Effect of single versus multiple courses of antenatal corticosteroids on maternal and neonatal outcome

Long-Term Outcomes of Multiple versus a Single Course of Antenatal Steroids: A Systematic Review

Multiple courses versus a single course of antenatal corticosteroids (ACS) have been associated with mild respiratory benefits but also adverse outcomes like smaller head circumference and birth weight. Long-term effects warrant study. We systematically reviewed long-term outcomes (≥1 year) in both preterm and term birth after exposure to preterm multiple courses (including a rescue dose or course) versus a single course. We searched seven databases from January 2000 to October 2021. We included follow-up studies of randomized controlled trials (RCTs) and cohort studies with births occurring in/after the year 2000, given advances in perinatal care. Two reviewers assessed titles/abstracts, articles, quality, and outcomes including psychological disorders, neurodevelopment, and anthropometry. Six follow-up studies of three RCTs and two cohort studies (over 2,860 children total) met inclusion criteria. Among children born preterm, randomization to multiple courses versus a single course of ACS was not associated with adjusted beneficial or adverse neurodevelopmental/psychological or other outcomes, but data are scant after a rescue dose (120 and 139 children, respectively, low certainty) and nonexistent after a rescue course. For children born at term (i.e., 27% of the multiple courses of ACS 5-year follow-up study of 1,728 preterm/term born children), preterm randomization to multiple courses (at least one additional course) versus a single course was significantly associated with elevated odds of neurosensory impairment (adjusted odds ratio = 3.70, 95% confidence interval: 1.57-8.75; 212 and 247 children, respectively, moderate certainty). In this systematic review of long-term outcomes after multiple courses versus a single course of ACS, there were no significant benefits or risks regarding neurodevelopment in children born preterm but little data after one rescue dose and none after a rescue course. However, multiple courses (i.e., at least one additional course) should be considered cautiously: after term birth, there are no long-term benefits but neurosensory harms. KEY POINTS: · We systematically reviewed the long-term impact of multiple versus a single course of ACS.. · Long-term follow-up data were scant after a rescue dose and absent after one rescue course of ACS.. · In children born preterm, multiple courses of ACS were not associated with long-term benefits/harms.. · In children born at term, multiple courses of ACS were associated with neurosensory impairment.. · Preterm administration of multiple courses of ACS should be considered cautiously..

Impact of corticosteroid exposure on preterm labor in neonates eventually born at term

OBJECTIVE

To evaluate the impact of antenatal corticosteroid therapy (ACS) on birth outcomes in term infants exposed during pregnancy.

STUDY DESIGN

Exposed newborns were compared with non-exposed controls in a 1 to 2 design. Multivariate analysis was used to assess the effect of ACS exposure on neonatal outcomes.

RESULT

408 newborns were included (136 exposed to ACS, 272 non-exposed). Mean ± SD head circumference (HC) was 33.7 ± 1.4 vs 34.3 ± 1.6 cm, p = 0.001 in exposed vs controls; birth weight was 3.1 ± 0.4 vs 3.3 ± 0.4 kg, p = 0.0001; and birth height was 47.9 ± 2.1 vs. 49.1 ± 2.0 cm, p < 0.0001. Hypocalcemia (4.4 vs 0.7%, p = 0.019) and feeding difficulties (5.1 vs 1.5%, p = 0.047) were significantly more common in exposed newborns. Multivariate analysis for HC showed a significant independent association with ACS exposure (β = -0.5, p = 0.009).

CONCLUSION

Term newborns exposed to ACS have lower birth HC and higher risk of neonatal complications.

CLINICAL TRIAL REGISTRATION

NCT05640596.

Long-term childhood outcomes for babies born at term who were exposed to antenatal corticosteroids

BACKGROUND

Antenatal corticosteroids improve neonatal outcomes when administered to infants who are at risk of preterm delivery. Many women who receive antenatal corticosteroids for threatened preterm labor proceed to deliver at term. Thus, long-term outcomes should be evaluated for term-born infants who were exposed to antenatal corticosteroids in utero.

OBJECTIVE

This study aimed to compare long-term outcomes between term-born children aged ≥5 years who were born to women who received antenatal corticosteroids for threatened preterm labor and children whose mothers were also evaluated for threatened preterm labor but did not receive antenatal corticosteroids.

STUDY DESIGN

We performed a retrospective cohort study of children born at ≥37 weeks' gestation, aged ≥5 years, and born to mothers diagnosed with threatened preterm labor during pregnancy. The primary exposure of interest was receiving antenatal corticosteroids. Among the collected childhood medical conditions, the primary outcome of interest was a diagnosis of asthma.

RESULTS

Of the 3556 term-born children aged ≥5 years, 629 (17.6%) were exposed to antenatal corticosteroids (all betamethasone), and 2927 (82.3%) were controls whose mothers were evaluated for threatened preterm birth but did not get antenatal corticosteroid injections. Women receiving antenatal corticosteroids had higher rates of maternal comorbidities (diabetes mellitus, hypertension; P≤.01). Antenatal corticosteroid-exposed children had no difference in diagnosis of asthma (12.6% vs 11.6%), attention deficit disorder, or developmental delay (P=.47, .54, and .10, respectively). Controlling for maternal and neonatal characteristics, asthma was not different between those exposed to antenatal corticosteroids and controls (odds ratio, 1.05; 95% confidence interval, 0.79-1.39). The odds of the child's weight percentile being <10% were increased for antenatal corticosteroid-exposed children born at term (odds ratio, 2.00; 95% confidence interval, 1.22-3.25).

CONCLUSION

Children born at term who were exposed to antenatal corticosteroids may have increased odds of being in a lower growth percentile than those not exposed. However, rates of diagnoses such as asthma, developmental delay, and attention deficit disorders were not different.

Lipopolysaccharide induces placental mitochondrial dysfunction in murine and human systems by reducing MNRR1 levels via a TLR4-independent pathway

Mitochondria play a key role in placental growth and development, and mitochondrial dysfunction is associated with inflammation in pregnancy pathologies. However, the mechanisms whereby placental mitochondria sense inflammatory signals are unknown. Mitochondrial nuclear retrograde regulator 1 (MNRR1) is a bi-organellar protein responsible for mitochondrial function, including optimal induction of cellular stress-responsive signaling pathways. Here, in a lipopolysaccharide-induced model of systemic placental inflammation, we show that MNRR1 levels are reduced both in mouse placental tissues in vivo and in human trophoblastic cell lines in vitro. MNRR1 reduction is associated with mitochondrial dysfunction, enhanced oxidative stress, and activation of pro-inflammatory signaling. Mechanistically, we uncover a non-conventional pathway independent of Toll-like receptor 4 (TLR4) that results in ATM kinase-dependent threonine phosphorylation that stabilizes mitochondrial protease YME1L1, which targets MNRR1. Enhancing MNRR1 levels abrogates the bioenergetic defect and induces an anti-inflammatory phenotype. We therefore propose MNRR1 as an anti-inflammatory therapeutic in placental inflammation.

Joint periviability counseling between neonatology and obstetrics is a rare occurrence

OBJECTIVE

To investigate the frequency with which neonatal and maternal-fetal medicine (MFM) providers perform joint periviability counseling (JPC), compare content of counseling, and identify perceived barriers to JPC.

STUDY DESIGN

An anonymous REDCap survey was e-mailed to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine and to members of the Society for MFM.

RESULTS

There were 424 neonatal and 115 MFM participants. Fifty-two percent of neonatal and 35% of MFM respondents reported rarely/never performing JPC (p < 0.001), while 80% and 82%, respectively felt it would improve counseling. Content of counseling was similar, except for length of stay with 93% of neonatal vs. 85% of MFM respondents addressing this (p = 0.03). The majority (>60%) of respondents in both groups reported that clinical duties posed a significant/great barrier to JPC.

CONCLUSION

JPC is recommended but infrequently performed, with both specialties interested in further collaboration to strengthen the counseling provided.

The Glucocorticoid Receptor in Cardiovascular Health and Disease

The glucocorticoid receptor is a member of the nuclear receptor family that controls many distinct gene networks, governing various aspects of development, metabolism, inflammation, and the stress response, as well as other key biological processes in the cardiovascular system. Recently, research in both animal models and humans has begun to unravel the profound complexity of glucocorticoid signaling and convincingly demonstrates that the glucocorticoid receptor has direct effects on the heart and vessels in vivo and in vitro. This research has contributed directly to improving therapeutic strategies in human disease. The glucocorticoid receptor is activated either by the endogenous steroid hormone cortisol or by exogenous glucocorticoids and acts within the cardiovascular system via both genomic and non-genomic pathways. Polymorphisms of the glucocorticoid receptor are also reported to influence the progress and prognosis of cardiovascular disease. In this review, we provide an update on glucocorticoid signaling and highlight the critical role of this signaling in both physiological and pathological conditions of the cardiovascular system. With increasing in-depth understanding of glucocorticoid signaling, the future is promising for the development of targeted glucocorticoid treatments and improved clinical outcomes.

