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0CLINICAL FEATURES OF RDS COURSE DEPENDING ON ANTE AND POSTNATAL PREVENTIVE ADMINISTRATION
OF SURFACTANT
1Ismailova M.A., 2Khodjamova N.K.
1,2Tashkent Pediatric Medical Institute https://doi org/10.5281/zenodo. 13834869
Abstract. The most common cause of death in premature infants is respiratory distress syndrome. The aim of this study is to evaluate the effectiveness of antenatal corticosteroid prophylaxis in combination with early surfactant administration to newborns on the course and outcomes of respiratory distress syndrome. The cohort study included 80 premature infants with gestation periods from 27 to 34 weeks. A comparative assessment of the effectiveness of antenatal corticosteroid prophylaxis and early therapy with curosurf in the delivery room on the course and outcomes of RDS was carried out. Antenatal corticosteroid prophylaxis in combination with early surfactant therapy with curosurf at a dose of200 mg / kg in the delivery room contribute to a more rapid normalization of the gas exchange function of the lungs in premature infants with respiratory distress syndrome; reduce the frequency of intraventricular hemorrhages; reduce the duration of respiratory support of the newborn and the need for mechanical ventilation by 2 times; reduce the length of stay in the intensive care unit and hospital by 2 times.
Keywords: respiratory distress syndrome, surfactant, antenatal corticosteroidprophylaxis, premature infants.
The incidence of premature birth in different countries ranges from 3.5 to 13% of the total number of pregnancies. One of the most common complications of premature birth is respiratory distress syndrome (RDS) of newborns, caused by insufficient production of surfactant in the immature lungs of premature infants. RDS is a major cause of morbidity and mortality in preterm infants [1,14]. The incidence of RDS decreases proportionally with increasing gestational age. RDS is more common in preterm infants, low birth weight infants, male infants, white infants, infants born to diabetic mothers, and the second child of twins. In a study of RDS rates by birth weight in 12 university hospital records, RDS was diagnosed in 42% of infants weighing 501 -1500 g, 71% of infants weighing 501-750 g, 54% of infants weighing 751-1000 g, 36% of infants weighing 1001-1250 g, and 22% of infants weighing 1251-1500 g [10]. There is an opinion that in children with ELBW in cases of severe RDS, in addition to surfactant deficiency, there is also its inactivation by plasma proteins that have leaked into the alveoli under the influence of the inflammatory process that began in utero with chorioamnionitis in the mother [2,6]
Studies have shown that planned cesarean section increases the incidence of respiratory distress in full-term infants [4,7]. RDS in full-term newborns can be expected in those born with early forms of sepsis or with meconium aspiration.
In recent years, a number of studies have indicated the presence of a genetic predisposition to RDS, since monozygotic twins have a higher incidence of RDS compared to dizygotic twins, and an increased incidence of RDS in families has also been reported [5,9]. Currently, the use of antenatal corticosteroid therapy in pregnant women with the risk of premature birth and the improvement of neonatal therapy for RDS have led to a significant decrease in the incidence of
severe forms of RDS and improved perinatal outcomes. ACT aimed at preventing RDS has become one of the main components in a set of measures carried out in pregnant women to improve outcomes in the newborn. ACT to accelerate the maturation of the fetal lungs in humans was first used in the early 70s of the last century, when it was shown that 2-fold administration of 12 mg of betamethasone with an interval of 24 hours to pregnant women with the risk of premature birth contributed to a decrease in the incidence of RDS and led to a decrease in neonatal mortality from hyaline membrane disease [3,8].
The issues of the clinical course of RDS and postnatal therapy using various complex approaches, including respiratory support, the use of surfactant replacement therapy are described in detail in neonatology guidelines. Before the widespread use of early CPAP, surfactant was used prophylactically in very preterm infants. Since 2013, when the indications for surfactant administration in neonates were revised and limited, surfactant therapy has been recommended as an early therapeutic option for RDS [12,13].
