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Quality Improvement

• QI Toolkits
  • Hospital Acquired Infection Prevention (rev. MARCH 2008)
  • Improving Initial Lung Function: Early CPAP, Surfactant and Other Means - REV. OCTOBER 2011
  • Antenatal Corticosteroid Therapy (rev. OCTOBER 2009)
    • Continuing Education Module
    • Toolkit Revision Summary
  • Postnatal Steroid Administration (rev. 11-2009)
  • Nutritional Support of the VLBW Infant - (rev. DECEMBER 2008)
  • Care and Management of the Late Preterm Infant Toolkit (rev. APRIL 2007)
  • Delivery Room Management Toolkit (revised July 2011)
  • Severe Hyperbilirubinemia Prevention (rev. OCTOBER 2005)
  • Prevention of Perinatal Group B Streptococcus Disease Toolkit (rev. AUGUST 2008)
  • Prevention of Perinatal HIV Toolkit (rev. SEPTEMBER 2008)
  • PQIP Education Committee, Protected
• CPQCC/CCS Healthcare Associated Infection (HAI) Collaborative
• Webcast Recordings
• PQIP Members
• CCS/CPQCC High Risk Infant Follow-up (HRIF) Quality of Care Initiative (QCI)
• Collaborative #2: CPQCC/CCS Breastmilk Nutrition QI Collaborative
• California Association of Neonatologists (CAN) 16th Annual Conference March 5-7, 2010
• CPQCC Members in the News
• Collaborative #3 - Delivery Room Management QI Collaborative
• 2011 NICU QI

Toolkit Revision Summary

SUMMARY OF ANTENATAL CORTICOSTEROID THERAPY TOOLKIT CHANGES
Third Edition, released June 2009

Acknowledgements:

1. First Edition – Release Date, October 2000
   

Authors:

• Elliott Main, MD
• Cele Quaintance, RN, MS
• Malaika Stoll, MD
• David Wirtschafter, MD

     2.  Second Edition - Release Date, July 2001

               Authors:

• Elliott Main, MD
• David Wirtschafter, MD

     3.  Third Edition - Release Date, June 2009

Authors:

• Elliott Main, MD
• Barbara Murphy, RN, MSN

The current NIH consensus statement on antenatal corticosteroid administration offers a clear rationale for antenatal corticosteroid use, and is essentially unchanged from the original consensus statement published in 1994.  These guidelines include:

1. The benefits of antenatal administration of corticosteroids to fetuses at risk of preterm delivery vastly outweigh the potential risks.  These benefits include not only a reduction in the risk of RDS but also a substantial reduction in mortality and IVH.
2. All fetuses between 24 and 34 weeks gestation at risk of preterm delivery should be considered candidates for antenatal treatment with corticosteroids
3. The decision to use antenatal corticosteroids should not be altered by fetal race or gender or by the availability of surfactant replacement therapy.
4. Patients eligible for therapy with tocolytics should also be considered for treatment with antenatal corticosteroids.
5. Treatment consists of two doses of 12 mg of betamethasone given intramuscularly 24 hours apart or four doses of 6 mg of dexamethasone given intramuscularly 12 hours apart. 
   
6. Because treatment with corticosteroids for less than 24 hours can be associated with significant reductions in neonatal mortality, RDS and IVH, antenatal corticosteroids should be given unless immediate delivery is anticipated.
7. In preterm premature rupture of membranes at less than 30 to 32 weeks’ gestation, in the absence of clinical chorioamnionitis, antenatal corticosteroid use is recommended because of the high risk of IVH at these early gestational ages.
8. In complicated pregnancies where delivery prior to 34 weeks’ gestation is likely, antenatal corticosteroid use is recommended unless there is evidence that corticosteroids will have an adverse effect on the mother or delivery is imminent.
   

Several areas of controversy regarding appropriate administration of antenatal corticosteroids identified in the first release of the CPQCC ANS Tool Kit remain, although there has been ongoing research and significant findings that help guide the clinician.

1. As stated in the original ANS Tool Kit, weekly repetitive courses of antenatal steroids are no longer recommended because of concerns for fetal head and somatic growth.  However, in mothers likely to deliver beyond 2 weeks from the primary course and before 34 weeks gestation, research shows that a single “rescue” course of antenatal corticosteroids appears to provide additional benefit. The same medication regimens should be utilized.
2. In selected situations beyond 34 weeks gestational age with an indicated delivery (e.g., placenta previa, prior uterine rupture) in the presence of an immature fetal lung profile, treatment with antenatal corticosteroids can be effective.  The same medication regimens should be utilized.
3. Identification of the safest and most effective steroidal agent has some controversy. The preferred agents, betamethasone and dexamethasone are favored over other forms of steroids because they have both been studied extensively, seem to react in identical fashion and readily cross the placenta.  Either drug is appropriate for antenatal corticosteroid therapy.
4. Antenatal steroids are equally effective in the setting of preterm rupture of membranes.  The upper limit of gestational age for use of antenatal steroids in this population has some controversy.  Some centers with higher rates of chorioamnionitis limit use to under 32 weeks of gestation while others use antenatal steroids up to the standard 34-week limit.

The CPQCC benchmark for the appropriate administration of antenatal corticosteroid therapy is an administration rate of greater than or equal to 85%.

 

ANTENATAL CORTICOSTEROID THERAPY TOOLKIT, REVISED 6/09 - Newsletter Article

Article Text (147.5 KB )

 

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