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Running Head: PRETERM PREGNANCY
The Effects of Corticosteroid used for Preterm Pregnancy
Brittany Brewer
University of South Florida
NUR4165
December 9, 2012
Word count: 4,887
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Introduction
According to the World Health Organization, it is estimated that 15 million babies are
born preterm annually across the world. Of this 15 million, one million babies will die from
complications related to their preterm birth. A preterm birth is classified as a birth being before
the 37-weeks of gestational pregnancy. The WHO has declared that this number of preterm
deaths is on the incline, putting the population of pregnant women at risk. In hopes to combat
this growing number, many interventions have been developed that are thought to be safe and
effective (WHO).
One intervention implemented is the use of corticosteroids in those who are at risk for
preterm pregnancy, in hopes that the steroid will increase lung maturation in preparing the
preterm baby. There is clear evidence to support the acute use of corticosteroids in neonates as
being safe and effective in saving lives. The complications specifically reduced are seen in the
areas of respiratory distress syndrome, reduction of intraventricular hemorrhages, and reduction
of neonatal mortality (Born Too Soon, 2012). However, upon researching, there has been much
controversy over the safety of corticosteroids in regards to the long-term effects on the infant.
Corticosteroid therapy is best thought to be given two to three days prior to the expecting birth
(Born Too Soon, 2012). However, preterm births cannot always be predicted. So repeat courses
of this corticosteroid often need to be given. This presents the issue of fetal overexposure of
corticosteroids. This too is being debated. Overexposure of corticosteroids to the fetus can cause
a decline in fetal development, may be linked to childhood asthma, and may cause orofacial
clefts. Also, according to one study, corticosteroid use during pregnancy show signs of
increasing the risks of infections and neonatal sepsis (Mariotti, 2004).
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A look at statistics shows that in 75 different countries across the world, it was estimated
that about 10 percent of the suitable mothers received antenatal corticosteroids during pregnancy
(Born Too Soon). The use of antenatal corticosteroids has also been increasing over the past few
years as the rates of preterm births have increased (WHO). If this is an increasing practice
through hospitals and facilitations, it is important to be educated on the risks and complications
that may come from using this intervention. A synthesized literature review has been conducted
to determine if there is evidence based studies that show the actual negative aspects of antenatal
corticosteroid use. It is important to determine if the benefits outweigh these possible negative
aspects as well.
The information supporting this topic has been found through the University of South
Florida’s library database, PubMed, The Cochrane Library, and Medline. The search terms used
in order to obtain these articles included: “preterm pregnancy,” “preterm birth,” “complications
of preterm births,” “antenatal corticosteroids,” and “betamethasone and pregnancy.” The sources
of information being reviewed include peer-reviewed articles. Articles not considered reliable
sources and articles from outside of the dates of 2007-2012 have not been used in this literature
review.
Synthesized Literature Review
The study conducted by Wapner, Sorokin, Mele, Johnson, & Dudley (2007) aimed to
research the long-term outcomes of repeat doses of antenatal corticosteroids. Previous studies
have shown improvement in acute neonatal outcomes, along with shown signs of reduced birth
weight and an increased risk of intrauterine growth restriction in these neonates. Wapner and
colleagues wanted to investigate the possible negative aspects of corticosteroid use. The study
compared those who received multiple doses of corticosteroids during fetal development to those
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who received one a single dose of corticosteroids to see if there was a difference in health
outcomes.
The populations of children being evaluated in this study have been discovered through
the mothers who were enrolled in the Maternal–Fetal Medicine Units Network trial at the time of
the study. The women participating in the trial gave written consent before the study took place.
There were a total of 495 patients. The women were only deemed eligible if they were carrying a
single fetus or twins between the gestational ages of 23-weeks and 31-weeks old. It was required
that they have intact membranes, and that they have met the criteria for being at risk for preterm
delivery. All participants received one course of either dexamethasone or betamethasone prior to
the study beginning, and depending on which group they were in for the trial; they would receive
more courses or none. The dexamethasone course is given in dosages of 6 milligram,
intramuscularly, given every 12 hours; typically four doses are given total. The betamethasone
course consists of 12 milligram doses given intramuscularly, repeated at the 24 hour intervals
point for two consecutive days. The women that were assigned to receive multiple courses of
corticosteroids were given weekly courses of the corticosteroids up until the birth of the baby.