The target treatment for surfactant deficiency is surfactant replacement therapy administered directly into the trachea. Surfactant administered within 30-60 minutes after delivery of preterm infants has been shown to have beneficial effects such as accelerating recovery and reducing the risk of pneumothorax, duration of respiratory support, interstitial emphysema, intraventricular hemorrhage (IVH), BPD, and hospital-acquired neonatal and infant mortality, respectively. According to the European Consensus Guidelines, 6th Edition, surfactant is administered to immature infants with FiO2 > 0.3 and to mature infants with FiO2 > 0.4. There is currently no clinically significant advantage to using one type of surfactant over another when administered at the same dose [6,11].
The purpose of the study. To evaluate the effectiveness of antenatal prophylaxis with corticosteroids in combination with early administration of surfactant on the course and outcomes of respiratory distress syndrome.
Materials and methods of research. Eighty pregnant women at risk of premature birth and their newborns were examined at the neonatal pathology departments of Tashkent Russian Orthodox Church. The pregnant women were divided into 2 groups depending on the ACT. The main group consisted of 40 pregnant women at risk of premature birth at a gestation period of 23 -34 weeks, who received antenatal prophylaxis of respiratory distress syndrome of the newborn with a single course of dexamethasone therapy during the next 7 days before delivery.
The comparison group included 40 pregnant women at risk of premature birth, for various reasons, who did not receive antenatal steroid prophylaxis of RDS in newborns. All pregnant women underwent general clinical, clinical and laboratory examinations, ultrasound and Doppler ultrasound of the fetus. Also, the criterion for selecting newborns in the main study group was postnatal prophylactic administration of poractant alpha (curosurf) at a dose of 200 mg / kg in the delivery room, while the comparison group included 40 newborns who did not receive prophylactic administration of surfactant in the delivery room. The children underwent standard clinical, laboratory and instrumental examination. The diagnosis of RDS was made on the basis of the clinical status of the child, laboratory examination, as well as the presence of a set of radiographic criteria.
The results of the study. Among the mothers included in the group, pregnancy was complicated by hypertensive disorders in 45.8% of women in group 1 and in 43.8% of women in group 2. In group 1, 75% of pregnant women and 62.5% of women in group 2 had urinary tract
infections during pregnancy. Primiparous women accounted for 55.0% in group 1 and 50.0% in group 2. In 8.3% of women in group 1 and in 12.5% of pregnant women in group 2, previous births were also premature.
Surgical delivery occurred in 43.8% of women in group 1 and in 32.5% of women in group 2. A comparative analysis of the gestation periods of the examined newborns (Fig. 1) of both groups showed that in the main group the number of children with a deep degree of prematurity, less than 28 weeks, was slightly higher (47.5% versus 35%). The percentage of children 29-34 weeks was 52.5% relative to 65% of the comparison group.
Fig. 1. Comparative analysis of gestational age of newborns in the study groups.
The Apgar score (Table 1) at 1 and 5 minutes of life was significantly lower in newborns of the comparison group compared to the main group (p<0.001).
Table 1
Apgar score of newborns in the study groups
Indicators Comparison group n= 40, (M±m) Main group n=40, (M±m)
Apgar score at 1st min 5,1±0,7 6,6±0,3*
Apgar score at 5th min 6,0±0,1 7,6±0,4*
Note: * - reliability of data between groups (P<0.05)
The severity of respiratory distress syndrome was assessed using the Silverman-Anderson scale and was significantly higher in infants (mean score 3.9±0.2 versus 7.2±0.3; P<0.05) whose mothers did not receive antenatal RDS prophylaxis.
It was found that 45% of children in the main group had severe RDS, compared to newborns in the comparison group, where this figure was 42.5%; extremely severe RDS was recorded in 57.5% of cases, while extremely severe RDS was not observed in the main group. Accordingly, mild and moderate RDS in the main group were recorded in 20% and 35% of children, while these degrees were not observed in the comparison group (Table 2)
The methods of respiratory support are determined by the severity of newborn's condition, maturity of the respiratory system and other parameters of oxygen saturation. Despite the fact that the frequency of severe RDS was significantly lower against the background of antenatal steroid prophylaxis and early postnatal surfactant administration, the frequency of artificial ventilation of the lungs in the first day of life in newborns of both groups was still quite high: 57.5% in the main group and 82.5% in the comparison group, with a significant prevalence in the group without prophylactic therapy.
