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91: Cost-effectiveness of antenatal steroids for preterm labor at 34 weeks
SMFM Abstracts 91
www.AJOG.org
COST-EFFECTIVENESS OF ANTENATAL STEROIDS FOR PRETERM LABOR AT 34 WEEKS ANJALI KAIMAL1, SARAH LITTLE2, BRIAN SHAFFER1, YVONNE CHENG1, MARYA ZLATNIK1, AARON CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, California, 2Brigham and Women’s Hospital, Obstetrics and Gynecology, Boston, Massachusetts OBJECTIVE: To investigate the cost-effectiveness of administering steroids with or without tocolysis for women with preterm labor presenting at 34⫹ weeks gestation STUDY DESIGN: A decision analytic model comparing three different strategies for managing women presenting at 34⫹ weeks with preterm labor with documented cervical change was designed: (1) administration of tocolysis and steroids, (2) administration of steroids without tocolysis, (3) expectant management without administration of steroids or tocolysis. Baseline assumptions were derived from the literature and included an incidence of RDS at 34 weeks of 13.5%, a 40% reduction in likelihood of delivery within 48 hours with administration of tocolysis, and a 33% reduction in RDS with a 48 hour course of steroids. One-way and multi-way sensitivity analyses were conducted to examine the robustness of the findings. RESULTS: Administration of steroids without tocolysis was the most cost-effective strategy at $46,512 per neonatal life year saved. Steroids with tocolysis was also marginally cost effective at $94,368 per life year saved. This finding was sensitive to variation in the cost of maternal hospitalization and the likelihood of delivery within 48 hours. In number needed to treat analysis, 36 women would have to be treated with tocolysis and steroids or 63 patients would have to be treated with steroids alone to prevent one case of RDS. CONCLUSION: For women presenting with preterm labor at 34⫹ weeks, steroid administration reduces neonatal morbidity, and is cost effective. Hospitalization with tocolysis and steroid treatment is cost effective for those at highest risk of delivery; for those at intermediate risk, steroid administration without tocolysis is the optimal strategy.
93
Cost-effectiveness of steroid administration beyond 34 weeks
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.104
Strategy
Cost
Neonatal Life Years
Incremental CE ratio
Tocolysis ⫹ Steroids Steroids No tocolysis No steroids
$16,579 $15,844 $15,185
29,9316 29,9238 29,9097
$94,368 $46,512
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.102
92
THE EFFECT OF EXPOSURE TO ANTENATAL CORTICOSTEROIDS ON THE ADMISSION RATES OF LATE PRETERM INFANTS TO SPECIAL CARE NURSERIES KARIN FUCHS1, OMAR MAURICE YOUNG1, PHYLLIS GYAMFI2, DAVID BATEMAN1, CYNTHIA GYAMFI1, 1Columbia University Medical Center, New York, New York, 2ORC Macro, Applied Research Division, Atlanta, Georgia OBJECTIVE: To evaluate whether exposure to antenatal corticosteroids prior to 34 weeks of gestation affects the rate of admission of late preterm infants to special care nurseries (NICU or transitional nursery). STUDY DESIGN: This was a retrospective cohort study using our institution=s obstetric database to identify deliveries in the late preterm period (defined as 34 0/7 weeks to 36 6/7 weeks of gestation) from January 2005 to December 2006. Data were then collected from an electronic charting system. Deliveries excluded from review included those with fetal anomalies and those with incomplete data. Variables of interest included mode of delivery (MOD), gestational age at delivery, exposure to antenatal corticosteroids for fetal lung maturity, singleton or multiple gestation, diabetes and intrauterine growth restriction (IUGR). RESULTS: We identified 738 deliveries in our study period. Overall, 18.2% (134/738) of infants born in the late preterm period had been exposed to antenatal corticosteroids prior to 34 weeks. The infants exposed to antenatal corticosteroids had a lower gestational age at delivery than those who were not exposed (35 2/7 weeks versus 35 6/7 weeks; p⬍0.001). Interestingly, a greater proportion of infants exposed to antenatal corticosteroids were admitted to a special care nursery (64/ 134; 47.8%) than those non-exposed infants (190/604; 31.5%) (p⬍0.001). When controlling for confounding variables including gestational age, mode of delivery, and plurality, the only factor influencing admission to the special care nursery was the gestational age at delivery (OR 0.37, 95% CI 0.29, 0.46, p⬍0.001). The rates of diabetes (10% versus 11.7%, p⫽0.653) and IUGR (5.2% versus 3.0%, p⫽0.199) were similar in steroid exposed and non-exposed infants. CONCLUSION: Admission to a special care nursery appears to be influenced by gestational age at delivery rather than antenatal exposure to corticosteroids. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.103
