Maduracion Pulmonar

Article in press - uncorrected proof
J. Perinat. Med. 36 (2008) 191–196 • Copyright by Walter de Gruyter • Berlin • New York. DOI 10.1515/JPM.2008.032

Recommendations and guidelines for perinatal practice

Guideline for the use of antenatal corticosteroids for fetal maturation*

Xavier Miracle1,**, Gian Carlo Di Renzo2, Ann Stark3, Avroy Fanaroff4, Xavier CarbonellEstrany1 and ErichSaling5 (Coordinators of WAPM Prematurity working group)
Neonatology Service, Hospital Clinic, Institut Clinic de Ginecologia, Obstetricia I Neonatologia, Universitat de Barcelona, Barcelona, Spain 2 Department of Obstetrics and Gynecology and Center for Perinatal and Reproductive Medicine, University of Perurgia, Italy 3 Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, USA 4Rainbow Babies and Children’s Hospital, Cleveland, Ohio and Case Western Reserve University School of Medicine, USA 5 Institute of Perinatal Medicine, Berlin, Neukoelln
1

Introduction
• Women at risk of preterm birth before 34 weeks’ gestation are routinely given a course of antenatal corticosteroids (ACS) because there is good evidence that treatment reduces neonatal death, respiratory distresssyndrome (RDS) and intraventricular hemorrhage (IVH). • The origin of this practice comes from Liggins and Howie’s first randomized trial in 1972 w26x which demonstrated a reduction in the incidence of RDS and mortality. • Subsequent randomized controlled trials have compared single courses of corticosteroids with either placebo or no intervention, confirming the efficacy of this treatment w37x.• Three major institutions have been elaborating and updating recommendations and guidelines on the use of antenatal corticosteroids: 1. The National Institutes of Health (NIH) published a Consensus Development Conference Statement in 1994 on the use of ACS w36x and in 2000 on the use of repeated courses of ACS w34x. 2. In May 2002, The American College of Obstetricians and Gynecologists’ Committeeon Obstetric Practice (ACOG) w5x supported the conclusions of the NIH consensus conference. 3. The Royal College of Obstetricians and Gynecologists (RCOG) w35x published the third edition of their guideline in February 2004 (previously published in April 1996 and December 1999). • In the last few years new relevant information has been published: The Cochrane Review on ACS (2006) w37x has beenupdated, aiming to assess the effects of ACS on fetal, neonatal and maternal morbidity and mortality and on child development. Regarding the controversial issue of single versus multiple courses of ACS therapy, two large randomized clinical trials have been recently published (Wapner et al. w43x, and Crowther et al. w7x) and included in an updated Cochrane review on repeat doses of prenatalcorticosteroids (2007) w9x. The larger study on multiple doses, the Canadian MACS trial w27x (Multiple Courses of Antenatal Corticosteroids for preterm birth Study) has finished recruitment and should probably be ready this year.

Abstract
The aim is to present a document, which is based on current evidence and serves as a guideline for use in clinical practice. The following questions are addressed: •Is the use of antenatal corticosteroids (ACS) an effective therapy? • Who are the candidates for antenatal corticosteroid therapy? • Is there benefit after 34 weeks’ gestation? • When is the optimal time to treat? • Which are the optimal steroids; what is the ideal dose and route of administration? • Are there any contraindications to the administration of ACS? • Are antenatal corticosteroidsindicated in women with premature rupture of membranes (PROM)? • Is the use of ACS recommended in pregnancies complicated by maternal diabetes mellitus? • Should the treatment with corticosteroids be repeated?
*This paper was worked out under the auspices of the WAPM to achieve consensus on issues in perinatal practice. Coordinator of the working group: Xavier Miracle. **Corresponding author: Dr....