Table 2
Assessment of RDS severity in the examined newborns
Silverman-Anderson scale score Main group Comparison group
Abs % Abs %
less than 5 points 8 20 0 0
5 points 14 35 0 0
6 - 9 points 18 45 17 42,5
10 points 0 0 23 57,5
We analyzed various methods of respiratory therapy in the examined newborns (Fig. 2).
Fig. 2. Characteristics of respiratory therapy in newborns with RDS.
The number of very premature infants prevailed in the main group, as indicated above. However, in children of this group with antenatal prophylaxis of RDS syndrome, the need for various types of respiratory therapy after birth was significantly lower (Fig. 2). The combined form of respiratory therapy with initial mechanical ventilation and transfer to CPAP was moderately lower (25% versus 32.5%), while in terms of the need for mechanical ventilation in children of the study groups, there was a significant difference of 17.5 percent (32.5% versus 50%). The use of CPAP therapy was also lower. The effectiveness of antenatal prophylaxis is also confirmed by the data of the analysis of the need for invasive mechanical ventilation (MV) / artificial ventilation (AV).
In the early neonatal period, the need for MV starting from the second day of life was significantly lower in the 1st group with postnatal prophylaxis of RDS (Fig. 3.).
Fig. 3. The need for mechanical ventilation in the dynamics of the early neonatal period in infants with RDS depending on postnatal prophylaxis (%)
A more favorable clinical course of respiratory distress syndrome against the background of prophylaxis led to a reduction in the duration of artificial ventilation of the lungs, as well as a decrease in the degree of oxygen dependence (Table 3).
Table 3.
Comparative analysis of the duration (days) of respiratory therapy in newborns in the study
groups
Indicators Main group Comparison group
n=40 (day) n=40 (day)
ALV+SPAP 18,8±2,6 32,8±3,0*
ALV 16,8±2,43 30,8±2,47*
SPAP 12,1±1,70 10,4±1,71
*- reliability of indicators P<0.05
The maximum duration of mechanical ventilation was noted in the 2nd group, the minimum - in the 1st group (P<0.05), as well as the duration of combined respiratory therapy of mechanical ventilation with the transition to CPAP was significantly lower in the main group. The data on the duration of CPAP use were almost identical.
A less pronounced degree of oxygen dependence was noted in the group of children with antenatal and postnatal prevention of RDS, which is confirmed by lower levels of FiO2 (Fig. 4) and a two-fold reduction in the duration of oxygen therapy, which averaged 3.1±0.9 days and 6.3±1.0 days in the 1st and 2nd groups, respectively (P<0.05).
The initial parameters of mechanical ventilation in the group of children who received postnatal prophylaxis of RDS did not differ significantly from those in infants who did not receive postnatal prophylaxis of RDS. However, already on the second day, the parameters of oxygen concentration in the inhaled mixture were significantly lower in the main group.
Cases of IVH grades I-III were diagnosed 2 times more often in newborns of the comparison group (25 children - 62.5%) compared to the main group (13 children - 32.5%).
We also identified the number of days spent by children with RDS in hospital (Fig. 5).
Fig. 4. FiO2 level (%) in infants with RDS in the dynamics of the early neonatal period
Fig. 5. Number of days spent by children with RDS in hospital.
When assessing the length of stay of premature infants in hospital, it was found that infants in the comparison group needed a longer stay both in the intensive care unit and in the neonatal pathology unit than children in the main group.
Conclusions. Antenatal one course of corticosteroid prophylaxis in combination with early surfactant therapy with curosurf at a dose of 200 mg / kg in the delivery room contribute to a more rapid normalization of the gas exchange function of the lungs in premature infants with respiratory distress syndrome; reduce the frequency of intraventricular hemorrhages; reduce the duration of respiratory support of the newborn and the need for mechanical ventilation by 2 times; reduce the length of stay in the intensive care unit and hospital by 2 times.
REFERENCES
1. Ariki S, Nishitani C, Kuroki Y. Diverse functions of pulmonary collectins in host defense of the lung. J Biomed Biotechnol. 2012; 532071.
