Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birthA correction was published in November for this title. Click here to antenatal steroids cochrane review the correction. This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. Wteroids is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course monounsaturated fat boost testosterone action is indicated by the condition of the patient, limitations of available resources, or advances antenatal steroids cochrane review knowledge or technology.
Antenatal corticosteroids for fetal lung maturation: an overview of Cochrane reviews | Cochrane
A correction was published in November for this title. Click here to view the correction. This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care.
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This Committee Opinion is updated as highlighted to reflect a limited focused change to clarify that, among specific populations, antenatal corticosteroids should be administered when a woman is at risk of preterm delivery within 7 days. Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario.
Continued surveillance of long-term outcomes after in utero corticosteroid exposure should be supported. Quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are encouraged.
This Committee Opinion was developed to help guide the timing and frequency of corticosteroid administration under various clinical contexts before preterm birth. Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes 1—5. The administration of antenatal corticosteroids to the woman who is at risk of imminent preterm birth is strongly associated with decreased neonatal morbidity and mortality 6— Neonates whose mothers received antenatal corticosteroids have significantly lower severity, frequency, or both, of respiratory distress syndrome relative risk [RR], 0.
A Cochrane meta-analysis reinforces the beneficial effect of this therapy regardless of membrane status and concludes that a single course of antenatal corticosteroids should be considered routine for all preterm deliveries 11, Betamethasone and dexamethasone are the most widely studied corticosteroids, and they generally have been preferred for antenatal treatment to accelerate fetal organ maturation.
Both cross the placenta in their active form and have nearly identical biologic activity. Both lack mineralocorticoid activity and have relatively weak immunosuppressive activity with short-term use. Although betamethasone and dexamethasone differ only by a single methyl group, betamethasone has a longer half-life because of its decreased clearance and larger volume of distribution It did not find significant scientific evidence to support a recommendation that betamethasone should be used preferentially instead of dexamethasone.
Of the 10 trials included in a Cochrane review on this issue, there were no differences in perinatal death or alterations in biophysical activity, but there was a decreased incidence of intraventricular hemorrhage with dexamethasone treatment Alternatively, an observational study reported less-frequent adverse neurological outcome at 18—22 months after betamethasone exposure These inconsistent and limited data are not considered sufficient to recommend one corticosteroid regimen over the other.
Treatment should consist of either two mg doses of betamethasone given intramuscularly 24 hours apart or four 6-mg doses of dexamethasone administered intramuscularly every 12 hours Because treatment with corticosteroids for less than 24 hours is still associated with significant reduction in neonatal morbidity and mortality, a first dose of antenatal corticosteroids should be administered even if the ability to give the second dose is unlikely, based on the clinical scenario 11, The benefit of corticosteroid administration is greatest at 2—7 days after the initial dose.
Therefore, corticosteroids should not be administered unless there is substantial clinical concern for imminent preterm birth. Specific data on the use of corticosteroids in the periviable period are supported by a combination of laboratory data on the response of lung tissue and clinical observational studies 1, 2 , 17 , The use of antenatal corticosteroid administration after preterm PROM has been evaluated in a number of clinical trials and has been shown to reduce neonatal mortality, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis 6, 12, 19 , Current data suggest that antenatal corticosteroids are not associated with increased risks of maternal or neonatal infection regardless of gestational age.
Whether to administer a repeat or rescue course of corticosteroids with preterm PROM is controversial, and there is insufficient evidence to make a recommendation for or against see Single Rescue Course. A Cochrane review concluded that although antenatal corticosteroids are beneficial in singleton gestations, further research is required to demonstrate an improvement in outcomes for multifetal gestations 21 , More recently, a well-designed retrospective cohort study concluded that administration of a complete course of antenatal corticosteroids 1—7 days before birth in twin pregnancies is associated with a clinically significant decrease in neonatal mortality, short-term respiratory morbidity, and severe neurological injury that is similar in magnitude to that observed among singletons The Maternal Fetal Medicine Units MFMU Network Antenatal Late Preterm Steroids trial 24 was a double-blind, placebo-controlled, randomized clinical trial designed to evaluate the use of antenatal betamethasone for pregnant women at high risk of delivery in the late preterm period.