The women assigned to the placebo group, received weekly placebo courses as well. The women
were assigned to each group randomly. In order to ensure sample distribution and in determining
variables, the chi-square test was used (Wapner et al., 2007).
A detailed evaluation occurred once the women gave birth to their baby. These
evaluations included detailed physical assessments, along with ultrasound examinations of their
heads. If the infant was born prior to 33-weeks gestational age, an ultrasound was conducted
before discharging the infant home. If the infant was born after 33-weeks of age, the ultrasound
was completed by 14-days of age. Follow up continued throughout the child’s developmental
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years. It was required that the child return for an evaluation between the ages of 24-months and
35-months old. Each child was reevaluated to determine if they were meeting their milestone
developments. They each received a neurological exam, a set of physical exams, and
measurements of psychomotor and mental development. These exams were done be trained and
certified study personnel: pediatricians and pediatric neurologists. These exams were completed
between the timeframe of July, 2002, and May, 2006. Statistical analysis was based on the
Bayley Mental Developmental Index score. Measurements of height, weight, and head
circumference were determined using scales and charts (Wapner, et al., 2007).
The results of the study were based only on the infants that were actually discharged
home alive, that number being 583 infants. There were four infants that died between being
discharged home and the first follow-up. Twenty-three participants were unavailable to come to
the first follow-up because they were born at a facility that stopped communication with the
study network of MFMU. Of the remaining 556 children, 465 underwent Bayley testing (the test
related to psychomotor and mental development) and 486 children had a complete physical and
neurological exam. This is a successful turn out, with the completion rate yielded more than 80percent. There were no significant differences in the patients that were clinically lost from either
of the two groups. The placebo group lost 13.8% of their patients and the treatment group lost
11.4% of their patients (Wapner, et al., 2007).
The significant findings of this study were the high rate of low percentile birth rates
among the children exposed to the repeated courses of corticosteroids when compared to the
placebo group. Another significant finding being the children in the repeated courses group also
showed percentages of children below the tenth percentile in height, weight, and head
circumference when comparing them to the placebo babies. There was no significance difference
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between the two groups when comparing occurrences of medical conditions such as: seizures,
pneumonia, hospitalizations, asthma, or high or low blood pressures. Cerebral palsy was
documented in six (2.9%) of the cases in the repeat-treatment group and one (0.5%) case in the
placebo group. The six children diagnosed with cerebral palsy in the repeat-treatment group were
born at 34-weeks or more and the one child in the placebo group was born at 33-weeks old. It is
concerning that the six children were diagnosed with cerebral palsy after the age it is most likely
to occur. Data is needed from other studies to confirm this, but it still raises a concern of
corticosteroids playing a role. The results of the study were similar to previous study outcomes,
ensuring results: corticosteroids may improve acute care of the neonatal, but there is no longterm benefits discovered and possible harm may be done instead.
Limitations for the study would be the reasons for the women being classified at risk for
preterm delivery are unknown. Whether it was related to hypertension, diabetes, or possible
infection, it may have affected the outcomes of the corticosteroid use. Another limitation was the
study was required to stop early, after only five repeat courses of corticosteroids had been issued.
The safety committee recommended the trial be stopped early due to the results of the second
interim analysis showing a significant weight reduction in the fetuses receiving the
corticosteroids.
The study conducted by Church, Ronald, Mele, Johnson, Dudley, & Spong (2010) aimed
to discover if repeated courses of antenatal corticosteroids had an effect on the auditory
brainstem responses—a measurement of neonatal brain maturity and auditory functional ability.
One of the studies that provoked this study was one that experimented on rats; that showed that
repeated corticosteroid treatment was linked to impaired brain myelination and neurologic
development in animals (Cotterrell, 1972). It was imperative that they wanted to study these
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effects of corticosteroids on the human brain. The comparison is made between neonates that
received one course of corticosteroids and neonates that received multiple courses. It was
mentioned that the study had no hypothesis on whether the use of corticosteroids would be
beneficial or harmful to the neonatal auditory brainstem responses (ABR).
The design of the study was considered to be a randomized, double-masked, placebocontrolled clinical trial. The trial took place at 18 different centers that are included in the
NICHD Maternal Fetal Medicine Units (MFMU) Network. In this clinical trial, the population
was constrained to women at 23-weeks to 31-weeks gestational age. The women were required
to be at an increased risk of preterm birth or diagnosed with placenta previa (chronic abruption of
placenta) and also had to have received only a single course of corticosteroid therapy before
participating in the trial. The women were randomly selected to be in either the treatment group
or the placebo group. The corticosteroid treatment group received courses of two injections of
betamethasone each given 24 hours apart. Weekly administrations of the corticosteroids
continued up until the pregnancy was 33-weeks along or if the women went into labor. The
placebo group received the same dosage of normal saline. Sixty-five women enrolled in the
study. Forty-nine women consented to participate in the ABR study. Of these 49 women, 11
mothers carried twins, putting the total infants studied at 60. Twenty-four of the infants were for
the repeated corticosteroid group and 27 of the infants were in the single treatment group. Nine
infants were unable to have their ABRs completed due to excessive movement, which altered the
results of the test. The original sample goal was 65 women per each group, those needs were not
met due to the trial ending early for the same reasons of the safety committee recommending
only a certain amount of corticosteroids be given.
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The ABR testing was limited to only six centers due to the need of having specific
equipment to measure this. The ABR testing is essentially a sensory evoked potential obtained
from an electroencephalogram (EEG). It is used to measure the neuron transmission times related
to the auditory pathway found along the peripheral and brainstem pathways of the brain. When
measuring maturity of the brain, brain maturation is measured by faster neural transmission times
occurring and having the presence of larger waves or amplitudes on the ABR. These sensory
evoked potentials were induced by Bio-logic equipment that conducted stimuli to the infants
between 45 and 70 decibels (normal hearing level). The infants received the stimuli through
either the use of TGH-39 headphones or through the use of ER-3 insert headphones depending
on what headphones they had available at the trial clinic. The study found no difference in results
between using the two different sets of headphones. There were parameters regarding the
increments the stimuli were given based on number of clicks per second. The right and left ears
were stimulated separately. There were electrodes placed on the infant’s upper forehead and on
either side of the lower mastoid region to measure the neuron transmission. The ABRs were
recorded through the use of these electrodes. To ensure reliability of the data collection, ABR
replication traces occurred at least twice per each electrode during the stimulus. These ABR tests
were sure to be completed on each infant within 36 hours of being discharged home and were
only completed if the infant was clinically stable; all participants were.
The results were demonstrated in tables, which made comparing the differences between
each clinical group much easier. It was demonstrated that in the repeated corticosteroid group,
the potentials of each wave were much more prolonged that those of the single corticosteroid
group. The longer wavelengths are related to slower neural transmission times, which signifies
an underdevelopment in neonatal brain development. The wavelengths showed these results
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occurred only in the 70 decibels left and right ear stimulation, not in the 45 decibels stimulation.
However, even with these results, there was still not enough statistical significance. The
wavelengths were though to be linked to the brain size of each neonate rather than the actual
numbers of uses of corticosteroids. It was demonstrated that those born more preterm, had a
higher occurrence of smaller circumferences of heads, meaning a smaller brain, which is linked
to the longer wavelengths. The study did show that those given multiple courses of
corticosteroids showed a reduction of birth weights and head circumferences.
The conclusion is that multiple treatments of corticosteroids have an effect on the fetal
growth. In regards to ABR, repeated courses were relatively sparing on the effect of neural
mechanisms. Follow-up studies occurred once each child turned three years of age. It was
demonstrated that the weight and height differences at birth, those that received multiple courses
of steroids met their developmental milestones by the ages of three years of age.
The weaknesses of the study pertained to the small sample size. Failure to recruit the
sample size goal of 130 participants was not met. The study also had a high occurrence of twins,
with a total of 23% of the infants being twins. This is consistent with other studies showing that
twins account for about 12-28% of preterm births. But having duplicates of genetically similar
infants may have created a negative affect on the accuracy of the results.
