Preparazione Polmonare EBM: passato e presente

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Ignazio Poletti
5 anni fa
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1 Preparazione Polmonare EBM: passato e presente Federico Prefumo Dipartimento di Ostetricia e Ginecologia Università di Brescia Spedali Civili di Brescia Azienda Ospedaliera

2 Roberts D, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD DOI: / CD pub2.

3 Mortalità

6 Mortalità Anni 70

7 Mortalità Anni 90

8 14 RCTs FROM HIGH-INCOME COUNTRIES comparing administration of antenatal steroids for preterm labour with placebo showing effect size on neonatal mortality outcome Mwansa-Kambafwile J et al. Int. J. Epidemiol. 2010;39:i122-i133

9 Meta-analysis of four RCTs from MIDDLE-INCOME COUNTRIES comparing administration of antenatal steroids for preterm labour with placebo showing effect size on neonatal mortality outcome Mwansa-Kambafwile J et al. Int. J. Epidemiol. 2010;39:i122-i133

10 Fixed effect meta-analysis of two observational studies from LOW/MIDDLE- INCOME countries comparing administration of antenatal steroids for preterm labour with placebo showing effect size on neonatal mortality outcome Mwansa-Kambafwile J et al. Int. J. Epidemiol. 2010;39:i122-i133

11 Quale farmaco ed a quale dosaggio? Betametasone 12 mg intramuscolo in 2 dosi a 24 h di distanza Desametasone 6 mg intramuscolo in 4 dosi a 12 h di distanza

12 Quale farmaco ed a quale dosaggio? Betametasone 12 mg intramuscolo in 2 dosi a 24 h di distanza Desametasone 6 mg intramuscolo in 4 dosi a 12 h di distanza* * possibile minore protezione verso la leucomalacia periventricolare

13 Dopo quanto tempo dalla somministrazione si osserva l effetto dello steroide? Massima efficacia 24 h dopo la somministrazione della 2 a dose Comunque riduzione della mortalità anche se parto <24 h dalla 1 a dose

14 Per quanto tempo si mantiene l efficacia dello steroide? Rischio di RDS Intevallo steroide-nascita 1-7 giorni

15 Per quanto tempo si mantiene l efficacia dello steroide? Rischio di RDS Intevallo steroide-nascita >7 giorni

16 Wilms et al. Optimal interval between antenatal corticosteroids and preterm birth. Am J Obstet Gynecol 2011;205:49.e1-7. Per quanto tempo si mantiene l efficacia dello steroide?

17 Wilms et al. Optimal interval between antenatal corticosteroids and preterm birth. Am J Obstet Gynecol 2011;205:49.e1-7. Per quanto tempo si mantiene l efficacia dello steroide?

18 Wilms et al. Optimal interval between antenatal corticosteroids and preterm birth. Am J Obstet Gynecol 2011;205:49.e1-7. Per quanto tempo si mantiene l efficacia dello steroide?

19 Perché allora non ripetere ogni settimana la somministrazione di steroide? Peltoniemi et al. Repeated antenatal corticosteroid treatment: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2011;90:

20 Perché allora non ripetere ogni settimana la somministrazione di steroide? Peltoniemi et al. Repeated antenatal corticosteroid treatment: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2011;90:

21 Perché allora non ripetere ogni settimana la somministrazione di steroide? Peltoniemi et al. Repeated antenatal corticosteroid treatment: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2011;90:

22 Perché allora non ripetere ogni settimana la somministrazione di steroide? Peltoniemi et al. Repeated antenatal corticosteroid treatment: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2011;90:

23 Perché allora non ripetere ogni settimana la somministrazione di steroide? Peltoniemi et al. Repeated antenatal corticosteroid treatment: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2011;90:

24 Perché allora non ripetere ogni settimana la somministrazione di steroide? Peltoniemi et al. Repeated antenatal corticosteroid treatment: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2011;90:

