Antenatal corticosteroids to reduce neonatal morbidity and mortality

Question 1

Antenatal steroids - benefit

Answer 1

Given within 7 days prior to PTB reduces perinatal and neonatal death and respiratory distress syndrome

Reduces neonatal death when the first dose is given within the 48 hours prior to birth, benefit also seen when given <24h of birth

Question 2

Antenatal steroids - Caesarean birth 37+0 to 38+6

Answer 2

Discuss risk risks/ benefits
May reduce admission to NICU for respiratory morbidity

Uncertain if any reduction in respiratory distress syndrome, transient tachypnoea of the newborn or neonatal unit admission overall

May result hypoglycaemia and potential developmental delay in neonate

Question 3

Antenatal steroids - when to offer

Answer 3

24+0 to 34+6 weeks in whom PTB is anticipation (established PTL, PPROM, planned PTB)

Question 4

Antenatal steroids - multiple pregnancy

Answer 4

Offer targeted antenatal corticosteroids for early birth in line with recommendations for singletons

Question 5

Antenatal corticosteroids - 22+0 to 34+6 - BENEFITS

Answer 5

Highly likely to reduce
- Perinatal mortality
- Neonatal death
- Neonatal respiratory distress

Likely to reduce
- Intraventricular haemorrhage
- Developmental delay

Most likely seen if 24-48h prior to birth
Reduction in respiratory morbidity (NOT mortality or IVH) if birth <7 days of treatement

Question 6

Antenatal corticosteroids - 22+0 to 34+6 - HARMS

Answer 6

Likely to: Affect maternal BMs (up to 5 days)
Reduce BW if birth >7 days after

No benefits likely to be seen if birth >7 days after

MAY increase psychiatric and behavioural diagnoses if children born at term

Question 7

Antenatal corticosteroids - 35+0 to 36 - BENEFITS

Answer 7

Likely to: reduce respiratory support

Question 8

Antenatal corticosteroids - 35+0 to 36 - HARMS

Answer 8

Likely to: increase neonatal hypoglycaemia

May increase psychiatric and behavioral diagnoses if children born at term

Question 9

Antenatal corticosteroids - before plan CS at 37-39 weeks - BENEFITS

Answer 9

May decrease admission to NNU with resp morbidity

Question 10

Antenatal corticosteroids - rescue course if treatment >7 days ago - BENEFITS

Answer 10

Likely to reduce respiratory spport

Question 10

Antenatal corticosteroids - before plan CS at 37-39 weeks - HARMS

Answer 10

May reduce educational attainment at school age

Question 11

Antenatal corticosteroids - rescue course if treatment >7 days ago - HARMS

Answer 11

Likely to reduce birthweight, head circumference and neonatal BP

Question 12

Antenatal corticosteroids - in GDM

Answer 12

Maternal blood glucose risk after administration for up to 5 days

Diabetes should not be considered a contraindication to antenatal corticosteroids for fetal lung maturation (NICE)

Question 13

Antenatal corticosteroid administration in GDM

Answer 13

Insulin-treated diabetes - additional insulin should be given according to an agreed protocol and the women should be monitored closely

Question 14

Antenatal corticosteroids - in hypertensive disorders

Answer 14

Offer if planned early birth for hypertension in pregnancy (NICE) - but do not delay birth for steroids

Cochrane Systematic Review
- No differences in corticosteroid effects on perinatal mortality, neonatal mortality and fetal death seen between women with and without hypertension syndromes
- Subgroup analyses = potentially a larger reduction in RDS seen in hypertensive mothers than other groups (uncertain)

Question 15

Antenatal corticosteroids - in PPROM

Answer 15

Corticosteroids to women with PPROM reduces the risks of RDS

No difference was observed between steroid and control groups concerning the risk necrotising enterocolitis, neonatal sepsis and Apgar score of <7 @5 minutes
Perinatal mortality was similar between steroid and control groups

Question 16

Antenatal corticosteroids - in FGR

Answer 16

Little evidence to suggest that steroids will perform differently in babies with growth restriction compared to the overall preterm population

RCOG guidance on SGA babies recommends that women with a SGA baby should receive antenatal corticosteroids to accelerate fetal lung maturation

Question 17

Beneficial Effects of Antenatal Magnesium (BEAM) randomised control trial

Answer 17

Investigated 1641 women with PPROM who received either one or two courses of antenatal corticosteroids

Similar rate of neonatal sepsis for 1 vs 2 courses of steroids
Secondary analysis = no increased risk of chorioamnionitis between the groups

Question 18

Antenatal corticosteroids - dose and route of administration

Answer 18

24mg dexamethasone IM in two divided doses
- 12mg 24 hours apart
- OR four divided doses of 6mg 12 hours apart

ALTERNATIVE
24 mg betamethasone sodium phosphate/acetate mix IM in two divided doses
- 12mg 24 hours apart

Question 19

Antenatal corticosteroids - dexamethasone vs betamethasone

Answer 19

Dexamethasone = reduced risk fo intra-ventricular haemorrhage

Betamethasone acetate/phosphate = most trialled formulation
May reduce risk of chorioamnionitis compared to dexamethasone

Question 20

Antenatal corticosteroids - betamethasone forumlations

Answer 20

Betamethasone sodium phosphate
- soluble
- short half-life

Betamethasone sodium acetate
- insoluble
- long half-life

(Available in 50:50 mixture in some countries)

Question 21

Antenatal corticosteroids - why not hydrocortisone?

Answer 21

Crosses placenta (and insufficient evidence to recommend)

Question 22

Antenatal corticosteroids - when are they effective?

Answer 22

Within 48h - reduces neonatal death

Within 24h - benefit also seen (still give)

Within 7 days (if 2nd dose) - most effective in reducing RDS

Question 23

Antenatal corticosteroids - when are they effective? Evidence

Answer 23

EPICE group demonstrated that any antenatal corticosteroid was associated with reduced mortality with the largest effect 24 hours to seven days after first injection (adjRR 0.5; 95% CI 0.4–0.6)

Further analysis demonstrated a significant risk reduction inmortality of 50% with a time of administration to birth interval of 18–36 hours

Question 24

Antenatal corticosteroids - repeat course?

Answer 24

Limited evidence to recommend repeat courses if imminent risk of PTB after 7 days

Further course may reduce need for respiratory support

No reduction in serious morbidity or long-term benefits have been seen with repeat corticosteroids

Babies who receive repeat doses of antenatal corticosteroids are smaller

Question 25

Antenatal corticosteroids - maximum number of courses (WHO guidance)

Answer 25

Single rescue course of antenatal corticosteroids if women remain at high risk of preterm birth and >7 days elapsed since previous treatment

Question 26

Antenatal corticosteroids - maximum number of courses

Answer 26

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