The study conducted by Pole, Mustard, To, Beyene, & Allen (2010) was designed to test
the hypothesis relating to evidence of antenatal steroid therapy increasing risks of childhood
asthma. This was a retrospective study design. This study came about due to the increasing use
of corticosteroids in Canada. Over the last 15 years, corticosteroid use during pregnancy before
the gestational age of 34-weeks has increased by 35 percent. Prior studies have not focused their
studies on examining asthma being a result of corticosteroid use. This study was a longitudinal
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analysis study. The exact hypothesis being studied is a fetus’ exposure to corticosteroids in the
gestational period is an isolated risk factor for development of asthma in the early stages of
childhood. It is hypothesized that it would have little to no effect in later childhood.
The population cohort study was based on pregnancies occurring in women who resided
in Nova Scotia, Canada. The study focused on those who gave birth to a single infant per
pregnancy during the dates of January 1, 1989, and December 31, 1998. Data about each
pregnancy and child was discovered through the Maternal-Child Health Database. This is a
longitudinal population database that showed information about all the mothers and infants that
gave birth during the time periods given. The first dose of each corticosteroid was discovered
through the MCHD. It was not important the timing or dosage of each betamethasone
administered. It was only important to know that the fetus was exposed to betamethasone at one
point or another, regardless of timing (Pole et al., 2010).
Specified exclusions included any pregnancies that resulted in more than one infant. It is
known that twins and triplets differ physiologically and obstetrically than single fetus births.
Mothers were excluded if they had any of the following medication conditions: thyroid
conditions (which alters hormone levels), women who have experienced asthma during their
pregnancy (which may have altered the health of the fetus and previously exposed them to
antenatal corticosteroids). The results yielded 113,145 births from the time period of January,
1989, and December, 1998, in Nova Scotia, Canada. 8,780 infants were excluded from the study
due to deaths that occurred before the infant turn the age of one, infants that were born with
multiple fetuses, or infants born from mothers who experienced asthma or thyroid complications
during pregnancy. There were a total of 104,365 infants found eligible for the study. However,
18,627 of those infants had medical data and birth records missing. Other issues such as
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migration and missing information led the final number of infants to be studied to 80,448 (Pole
et al., 2010).
It was necessary to identify a strict definition in order to effectively examine the study
participants’ outcomes of being classified as having asthma or not. The criteria for this definition
is a child must be examined by a physician and be given the primary diagnostic field of asthma,
or asthma-related issues. Children must have experienced at least two of these health care
interactions in a year’s length of time, starting at three years of age, or must have required one
hospitalization specifically due to asthma to be considered asthmatic.
The study identified two environmental factors that were thought to influence the
presence of asthma: having a high number of siblings within the household and living in a
household in low socioeconomic status. Therefore, the factors of marital status and neighborhood
income quintiles were measured along side the data. The data was analyzed using proportional
hazards regression models. These models focus on relating a time before an event occurring to
the hazard time that may occur with it. In these models, variables or covariates increase in
regards to the hazard rate. To quantify the hazard rate between corticosteroids administration and
development of asthma effectively with time, an extended regression, including time-dependent
covariates, were used. Steroid effects were described by three hazard ratios (three different time
frames). The first ratio being from the time of steroid administration just to 156 to 260 weeks
after administration, the next ratio was the time between 261 to 364 weeks after administration,
and the last ratio was when time was greater 364 weeks after administration.
The results of the study demonstrated that, on average, asthma developed in this cohort
study around 287 weeks, or five and half years old, in 25.4% of the participants. It was noted that
the rates of antenatal steroid therapy administration increased three-fold over the 10 year time
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period. The occurrence of preterm births increased as well, increasing by approximately 30
percent. The hazard function was highest in the early stages of childhood. At 250 weeks, hazard
function was almost four times higher than the hazard function for 500 weeks. This indicates the
prevalence of asthma was much higher in the early childhood, as it was predicted. It is concluded
that antenatal corticosteroid administration is an independent risk factor in developing asthma
during young childhood.