Glucocorticoids and programming of the microenvironment in heart

Glucocorticoids are primary stress hormones and can improve neonatal survival when given to pregnant women threatened by preterm birth or to preterm infants. It has become increasingly apparent that glucocorticoids, primarily by interacting with glucocorticoid receptors, play a critical role in late gestational cardiac maturation. Altered glucocorticoid actions contribute to the development and progression of heart disease. The knowledge gained from studies in the mature heart or cardiac damage is insufficient but a necessary starting point for understanding cardiac programming including programming of the cardiac microenvironment by glucocorticoids in the fetal heart. This review aims to highlight the potential roles of glucocorticoids in programming of the cardiac microenvironment, especially the supporting cells including endothelial cells, immune cells and fibroblasts. The molecular mechanisms by which glucocorticoids regulate the various cellular and extracellular components and the clinical relevance of glucocorticoid functions in the heart are also discussed.

The window of improved neonatal respiratory compliance after rescue antenatal steroids

OBJECTIVE

To evaluate whether premature infants delivered ≤7 days after rescue antenatal steroid treatment (ideal treatment) have increased passive respiratory compliance compared to those delivered >7 days after treatment (remote treatment).

METHODS

Secondary analysis of a randomized trial of rescue antenatal steroids on respiratory compliance. Infants in the treatment group were stratified by the interval between rescue antenatal steroids and delivery. We then compared the respiratory compliance in the ideal vs. remote groups.

RESULTS

Forty-four women (56 infants) received rescue antenatal steroids. Forty-nine infants had evaluable respiratory compliance measurements, with 27 (GA 30.1 weeks, BW 1362 g) "ideally" treated, and 22 (GA 33.8 weeks, BW 2248 g) "remotely" treated. Respiratory compliance was significantly higher for the ideal compared to the remote group (1.32 vs. 1.06 mL/cm H2O/kg; p = 0.037).

CONCLUSION

Infants treated with rescue antenatal steroids have a significantly higher respiratory compliance if delivery occurs within 7 days after treatment.

Maternal hormonal milieu influence on fetal brain development

An adverse maternal hormonal environment during pregnancy can be associated with abnormal brain growth. Subtle changes in fetal brain development have been observed even for maternal hormone levels within the currently accepted physiologic ranges. In this review, we provide an update of the research data on maternal hormonal impact on fetal neurodevelopment, giving particular emphasis to thyroid hormones and glucocorticoids. Thyroid hormones are required for normal brain development. Despite serum TSH appearing to be the most accurate indicator of thyroid function in pregnancy, maternal serum free T4 levels in the first trimester of pregnancy are the major determinant of postnatal psychomotor development. Even a transient period of maternal hypothyroxinemia at the beginning of neurogenesis can confer a higher risk of expressive language and nonverbal cognitive delays in offspring. Nevertheless, most recent clinical guidelines advocate for targeted high-risk case finding during first trimester of pregnancy despite universal thyroid function screening. Corticosteroids are determinant in suppressing cell proliferation and stimulating terminal differentiation, a fundamental switch for the maturation of fetal organs. Not surprisingly, intrauterine exposure to stress or high levels of glucocorticoids, endogenous or synthetic, has a molecular and structural impact on brain development and appears to impair cognition and increase anxiety and reactivity to stress. Limbic regions, such as hippocampus and amygdala, are particularly sensitive. Repeated doses of prenatal corticosteroids seem to have short-term benefits of less respiratory distress and fewer serious health problems in offspring. Nevertheless, neurodevelopmental growth in later childhood and adulthood needs further clarification. Future studies should address the relevance of monitoring the level of thyroid hormones and corticosteroids during pregnancy in the risk stratification for impaired postnatal neurodevelopment.

Committee Opinion No.677: Antenatal Corticosteroid Therapy for Fetal Maturation

Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation, including for those with ruptured membranes and multiple gestations. It also may be considered for pregnant women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family's decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation at imminent risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids. A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who have an imminent risk of preterm delivery within the next 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. 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.

Antenatal corticosteroids for preterm premature rupture of membranes: single or repeat course?

OBJECTIVE

The aim of this article is to determine the risk of maternal chorioamnionitis and neonatal morbidity in women with preterm premature rupture of membranes (PPROM) exposed to one corticosteroid course versus a single repeat corticosteroid steroid course.

STUDY DESIGN

Secondary analysis of a cohort of women with singleton pregnancies and PPROM. The primary outcome was a clinical diagnosis of maternal chorioamnionitis. Using multivariate logistic regression, we controlled for maternal age, race, body mass index, diabetes, gestational age at membrane rupture, preterm labor, and antibiotic administration. Neonatal morbidities were compared between groups controlling for gestational age at delivery.

