AAMJ, VOL10, NO4, OCT 2013 SUPLL 2

THE EFFECT OF ANTENATAL STEROIDS ON FETAL

OUTCOME AFTER THE 34 WEEKS OF PREGNANCY IN
WOMEN AT HIGH RISK OF PRETERM LABOR
Farid A. Kassab
Department of obstetrics and gynecology, AL-Azhar faculty of medicine

ABSTRACT
Objective:

To assess the effect of prophylactic corticosteroids

administration after 34 weeks until 37 weeks of pregnancy on neonatal

outcomes in women at high risk of preterm labor. Methods: Patients are
classified randomly into two groups: Group (I) include 100 women receive a
single course of dexamethasone after 34 weeks of pregnancy while group (II)
include 100 women coming to emergency unit in labor without taking
dexamethasone after 34 weeks of pregnancy. Results: Regarding maternal age
, gestational age and body mass index there was no statistically significant
difference between both groups . There was statistical significant difference
between both groups regarding APGAR score at one and five minutes and post
delivery

neonatal

complications.

Conclusion:

Steroids

was

given

prophylactically to those who are known to have increased risk of preterm

labor. Antenatal steroids reduced respiratory distress in babies born by
caesarean section at term.
Key words: Steroids Fetal outcome Preterm labor
INTRODUCTION
Preterm delivery is seen in about 7-10 % of pregnancies. Conservative
management is recommended in pregnants after 34 weeks of pregnancy with
possible pulmonary maturatiuon. Advances in perinatology achieved in the last
30 years have not decreased the incidence of preterm delivery but have led to
significant changes in perinatal and neonatal morbility and surrvival (1)
262

Farid A. Kassab

A decrease in the rate of respiratory distress syndrome (RDS) by 50% after

maternal administration of corticosteroids was shown first by legins and howie
.the beneficial effects of a complete course of corticosteroids were found to be
greatest if more than 24 hours and less than 7 days passed between the
adminstration of therapy and delivery there are few data on the neonatal effect
of an incompelete course of antenatal corticosteroids, but they still confirm that
incomplete courses are also beneficial. Therefore we decided to test the efficacy
of a single dose thereby avoiding the need to administer an unnecessary second
dose ,and by this we think that fewer side effects will be encountered (2)
Infants born at term elective caesarean delivery are more likely to develop
respiratory morbidity than infants born vaginally . prophylactic corticosteroids
in singleton preterm pregnancies accelerate lung maturation and reduce the
incidence of respiratory complication.(3)
Maternal administration of synthetic corticosteroids (dexamethasone), is
used for acceleration the maturity of the fetal lung , reduces neonatal
mortality,respiratory distress syndrome , intraventricular haemorrhage and
necrotising enterocolitis in preterm infant (4)
Babies born at term (at or after 37 weeks) by planned (elective) cesarean
section and before onset of labor are more likely to develop respiratory
complication than babies born vaginally .the risk of respiratory complications
mostly respiratory distress syndrome and transient tachypnoea, decrease from
37 to 39 weeks of gestation at which stage it is low (5). The giving of injections
called (corticosteroids) to the mother has been shown to reduce the risk of
newborn babies having breathing problems in babies born before 34 weeks (6).
Steroids would reduce respiratory distress in babies born by elective caesarean
section at term. They concluded that antenatal betamethasone and delaying
delivery till 39 weeks both reduce admissions to special care baby units with
respiratory distress after elective caesarean section at term or give steroids
263

AAMJ, VOL10, NO4, OCT 2013 SUPLL 2

prophylactically to those who are known to have increased risk of preterm labor
(7) .
PATIENTS AND METHOD
This study was carried out prospectively between october 2012 and august
2013 at Al -Azhar university hospitals on 200 pregnant women in their 34th
37th weeks of pegnancy at high risk of preterm labor. Our hospital is a tertiary
care unit where cases are referred to it from all other hospitals and diagnosed as
a cases of preterm labor and other cases came to our outpatient clinic and have
one or more risk factors of preterm labor and have admitted in the hospital . An
informed consent was taken from each patient . these patients are classified
randomly into two groups :
Group I : inculde 100 women receive twice doses of dexamethasone
12mg/12 hours after 34 weeks of gestation.
Group 2: inculde 100 women in labor coming to emergency unit without
taking dexamethasone after 34 weeks of pregnancy . patiants are delivered at
least 24 hours of dexamethasone are included in this study . then assessment of
fetus after delivery by APGAR score , need for neonatal ICU admission and
incidence of hyaline membrane disease .
THIS STUDY INCLUDES
women at high risk of preterm labor& women after 34 weeks of gestation
based on 1st day of last menstrual period & patients with obstetric complication
and severe hypertensive patients and patients who have advanced chronic
disease
METHODS AND MEASUREMENTS
Patients were classified as preterm delivery whenever they met the
following criteria:
Gestational age: Between 34 weeks day 0 - 37 weeks day 0 based on the
mother's 1st day of last menstrual period , fetal biometric measurements of 34264

