Is there a Role for Antenatal Corticosteroids in Term Infants before Elective Cesarean Section?

Arruda, Augusta; Ormonde, Mariana; Stokreef, Sarah; Fraga, Beatriz; Franco, Catarina; Dâmaso, Catarina; Lima, Ana

doi:10.1055/s-0041-1726055

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Revista Brasileira de Ginecologia e Obstetrícia

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Sumário

Original Article • Rev. Bras. Ginecol. Obstet. 43 (04) • Apr 2021 • https://doi.org/10.1055/s-0041-1726055 copy

Is there a Role for Antenatal Corticosteroids in Term Infants before Elective Cesarean Section?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

Cesarean section (CS) delivery, especially without previous labor, is associated with worse neonatal respiratory outcomes. Some studies comparing neonatal outcomes between term infants exposed and not exposed to antenatal corticosteroids (ACS) before elective CS revealed that ACS appears to decrease the risk of respiratory distress syndrome (RDS), transient tachypnea of the neonate (TTN), admission to the neonatal intensive care unit (NICU), and the length of stay in the NICU.

Methods

The present retrospective cohort study aimed to compare neonatal outcomes in infants born trough term elective CS exposed and not exposed to ACS. Outcomes included neonatal morbidity at birth, neonatal respiratory morbidity, and general neonatal morbidity. Maternal demographic characteristics and obstetric data were analyzed as possible confounders.

Results

A total of 334 newborns met the inclusion criteria. One third of the population study (n=129; 38.6%) received ACS. The present study found that the likelihood for RDS (odds ratio [OR]=1.250; 95% confidence interval [CI]: 0.454-3.442), transient TTN (OR=1.,623; 95%CI: 0.556-4.739), and NIUC admission (OR=2.155; 95%CI: 0.474-9.788) was higher in the ACS exposed group, although with no statistical significance. When adjusting for gestational age and arterial hypertension, the likelihood for RDS (OR=0,732; 95%CI: 0.240-2.232), TTN (OR=0.959; 95%CI: 0.297--3.091), and NIUC admission (OR=0,852; 95%CI: 0.161-4.520) become lower in the ACS exposed group.

Conclusion

Our findings highlight the known association between CS-related respiratory morbidity and gestational age, supporting recent guidelines that advocate postponing elective CSs until 39 weeks of gestational age.

Keywords:
elective cesarean section delivery; neonatal outcomes; antenatal corticosteroids

Major indication for elective cesarian section (n = 334)
Previous uterine surgery	138 (41.3%)
Fetal malpresentation and malposition	85 (25.5%)
Unspecified	63 (18.8%)
Maternal contraindication for vaginal delivery	28 (8.4%)
Pregnancy associated comorbidity	12 (3.6%)
Suspected fetal macrosomia	8 (2.4%)

Perinatal data
	All (n = 334)	Group with antenatal corticosteroids (n = 129)	Group without antenatal corticosteroids (n = 205)	p-value ^* * P-value represents χ2 or Fisher test statistics of comparison among two groups for categorical variables
Gestational age				< 0.001
(weeks)
37 0/7–37 6/7	69 (20.7%)	42 (32.1%)	27 (12.9%)
38 0/7–38 6/7	265 (79.3%)	87 (67.9%)	178 (87.0%)
Birthweight (grams)				0.12
≥2500	312 (93.5%)	117 (90.7%)	195 (95.2%)
< 2500	22 (6.5%)	12 (9.3%)	10 (4.9%)
Gender	F 185 (55.4%) M 149 (44.6%)	F 78 (60.5%) M 51 (39.5%)	F 107 (52.2%) M 98 (47.8%)	0.120