RESULTS

Of 1,652 women with PPROM, 1,507 women received one corticosteroid course and 145 women received a repeat corticosteroid course. The incidence of chorioamnionitis was similar between groups (single course = 12.3% vs. repeat course = 11.0%; p = 0.8). Women receiving a repeat corticosteroid course were not at increased risk of chorioamnionitis (adjusted odds ratio, 1.28; 95% confidence interval, 0.69-2.14). A repeat course of steroids was not associated with an increased risk of any neonatal morbidity.

CONCLUSION

Compared with a single steroid course, our findings suggest that the risk of maternal chorioamnionitis or neonatal morbidity may not be increased for women with PPROM receiving a repeat corticosteroid course.

Glucocorticoids and foetal heart maturation; implications for prematurity and foetal programming

Glucocorticoids are steroid hormones, essential in mammals to prepare for life after birth. Blood levels of glucocorticoids (cortisol in most mammals including humans; corticosterone in rats and mice) rise dramatically shortly before birth. This is mimicked clinically in the routine administration of synthetic glucocorticoids to pregnant women threatened by a preterm birth or to preterm infants to improve neonatal survival. Whilst effects on lung are well documented and essential for postnatal survival, those on heart are less well known. In this study, we review recent evidence for a crucial role of glucocorticoids in late gestational heart maturation. Either insufficient or excessive glucocorticoid exposure before birth may alter the normal glucocorticoid-regulated trajectory of heart maturation with potential life-long consequences.

The role of cortisol in chronic binge alcohol-induced cerebellar injury: Ovine model

Women who drink alcohol during pregnancy are at high risk of giving birth to children with neurodevelopmental disorders. Previous reports from our laboratory have shown that third trimester equivalent binge alcohol exposure at a dose of 1.75 g/kg/day results in significant fetal cerebellar Purkinje cell loss in fetal sheep and that both maternal and fetal adrenocorticotropin (ACTH) and cortisol levels are elevated in response to alcohol treatment. In this study, we hypothesized that repeated elevations in cortisol from chronic binge alcohol are responsible at least in part for fetal neuronal deficits. Animals were divided into four treatment groups: normal control, pair-fed saline control, alcohol and cortisol. The magnitude of elevation in cortisol in response to alcohol was mimicked in the cortisol group by infusing pregnant ewes with hydrocortisone for 6 h on each day of the experiment, and administering saline during the first hour in lieu of alcohol. The experiment was conducted on three consecutive days followed by four days without treatment beginning on gestational day (GD) 109 until GD 132. Peak maternal blood alcohol concentration in the alcohol group was 239 ± 7 mg/dl. The fetal brains were collected and processed for stereological cell counting on GD 133. The estimated total number of fetal cerebellar Purkinje cells, the reference volume and the Purkinje cell density were not altered in response to glucocorticoid infusion in the absence of alcohol. These results suggest that glucocorticoids independently during the third trimester equivalent may not produce fetal cerebellar Purkinje cell loss. However, the elevations in cortisol along with other changes induced by alcohol could together lead to brain injury seen in the fetal alcohol spectrum disorders.

Effects of glucocorticoid treatment given in early or late gestation on growth and development in sheep

Antenatal corticosteroids are used to augment fetal lung maturity in human pregnancy. Dexamethasone (DEX) is also used to treat congenital adrenal hyperplasia of the fetus in early pregnancy. We previously reported effects of synthetic corticosteroids given to sheep in early or late gestation on pregnancy length and fetal cortisol levels and glucocorticoids alter plasma insulin-like growth factor (IGF) and insulin-like growth factor binding protein (IGFBP) concentrations in late pregnancy and reduce fetal weight. The effects of administering DEX in early pregnancy on fetal organ weights and betamethasone (BET) given in late gestation on weights of fetal brain regions or organ development have not been reported. We hypothesized that BET or DEX administration at either stage of pregnancy would have deleterious effects on fetal development and associated hormones. In early pregnancy, DEX was administered as four injections at 12-hourly intervals over 48 h commencing at 40–42 days of gestation (dG). There was no consistent effect on fetal weight, or individual fetal organ weights, except in females at 7 months postnatal age. When BET was administered at 104, 111 and 118 dG, the previously reported reduction in total fetal weight was associated with significant reductions in weights of fetal brain, cerebellum, heart, kidney and liver. Fetal plasma insulin, leptin and triiodothyronine were also reduced at different times in fetal and postnatal life. We conclude that at the amounts given, the sheep fetus is sensitive to maternal administration of synthetic glucocorticoid in late gestation, with effects on growth and metabolic hormones that may persist into postnatal life.

Antenatal steroids and the IUGR fetus: are exposure and physiological effects on the lung and cardiovascular system the same as in normally grown fetuses?

