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Pulmonary maturation is based on accelerating the maturation of the fetal lungs, fetal respiratory function, to improve the prognosis of the premature newborn (RN).The respiratory system is the last fetal system to mature and is the immediate limiting element for the survival of the RN. Corticosteroids are the only known group of drugs that can exert this effect, they stimulate the synthesis and secretion of a pulmonary intraalveolar substance known as Surfactant that allows the alveoli to fill with air and stay inflated so that the gas exchange occurs. the breathing.
There are other conditions associated with prematurity but pulmonary function is absolutely necessary to tolerate extrauterine life, the most urgent and difficult to manage
Other conditions of the premature newborn are:
- Inadequate control of body temperature
- Inability to feed
- Digestive immaturity
- Immaturity of the immune system
With very few exceptions, all pregnant women at risk of premature birth should receive some scheme of fetal lung maturation with steroids. There are no other medications of comparable effect so they will not be discussed in this article.
Fetal neuroprotection It is based on the use of Magnesium Sulfate before the imminent birth of a premature fetus to prevent neonatal brain injuries due to prematurity and to improve its general prognosis, survival and postnatal neurological sequelae.
What are the benefits of prenatal corticosteroids?
Prenatal steroids are associated with a significant reduction in combined fetal and neonatal death rates, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, systemic infections, and developmental delay during childhood.
Prenatal steroids have no known benefit to the mother under these circumstances.
At what gestational age should prenatal steroids be used?
Physicians should offer a single course of antenatal corticosteroids for women between 24 and 34 weeks of gestation who are at risk of preterm delivery.
Although of debatable utility, its use can be considered in women between 23 + 0 and 23 + 6 weeks of gestation with risk of premature birth.
How long after the administration of the prenatal corticosteroids effect is obtained?
Prenatal steroids are more effective in reducing Newborn Respiratory Distress Syndrome (RNDR) in infants who are born 24 hours later and up to 7 days after the administration of the second dose of prenatal corticosteroids.
The use of prenatal corticosteroids reduces neonatal mortality within the first 24 hours of its administration, therefore, they can be administered even if the birth is expected within the next 24 hours.
No benefits were shown of its use in those born after seven days or more of the administration of the treatment (WHO 2006)
Is the use of prenatal corticosteroids safe?
Its use does not seem to generate significant short-term complications in the mother, the fetus or the newborn.
There is insufficient evidence on the long-term benefits and risks of multiple doses of prenatal corticosteroids. We have cases in which the fetus or the indication of prematurity advances slowly (but with unexpected potential deterioration) and we are forced to keep the doses repeated. Literature does not support this scheme; however, in any condition in which one has evidence that in the next 7 days the baby could maintain the risk of being born prematurely I believe that the weekly dosage of steroids should be maintained.
Who should receive antenatal corticosteroids?
Prenatal corticosteroids should be given to all women at risk of premature birth, delivery or caesarean section, up to 34 + 6 weeks of gestation.
Prenatal corticosteroids should be given to all women for whom an elective cesarean is planned before 38 + 6 weeks of gestation (this indication has been much discussed).
There is evidence of benefit in all major subgroups of preterm infants, such as women with premature rupture of membranes and pregnancy-induced hypertension. This benefit is without distinction of race or gender.
A single course of prenatal corticosteroids should be considered routine for preterm delivery with few exceptions.
When should a course of prenatal corticosteroids be repeated?
Repeated doses of prenatal corticosteroids reduce the occurrence and severity of neonatal respiratory disease, but the short-term benefits were associated with weight reduction and fetal abdominal circumference. Weekly repetition courses are not recommended but in practice we use them very often in complex cases without any type of maternal-fetal problem
Fetal Novel Protection: Magnesium Sulfate
Neuroprotection is an element that goes hand in hand with lung maturation and that should be applied in all that pregnancy where imminent premature birth is detected within the next 24 hours.
It is based on the use of Magnesium Sulfate in high doses administered to the mother at least 4 hours before birth to obtain adequate fetal blood levels to prevent neonatal neurological problems associated with extreme prematurity (cerebral palsy, impairment of cognitive and sensorineural function). ) and prolonged stay in Neonatal Intensive Care.
The recommended schedule includes a dose of impregnation of 6 grams intravenously in 30 minutes and then 2 grams in continuous infusion until the birth of the baby (WHO recommendations on interventions to improve preterm birth outcomes) . This scheme is also effective in preventing eclamptic seizures in cases in which the termination of pregnancy is associated with severe preeclampsia.
Despite being the domain of many obstetricians and being within the guidelines of many health centers, this scheme is fulfilled in less than 50% of the cases in which it would be indicated to do it for very varied reasons (ignorance or fear of the obstetrician for associated side effects, lack of medication, absence of adequate monitoring methods during administration, untimely interruption before giving time to place the medication, etc.)