Maternal demographic and obstetric data
Variables	All (n = 334)	Group with ACS (n= 129)	Group without ACS (n = 205)	p-value ^* * P-value represents χ2 or Fisher test statistics of comparison among two groups for categorical variables
Age (years old) > 34 20–34 ≤ 20	129 (38.6%) 206 (61.7%) 9 (2.7%)	59 (45.7%) 68 (52.7%) 2 (1.6%)	70 (34.1%) 138 (67.3%) 7 (3.4%)	0.08
Ethnicity Caucasian African American Others	305 (98.4%) 4 (1.2%) 1 (0.3%)	121 (99.2%) 1 (0.8%) 0 (0%)	190 (98%) 3 (1.5%) 1 (0.5%)	0.604
Short cervix Yes No	9 (2.7%) 325 (97.2%)	7 (5.4%) 122 (94.6%)	2 (1%) 203 (99%)	0.014
Threatened preterm birth Yes No	19 (5.6%) 315 (94.4%)	15 (11.6%) 114 (88.4%)	4 (2%) 201 (98%)	<0.001
Premature rupture of membranes Yes No	2 (0.6%) 132 (99.4%)	0 (0%) 129 (100%)	2 (1%) 203 (99%)	0.524
Uterine bleeding during pregnancy Yes No	18 (5.4%) 340 (94.6%)	8 (6.2%) 122 (94.6%)	10 (4.9%) 11 (95.1%)	0.602
Oligohydramnios Yes No	7 (2.1%) 327 (97.9%)	3 (2.1%) 126 (97.9%)	4 (2%) 201 (98%)	1.000
Fetal growth restriction Yes No	21 (6.3%) 313 (93.7%)	10 (7.8%) 119 (92.2%)	11 (5.4%) 194 (94.6%)	0.382
Previous preterm birth Yes No	12 (3.6%) 317 (96.4%)	5 (3.9%) 123 (96.1%)	7 (3.4%) 194 (96.6%)	0.842
Previous birth by cesarean section Yes No	150 (44.9%) 181 (55.1%)	53 (41.1%) 75 (58.9%)	97 (47.3%) 106 (52.7%)	0.256
Arterial hypertension Yes No	56 (16.8%) 278 (83.2%)	31 (24.0%) 98 (76.0%)	25 (12.2%) 180 (87.8%)	0.005
Diabetes Yes No	39 (11.7%) 295 (88.3%)	15 (11.6%) 114 (88.4%)	24 (11.7%) 181 (88.3%)	1.000

Primary Outcomes
Variables	All (n = 334)	Group with ACS (n = 129)	Group without ACS (n = 205)	p-value ^* * P-value represents χ2 or Fisher test statistics of comparison among two groups for categorical variables.
Morbidity at birth
Need for oxygen supplementation Yes No	32 (9.6%) 300 (90.4%)	14 (10.8%) 115 (89.2%)	18 (8.9%) 185 (91.1%)	0.961
Need for IPPV Yes No	28 (8.4%) 304 (91.6%)	11 (8.5%) 118 (91.5%)	17 (8.3%) 186 (91.7%)	0.961
Need for EOT Yes No	5 (1.5%) 327 (98.5%)	1 (0.8%) 128 (99.2%)	4 (1.9%) 199 (98.1%)	0.652
Apgar score at the 1^st minute of life 7–10 0–6	319 (95.8%) 14 (4.2%)	123 (96.9%) 4 (3.1%)	194 (95.1%) 10 (4.9%)	0.425
Apgar score at the 5^th minute of life 7–10 0–6	330 (99.1%) 3 (0.9%)	127 (98.4%) 2 (1.6%)	203 (99.5%) 1 (0.5%)	0.562
Composite morbidity at birth outcome^# # Composite morbidity at birth outcome combines oxygen supplementation, need for intermittent positive airway pressure, need for EOT, Apgar score at the 1st minute of life < 7 and Apgar score at the 5th minute of < 7. Yes No	37 (11.1%) 295 (88.9%)	15 (11.6%) 114 (88.4%)	22 (10.8%) 181 (89.2%)	0.823
Respiratory morbidity in the first 72 hours
Need of oxygen supplementation Yes No	10 (3%) 324 (97%)	5 (3.8%) 124 (96.2%)	5 (2.4%) 200 (97.5%)	0.453
Need for noninvasive respiratory support Yes No	0 (0%) 334 (100%)	0 (0%) 129 (100%)	0 (0%) 205 (100%)	−
Need for invasive respiratory support Yes No	1 (0.3%) 333 (99.7%)	0 (0%) 129 (100%)	1 (0.5%) 204 (99.5%)	1.000
Need for sufactant therapy Yes No	0 (0%) 332 (100%)	0 (0%) 129 (100%)	0 (0%) 203 (100%)	1.000
Newborn RDS Yes No	16 (4.8%) 318 (95.2%)	7 (5.4%) 122 (94.6%)	9 (4.3%) 196 (95.7%)	0.666
TTN Yes No	14 (4.2%) 334 (95.8%)	7 (5.4%) 122 (94.6%)	7 (3.4%) 198 (96.6%)	0.408
Composite respiratory morbidity outcome^† † Composite respiratory morbidity combines need of oxygen supplementation, need of noninvasive respiratory support, need of invasive respiratory support, need of surfactant therapy and newborn respiratory distress syndrome. Yes No	16 (4.8%) 316 (95.3%)	7 (5.4%) 122 (94.6%)	9 (4.4%) 194 (95.6%)	0.681

