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  1. 1. dnbpaediatrics.blogspot.inSTEROIDS IN PERINATALMEDICINEDr Sushmita GhoshDNB PediatricsBhilai Steel Plant Hospital
  2. 2. Definition Perinatal period- period from the 28th week of gestation through the 7th day of life Extended perinatal period-extends from 22nd wk of gestation to 7th day of life. dnbpaediatrics.blogspot.in
  3. 3.  Steroids are one of the most potent drugs in neonatology Steroids have immediate physiologic effects on lung function of preterm infants (Halliday biol neonate 1999) Survey shows 95% neonatologists use steroids in preterm infants at risk of CLD (Bull et al,Clin Res 1993) dnbpaediatrics.blogspot.in
  4. 4. INDICATIONS Antenatal steroids for lung maturation Postnatal steroids for CLD(BPD) Post extubation laryngeal oedema Ionotrope resistant hypotension Resistant or persistant hypoglycemia Primary adrenal insufficiency Surgical conditions dnbpaediatrics.blogspot.in
  5. 5. Antenatal steroidsHelps in transition to air breathing by- Acceleration of maturation of developmentally regulated proteins Stimulate cytodifferentiation in type II pneumocytes production of surfactant, lung compliance and maximal lung volume Reduces protein leak Accelerate clearance of lung liquid Preffered –betamethasone dnbpaediatrics.blogspot.in
  6. 6. Recommendation All pregnant women between 24-34 wks gestation at risk of delivering within 7 days- single course of corticosteroids Betamethasone 12 mg im 2 doses 24 hrs apart Betamethasone better than dexamethasone because it lowers risk of cystic periventricular leukomalacia and it significantly decreases neonatal death dnbpaediatrics.blogspot.in
  7. 7. BENEFITS RDS IVH NEC Pneumothorax Severe ROP PDA Perinatal Mortality dnbpaediatrics.blogspot.in
  8. 8. Effect On BPD?DOES NOT ALTER INCIDENCE OFBPD dnbpaediatrics.blogspot.in
  9. 9. Benefits of ANS not affected by-race/gender-presence of PROM-there is no incidence of maternal and neonatal infection-no alteration in lung mechanics-on follow up there was no problem with general health-no neurodevelopmental delay dnbpaediatrics.blogspot.in
  10. 10. CHRONIC LUNG DISEASE What is CLD/BPD? Infants born at <32 wks gestation who remain in 02 for the first 28 days, At 36 wks PMA -Mild BPD-no 02 requirement -Mod BPD-supplemental 02 requirement <30% -severe BPD ≥30% 02,CPAP or ventilatory support dnbpaediatrics.blogspot.in
  11. 11. Infants born at ≥32 wks gestation BPDdefined as supplemental 02 requirementfor the first 28 days with severity levelbased on 02 requirement at 56 days dnbpaediatrics.blogspot.in
  12. 12. EPIDEMIOLOGY infants <1250 grams birth weight are the most affected risk is less in girls and african - americans dnbpaediatrics.blogspot.in
  13. 13. Pathogenesis dnbpaediatrics.blogspot.in acute lung injury proinflammatory cytokines (IL 1β,IL-6,IL-8,TNF- α) leakage of water and protein emphysematous changes collapse, hyperinflation ,peripheralairway dilation
  14. 14. chronic phase of lung injuryrelease of growth factorsfibrosis, cellular hyperplasiapulmonary fluid retentionlung Cs, airway resistance ventilation perfusion mismatch dnbpaediatrics.blogspot.in
  15. 15. Chronic lung disease Systemic steroids reduce pulmonary inflammatory mediators inhibit synthesis of prostaglandins and fibronectin enhanced surfactant synthesis anti-oxidant production stabilization of lysosomal and cellular membranes dnbpaediatrics.blogspot.in
  16. 16. Postnatal steroids for prevention of CLD Group benefits Adverse effects Late outcomesEarly(<96 •Earlier extubation • GI Haemorrhage •Cerebral palsy • pda • Intestinal •Abnormalhrs) perforation neurological • severe rop • death or CLD • Hyperglycemia examination • hypertensionModerately •Earlier extubation • hypertension •No adverse • mortality and CLD at • Hyperglycemia increase inearly(7-14 neurological 28 days and/or 36 wks • GI bleedingdays) outcome • Infection • Hypertrophic cardiomyopathyDelayed(>3 • failure to extubate • glycosuria No increase in major • CLD or death at 36 • hypertension neurosensoryweeks) disability death wks • ROP • need for late rescue therapy with steroids •discharge to home dnbpaediatrics.blogspot.in with o2
  17. 17. Other Treatment Modalities Of BPD -Vitamin A(5000 U IM) for Prevention threetimes weekly for the first 28 days in ELBW -Diuretics -Bronchodilators -pain management -electrolyte supplements dnbpaediatrics.blogspot.in
  18. 18. Post extubation laryngeal oedema Coricosteroids prevents or treats need for subsequent reintubation prolonged stay in NICU useful in infants with prolonged intubation >2 weeks,or who had multiple or traumatic intubations(cochrane systemic reviews) dnbpaediatrics.blogspot.in
  19. 19. Corticosteroids in hypotension Systemic hypotension a common problem in VLBW infants Cortisol levels low in VLBW infants IVH contributes to hypotension In addition to volume replacement and vasopressors Hydrocortisone has been successfully used to treat ionotrope resistant hypotension Used in low doses 0.1mg/kg/dose 4 hrly dnbpaediatrics.blogspot.in
  20. 20. Corticosteroids in hypoglycemia Useful in resistant or persistent hypoglycemia Resistent hypoglycemia is requirement of dextrose infusion rate>12 mg/kg/min Persistent hypoglycemia is hypoglycemia persisting for more than a week Should rule out hyperinsulinemic state or inborn errors of metabolism Hydrocortisone used 5-10 mg/kg/day in two divided doses iv dnbpaediatrics.blogspot.in
  21. 21. SURGICAL CONDITIONS Mothers with antenatal diagnosis of CDH- Betamethasone to be given even if term gestation Cystic adenomatoid malformation of lung(surfactant deficiency) diagnosed antenatally by US/MRI-Antenatal steroids indicated CONTD. dnbpaediatrics.blogspot.in
  22. 22.  HAEMANGIOMAcan be treated with steroids a)topical b)intralesional c)oral d)parenteral Within 1-2 wks 35% show dramatic response,45% equivocal response If no response after 2 wks, should be rapidly tapered Intralesional injection preferred in well localized haemangiomas i.e in eyelids dnbpaediatrics.blogspot.in
  23. 23. Research potential and conclusions Need to evaluate the use of multiple courses of antenatal steroids in clinical trials Though systemic steroids are useful in preventing CLD,there is concern regarding long term neurologic problems Further studies are being done to focus on finding minimum dose and duration of treatment that will be effective dnbpaediatrics.blogspot.in
  24. 24. Visit dnbpaediatrics.blogspot.in