Farid A. Kassab

37 weeks on abdominal ultrasonograghy (done on admission ) the mother had at

least 2 contractions lasting for more than 30 s in 10 min on cardiotocography ,
and cervical dilatation 1-3 cm with 80% effacement .
The following demographic characteristics of the patients were recorded :
Age , gravidity , parity and gestational age - Examination of the patient was
done including the following :
General examination , abdominal examination and pelvic examinationDuring the therapy tocolysis were given to stop uterine contractions. The
women were clasasified into two groups . ( Group 1) Hundred of patients were
administered 1,5 ampoule\12 hours of dexamethazone intramuscularly twice
doses

(dexamethazone 8mg\2ml ampoule sigma Tec Pharmaceutical

industeries- Egypt-S.A.E.) . the other 100 patients coming to emergency unit in

labor( group II) and did not receive dexamethasone for fetal lung maturation .
patients delivered at least 24 hours after dexamethasone were included in this
study. After delivery, we compared APGAR score at 1 and 5 minutes , the need
for resuscitation and the development of RDS in the neonates as a measurement
of fetal lung maturation . All neonates were examined by a neonatologist and
the diagnosis of RDS was confirmed clinically and radiologically by the
department of neonatology. The diagnosis of RDS was based upon the findings
of respiratory

difficulty that necessitated mechanical ventilation support,

including needing to provide continous positive air way pressure which was
necessary during the first hour of life and lasted for at least24 hours and was
furthermore consistent with typical radiological findings of the lung. Patients
with fetal distress( meconium stained liquor) and who delivered within less than
24 hours were excluded from the study .

APGAR score was developed in

1952 by an anesthesiologist named Virginia APGAR , you may have also heard
it referred to as an acronym for five factors are used to evaluate the babys
condition and each factor is scored on a scale of 0 to 2 Appearance , Pulse ,
265

AAMJ, VOL10, NO4, OCT 2013 SUPLL 2

Grimace , Activity , and Respiration. APGAR test is usually given to a baby

twice: once at 1 minute after birth and again at 5 minutes after birth . if the score
at 5 minutes is low the test may be scored for a third time at 10 minutes after
birth. APGAR scores range from zero to two for each item with a maximum
final total score of ten . At the one minute APGAR scores between seven and
ten indicate that the baby will need only routine post delivery care. Scores
between four and six indicate that some assistance for breathing might be
required . Scores under four can call for prompt , life saving measures. At the
five minute APGAR score of seven to ten is normal. If the score falls below
seven, the baby will continue to be monitored and retested every five minutes
for up to twenty minutes.
RESULTS
In table (1) in group I age ranged 20-38 with mean value 27.6 7.754 while
in group II age ranged 19-37 with mean value 28.8 6.25. Regarding maternal
age there was no statistical significant difference between the two studied
groups. (P > 0,05). In group I, gestational age ranged 34 -37 with mean value
36.2 1.03 . there was no statistical significant difference between the two
studied groups regarding gestational age (P > 0.05). in group I body mass
index ranged 23.3- 29.5 with mean value 26.52 1.23 while in group II ranged
22.1 -28.6 with mean value 25.1 0.98 .there was no statistical significant
difference between the studied groups regarding body mass index (P > 0.05)
TABLE (2) In group I APGAR score at 1 Min ranged 3-10 with mean
value 7.982.65 while in group II ranged 3-9 with mean value6.13 3.023. In
group I, APGAR at 5 min ranged 4-10 with mean value 8.92 2.07 while in
group II ranged 3-10 with mean value 7.0912 2.11. there was statistical
significant difference between the two studied groups regarding the APGAR
score at 1 and 5 min (P < 0.05)