The limitations of this study were related to the retrospective nature of the design. There
was a lack of reliability and validity of the information found in the medical data regarding each
asthma diagnosis. Another limitation of the study is the lack of information regarding the exact
measure of corticosteroids administered to each mother. Finally, this study cohort took place in
only Nova Scotia, Canada. In order for validity to occur, the study needs to take place elsewhere
and yield the same results to be certain. One strength of this study was the large number of study
participants.
The Murphy et al. (2012) study attempted to determine whether there is a relationship
between neonatal size and the number of courses of antenatal corticosteroids received. The study
was a secondary analysis of a prior preterm birth study, which was a double-blinded randomized
trial. This sample included women at risk for preterm birth. A requirement of the study was the
women had to be carrying only a single fetus; twins and triplets were excluded from this study.
The two compared groups of the study included the women who received multiple courses of
betamethasone and those who only received one course of betamethasone. There were 1,858
women who participated in the study. The groups were equally divided made by random
selection. The dosage used was similar to other studies. The multiple corticosteroid group
received courses of two injections of betamethasone each given 24 hours apart. Weekly
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administrations of the corticosteroids continued up until 34-weeks gestational age or if the
women had given birth before that.
Data was analyzed using the multiple linear regression strategy. The data was explained
in text and though linear models, which made understanding the data much easier. The results
yielded those who received multiple doses of corticosteroids were born more preterm than those
who only received one course. The infants from the multiple corticosteroids group showed a
decrease in birth weight (-33.50 g), in length (-.339 cm), and in head circumference (-.296 cm).
For each additional course of corticosteroid used, the more substantial the increments decreased
relating to these issues. It is concluded that fetuses exposed to multiple courses of corticosteroid
during fetal development, are at risk for being born at an earlier age and having decreased fetal
growth. The limitations of this study are there were no long-term effects studied. It is unknown if
the infants reached their ideal weights, heights, and head circumferences later on in childhood.
The study should be done in a more longitudinal approach for future trials to test the theory of
long-term effects of corticosteroids.
The study conducted by Hviid and Molgaard-Nielsen researched corticosteroids being
linked to orofacial clefs throughout Denmark. Prior to this study, there was no available evidence
to support this theory or to oppose it. Prior studies have showed links to corticosteroids and
orofacial clefs in animals, which stemmed the idea of this study. Also, prior studies have lacked
statistical power and have been limited by recall bias.
The study cohort was based on using the Danish Medical Birth Registry. This is a reliable
source; it contains all birth information in all of Denmark, dating back to 1968. Hviid and
colleagues were able to gather sound information from this. The registry included information on
the mother, father, newborn, and complications of birth. Using this information, they gathered a
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cohort study of all births in Denmark from January, 1996, to September, 2008. The information
regarding the use of corticosteroids for each of these pregnancies were obtained through the
Danish Prescription Drug Register. They were able to link the mothers to the prescriptions
through personal identification numbers. The children that had orofacial clefts were found
through the National Hospital Discharge Register. It contains information on each person
through the same personal identification number. Diagnoses of cleft lip that were made during
the first year of life were included in the study (Hviid, 2011).
The information was statistically analyzed through logistic regression analysis. This was
used estimate the odds ratios with confidence intervals to ultimately compare prevalence odds of
cleft lips occurring in births with corticosteroids and in those without the use of them. There
were a total of 832, 636 live births included in the study cohort. There were a total of 1,232
orofacial clefts diagnosed within the first year of life among this sample. In that cohort, there
were 163, 494 women who used corticosteroids during the pregnancy. It was discovered that
women who used any type of corticosteroid during the first trimester were not significantly at
risk for their offspring of developing an orofacial cleft. When looking at the females that used
dermatological corticosteroids, there was an increase incidence of orofacial clefts in this
population.
The overall interpretation of the data led to the conclusion that in this large cohort of
births, use of general corticosteroids during pregnancy was not statistically linked to incidence of
orofacial clefts; with the exception of dermatologic corticosteroids having a higher incidence.
Other studies prior to this showed increased risk of orofacial clefts in the population that used
oral corticosteroids. But these studies lacked statistical evidence to prove this to be true.