25 RCOG, Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality, 2010

26 Controindicazioni

27 Gravidanze multiple

28 Diabete mellito Quasi sempre un criterio di esclusione dagli RCT

29 Restrizione di crescita (IUGR) Schaap AH et al. Effects of antenatal corticosteroid administration on mortality and long-term morbidity in early preterm, growth-restricted infants. Obstet Gynecol 2001;97:

30 Restrizione di crescita (IUGR) No difference in neonatal mortality was seen in any of the reviewed studies and RDS, IVH, and NEC incidence did not differ between treated and untreated IUGR fetuses In SGA fetuses, results on RDS incidence and intracranial outcome were inconclusive Antenatal steroid treatment does not seem to have an effect on neonatal mortality or morbidity in IUGR fetuses Torrance HL et al. Is antenatal steroid treatment effective in preterm IUGR fetuses? Acta Obstet Gynecol Scand 2009;88:

31 Restrizione di crescita (IUGR) In SGA fetuses, it remains unclear if antenatal steroid treatment is beneficial due to heterogeneous populations and treatment regimens A randomized controlled trial should be performed to confirm prior results and answer further questions regarding antenatal steroid treatment of these fetuses. Torrance HL et al. Is antenatal steroid treatment effective in preterm IUGR fetuses? Acta Obstet Gynecol Scand 2009;88:

32 Restrizione di crescita (IUGR) If possible, corticosteroids should not be administered to a growth restricted fetus without prior evaluation of feto-placental hemodynamics by Doppler sonography Caution should be exercised when corticosteroids are used in growth restricted fetuses with absent end-diastolic flow, and continuous electronic fetal monitoring may be necessary for up to 3 days after administration Vidaeff AC, Blackwell SC. Potential Risks and Benefits of Antenatal Corticosteroid Therapy Prior to Preterm Birth in Pregnancies Complicated by Severe Fetal Growth Restriction. Obstet Gynecol Clin North Am Jun;38(2):205-14

33 Restrizione di crescita (IUGR) When the Doppler evaluation is indicative of increased placental resistance and more advanced stages of fetal hypoxemia such as suggested by fetal circulatory redistribution towards brainstem centers and abnormal venous flow dynamics, expedited delivery becomes necessary and corticosteroids administration may be hazardous or impractical In the absence of a prior evaluation, Doppler assessment performed only after corticosteroids administration may be falsely reassuring in those cases with temporary regain of the blood flow throughout diastole. The clinician would not recognize the true degree of fetal compromise and may schedule inappropriate fetal surveillance. Vidaeff AC, Blackwell SC. Potential Risks and Benefits of Antenatal Corticosteroid Therapy Prior to Preterm Birth in Pregnancies Complicated by Severe Fetal Growth Restriction. Obstet Gynecol Clin North Am Jun;38(2):205-14

34 Restrizione di crescita (IUGR) Because DXM is more potent than BTM in eliciting potentially unfavorable nongenomic effects, when available, BTM should be preferred to DXM Because of the conflicting reports and lack of good quality data to confirm or refute the efficacy of antenatal corticosteroids in FGR, discontinuation of this practice cannot be advocated. Vidaeff AC, Blackwell SC. Potential Risks and Benefits of Antenatal Corticosteroid Therapy Prior to Preterm Birth in Pregnancies Complicated by Severe Fetal Growth Restriction. Obstet Gynecol Clin North Am Jun;38(2):205-14

24 +0 33 +6 24 +0 34 +6 24 +0 33 +6 Taglio

35 A che epoca gestazionale somministrare gli steroidi in caso di parto pretermine? Taglio cesareo elettivo? Valutazione maturazione polmonare fetale?

36 E prima di 24 +0? Nessuna evidenza da studi randomizzati Studi non randomizzati suggeriscono un beneficio Valutare caso per caso in base a condizioni cliniche, variabili prognostiche (ad es. peso stimato), colloquio con la coppia

37 Grazie

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