Early Neonatal Outcomes Among Mothers Receiving Variable Doses Of Dexamethasone For Management Of Preterm Premature Rupture Of Membranes At Kenyatta National Hospital Between 2011 And 2015: A Retrospective Cohort Study

Abstract

Background: Antenatal corticosteroids reduce neonatal complications that arise in preterm births. Globally, the prevalence of preterm birth is 11%. In Sub-Saharan Africa and in Kenya, the preterm birth rate is 18% and 12% respectively. Of the Neonatal deaths which arise from preterm birth, 75% occur in the developing countries. There is no consensus on the optimal dosing of antenatal corticosteroids. However, authors agree that they should be administered even when delivery is anticipated within 12 hours. Therefore does incomplete dosing of dexamethasone confer any benefit to premature neonates? Objective: To compare the early neonatal outcomes among mothers who had preterm PROM and received two doses of 12 mg dexamethasone to those who received one 12-mg dose of dexamethasone between 28 to 34 weeks gestation at Kenyatta National Hospital Methods: This was a retrospective cohort study where the study participants were consecutive neonates of mothers who had preterm premature rupture of membranes (PPROM) at 28 to 34 weeks gestation in KNH in the period between January 1, 2011, and December 31, 2015 and received dexamethasone (either two 12-mg dose-exposed group or one 12-mg dose-unexposed group). Data was collected from 328 neonates with 164 neonates in each arm to detect either a decrease in early neonatal morbidity or mortality with two 12-mg doses of dexamethasone compared with a single 12-mg dose of dexamethasone. The groups were compared for early neonatal outcomes such as Respiratory Distress Syndrome (RDS), Necrotizing Enterocolitis (NEC, neonatal septicaemia, neonatal mortality and duration of hospital stay. Univariate comparison of the socio-demographic and reproductive characteristics of the two 12-mg dose group (exposed) versus one12-mg dose dexamethasone treatment was conducted using proportions. Bivariate analysis of relative risk for the different neonatal outcomes was calculated. A multivariate logistic regression was calculated with early neonatal outcome as the dependent variable. P value was set at <0.05, precision at 95% confidence intervals and 80% power. Results: There was a difference in the gestational ages at delivery; 30-31 weeks versus 32-34 weeks for mothers who received single 12-mg versus two 12-mg dexamethasone doses respectively. The incidence of neonatal septicemia was lower in the single 12-mg cohort (RR 0.78, 95% CI 0.62 to 0.99; p=0.039), however there were no differences in the other early neonatal outcomes studied (Apgar score <7 at 5 minutes, RDS, NEC, mortality and duration of hospital stay). Subgroup analysis by gestational ages showed increased neonatal mortality in the single 12-mg dose group (RR 2.09 95%CI 1.11-3.93; p=0.023). Conclusion: The incidence of early neonatal outcomes of mothers with preterm PROM at 28 to 34 weeks gestation at KNH in 2011 to 2015 were similar for mothers who received two doses of 12 mg dexamethasone and those who received single dose dexamethasone dose apart from early neonatal septicemia which was increased in the two 12 mg dexamethasone group Recommendations: A single dose of dexamethasone reduces some adverse early neonatal outcomes in mothers with preterm PROM at 28 to 34 weeks gestation and it should be given at the earliest opportunity even when the standard two 12 mg doses of dexamethasone may not be completed. Further studies are needed on the association of two 12-mg dexamethasone doses with neonatal septicemia