S40
STEROIDS TO ENHANCE FETAL LUNG MATURITY: HOW DO OBSTETRICIANS PRESCRIBE? ANWAR NASSAR, NADIM BOU ZGHEIB, SAMER CHEAIB, ABDALLAH ADRA, MD, IHAB USTA, American University of Beirut-Medical Center, Department of Obstetrics and Gynecology, Beirut, Lebanon OBJECTIVE: To study the practices of steroid use for fetal lung maturity among Lebanese obstetricians and assess their compliance with current recommendations. STUDY DESIGN: Questionnaires that solicited practice patterns of steroid use for enhancing fetal lung maturity were mailed to a random sample of Lebanese obstetricians (n⫽175). Descriptive statistical methods were used to evaluate the responses. RESULTS: Questionnaires were returned by 149 physicians (85.1%). 99.3% of responders use steroids routinely in the context of preterm labor and 74.7% use it with preterm rupture of the membranes. NIH recommended doses are used by 43.6% of physicians; 49% use 12 mg betamethasone every 12 hrs. Whereas 96.6% believe that steroids have a strong positive effect on respiratory distress syndrome (RDS), 22.8%, 34.1% and 60.4% believe it has such an effect on necrotizing eneterocolitis, intraventricular hemorrhage, and mortality, respectively. Of responders, 24.8% do not repeat, 66.4% sometimes repeat and 8.8 % always repeat the courses, mostly for twin gestations or extreme prematurity. If courses are repeated, an extra course is given by 36.6% whereas multiple courses are given by the rest; 14.3% would continue till 34 weeks. 51.8% repeat courses weekly and 23.2% repeat every other week. The obstetrician¡⫺s major concerns for repeating courses are the need for more safety data and fear of infection. Almost half responded that they are aware of recent prospective trials about steroids: 47.9% believe that those studies are in favor of repeat courses which are associated with a lower risk of RDS and 27.1% believe that results are conflicting. A significantly larger proportion of obstetricians ⬍50 years of age are aware of new literature (63.0% vs 32.4%, P⬍0.001) and prescribe the correct formulation (51.8% vs 30.9%, P⫽0.016) compared with those ⱖ50 years. CONCLUSION: In a representative sample of Lebanese obstetricians, 50% of responders are aware of new literature regarding steroids and only 25% are compliant with the current recommendations of single course of steroids.
94
CAN SULFASALAZINE PREVENT INFECTION-MEDIATED PRETERM BIRTH? CARL NATH1, JOHN SMULIAN1, CANDE ANANTH1, MORGAN PELTIER1, 1UMDNJ-Robert Wood Johnson Medical School, Obstetrics Gynecology and Reproductive Sciences, New Brunswick, New Jersey OBJECTIVE: Sulfasalazine (SAS) is an antibiotic that exhibits anti-inflammatory activity by blocking nuclear factor-kappa B (NF-kB) - one of the earliest signals in the inflammatory response. Therefore, we hypothesized that SAS may be useful for preventing infection-mediated preterm birth in a murine model. STUDY DESIGN: Timed-pregnant CD-1 mice (n⫽50) were assigned to 1 of 5 groups: 1) Sham infection (SI) ⫹ Vehicle (V), 2) Low dose infection (LI) ⫹ V, 3) LI ⫹ SAS, 4) High dose infection (HI) ⫹ V; and 5) HI ⫹ SAS. LI and HI infections consisted of 104 and 106 CFU live E. coli, respectively, injected intrauterine via laparotomy on gestational day (gd) 14.5. SI consisted of an equivalent volume of sterile broth. SAS (150 mg/kg in PBS) was administered by subcutaneous injection daily for 3 days begining at gd 14.5. Mice were observed twice daily for delivery and number of live pups and stillbirths. Deliveries prior to gd 18.5 were considered preterm. Pups were weighed within 24 hours of birth. RESULTS: All dams infected with 106 CFU E. coli delivered on gd 15.5 and SAS had no effect on time of delivery or pregnancy outcome. Mice infected with 104 CFU E. coli had variable gestational lengths. SAS significantly increased the proportion of mice delivering after gd 18.5 with a trend toward increased litter size and increased pup weight.
