Vermont Oxford Network, Burlington, Vermont.
Department of Pediatrics, Robert Larner College of Medicine, University of Vermont, Burlington.
JAMA Netw Open. 2018 Oct 5;1(6):e183235. doi: 10.1001/jamanetworkopen.2018.3235.
Although evidence of antenatal steroids (ANS) efficacy at 22 to 25 weeks' gestation is limited, increasingly these infants are treated with postnatal life support.
To estimate the proportion of infants receiving postnatal life support at 22 to 25 weeks' gestation who had exposure to ANS, and to examine if the provision of ANS was associated with a higher rate of survival to hospital discharge and survival without major morbidities.
DESIGN, SETTING, AND PARTICIPANTS: This multicenter observational cohort study consisted of 33 472 eligible infants liveborn at 431 US Vermont Oxford Network member hospitals between January 1, 2012, and December 31, 2016. We excluded infants with recognized syndromes or major congenital anomalies. Of the eligible infants, 29 932 received postnatal life support and were included in the analyses. Data analysis was conducted from July 2017 to July 2018.
Antenatal steroids administered to the mother at any time prior to delivery.
Survival to hospital discharge, major morbidities among survivors, and the composite of survival to discharge without major morbidities.
Among 29 932 infants who received postnatal life support, 51.9% were male, with a mean (SD) gestational age of 24.12 (0.86) weeks and mean (SD) birth weight of 668 (140) g; 26 090 (87.2%) had ANS exposure and 3842 (12.8%) had no ANS exposure. Survival to hospital discharge was higher for infants with ANS exposure (18 717 of 25 892 [72.3%]) compared with infants without ANS exposure (1981 of 3820 [51.9%]); the adjusted risk ratio for 22 weeks was 2.11 (95% CI, 1.68-2.65), for 23 weeks was 1.54 (95% CI, 1.40-1.70), for 24 weeks was 1.18 (95% CI, 1.12-1.25), and for 25 weeks was 1.11 (95% CI, 1.07-1.14). Survival to hospital discharge without major morbidities was higher for infants with ANS exposure (3777 of 25 833 [14.6%]) compared with infants without ANS exposure (347 of 3806 [9.1%]); the adjusted risk ratio for 22 through 25 weeks was 1.67 (95% CI, 1.49-1.87).
Concordant receipt of ANS and postnatal life support was associated with significantly higher survival and survival without major morbidities at 22 through 25 weeks' gestation compared with life support alone. Although statistically higher with ANS, survival without major morbidities remains low at 22 and 23 weeks. There is an opportunity to reevaluate national obstetric guidelines, allowing for shared decision making at the edge of viability with concordant obstetrical and neonatal treatment plans.
尽管在 22 至 25 周妊娠时产前类固醇（ANS）疗效的证据有限，但越来越多的婴儿在出生后接受生命支持。
评估在 22 至 25 周妊娠时接受生命支持的婴儿中接触过 ANS 的比例，并研究提供 ANS 是否与更高的存活率和无重大并发症存活率相关。
设计、地点和参与者：这是一项多中心观察性队列研究，纳入了 2012 年 1 月 1 日至 2016 年 12 月 31 日期间在 33472 名美国佛蒙特州牛津网络成员医院出生的 431 名符合条件的活产婴儿。我们排除了有明确综合征或重大先天性异常的婴儿。在符合条件的婴儿中，有 29932 名接受了产后生命支持，并纳入了分析。数据分析于 2017 年 7 月至 2018 年 7 月进行。
在分娩前的任何时间给母亲使用的产前类固醇。
出院存活率、幸存者的主要并发症以及无重大并发症出院的存活率。
在接受产后生命支持的 29932 名婴儿中，51.9%为男性，平均（SD）胎龄为 24.12（0.86）周，平均（SD）出生体重为 668（140）g；26090 名（87.2%）婴儿接触过 ANS，3842 名（12.8%）婴儿没有接触过 ANS。与未接触过 ANS 的婴儿（1981 名[51.9%]）相比，接触过 ANS 的婴儿（25892 名中有 18717 名[72.3%]）出院存活率更高；22 周的调整风险比为 2.11（95%CI，1.68-2.65），23 周为 1.54（95%CI，1.40-1.70），24 周为 1.18（95%CI，1.12-1.25），25 周为 1.11（95%CI，1.07-1.14）。与未接触过 ANS 的婴儿（3806 名中有 347 名[9.1%]）相比，接触过 ANS 的婴儿（25833 名中有 3777 名[14.6%]）出院且无重大并发症的存活率更高；22 至 25 周的调整风险比为 1.67（95%CI，1.49-1.87）。
与单独接受生命支持相比，同时接受 ANS 和产后生命支持的婴儿在 22 至 25 周妊娠时的存活率和无重大并发症存活率显著更高。尽管统计学上更高，但 22 周和 23 周无重大并发症的存活率仍然较低。这为重新评估国家产科指南提供了机会，允许在产科和新生儿治疗计划一致的情况下，在生存边缘进行共同决策。