Glucocorticoids are administered to pregnant women at risk of preterm labour to promote fetal lung surfactant maturation. Intrauterine growth restriction (IUGR) is associated with an increased risk of preterm labour. Hence, IUGR babies may be exposed to antenatal glucocorticoids. The ability of the placenta or blood brain barrier to remove glucocorticoids from the fetal compartment or the brain is compromised in the IUGR fetus, which may have implications for lung, brain, and heart development. There is conflicting evidence on the effect of exogenous glucocorticoids on surfactant protein expression in different animal models of IUGR. Furthermore, the IUGR fetus undergoes significant cardiovascular adaptations, including altered blood pressure regulation, which is in conflict with glucocorticoid-induced alterations in blood pressure and flow. Hence, antenatal glucocorticoid therapy in the IUGR fetus may compromise regulation of cardiovascular development. The role of cortisol in cardiomyocyte development is not clear with conflicting evidence in different species and models of IUGR. Further studies are required to study the effects of antenatal glucocorticoids on lung, brain, and heart development in the IUGR fetus. Of specific interest are the aetiology of IUGR and the resultant degree, duration, and severity of hypoxemia.

Dosage regimen of antenatal steroids prior to preterm delivery and effects on maternal and neonatal outcomes

OBJECTIVE

The objective of this study was to compare the effects of two betamethasone dosage regimens on selected parameters in mothers and on the status of the preterm newborn.

METHODS

The analysis included 121 patients who gave birth by gestational week 35 and within 7 days after the completion of a full course of steroid treatment (24 mg). The study group consisted of 45 patients receiving six 4-mg doses of betamethasone every 8 h. The control group consisted of 76 patients receiving two 12-mg doses of betamethasone separated by 24 h.

RESULTS

After treatment, a significant increase in the leukocyte count was observed in the control group. Significant reductions in the erythrocyte counts, hemoglobin levels and hematocrit after treatment were also found in the control group. The post-natal status of newborns did not differ significantly between groups. The betamethasone dosage regimen used did not affect the incidence of moderate and severe respiratory disorders, intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), retinopathy (ROP), infection, hyperbilirubinemia or anemia in neonates. Mild respiratory disorders were slightly more common in the study group.

CONCLUSION

A reduction in the single steroid dose administered to patients at risk of premature birth may reduce maternal side-effects.

Causal ACTH-Depot Therapy during Pregnancies following Infertility Treatment

The aim of this paper was to confirm the efficacy of adrenocorticotropin depot (ACTH-depot) therapy in pregnancies with threatened miscarriage and preterm delivery through the desired stimulation of the adrenal glands controlled by the rest of organism. The activity of hypothalamic-pituitary-adrenal axis plays a key role in pregnancy. Such naturally stimulated endogenous corticosteroid hormones are free from unwanted side effects of their synthetics analogs. Low level of maternal blood ACTH and insufficient increase of induced by hypothalamic hormones oxytocinases (cystine-β-aminopeptidases) were indication to ACTH-depot therapy (0.5 mg/week) in our consecutive prospective studies. Contrary to antenatal use of synthetic corticosteroids, there are no temporal limits of this therapy, which has to be more often recommended into clinical prevention of fetal morbidity, treatment of premature delivery, and finally elimination of the newborn's mortality caused by the neuroendocrinological gestoses.

Dexamethasone and betamethasone protect against lipopolysaccharide-induced brain damage in neonatal rats

INTRODUCTION

The aim of this study was to test whether dexamethasone (Dex) and betamethasone (Beta), two of the most commonly used corticosteroids, protect against lipopolysaccharide (LPS)-induced white matter damage and neurobehavioral dysfunction.

METHODS

LPS or sterile saline was injected into the brain white matter of rat pups at postnatal day 5 (P5), and Dex or Beta was given intraperitoneally to the rat pups 1 h before the LPS microinjection. Brain inflammatory response, brain damage, and myelination were examined at P6, P8, and P14. Neurobehavioral tests were performed from P3 through P22.

RESULTS

Our results demonstrate that Dex and Beta markedly diminish the LPS-induced brain inflammatory response, restore myelin basic protein (MBP) expression, and alleviate lateral ventricle dilation. Both corticosteroids demonstrate significant protection against most LPS-induced behavioral deficits, including those in rearing, vibrissa-elicited forelimb-placing, beam walking, learning, and elevated plus-maze test. Of note, only Beta improved the locomotion and stereotype dysfunction. In contrast to their beneficial effects, neither drug prevented LPS-induced delay in body weight gain from P6 through P21.

DISCUSSION

Our study suggests that if their adverse effects are minimized, corticosteroids may be the potential candidate drugs to prevent brain damage in premature infants.

Effects of antenatal glucocorticoid therapy on hippocampal histology of preterm infants

OBJECTIVE

To investigate if antenatal glucocorticoid treatment has an effect on hippocampal histology of the human preterm newborn.