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One limitation of this study is that the information used did not include abortions. There
could have possibly been orofacial clefts present in that population that has gone unaccounted
for. Another limitation is the report relied on corticosteroid usage information from the national
prescription drug registry. This information only signified that the woman filled the prescription,
there was no actual evidence showing that the mother actually used it during her pregnancy. One
final limitation being the study looked at the use of many different corticosteroids. It included the
use of nasal sprays, inhalants, and oral prescriptions. It was not specific to the use of
corticosteroids in preventing preterm birth complications.
Discussion
It is consistent through the articles reviewed that corticosteroids seem to have a benefit on
those who are born preterm. It is used as an acute life saving treatment. But it is also seen to
cause issues relating to diminished birth weight and possible asthma risks in early childhood.
The articles were similar and different in their own ways. One consistent finding seen throughout
the research were the types and dosages of each corticosteroid used. It was either the
corticosteroid, dexamethasone, which was given intramuscularly in increments of 6 milligram
dosages or betamethasone, which was given intramuscularly in 12 milligram doses. Each study
aimed to compare single courses of corticosteroids to multiple courses corticosteroids.
A common theme, in almost all the studies, was the decrease in height, weight, and head
circumference in the infants who received multiple courses of corticosteroids in comparison to
those who only received a single course. The reasoning behind this is not known, but future
research should be aimed at studying why this occurs. These studies conclude that there are risks
of overexposing the fetus to corticosteroids. Caution needs to be used in determining whether to
administer corticosteroids or not. It is determined that corticosteroids can save lives, but it needs
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to be used cautiously. It should not be given unless the woman has high risks of having a preterm
birth. It should not be used just as a precaution that maybe she will go into labor preterm.
All studies reviewed varied greatly in their sample sizes. The sample sizes ranged from
the largest being 86,000 participants and the smallest being 60 participants. It is known that the
larger the sample studied, the more likely it represents the general population. The smaller
sample sizes are much less statistically significant.
Throughout two of the studies, signs of increased incidence of cerebral palsy and asthma
in early childhood in those exposed to four or more courses of corticosteroids were presented. It
was discovered that infants who have been given corticosteroids as a precaution and were born
term seem to have more complications due to the overexposure to corticosteroids. The Pole, et al.
(2010) study was specifically important to this review because this study followed the infants
through their childhood, up to them turning eight years old. This was important to determine the
possible long-term effects of corticosteroids; whereas the other studies focused on the infant at
birth. This means that education needs to be implemented in the healthcare field about these
corticosteroid precautions. The benefits are made known, but the dangers need to be as well.
Nurses need to be made aware of these and the patient should be well informed too. Education
also needs to be made on preterm pregnancy risk factors. Therefore, providers are more educated
on which women should receive corticosteroids and which women could be spared the risks. If
the women are determined to be at risk for preterm pregnancy, the number of doses to be given
of the corticosteroids should be limited to one or two courses. It has been proven that four
courses and more have affected the health of the infant.
Conclusion
In conclusion, this synthesized literature review shows that these studies do not oppose
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the use of corticosteroids. What was being determined was if they could find evidence on
whether there were risks of using multiple courses of corticosteroids-which were found.
Corticosteroids should be used cautiously and only given to the mothers most at risk for
delivering preterm.
Research gaps include how the corticosteroids affect the infant long term. Only one of
these studies focused on the infant beyond the age of one. Future studies could focus on that
aspect. Lastly, all studies and trials to date on corticosteroids have been conducted in hospital
settings where access to acute lifesaving devices, and medications are available. The uses of
corticosteroids in areas of poverty, where these interventions are not available have yet to be
established. Births at less equipped facilities and births at home should be evaluated with the use
of corticosteroids to see the effectiveness and risks in these environments.
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References
Born too soon: The Global action report on preterm birth. (2012). The World Health
Organization. Retrieved from:
http://www.who.int/pmnch/media/news/2012/preterm_birth_report/en/index.html
Church, M.W., Ronald, J.W., Mele, L.M., Johnson, F., Dudley, D., & Spong, C. (2010).