Secondary Outcomes
Variables	All (n = 340)	Group with ACS (n = 131)	Group without ACS (n = 209)	p-value ^* * P-value represents χ2 or Fisher test statistics of comparison among two groups for categorical variables.
Prolonged hospital staying (in days) 0–5 > 5	329 (98.5%) 5 (1.5%)	128 (99.2%) 1 (0.8%)	201 (98%) 4 (2%)	0.652
Admission at the NIUC				0.436
Yes	7 (2.1%)	4 (3.1%)	3 (1.5%)
No	328 (97.9%)	126 (96.9%)	202 (98.6%)
Nutrition through nasogastric tube				1.000
Yes	5 (1.5%)	2 (1.6%)	3 (1.5%)
No	329 (98.5%)	127 (98.4%)	202 (98.5%)
Jaundice with need for phototherapy Yes No	15 (4.5%) 319 (95.5%)	8 (6.2%) 121 (93.8%)	7 (3.4%) 198 (96.6%)	0.231
Sepsis evaluation Yes No	22 (6.6%) 312 (93.4%)	6 (4.7%) 123 (95.3%)	16 (7.8%) 189 (92.2%)	0.258
Treatment with antibiotics Yes No	7 (2.1%) 327 (97.9%)	2 (1.6%) 127 (98.4%)	5 (2.4%) 200 (97.6%)	0.711
Hypoglycemia Yes No	10 (3%) 324 (97%)	4 (3.1%) 125 (96.9%)	6 (2.9%) 199 (97.1%)	0.928
General neonatal morbidity outcome^# # General neonatal morbidity outcome combines prolonged hospital staying (in days), admission at the neonatal care unit, nutrition through nasogastric tube, jaundice with need for phototherapy, sepsis evaluation, treatment with antibiotics, and hypoglycemia Yes No	38 (11.4%) 296 (88.6%)	14 (10.9%) 115 (89.1%)	24 (11.7%) 181 (88.3%)	0.811

Variables	Crude odds ratio (95%CI)	Adjusted odds ratio (95%CI)
Morbidity at birth
Composite morbidity at birth outcome^# # Composite morbidity at birth outcome combines oxygen supplementation, , need for intermittent positive airway pressure , need for EOT, Apgar score at the 1st minute of life < 7 and Apgar score at the 5th minute of life < 7.	1.083 (0.539–2.173)	0.901 (0.422–1.924)
Respiratory morbidity in the first 72 hours of life
Newborn RDS	1.250 (0.454–3.442)	0.732 (0.240–2.232)
TTN	1.623 (0.556–4.739)	0.959 (0.297–3.091)
Composite respiratory morbidity outcome^† † Composite respiratory morbidity combines need of oxygen supplementation, need of noninvasive respiratory support, need of invasive respiratory support, need of sufactant therapy, newborn respiratory distress syndrome, and transient tachypnea of the neonate.	1.237 (0.449–3.407)	0.727 (0.239–2.216)
General neonatal morbidity
NICU admission	2.155 (0.474–9.788)	0.852 (0.161–4.520)
Prolonged hospital stay (≥ extra days)	0.393 (0.043–3.552)	0.128 (0.012–1.407)
Composite general neonatal morbidity outcome*	0.918 (0.456–1.848)	0.609 (0.282–1.319)

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[1] Address for correspondence Augusta Arruda, Pediatric Department Hospital do Divino Espírito Santo, de Ponta delgada EPER. D. Manuel I Avenue 9500-370, Ponta Delgada, São Miguel, Açores Portugal (e-mail: augusta.A.Arruda@azores.gov.pt).