PATIENTS AND METHODS

Included were consecutive neonates with a gestational age between 24 and 32 weeks, who were born between 1991 to 2009, who had died within 4 days after delivery and underwent brain autopsy. Excluded were neonates with congenital malformations and neonates treated postnatally with glucocorticoids. The brains were routinely fixed, samples of the hippocampus were stained with haematoxylin and eosin and sections were examined for presence or absence of large and small neurons in regions of the hippocampus. Additional staining with GFAP, neurofilament and vimentin was performed to evaluate gliosis and myelination. The proliferation marker Ki67 was used to evaluate neuronal proliferation. Staining with acid fuchsin-thionin was performed to evaluate ischemic damage.

RESULTS

The hippocampi of ten neonates who had been treated with antenatal glucocorticoids showed a lower density of large neurons (p = 0.01) and neurons irrespective of size (p = 0.02) as compared to eleven neonates who had not been treated with glucocorticoids. No difference was found in density of small neurons, in myelination, gliosis, proliferation or ischemic damage.

CONCLUSION

We found a significantly lower density of neurons in the hippocampus of neonates after antenatal glucocorticoid treatment. Although the pathophysiological and clinical interpretations of these findings are not clear, they are consistent with those from experiments in mice and rhesus monkeys.

Pregnancy outcomes in patients with autoimmune diseases and anti-Ro/SSA antibodies

Anti-Ro/SSA antibodies are associated with neonatal lupus (congenital heart block (CHB), neonatal transient skin rash, hematological and hepatic abnormalities), but do not negatively affects other gestational outcomes, and the general outcome of these pregnancies is now good, when followed by experienced multidisciplinary teams. The prevalence of CHB, defined as an atrioventricular block diagnosed in utero, at birth, or within the neonatal period (0-27 days after birth), in the offspring of an anti-Ro/SSA-positive women is 1-2%, of neonatal lupus rash around 10-20%, while laboratory abnormalities in asymptomatic babies can be detected in up to 27% of cases. The risk of recurrence of CHB is ten times higher. Most of the mothers are asymptomatic at delivery and are identified only by the birth of an affected child. Half of these asymptomatic women develop symptoms of a rheumatic disease, most commonly arthralgias and xerophtalmia, but few develop lupus nephritis. A standard therapy for CHB is still matter of investigation, although fluorinated corticosteroids have been reported to be effective for associated cardiomyopathy. Serial echocardiograms and obstetric sonograms, performed at least every 1-2 weeks starting from the 16th week of gestational age, are recommended in anti-Ro/SSA-positive pregnant women to detect early fetal abnormalities that might be a target of preventive therapy.

Does in utero exposure to synthetic glucocorticoids influence birthweight, head circumference and birth length? A systematic review of current evidence in humans

Synthetic glucocorticoids are the mainstay treatment for stimulating lung maturation in threatened preterm delivery. Animal studies suggest that in utero exposure to glucocorticoids leads to a reduction in birth size. Smaller birthweight has been associated with higher risk of many chronic diseases. Therefore, the authors undertook a systematic review of human studies examining the association between synthetic glucocorticoid treatment and birth size. Medline, EMBASE, PubMed, Cochrane, Google scholar and Institute of Life Science databases were searched for studies published between 1978 and 2009 investigating the association between synthetic glucocorticoids and birthweight, head circumference, birth length and ponderal index. All studies controlling for gestational age were examined. Seventeen studies were included in the analysis. Nine out of 17 studies reported a reduction in birthweight (range 12-332 g), five of nine a reduction of head circumference (range 0.31-1.02 cm) and two of four a reduction of 0.8 cm in birth length. Despite methodological inconsistencies and limitations that impede clear conclusions, the evidence suggests an association between in utero exposure to synthetic glucocorticoids and reduced birth size.

Critical appraisal and clinical utility of atosiban in the management of preterm labor

Preterm birth is the major cause of perinatal morbidity and mortality in the developed world, and spontaneous preterm labor is the commonest cause of preterm birth. Interventions to treat women in spontaneous preterm labor have not reduced the incidence of preterm births but this may be due to increased risk factors, inclusion of births at the limits of viability, and an increase in the use of elective preterm birth. The role of antibiotics remains unproven. In the largest of the randomized controlled trials, evaluating the use of antibiotics for the prevention of preterm births in women in spontaneous preterm labor, antibiotics against anaerobes and bacterial vaginosis-related organisms were not included, and no objective evidence of abnormal genital tract flora was obtained. Atosiban and nifedipine are the main tocolytic agents used to treat women in spontaneous preterm labor, but atosiban is the tocolytic agent with the fewest maternal - fetal side effects. A well conducted randomized controlled trial comparing atosiban with nifedipine for their effectiveness and safety is needed.

