Are weekly courses of antenatal steroids beneficial or dangerous?

Repeated courses of antenatal corticosteroids: is it justified?

The benefits of a single course of antenatal corticosteroids on neonatal outcomes are well established. There is, however, much controversy about how long this treatment should continue, and whether repeated courses should be administered if the women remain at risk for preterm delivery 7 days after the initial therapy. This review aims to discuss current evidence on the effectiveness and safety of repeated courses of antenatal corticosteroids.

Antenatal corticosteroid therapy for fetal maturation

OBJECTIVES

To assess the benefits and risks of antenatal corticosteroid therapy for fetal maturation.

OPTIONS

To administer antenatal corticosteroids or not to women at risk of preterm birth.

OUTCOMES

Perinatal morbidity, including: respiratory distress syndrome, intraventricular hemorrhage, infection, adrenal suppression, somatic and brain growth; perinatal mortality; and maternal morbidity, including infection and adrenal suppression.

EVIDENCE

MEDLINE and PubMed searches 1996 to August 2002 for English-language articles related to antenatal corticosteroid therapy for fetal maturation, the Cochrane Library, and national statements including that of the National Institutes of Health (NIH), the American College of Obstetricians and Gynecologists, and the Royal College of Obstetricians and Gynaecologists.

VALUES

The evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and recommendations were made according to guidelines developed by the Canadian Task Force on the Periodic Health Exam. BENEFITS AND HARMS: A single course of corticosteroids reduces perinatal mortality, respiratory distress syndrome, and intraventricular hemorrhage. Information regarding repeat courses of corticosteroids is limited and conflicting, with many studies being retrospective and non-randomized. Some studies suggested a reduction in respiratory distress syndrome with repeat courses, but some found increased rates of neonatal and maternal infection; fetal, neonatal, and maternal adrenal suppression; decreased fetal or neonatal somatic and brain growth; and increased perinatal mortality.

RECOMMENDATIONS

The SOGC supports the recommendations of the NIH Consensus Development Panel: 1. All pregnant women between 24 and 34 weeks' gestation who are at risk of preterm delivery within 7 days should be considered candidates for antenatal treatment with a single course of corticosteroids. (I-A) 2. Treatment should consist of two 12 mg doses of betamethasone given IM 24 hours apart, or four 6 mg doses of dexamethasone given IM 12 hours apart (I-A). There is no proof of efficacy for any other regimen. 3. Because of insufficient scientific data from randomized clinical trials regarding efficacy and safety, repeat courses of corticosteroids should not be used routinely (II-2E) but be reserved for women participating in randomized controlled trials.

VALIDATION

This Committee Opinion has been reviewed and approved by the Maternal-Fetal Medicine Committee of the SOGC and approved by SOGC Council.