CONCLUSION: SAS reduced rates of preterm birth and improved pregnancy outcomes for mice infected with low but not high doses of E. coli, suggesting that it may alter outcomes of pregnancies complicated by intrauterine infection. The high survival rate and low birth weight of pups born to dams infected with 104 CFU E. coli suggests that this may be an excellent model to study interventions to prevent infection-mediated preterm birth. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.105
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2007
www.AJOG.org
COST-EFFECTIVENESS OF ANTENATAL STEROIDS FOR PRETERM LABOR AT 34 WEEKS ANJALI KAIMAL1, SARAH LITTLE2, BRIAN SHAFFER1, YVONNE CHENG1, MARYA ZLATNIK1, AARON CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, California, 2Brigham and Women’s Hospital, Obstetrics and Gynecology, Boston, Massachusetts OBJECTIVE: To investigate the cost-effectiveness of administering steroids with or without tocolysis for women with preterm labor presenting at 34⫹ weeks gestation STUDY DESIGN: A decision analytic model comparing three different strategies for managing women presenting at 34⫹ weeks with preterm labor with documented cervical change was designed: (1) administration of tocolysis and steroids, (2) administration of steroids without tocolysis, (3) expectant management without administration of steroids or tocolysis. Baseline assumptions were derived from the literature and included an incidence of RDS at 34 weeks of 13.5%, a 40% reduction in likelihood of delivery within 48 hours with administration of tocolysis, and a 33% reduction in RDS with a 48 hour course of steroids. One-way and multi-way sensitivity analyses were conducted to examine the robustness of the findings. RESULTS: Administration of steroids without tocolysis was the most cost-effective strategy at $46,512 per neonatal life year saved. Steroids with tocolysis was also marginally cost effective at $94,368 per life year saved. This finding was sensitive to variation in the cost of maternal hospitalization and the likelihood of delivery within 48 hours. In number needed to treat analysis, 36 women would have to be treated with tocolysis and steroids or 63 patients would have to be treated with steroids alone to prevent one case of RDS. CONCLUSION: For women presenting with preterm labor at 34⫹ weeks, steroid administration reduces neonatal morbidity, and is cost effective. Hospitalization with tocolysis and steroid treatment is cost effective for those at highest risk of delivery; for those at intermediate risk, steroid administration without tocolysis is the optimal strategy.
93
Cost-effectiveness of steroid administration beyond 34 weeks
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.104
Strategy
Cost
Neonatal Life Years
Incremental CE ratio
Tocolysis ⫹ Steroids Steroids No tocolysis No steroids
$16,579 $15,844 $15,185
29,9316 29,9238 29,9097
$94,368 $46,512
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.102
92
THE EFFECT OF EXPOSURE TO ANTENATAL CORTICOSTEROIDS ON THE ADMISSION RATES OF LATE PRETERM INFANTS TO SPECIAL CARE NURSERIES KARIN FUCHS1, OMAR MAURICE YOUNG1, PHYLLIS GYAMFI2, DAVID BATEMAN1, CYNTHIA GYAMFI1, 1Columbia University Medical Center, New York, New York, 2ORC Macro, Applied Research Division, Atlanta, Georgia OBJECTIVE: To evaluate whether exposure to antenatal corticosteroids prior to 34 weeks of gestation affects the rate of admission of late preterm infants to special care nurseries (NICU or transitional nursery). STUDY DESIGN: This was a retrospective cohort study using our institution=s obstetric database to identify deliveries in the late preterm period (defined as 34 0/7 weeks to 36 6/7 weeks of gestation) from January 2005 to December 2006. Data were then collected from an electronic charting system. Deliveries excluded from review included those with fetal anomalies and those with incomplete data. Variables of interest included mode of delivery (MOD), gestational age at delivery, exposure to antenatal corticosteroids for fetal lung maturity, singleton or multiple gestation, diabetes and intrauterine growth restriction (IUGR). RESULTS: We identified 738 deliveries in our study period. Overall, 18.2% (134/738) of infants born in the late preterm period had been exposed to antenatal corticosteroids prior to 34 weeks. The infants exposed to antenatal corticosteroids had a lower gestational age at delivery than those who were not exposed (35 2/7 weeks versus 35 6/7 weeks; p⬍0.001). Interestingly, a greater proportion of infants exposed to antenatal corticosteroids were admitted to a special care nursery (64/ 134; 47.8%) than those non-exposed infants (190/604; 31.5%) (p⬍0.001). When controlling for confounding variables including gestational age, mode of delivery, and plurality, the only factor influencing admission to the special care nursery was the gestational age at delivery (OR 0.37, 95% CI 0.29, 0.46, p⬍0.001). The rates of diabetes (10% versus 11.7%, p⫽0.653) and IUGR (5.2% versus 3.0%, p⫽0.199) were similar in steroid exposed and non-exposed infants. CONCLUSION: Admission to a special care nursery appears to be influenced by gestational age at delivery rather than antenatal exposure to corticosteroids. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.103