Dose-response effects of betamethasone on maturation of the fetal sheep lung

OBJECTIVE

Glucocorticoid administration to women in preterm labor improves neonatal mortality and morbidity. Fetal exposure to glucocorticoid levels higher than those appropriate to the current gestational stage has multiple organ system effects. Some, eg, fetal hypertension, are maximal at lower than the clinical dose. We hypothesized that the clinical dose has supramaximal lung maturational effects.

STUDY DESIGN

We evaluated the full, half, and quarter clinical betamethasone dose (12 mg/70 kg or 170 microg/kg intramuscularly twice 24 hours apart) on fetal sheep lung pressure volume curves (PVC) after 48 hours' exposure at 0.75 gestation. We measured key messenger RNAs and protein products that affect lung function and total lung dipalmitoyl phosphatidyl choline.

RESULTS

Full and half doses had similar PVC and total lung dipalmitoyl phosphatidyl choline effects. Messenger RNA for surfactant proteins A, B, and D and elastin increased in a dose-dependent fashion.

CONCLUSION

Half the clinical betamethasone dose produces maximal PVC improvement in fetal sheep at 0.75 gestation.

A comparison of the effectiveness of single-dose vs multi-dose antenatal corticosteroids in pre-term neonates

The purpose of this study was to compare the outcome between exposure to single vs multiple courses of antenatal corticosteroids (AC) in pre-term births. The study involved 704 neonates delivered between 24-32 weeks. Maternal and perinatal outcome were compared between 294 (42%) neonates who received no AC; 257 (36%) who received single AC and 153 (22%) who received multiple AC. Any AC compared with no AC showed decreased composite neonatal morbidity (51% vs 62%, p = 0.004, odds ratio (OR) = 0.6), neonatal death (52% vs 62%, p = 0.004, OR = 0.6) and hyaline membrane disease (45% vs 57%, p = 0.002, OR = 0.6) with increased chorioamnionitis (17% vs 11%, p = 0.037, OR = 1.6) and pulmonary oedema (12% vs 1%, p = 0.0001, OR = 13). Multiple AC compared with single AC was associated with increased positive maternal cultures (44% vs 31%, p < or =0.005, OR = 1.8), small for gestational age infants (35% vs 21%, p = 0.001, OR = 2) and intraventricular haemorrhage (45% vs 34%, p <0.05, OR = 1.6). Multiple corticosteroid courses when compared with single corticosteroid course did not further reduce composite neonatal morbidity but increased the risk of positive maternal cultures and neonatal small for gestational age and intraventricular haemorrhage.

Gene profiling studies in the neonatal ovine lung show enhancing effects of VEGF on the immune response

Preterm and young neonates have an increased predisposition to respiratory distress syndrome (RDS) associated with an immature development of lung surfactant. Glucocorticoids (GCs) are the major immunomodulatory agents used to increase lung development and reduce the mortality and morbidity of preterm infants with RDS. However, their safety remains uncertain, and the precise mechanisms by which they improve lung function are unclear. In previous studies, we found that vascular endothelial growth factor (VEGF) enhances the innate immune response by respiratory epithelial cells, causes a monocytic infiltration into the lung, and reduces the severity of infection by respiratory syncytial virus (RSV), a respiratory pathogen known to affect preterm infants at a high prevalence. The purpose of this study is to measure the effects of VEGF administration on local immune responses in neonatal lambs, as the ovine lung is well suited for comparison to the human lung, due to similarities in alveolar development, immune responses, and RSV susceptibility. We hypothesized that VEGF induces the expression of genes necessary for host immune responses. We analyzed global gene expression profiles in the lungs of neonate lambs treated with VEGF by real-time qPCR. We report that VEGF induced the expression of chemokines (IL-8, RANTES, MCP-1), cytokines (IFN-gamma, IL-6, TNF-alpha, GMCSF), Toll-like receptor (TLR)-4, complement family members (C3, CFB, CFH) and collectins (SP-A, SP-D). These results suggest that VEGF can regulate local immune gene expression in vivo and should be further explored as a potential exogenous therapy for various lung diseases.

Adverse effects of antenatal glucocorticoids on cerebral myelination in sheep

OBJECTIVE

To determine in fetal sheep the effect of betamethasone on myelination in relation to stage of myelination, number of treatment courses, dose, and route of administration.