Women were identified to be at high risk if they presented in preterm labor, had preterm PROM, or if they had a planned delivery in the late preterm period, with the indication at the discretion of the obstetrician—gynecologist or other health care provider. Tocolysis was not employed as a part of this trial, and delivery was not delayed for obstetric or medical indications. The study found that the administration of betamethasone led to a significant decrease in the primary outcome, which was the need for respiratory support.
A larger decrease was demonstrated for severe respiratory complications, from There were also significant decreases in the rates of transient tachypnea of the newborn; bronchopulmonary dysplasia; a composite of respiratory distress syndrome RDS , transient tachypnea of the newborn and RDS; and the need for postnatal surfactant.
Infants exposed to betamethasone were less likely to require immediate postnatal resuscitation. There was no increase in proven neonatal sepsis, chorioamnionitis, or endometritis with late preterm betamethasone. Hypoglycemia was more common in the infants exposed to betamethasone The rates of hypoglycemia found in the trial are similar to what is reported in the general population of late preterm infants Although not studied in this trial, long-term adverse outcomes of prolonged and persistent neonatal hypoglycemia have been described 26 , The American Academy of Pediatrics recommends the monitoring of neonatal blood sugars for late preterm infants because late preterm birth is a known risk factor for hypoglycemia.
There are important considerations specific to the administration of late preterm corticosteroids that should be noted and are derived from the methodology used by the trial. Late preterm administration of antenatal corticosteroids is not indicated in women diagnosed with clinical chorioamnionitis intrauterine infection Furthermore, tocolysis should not be used in an attempt to delay delivery in order to administer antenatal corticosteroids in the late preterm period, nor should an indicated late preterm delivery such as for preeclampsia with severe features be postponed for corticosteroid administration Groups not studied by the Antenatal Late Preterm Steroids trial include women with multiple gestations, women with pregestational diabetes, women who previously had received a course of corticosteroids, and women who gave birth by cesarean at term.
Whether or not late preterm corticosteroids provide benefit in these populations is unknown. Because of concerns for maternal and fetal harm, and the balance of risk and benefits, planned multiple courses are not recommended. In a randomized trial of single versus serial courses of antenatal corticosteroids, a reduction in birth weight and an increase in the number of infants who were small for gestational age were found, especially after four courses of corticosteroids Although not consistent, six studies found decreased birth weight and head circumference with repeat courses 29—35 and three studies did not 36— Follow-up of children at 2 years of age who were exposed to repeat courses of antenatal corticosteroids showed no significant difference in physical or neurocognitive measures in two studies 39 , 40 , and the same outcome was found in younger children in a third study Although not statistically significant, the relative risk of cerebral palsy in infants exposed to serial courses of antenatal corticosteroids RR, 5.
Maternal effects include increased risk of infection and suppression of the hypothalamic—pituitary—adrenal axis 31 , Regularly scheduled repeat courses or serial courses more than two are not currently recommended Although the initial data 43 suggested the benefit of corticosteroids may decrease after 7 days, the duration of corticosteroid benefit remains controversial No increase in newborn complications or intrauterine growth restriction was identified, although the power to evaluate these individual outcomes was low.
There was no difference in bronchopulmonary dysplasia, and long-term outcome developmental data are not available for these patients. The Crowther Cochrane meta-analysis 10 trials, 4, women and 5, infants included trials with a repeat course of corticosteroids as early as 7 days from initial course. The results of the meta-analysis showed reduction in RDS and there was noted an associated small reduction in size at birth, but no significant adverse outcomes.
Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario, given the Cochrane meta-analysis results 11, Whether to administer a rescue course of corticosteroids with PROM is controversial, and there is insufficient evidence to make a recommendation for or against 6, The concern that corticosteroids may have the potential to adversely affect neurodevelopmental outcomes is largely based on animal data and from studies of multiple course corticosteroids The MFMU study of repeat course corticosteroids suggested that four or more courses may be associated with the development of cerebral palsy This single signal does not lead us to caution against corticosteroid use, particularly as it refers to term exposure, but continued surveillance of long-term outcomes should be supported.
The year neurodevelopmental follow-up of this cohort were exposed to corticosteroids from Cognitive functioning as measured by the Weschler scales, working memory and attention, and other neurocognitive assessments were not different between exposure groups. The MFMU Antenatal Late Preterm Steroids study has not yet obtained long-term outcome data but doing so would add significantly to limited available literature.
A final additional consideration regarding corticosteroid risks is that in the context of maternal critical care, antenatal corticosteroids are not contraindicated, even in the setting of sepsis 1, Perinatal Quality Collaboratives, such as the Ohio Perinatal Quality Collaborative, California Perinatal Quality Care Collaborative, and the March of Dimes Big 5 State Perinatal Collaborative have worked to improve use of antenatal corticosteroids through a focus on the identification of missed opportunities and use of quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration.
Implementation of preterm labor assessment toolkits, standardized order sets for women at risk of early delivery, timely availability of medication in settings where pregnant women are cared for, maternal transfer protocols that indicate corticosteroids should be given before transport, and appropriate documentation of first course and rescue course antenatal corticosteroids in inpatient and outpatient health records, have been among the proposed strategies to improve appropriate and timely antenatal corticosteroid use.
One study reported qualitative focus group data describing conditions that enable delivery of antenatal corticosteroids with high reliability at hospitals that participated in the Ohio Perinatal Quality Collaborative antenatal corticosteroid project Six major themes supporting reliable implementation of antenatal corticosteroids were described, including 1 presence of a high reliability culture, 2 processes that emphasize high reliability, 3 timely and efficient administration process, 4 involvement of multiple disciplines, 5 evidence of benefit supports antenatal corticosteroid use, and 6 benefit is recognized at all levels of the care team.
Participating obstetrician—gynecologists or other health care providers and staff described that these key processes and supports were needed to ensure appropriate and timely delivery of antenatal corticosteroids with high reliability A collaborative of 54 hospitals from across the Big 5 States has been convened to pilot the new resources to standardize the identification of eligible patients and to improve the appropriate timing of corticosteroid therapy. The Ohio Perinatal Quality Collaborative reported that antenatal corticosteroid rates increase and are maintained at high levels when hospitals are aware that antenatal corticosteroid use is monitored, and missed opportunities are identified and reviewed.
The collaborative worked with Ohio vital records to add antenatal corticosteroid administration to the Ohio birth certificate registry. Monitoring hospital rates provided incentive for hospitals to improve appropriate administration and documentation.
This work by state and regional collaboratives demonstrates that quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are effective and should be encouraged. Therefore, the administration of antenatal corticosteroids should be monitored and missed opportunities reviewed. Overuse of antenatal corticosteroids was recently addressed at the Society for Maternal—Fetal Medicine conference in In view of this, it is critical to have ongoing development of strategies that encourage timely corticosteroid administration to women at risk of preterm delivery within 7 days and avoid overuse of corticosteroids for low risk women.
Collecting measures that track antenatal corticosteroids use for infants born before 34 weeks of gestation and timing of corticosteroids in relation to delivery will support quality improvement efforts to optimize appropriate and timely antenatal corticosteroid administration. The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients.
You may view these resources at www. These resources are for information only and are not meant to be comprehensive. The resources may change without notice. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
Antenatal corticosteroid therapy for fetal maturation. American College of Obstetricians and Gynecologists. Women's Health Care Physicians.
Recommendations The American College of Obstetricians and Gynecologists makes the following recommendations: