Mar 17, 2013

the steroid shot dilemma

At my last MFM appointment, my doctor let me know that this coming week (24 weeks), I am eligible to receive a course of steroid injections, which will help to mature the baby's lungs should she make an early arrival. Since respiratory issues are the most significant obstacle for many preemies, the ability to jump-start lung maturation is obviously a pretty big deal. There are 2 decisions we need to make 1) whether we want the steroid shots (or under what set of circumstances we would want them) and 2) when we want them.

I think it is the second issue - the timing of the injections, that I am having the greatest difficulty with. The potential side effects of the steroids to the baby are fairly minimal in my opinion - babies who have been subjected to repeated courses of steroid injections in utero tend to weigh less than their untreated counterparts. However, this is much less of an issue today.

Apparently, because there is a long-held belief that the steroids are no longer maximally effective after 7 days, it was common practice in the 1990s to give a course of steroid injections around viability to at-risk women and then to give repeat doses every 7-14 days if the woman hadn't delivered yet.

That is no longer done today - my understanding is that at most you might receive an initial course of steroid injections and then if you still haven't delivered, say 2 months later, but you are in imminent danger of delivering and the baby is still <34 weeks, then they might give a rescue course, so that is 2 courses of injections at the most.

The second minor concern is that in animal studies some rats exposed to steroids in utero at doses many, many times higher than the dose given to human patients showed minor neurodevelopmental deficits. Again, this doesn't really concern me very much, especially knowing that steroids have been used in the context of speeding up lung maturation in utero since the 1970s, so pretty good follow-up data exists for humans. In short, I see little downside to getting the injections.

The second issue is timing - a long-held belief is that the maximal effect begins to dwindle 7 days after the 2nd (final) injection. However, newer studies have called into question the original data that led to this conclusion and it seems possible that you actually get pretty good coverage past 7 days - maybe even up to a month after the 2nd injection.

That being said, there is no doubt that after a certain period of time, the effect diminishes, so if you don't deliver within x weeks of the 2nd injection, it is probably not super helpful. I found it really hard to get a good sense from the literature exactly how quickly and at what time point the effect of the shots becomes worthless...I think it is still a contested issue.

I could get the shots this week at 24 weeks, which could be really nice from an emotional perspective -  knowing that if G-d forbid something happens during what is a disastrous gestation for birth, our chances would be better. On the other hand, there is no hard data that leads me to believe I am in imminent danger of giving birth, just a whole lot of fear based on my past.

So far, my cervix has stayed stable. I have been contracting fairly regularly, but my doctors assure me this is much more annoying than worrisome since my cervix hasn't changed. My placenta scan looked great and I haven't had any bleeding. Aside from my awful past, there is nothing concrete to suggest imminent danger (in spite of this, of course I worry like crazy - I don't ever want to be the sucker who assumes everything is going to be just dandy only to be rudely awakened).

Based on this information, it seems wise to hold off on the injections for a few more weeks -- maybe wait until between 26-28 weeks, when then at least I will hopefully get some coverage from them until at least 30 weeks. But then there is the emotional part of me who doesn't want to say "I told you so!" if something horrible happens in the next few weeks.

So what do you guys think? What would you do? Clearly there is no single right answer here - if there was, I am pretty sure my doctor wouldn't be leaving the decision in our hands.

12 comments:

  1. I don't know what I'd do in your place, but do try to remember that you are making the best decision you can with the resources you have...there should never be an "I told you so."

    I have a food feeling that this little one is going to stay right where it is for a while. Fingers crossed that the worrying is all for nothing!

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  2. A lot to think about, of course, but I would try not to put too much weight on this one decision, which I know is very difficult. We had our two shots on consecutive days at 32w (moved up from 33). Honestly, I just took my Dr's. reco on this, they should be able to give you more guidance, so you don't feel like you are out on your own here. I was thankful we did them, even though we made it farther than I ever thought, as I was still obviously concerned about respiratory issues from them arriving early. GL deciding.

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  3. Sass is right: you can only do your best with what you have. My two cents would be that, as long as your cervix is holding steady, wait until 26/28 weeks. But, hey, I'm not you! Hoping that you find a solution that leaves you peaceful.

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  4. How often are you going in for checks and monitoring? I agree that as long as your cervix looks good, holding off on the injection seems appropriate. I also think it is a good sign that the decision has been left up to you at this point. I've always heard that the best way to phrase a question to a Dr about a decision like this is to ask what they would do if it were their own pregnancy and baby. Best.

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  5. I think my first comment didn't go through... Just wanted to share that I would lean towards earlier because I'm anxious myself, but everything sounds like it's going really well. I agree that the doc could give more guidance. Sending good thoughts.

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  6. Hi A, I am in the same situation as you and I have already had this discussion with my doctor. I am going to get the injections at 24 weeks. I had my first injection at 24 weeks with the twins as well, I had the second at 24.3 and they were born at 24.5. Arthur would not have lived without the injection, so for me my decision is based completely on my past experience. I guess I just want to cover all avenues. However I think if your cervix looks good and and you feel comfortable holding out till 26/28 is also good. I think for me the 24 week mark has so much attached to it and I had no warning sign as things just happened so quickly. My doctor does think I should be OK for this pregnancy as its a singleton but I just want to be safe and she agrees with me that it is a good idea.

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  7. As an NICU nurse, I would give you this advice. If your baby was born at 24 weeks would you want to do everything possible to save her? If the answer is yes, go for the shots now, at 24 weeks-25 weeks. If the effects last upwards of a month (and they probably do), that will get you to at LEAST 28 weeks, in which case the baby has an all over better chance, even without steroids. If your answer is "No, I would want to do everything possible at a later gestational age, when my baby would have a better chance of living a healthy normal life", then wait until that gestational age (whatever it is, 25, 26 weeks etc) to give the steroids.

    Also you may have come across in your literature, but the steroids work better on more mature lung tissue, therefore my advice is still to give them at the gestational age you feel you and your husband would be comfortable "going all in", in terms of resuscitation and long term outcomes.

    Good luck. It's not an easy decision.

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  8. It's definitely a tough decision. My instinct would be to go with earlier though. I opted to get them at 24 weeks because my doctors thought that delivery was imminent--and in fact, had they not been able to stop my labor at 27 weeks, the shots would have helped a lot. As we slowly moved out of that window of effectiveness, however, I began to worry that I had gotten them too soon. My doctors and nurses addressed those fears by saying exactly what Emily said above: at 24 weeks, the shots would have benefited the twins had they been born anytime between then and ~28 weeks. After that, their prognosis (including lung maturation) was markedly better anyway. Good luck, A, with whatever you choose. I'm praying for you!

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  9. This is a hard one. I think there's a few things to ask yourself that Emily brings up. Still, it's a tough call. And frankly I can see arguments for both.

    Talk with your husband and your doctor. And no matter what decision you make, don't look back. You're doing the best you can with the information you've got available. Each case is different and there is no telling what would have been the absolute best option until after you're past all of this. So do what seems best. And no regrets.

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  10. Thanks so much for all of the support and insightful points, guys (and thanks to Emily for crystallizing it more into a very direct question). To be honest, I am still not totally sure what we will do...I think I need to discuss it a little more with the MFM. I will update after my appointment on Thursday.

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