Repeated courses of antenatal corticosteroids: Are there effects on the infant’s auditory
brainstem responses? Neurotoxicol Teratol, 32(6), 605-610. doi:
10.1016/j.ntt.2010.05.006
Cotterrell, M., Balazs, R., Johnson, A.L. (1972). Effects of corticosteroids on the
biochemical maturation of rat brain: Postnatal cell formation. Journal of Neurochemistry,
19(9), 2151-67.
Hviid, A., & Molgaard-Nielsen, D. (2011). Corticosteroid use during pregnancy and risk of
orofacial clefts. Canadian Medical Association Journal, 183(7), 796-804.
Mariotti, V., Marconi, A.M., Pardi, G. (2004). Undesired effects of steroids during pregnancy.
Journal of Maternal-Fetal & Neonatal Medicine, 2(16), 3-7.
Murphy, K.E., Willian, A.R., Hannah, M.E., Ohlsson, A., Kelly, E.N., Matthews, S.G., . . .
Armson, B.A. (2012). Effect of Antenatal Corticosteroids on Fetal Growth and
Gestational age at Birth. Department of Obstetrics and Gynecology and Pediatrics,
119(5), 917-23.
Pole, J.D., Mustard, C.A., To, T., Beyene, J., & Allen, A.C. (2010). Antenatal steroid therapy for
fetal lung maturation and subsequent risk of childhood asthma: A longitudinal analysis.
Journal of Pregnancy, 2010. doi: 10.1155/2010/789748
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The World Health Organization. Preterm Birth. Retrieved from:
http://www.who.int/mediacentre/factsheets/fs363/en/index.html
Wapner, R.J., Sorokin, Y., Mele, L., Johnson, F., Dudley, D. (2007). Long-term outcomes after
repeat doses of antenatal corticosteroids. The New England Journal of Medicine, 357,
1190-1198. doi: 10.1056/NEJMoa071453
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Criteria
Read Chapters 2-4 in APA Manual
Introduction: Describe the extent of the problem for which you will review the literature or
the driving question or clinical problem that requires addressing in this review. The topic
should be important and have implications for nursing practice, patient or community health
(i.e., interventions to reduce obesity in children or the diabetes epidemic). The extent of the
problem should be substantiated by authoritative statistics such as the CDC, government
statistics, American Heart Association or the National Cancer Institute. Include a paragraph
describing the scope of the literature that will be reviewed, the databases used, and search
terms used to obtain the articles; clarify what will not be reviewed (publications between
2007-2012 permitted only). (1 page)
Synthesized Literature Review: FIVE high quality articles are reviewed and critiqued.
All articles reviewed must be methodologically sound in terms of design and measurement.
The format for describing each study begins with the purpose of the study, the design, the
sample studied, the intervention investigated, the results and the strengths and
weaknesses of each study. (6 ½ pages)
Discussion: First note similarities and differences, strengths and weaknesses of the
studies reviewed. Second, compare the best evidence from the research literature with
current practice and how practice might be altered based on the review. Use specific
examples from practice and compare to specific literature recommendations from your
review. Provide recommendations for future practice and research. (2 pages)
Conclusion: Summarize key research finding, key gaps between research and practice,
and key recommendation for future research and practice (1/2 page)
Written Communication Style, Language, grammatical accuracy:
Title page: Page margins are 1 inch on all sides, arial or Times Roman font, pages are
numbered, title page includes title of literature review, name, course title and number, date,
and word count. Manuscript is double spaced, reference list in on a separate page and is
complete in APA format with NO .com websites in the list. WORD COUNT MINIMUM: 1500
or no more than 10 pages (not including title page or references). Use these headings:
Introduction, Synthesized literature review, Discussion, Conclusion, References.
Conforms to APA format (see chapter 3 & 4), free of quotes, slang, spelling out all
acronyms in first mention, free of sexist language. Free of plagiarism, citing others
appropriately in text but in your own words, writing only in the third person. Every sentence
is complete, consistent use of tenses, proper use of commas and other punctuation marks,
no 2 sentence paragraphs or page long paragraphs, transition sentences between
paragraphs.
Please use Writing center at USF for help.
Points
assigned
10
Total Points
100
35
25
10
20
Points
Earned
10