266

Farid A. Kassab

Table (3) neonatal require resuscitation in group I were 14 (14%) while in

group II were 32 (32%). RDS in group I were 4 (4%) while in group II were 16
(16%) . There was statistical significant difference between the studied groups
regarding the post delivery foetal c
Table (1): comparison between the two studied groups regarding age and
gestational age and body mass index.
Age
Range
Mean
S.D. :
Gestational age
Range :
Mean :
S.D. :
BMI
Range :
Mean :
S.D. :

Group I

Group II

20.38
27.6
7.75

19-37
28.8
6.25

34-37
36.2
1.06

34-37
35-.6
1.03

23.3 29.5
26.52
1.23

22.1-28.6
25.1
0.98

P
0.255

0.243

0.685

Table(2): comparison between the two studied groups regarding the

APGAR score at 1 and 5 min.
APGAR score
I. at 1min
Range :
Mean :
S.D. :
II. at 5min
Range :
Mean :
S.D. :

Group I

Group "II

3-10
7.98
2.65

3-9
6.13
3.02

4-10
8.92
2.07

3-10
7.01
2.11

267

P
0,013*

0.001*

AAMJ, VOL10, NO4, OCT 2013 SUPLL 2

Table(3): comparison between the two studied groups regarding the post
delivery neonatal complications
Group I
Require resuscitation
RDS

GroupII
P

NO.
14

%
14.0

NO.
32

%
32.0

0.0133*

4.0

16

16.0

0.021*

DISCUSSION
Antenatal

glucocorticoids have been used for 30 years to induce

maturation of fetal preterm lung. Stimulation of pulmonary surfactant system

has been regarded as the the most important effect of antenatal glucocorticoids
(8). Maternal steroid treatment before preterm delivery is one of the best
documented and most cost effective life saving treatments in prenatal medicine
(9).

In agreement with our study, Osman B et al (10). Study 100 pregnant

women in their 34 -36 weeks of pregnancy who were diagnosed as susceptible

to have preterm labor . Fifty patients not receive betamethasone (control l
group).the other 50 patients were administrated 12 mg betamethsone in a single
dose. Patients are deliverd at least 24 hours of betamethasone administration
are included in this study. Then assessment of fetus after delivery APGAR
score, need for neonatal IC-U admission and incidence of hyaline membrane
disease. Osman Balci found that the mean age of patients in control group was
27.43.71 years and in the intervention group was 27.1 3.71 years. There were
no statistical significant differences between the two groups. As regarding the
APGAR score at 1 and 5 minutes . in our study: In group I, APGAR score at 1
minute ranged 3-10 with mean value 7.98 2.65 while in group II ranged 3-9
with mean value6.13 3.02. In group I , APGAR score at 5 minutes ranged 410 with mean value 8.92 2.07 while in group II ranged 3-10 with mean value
7.02 2.11 . With agreement with Osman B et al APGAR score at 1 minute
was7.4080.85 and 7.860.78. APGAR score at 5 minutes was 7.98 .74 and
268

Farid A. Kassab

8.60 0.75 for group I and group II ,

respectively. Group II babies had better

APGAR scores when compared to group I,and the difference was statistically
significant(p < 0.oo6at 1 minute and p < 0.oo1 at 5 minutes(10).Regarding the
post delivery foetal complication : neonates require resuscitation in group I were
14 (14%) while in groupo II were 32 (32%). RDS in group I were 4 (4%) while
in group II were 16 (16%). There was statistical significant difference between
the two studied groups regarding the post delivery foetal complication. With
disagreement with our study Ana Maria. et al 2011 study 320 women between
34-36 weeks of gestation were randomized, 163 of whom were assigned to the
treatment group and 157 to the controls. Final analysis included 143 and 130
infants ,respectively. The rate of respiratory distress syndrome was low
two(1.4%) in the corticosteroid group and one (0.8%) in the placebo group.
Treatment with corticosteroids failed to reduce the risk of any respiratory
morbidity . necessity for ventilatory support was also similar, about 28 cases
(20%)in the corticosteroid group and 24 cases (19%)in the placebo group. This
study shows that antenatal treatment with corticosteroid in women at 34-36
weeks of pregnancy at risk of imminent premature delivery is ineffective in
reducing respiratory disorders in the babies(11). In agreement with our study,
Arnon et al, analysed 207 patients who gave birth at 34-36 weeks of gestational
age and did not receive antenatal corticosteroids. They found that antenatal
complications were prevalent in these patients, 20% of the neonates were
admitted to a neonatal intensive care unit. Therefore they concluded that labor
should not be induced at 34 and 35 weeks of gestation and that tocolytic agents
and maternal prenatal steroids may be considerd in preterm delivery during
this period (12). In agreement with our study, shanks et al studied pregnancies
between 34-36 weeks under going

amniocentesis to determine fetal lung

maturity. Women with negative fetal lung maturity were randomely assigned to
intramuscular glucocorticoids injection or no treatment, the researchers
269

AAMJ, VOL10, NO4, OCT 2013 SUPLL 2

concluded that a single course of intramuscular glucocorticoids after 34 weeks

in pregnancies with documented fetal lung immaturity significantly increases
fetal lung maturity and decrease the neonatal morbidity (13).

CONCLUSIONS
Steroids have a significant benefit on fetal wellbeing even if used after 34
weeks of pregnancy. Steroids was given prophylactically to those who are
known to have increased risk of preterm labor. Antenatal steroids would reduce
respiratory distress in babies born by caesarean section at term

270

Farid A. Kassab

REFERENCES
(1) Harald L, Barbara Bonder-Adler, Msthias Brunbuer , Alexandra K,
Chrristian E Peter H (2003):

Bacterial vaginosis as a risk factor for

preterm delivery. Ameta analysis. Am J Obstet Gynecol. 189:139-47.

(2) Costa , Zecca E, De Luca D, De Carolis MP , Romagnoli C (2007) :
Efficacy of a single dose of antenatal corticosteroids on morbidity and
mortality of preterm infants , Eur J Obstet Gynecol Reprod Biol 2007 :
131: 154-257.
(3) Ballard PL and Ballard RA (1995). Scientific basis and therapeutic regimens
for use of antenatal glucocorticoids Am J . Obstet Gynecol : 173:254-262.
(4) Sotiriadis A, Makrydimas G, Papatheodorou S , Ioannidis JPA (2009).
Corticosteroids for preventing of neonatal respiratory morbidity after
elective caesarean section at term. Cochrane Database of Systematic
Reviews , Issue 4 . Art. No: CD006614. DOI: 10. 1002l 14651858.
CD006614.
(5) Gyamfi-Bannerman C, Gilbert S , Landon MB, Spong CY, Rouse DJ,et al.
(2012):

Effect of antenatal corticosteroids on respiratory morbidity in

sigletons after late preterm birth . Obstet Gynecol;119:555-559.

(6) American College of Obstetricians and Gynecologists (2013) : Cesarean
delivery on maternal request . Committee Opinion No. 559. American
College of Obstetricians and Gynecologists. Obstet Gynecol ;121 :904-7.
( 7) Stutchfield PR , Rhiannon Whitaker ,Ian Russell(2006) . Antenatal steroids
for elective Caesarean Section, BMJ ; 331 :662-4.
(8) Crowther CA and Harding JE (2008): Repeated doses of prenatal
corticosteroids for women at risk of preterm birth for preventing neonatal
271

AAMJ, VOL10, NO4, OCT 2013 SUPLL 2

respiratory disease. Cochrane Database of Systematic Reviews ;Issue 3.

Art. No.:CD CD 003935.
(9) Marciniak B , and Patro- Malysza J (2011). Glucocorticoids in pregnancy.
Curr

Pharm Biotechnol. 2011 Feb 22.

(10) Balci O , 0zdemir S, Mahmoud AS , (2010) : The effect of antenatal

steroids on fetal lung maturation between the 34th and 36th week of
pregnancy. Gynecol Obstet Invest. 2010 :70 (2):95-9 Pub 2010 Mar17.
(11) Ana Maria Feitosa Porto , I.C. Coutinho J. B.. Correia and M. M.R.
Amorim,(2011) Effectiveness of antanatal corticosteroids in reducing
respiratory disorders in late preterm infants :randomised clinical trial,
British Medical Journal, vol. 342, no.7802, Article Idd1696.
(12) Arnon S , Dolfin T, Litmanovitz I, Regev R, Bauer S,Fejgin M,(2001)
Preterm labor between 34- 36 weeks of gestation :should it be arrested?
Pediatr. Perinat. Epidemiol :15:252-256.
(13) Shanks A, GrossG, Shim T ,Allsworth J , Sadovsky Y , Bildirici I .
(2010).. Administration of steroids after 34 weeks of gestation enhances
fetal lung maturity profiles, Am

Epub2010 .

272

Obstet

Gynecol: 203(1)47.el-5.