delivery suite triage

unit. Of these, 85.9% had received at least one dose of

antenatal corticosteroids, as shown in Fig. 1. Only 22.1%

had delivered within the window of efficacy (≥ 48 h to

≤ 7 days after the first dose of antenatal corticosteroids).

A large proportion of preterm deliveries who presented

at gestation age ≤ 34+6 (45.7%) did not receive adequate

exposure to antenatal corticosteroids before birth (either

Arch Gynecol Obstet (2018) 297:373–379 375

1 3

not given or delivered less than 48 h after the first dose of

corticosteroid). No repeat courses of antenatal corticosteroids

were administered.

Based on our KKH regime, an additional of 38 women

who had presented between 35+

0 and 36+

0 weeks’ gestation

received antenatal corticosteroids (12.8% of all

preterm deliveries). Out of these 38 women, 16.1% had

delivered within the window of efficacy.

Amongst the term deliveries, 5.42% had received a

course of antenatal corticosteroids at preterm gestations.

Overall, 1 in 2.2 antenatal corticosteroids courses had been

administered to women who eventually delivered at term.

The top indications for antenatal corticosteroids for the

preterm deliveries in our centre were spontaneous preterm

labour (PTL) (38.9%), preterm premature rupture of

membranes (PPROM) (25.7%) and hypertensive disorders,

where early delivery was indicated (13.9%) (Table 1

In our study, we found that gestational

age at presentation, the presence of regular uterine

activity on tocography and cervical change is associated

with delivery within 1 week

 

Such models may be adapted for validation in our centre

and form the basis of a protocol to aid doctors in decisionmaking.

The New York Centre [24], who reported the best

optimal timing of corticosteroids so far in 40% of their

women, had a defined policy and procedures for corticosteroid

administration.

 

 

 

 

 

 

 

 

LEVIN  BJOG. 2016 Feb;123(3):409-14. doi: 10.1111/1471-0528.13730. Epub 2015 Oct 20.

Clinical indication and timing of antenatal corticosteroid administration at a single centre.  Levin HI1, Ananth CV1,2, Benjamin-Boamah C1, Siddiq Z1, Son M1, Friedman AM1.

Columbia  NEW YORK

 

 

MOVES ANS SURVEILLENCE FROM ANY ANS PRIOR TO PRETERM BIRTH

TO OPTIMAL TIMING OF PRETERM BIRTH

 

NOTES THAT A SIX YEAR EFFORT WAS NEEDED TO MOVE RESCUE DOSING FROM 40% TO 80%

 

 

Of 630 women who delivered preterm, 589 (93%) received ACS prior to delivery. ACS timing was optimal in 40% (238 of 589) of cases. Women with hypertensive disorders were most likely to have steroids optimally timed (62%). Asymptomatic women at increased risk for preterm delivery were less likely to receive optimally timed ACS (12%). The majority of women who received steroids >2 weeks prior to delivery (57%) received a second course

 

 

 

versus

 

 

 

 

Antenatal corticosteroid timing: accuracy after the introduction of a rescue course protocol

N K Makhija

American journal of obstetrics and gynecology. , 2016, Vol.214(1), p.1200-6

 

PROSPECTIVE TOOL—DEVELOPMENT

 

Seattle

 

 

 

A cautionary tale :  b/c of how the difficulty of predicting preterm delivery and its effect on ordering ANS appropriately

 

 

No usable data

The opportunity for a second course of antenatal

corticosteroid did not improve the number of women who delivered within

any optimal antenatal corticosteroid window. Administration timing was

similar for the initial course and the rescue course, with approximately

one-quarter of women delivering within the optimal antenatal corticosteroid window. These findings likely reflect the few circumstances in which

rescue antenatal corticosteroid is useful and the poor predictability of

preterm birth. Future focus should be aimed at tools to predict the timing of

preterm birth to optimize antenatal corticosteroid administration

 

 

 

 

 

 

 

 

Antenatal corticosteroids administration: are we giving them

at the right time?

Tifany Tuck Chin Wong  arch ob gyn 2018

 

 

 

good discussion of audit and  analysis but definitions are enough differrent as to make it difficult to combine  into a summary table so I omitted from the table

 

very practical approach (I think but then again I am not  an  OB!

 

 

Results 85.9% of women who delivered at gestational

age ≤ 34+6 received at least one dose. 22.1% had delivered

within the window of efcacy. Gestational age > 32 weeks

at presentation, uterine activity on tocography and cervical dilation with efacement were associated with preterm

delivery within 1 week of presentation.

Conclusion Overall, our antenatal corticosteroids administration rate is comparable to that attained by centres in other

developed countries. It is difcult but important to discriminate women who will beneft from this timely intervention.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

           

 

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