Updated WHO Recommendations to Improve Preterm Birth Results

Nigar Sofiyeva, MD with honors, completed Obstetrics and Gynecology residency at Istanbul University. Nigar is certified in Clinical Research from Harvard, holds a master's from Dresden. In this article she overlooks updated WHO recommendations to improve preterm birth results and express her opinion on this topic.

Fetuses beyond the 22nd pregnancy weeks are viable; all have the human right to live and receive adequate medical assistance after birth. Reaching the term, in other words, completing 37 gestational weeks, is the medical equivalent of being compatible with life outside the womb. After delivery, the main difficulty in surviving the outside world is the ability to use their lungs.

Fetuses do not breathe air nor use their lungs as they do after birth. The required oxygen is supplied by the mother and delivered with the umbilical cord. Lung maturation is completed by the 34th week; thus, babies born before this point may have respiration difficulties and require assistance to support adequate oxygen levels.

Since the 1990s, major studies have presented the beneficial effects of corticosteroid use in preterm deliveries; the treatment effectively reduced respiratory distress syndrome (RDS) due to poor lung functioning, neonatal mortality, and bleeding to brain chambers in newborns.

However, debates were revolving around other health issues; most preterm deliveries are observed in women with high blood pressure or early water breakage. Does corticosteroid treatment affect maternal parameters and cause infection?

A 2015 ACT trial analyzing nearly 100 000 birth data showed that corticosteroid treatment increases not only the maternal infection rate but also the 28-day neonatal mortality rate.

Following this report, the WHO presented the conditions in which cases corticosteroid treatment is a suitable choice. But was this the final verdict?

Nearly 30 large studies, including WHO researchers, investigated these questions in the last few years. Also, the Cochrane Reviews, the “Bible” of medical evidence-based literature, updated their recommendation over the last decade on the advantages and disadvantages of corticosteroid use, and in the most recent report (2020) showed that the treatment reduces perinatal (before, during, and after birth) death, neonatal death, and RDS, but does not impact maternal infection and death significantly.

An updated 2022 WHO recommendation was presented with all the latest information.

The new findings are pro-treatment; corticosteroid treatment does not increase neonatal morbidity; on the contrary, in pregnancies less than 34 weeks even reduces death rates.

Evidence supports that the corticosteroid effect lasts from 1 to 7 days; thus, treatment should be given in cases when a very high likelihood of preterm birth is expected within seven days, WHO recommends.

Another big debate-inducing concern was birth contractions; should we stop them, or is it better to let the natural process flow? With previous knowledge, the latter was recommended: no need to prolong the period and increase maternal infection risk after we secured the baby’s lung issue.

Recent Cochrane research on the subject was not against all contraction-reducing drugs; instead, they showed that some might even have positive effects. Thus, the new WHO recommendation also updated the points on tocolytic, contraction-reducing drug use.

The latest data are extensive; they analyze thousands of birth results from low, middle, and high resource settings. It gives substantial reassurance to families and physicians on handling the days toward preterm birth. Pregnancies between the 24–34th week with a high likelihood of delivery onset and without infection symptoms are good candidates for the corticosteroid treatment.

What would one to seven days give us, we may ask.

First, even 24 hours are valuable for a baby’s lungs to mature under the corticosteroid treatment.

At the same time, since the birth symptoms start unexpectedly, there is a very high likelihood that mothers are not prepared; they might be away from the medical facility or from the centers equipped to take care of premature babies. Even with corticosteroid treatment, premature babies might still need respiratory support and long-term care. Therefore, this window is valuable to mature the lungs and secure safe delivery and after-birth care conditions.

Since we mentioned the importance of a few days, why don’t we prolong this period beyond seven days? In exceptional cases, it might be considered, which will require the second corticosteroid dose. However, in general, delaying delivery after pregnancy water breaks brings infection risk to the placenta and baby’s water (chorioamnionitis), womb’s inner layer (endometritis), and even beyond, spreading to other organs via blood (sepsis). All these conditions may have life-threatening results, as years-long studies and guidelines investigated.

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