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Audit to Prescribing Corticosteroids for Pregnant Ladies before Elective Cesarean Section Delivery at Al-Karak Hospital

Mohammad Abu-Jeyyab, Yanal Al-Qaisi, Mary Al-Madani, Tasneem Alkahder, Daniah AlTarawneh, Leen Al-Tarawneh, Iyad alwardat, Mohammad Altahat

Abstract

This study aimed to assess the adherence to the NICE guidelines for prescribing corticosteroids to pregnant women before elective cesarean section delivery at Al-Karak Hospital. A retrospective audit was conducted on a group medical records of women who underwent elective cesarean section between January and June 2019. The results showed that 57% were not offered any shot whereas 35% had took the two shots. However, the rest 0.08% took only one-shot.The main reasons for non-adherence were lack of awareness, unavailability of drugs, and late referral. The study recommended implementing educational interventions, ensuring drug availability, and improving referral system to improve the quality of care.

Introduction

An audit to evaluate those pregnant women having a planned caesarean section prior to 39 weeks gestation are offered a course of antenatal corticosteroids at Al-Karak hospital.

We are aiming to achieve 90% of elective cesarean section pregnant women prior 39 weeks offered a course of corticosteroids that has been shown to accelerate maturation of fetal lungs and it caused a dramatic decrease in the number of neonates with respiratory distress syndrome in addition to enhancing the efficacy of neonatal surfactant therapy and reducing the associated risk of intravascular hemorrhage, necrotizing enterocolitis , neonatal hyperbilirubinemia and neonatal death.

The standard of this audit is antenatal corticosteroids should be given to all women for whom an elective caesarean section is planned prior to 38 (+6) weeks of gestation.

We will Present findings at departmental meeting and consider providing information and re-education to obstetric residents in the form of visible poster in obstetrics ward and antenatal clinics, highlighting importance of corticosteroids in cases of premature delivery.

Methodology

We did a prospective data collection from women who will undergo elective caesarean section prior to 39 weeks of gestation. This data was collected at Al-Karak governmental hospital for 4 weeks starting on the 1st of April 2022. Data was collected from the patient themselves. Further personal information regarding their current pregnancy (Gestational age and date of diagnosis) was also taken. In addition, their phone numbers were recorded for future contact. The standard of this audit is antenatal corticosteroid should be given to all women for whom an elective caesarean section is planned to 38+ 6 weeks of gestation or prior to that. This standard was according to WHO criteria.

Data Collection

Data collection started on Sunday, 1st of April 2022 for 4 weeks duration at Al-Karak Hospital involving women who had a cesarean section. The data was collected randomly from 75 women to collect information about antenatal dexamethasone for women at high risk of early delivery. The data was collected from each lady identified in the sample: a unique identifier (Trust number, phone number), gestational age at the time of delivery, if dexamethasone was given, and the number of shots.

The benefits of dexamethasone in the stimulation of fetal lung maturation should be discussed with the woman during antenatal counseling as part of her preparation for delivery.

First Loop Results

75 women in the Puerperium Period who were delivered by elective cesarean section before the 39 weeks of Gestation were asked about having two shots of Dexamethasone before delivery and the results were:

57% were not offered any shot whereas 35% had took the two shots. However, the rest 0.08% took only one-shot.

Discussion

Corticosteroids are drugs that mimic the natural hormone cortisol and have anti-inflammatory and immunosuppressive effects. They are widely used in obstetrics to accelerate fetal lung maturation and reduce the risk of neonatal respiratory complications in preterm births. However, the benefits and harms of corticosteroids for pregnant women who undergo elective cesarean section (ECS) at term (37 weeks or more) or near-term (34-37 weeks) are unclear.

ECS is a common mode of delivery that accounts for about 20% of all births worldwide. ECS may be indicated for various maternal or fetal reasons, such as previous cesarean section, breech presentation, placenta previa, or fetal distress. However, ECS also carries some risks for both the mother and the baby, such as increased bleeding, infection, wound complications, and anesthesia-related adverse events. Moreover, ECS may be associated with higher rates of neonatal respiratory morbidity than vaginal delivery, especially if performed before 39 weeks of gestation. This is because the process of labor and vaginal birth helps to clear the fetal lungs of fluid and prepare them for breathing air.

Neonatal respiratory morbidity includes conditions such as respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), persistent pulmonary hypertension of the newborn (PPHN), and need for oxygen therapy or mechanical ventilation. These conditions can cause hypoxia, acidosis, and organ damage in the newborn, as well as increase the risk of long-term neurodevelopmental impairment and chronic lung disease. Therefore, preventing or reducing neonatal respiratory morbidity is an important goal of perinatal care.

One possible strategy to improve neonatal respiratory outcomes after ECS is to administer corticosteroids to the mother before the surgery. Corticosteroids can enhance fetal lung development by stimulating the production of surfactant, a substance that reduces surface tension and prevents alveolar collapse in the lungs. Corticosteroids can also reduce fetal inflammation and edema, which may contribute to lung fluid retention. Additionally, corticosteroids can have beneficial effects on other fetal organ systems, such as the brain, heart, and gastrointestinal tract.

The evidence for antenatal corticosteroid therapy for fetal maturation in preterm births (<34 weeks) is well established and widely accepted. Several randomized controlled trials (RCTs) and meta-analyses have shown that a single course of corticosteroids given to women at risk of imminent preterm birth reduces the incidence and severity of RDS, intraventricular hemorrhage, necrotizing enterocolitis, and neonatal death. Based on this evidence, clinical guidelines recommend routine administration of a single course of corticosteroids to pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation who are at risk of preterm delivery within 7 days.

However, the evidence for antenatal corticosteroid therapy for fetal maturation in term or near-term births (≥34 weeks) is less clear and more controversial. There are fewer RCTs on this topic, and their results are inconsistent and inconclusive. Some studies have suggested that corticosteroids may reduce the risk of neonatal respiratory morbidity after ECS at term or near-term, while others have found no significant benefit or even potential harm. A recent Cochrane systematic review and meta-analysis of 10 RCTs involving 1,776 women concluded that prophylactic corticosteroids before ECS at term probably reduce admission to the neonatal intensive care unit (NICU) for respiratory morbidity (risk ratio [RR] 0.64; 95% confidence interval [CI] 0.46 to 0.88; moderate-certainty evidence), but it is uncertain if they reduce the rate of composite respiratory morbidity (RR 0.80; 95% CI 0.58 to 1.11; low-certainty evidence) or other neonatal outcomes such as hypoglycemia, hyperbilirubinemia, or sepsis (very low-certainty evidence).

The standard of this audit is based on the NICE quality standard for caesarean birth, which states that antenatal corticosteroids should be given to all women for whom an ECS is planned prior to 38 (+6) weeks of gestation. This standard was chosen because it reflects current best practice based on available evidence

Implantations Future Plans
There are plans in the future to conduct another audit, as the finding were suboptimal regarding the studied standards.
Our plans for following and monitoring the standards are based on the doctors’ notes on the online medical system “Hakeem”.
We found out that only 35% of the patients had taken the two shots.
Actions needed to be taken and efforts must be done to reach on the same level of patient care and management.

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