2. Carlton DP, Albertine KH, Cho SC, Lont M, Bland RD. Role of neutrophils in lung vascular injury and edema after premature birth in lambs. J Appl Physiol (1985). 1997 Oct; 83(4): 1307-17.
3. Jobe A.H., Kemp M., Schmidt A., Takahashi T., Newnham J., et al. Antenatal corticosteroids: a reappraisal of the drug formulation and dose //Pediatr Res. 2021; 318-325.
4. Gasymova Yegana Aydin, and Mirzoeva Ilhama Azizulla. Modern aspects of etiopathogenesis, diagnosis and treatment of respiratory distress syndrome of newborns // European Journal Of Biomedical And Life Sciences. 2018; 4: 3-10.
5. Kryuchko Daria Sergeevna. CPAP and surfactant in premature infants: instead of or together? // Neonatology: News. Opinions. Training. 2016; 1 (11): 74-80.
6. Lenyushkina A.A., Andreev A.V., Ionov O.V., Zubkov V.V. Review of recommendations for the management of newborns with respiratory distress syndrome // Neonatology: news, opinions, training. 2024; 12(1): 84-99. DOI: https://doi.org/10.33029/2308-2402-2024-12-1-84-99
7. Levit O, Jiang Y, Bizzarro MJ, Hussain N, Buhimschi CS, Gruen JR, Zhang H, Bhandari V. The genetic susceptibility to respiratory distress syndrome. Pediatr Res. 2009 Dec; 66(6): 6937.
8. Li Y, Wang W, Zhang D. Maternal diabetes mellitus and risk of neonatal respiratory distress syndrome: a meta-analysis. Acta Diabetol. 2019 Jul; 56(7): 729-740.
9. Moroz V.V. Respiratory distress syndrome of the newborn. Pathogenesis, diagnostics, clinical picture, treatment // V.V. Moroz, A.M. Golubev, S.A. Perepelitsa. - Moscow: Palmarium Academic Publishing. 2014; 36.
10. Шойимова, Ш., Хаитов, К., & Рахматуллаев, А. (2023). Вопросы эффективности проектных технологий обучения в медвузах. Актуальные проблемы обучения социально-гуманитарных наук в медицинском образовании, 1(1), 447-456.
11. Шойимова, Ш. (2023). Роль коммуникативной компетенции в эффективности деятельности преподавателей медицинских вузов. Актуальные проблемы обучения социально-гуманитарных наук в медицинском образовании, 1(1), 405-412.
12. Шойимова, Ш. (2023). Вопросы развития системы профессиональной подготовки учащихся общеобразовательных школ. Актуальные проблемы обучения социально -гуманитарных наук в медицинском образовании, 1(1), 419-426.
13. Шойимова, Ш. С. (2023). ФАКТОРЫ, ВЛИЯЮЩИЕ НА РАЗВИТИЕ ПРОФЕССИОНАЛЬНОЙ КОМ-ПЕТЕНТНОСТИ ПЕДАГОГА: Шойимова Шохиста Санакуловна Кандидат психологический наук, доцент. Ташкентский педиатрический медицинский институт Узбекистан, г. Ташкент. Образование и инновационные исследования международный научно-методический журнал, (11), 397-402.
14. Nitta K, Kobayashi T. Impairment of surfactant activity and ventilation by proteins in lung edema fluid. Respir Physiol. 1994 Jan; 95(1): 43-51
15. Singh N, Halliday HL, Stevens TP, Suresh G, Soil R, Rojas-Reyes MX. Comparison of animal-derived surfactants for the prevention and treatment of respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev. 2015 Dec 21; 2015(12): CD010249.
16. Suleimenova I.E., Makhashova A.M., Omirbekova N.B., Asylbekova A.K., and Altynbekova M.Zh. Respiratory distress syndrome of the newborn: a modern view of the problem // Bulletin of the Kazakh National Medical University. 2018; 1: 137-138.
17. Vinogradova Irina Valerievna. "Postnatal adaptation of the respiratory system in premature infants and its correction (literature review) // Bulletin of modern clinical medicine. 2013; 6 (6): 55-59.
18. Volodin N.N. Actual problems of neonatology // M., Publishing house "GEOTAR-MED". 2016; 231-245.