S40
STEROIDS TO ENHANCE FETAL LUNG MATURITY: HOW DO OBSTETRICIANS PRESCRIBE? ANWAR NASSAR, NADIM BOU ZGHEIB, SAMER CHEAIB, ABDALLAH ADRA, MD, IHAB USTA, American University of Beirut-Medical Center, Department of Obstetrics and Gynecology, Beirut, Lebanon OBJECTIVE: To study the practices of steroid use for fetal lung maturity among Lebanese obstetricians and assess their compliance with current recommendations. STUDY DESIGN: Questionnaires that solicited practice patterns of steroid use for enhancing fetal lung maturity were mailed to a random sample of Lebanese obstetricians (n⫽175). Descriptive statistical methods were used to evaluate the responses. RESULTS: Questionnaires were returned by 149 physicians (85.1%). 99.3% of responders use steroids routinely in the context of preterm labor and 74.7% use it with preterm rupture of the membranes. NIH recommended doses are used by 43.6% of physicians; 49% use 12 mg betamethasone every 12 hrs. Whereas 96.6% believe that steroids have a strong positive effect on respiratory distress syndrome (RDS), 22.8%, 34.1% and 60.4% believe it has such an effect on necrotizing eneterocolitis, intraventricular hemorrhage, and mortality, respectively. Of responders, 24.8% do not repeat, 66.4% sometimes repeat and 8.8 % always repeat the courses, mostly for twin gestations or extreme prematurity. If courses are repeated, an extra course is given by 36.6% whereas multiple courses are given by the rest; 14.3% would continue till 34 weeks. 51.8% repeat courses weekly and 23.2% repeat every other week. The obstetrician¡⫺s major concerns for repeating courses are the need for more safety data and fear of infection. Almost half responded that they are aware of recent prospective trials about steroids: 47.9% believe that those studies are in favor of repeat courses which are associated with a lower risk of RDS and 27.1% believe that results are conflicting. A significantly larger proportion of obstetricians ⬍50 years of age are aware of new literature (63.0% vs 32.4%, P⬍0.001) and prescribe the correct formulation (51.8% vs 30.9%, P⫽0.016) compared with those ⱖ50 years. CONCLUSION: In a representative sample of Lebanese obstetricians, 50% of responders are aware of new literature regarding steroids and only 25% are compliant with the current recommendations of single course of steroids.
94
CAN SULFASALAZINE PREVENT INFECTION-MEDIATED PRETERM BIRTH? CARL NATH1, JOHN SMULIAN1, CANDE ANANTH1, MORGAN PELTIER1, 1UMDNJ-Robert Wood Johnson Medical School, Obstetrics Gynecology and Reproductive Sciences, New Brunswick, New Jersey OBJECTIVE: Sulfasalazine (SAS) is an antibiotic that exhibits anti-inflammatory activity by blocking nuclear factor-kappa B (NF-kB) - one of the earliest signals in the inflammatory response. Therefore, we hypothesized that SAS may be useful for preventing infection-mediated preterm birth in a murine model. STUDY DESIGN: Timed-pregnant CD-1 mice (n⫽50) were assigned to 1 of 5 groups: 1) Sham infection (SI) ⫹ Vehicle (V), 2) Low dose infection (LI) ⫹ V, 3) LI ⫹ SAS, 4) High dose infection (HI) ⫹ V; and 5) HI ⫹ SAS. LI and HI infections consisted of 104 and 106 CFU live E. coli, respectively, injected intrauterine via laparotomy on gestational day (gd) 14.5. SI consisted of an equivalent volume of sterile broth. SAS (150 mg/kg in PBS) was administered by subcutaneous injection daily for 3 days begining at gd 14.5. Mice were observed twice daily for delivery and number of live pups and stillbirths. Deliveries prior to gd 18.5 were considered preterm. Pups were weighed within 24 hours of birth. RESULTS: All dams infected with 106 CFU E. coli delivered on gd 15.5 and SAS had no effect on time of delivery or pregnancy outcome. Mice infected with 104 CFU E. coli had variable gestational lengths. SAS significantly increased the proportion of mice delivering after gd 18.5 with a trend toward increased litter size and increased pup weight.
CONCLUSION: SAS reduced rates of preterm birth and improved pregnancy outcomes for mice infected with low but not high doses of E. coli, suggesting that it may alter outcomes of pregnancies complicated by intrauterine infection. The high survival rate and low birth weight of pups born to dams infected with 104 CFU E. coli suggests that this may be an excellent model to study interventions to prevent infection-mediated preterm birth. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.105
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2007