METHODS

Fetal expression of myelin basic protein (MBP), a marker of mature oligodendrocytes and myelin, was determined between 0.27 and 0.93 gestation. Short-term betamethasone effects were examined 24 hours after one maternal intramuscular treatment course (weight adjusted to equal the clinical dose of 2 x 8 mg betamethasone to a 70-kg woman) at 0.63, 0.75, and 0.87 gestation or after continuous 48-hour fetal intravenous infusion at 0.75 and 0.87 gestation. Lasting effects were examined 20 days after one and two treatment courses weight-adapted to the clinical dose of 2 x 8 mg or 2 x 12 mg betamethasone at 0.75 gestation.

RESULTS

Myelin basic protein immunoreactivity was first detected in the internal capsule at 0.53 gestation, followed by the centrum semiovale, the superficial white matter, and corpus callosum at 0.63 gestation. Within 24 hours after treatment, betamethasone reduced the number of mature oligodendrocytes and MBP immunoreactivity. The effect decreased with gestational age. Maternal and fetal betamethasone administration had similar effects. Loss of MBP immunoreactivity was not reversed 20 days after two treatment courses, independent of dose.

CONCLUSION

Betamethasone-induced delayed cerebral myelination is dependent on the stage of brain development in sheep. Betamethasone-related disturbances in myelination and any potential contribution to childhood behavior deficits need to be confirmed in clinical studies.

Corticosteroid-induced adverse events in adults: frequency, screening and prevention

Corticosteroids represent the most important and frequently used class of anti-inflammatory drugs and are the reference therapy for numerous neoplastic, immunological and allergic diseases. However, their substantial efficacy is often counter-balanced by multiple adverse events. These corticosteroid-induced adverse events represent a broad clinical and biological spectrum from mild irritability to severe and life-threatening adrenal insufficiency or cardiovascular events. The purpose of this article is to provide an overview of the available data regarding the frequency, screening and prevention of the adverse events observed in adults during systemic corticosteroid therapy (topically administered corticosteroids are outside the remit of this review). These include clinical (i.e. adipose tissue redistribution, hypertension, cardiovascular risk, osteoporosis, myopathy, peptic ulcer, adrenal insufficiency, infections, mood disorders, ophthalmological disorders, skin disorders, menstrual disorders, aseptic necrosis, pancreatitis) and biological (i.e. electrolytes homeostasis, diabetogenesis, dyslipidaemia) events. Lastly, data about the prescription of corticosteroids during pregnancy are provided. This review underscores the absence of data on many of these adverse events (e.g. lipodystrophy, dyslipidaemia). Our intent is to present to practitioners data that can be used in a practical way to both screen and prevent most of the adverse events observed during systemic corticosteroid therapy.

Corticosteroids in perinatal medicine: how to improve outcomes without affecting the developing brain?

Antenatal glucocorticoid therapy remains one of the most striking successes in the perinatal management of complicated pregnancies that result in premature birth. The anti-inflammatory and maturative properties of fluorocorticoids are such that all women at risk of preterm delivery before 34weeks gestation should be treated. Betamethasone is preferred to dexamethasone and no more than two courses, 2weeks apart, should be given until the evidence from further controlled trials on repeated doses becomes available. In particular, the early use of postnatal dexamethasone should be avoided in preterm infants because of the deleterious effects on neurological development, including not only cerebral palsy but also cognitive function and psychiatric-related behavior. Treatment with other steroids should be restricted to the context of randomized controlled trials.

Multiple courses of antenatal steroids

The benefits and risks of multiple courses of antenatal steroids (ANS) are still unresolved issues. This was a prospective cohort study in a level III neonatal unit. Preterm babies < or = 35 wk gestation were included. Malformations, chronic maternal steroid intake, exchange transfusions prior to cortisol sampling and incomplete ANS courses were exclusion criteria. Subjects were classified into: No course (Group 0), 1 course (group 1), 2 courses (Group 2), > 2 courses (Group 3) of antenatal dexamethasone. The key outcome was adrenal function assessed by basal and post-ACTH cortisol on day 3. Other outcomes were neonatal morbidity, mortality, growth parameters at birth, long term growth and neuro-development. Of 210 eligible babies, 124 were enrolled. 38, 51, 10 and 25 babies belonged to groups 0, 1, 2 and 3 respectively. Basal and post-ACTH serum cortisol did not show any significant difference between groups (p=0.5 and p=0.9 respectively). Incidence of severe HMD requiring ventilation was significantly lower (p=0.02) in multiple course group (combined groups 2 and 3) compared to single course group. There were no differences in other neonatal morbidity, birth OFC and weight between single and multiple ANS groups. Follow up data at a mean age of 22 mth was available in 59 subjects (69%) belonging to groups 1-3. No differences were noted in the proportion of patients with abnormal neurological examination (p=0.1), abnormal PDI (p=0.9), abnormal MDI (p=0.9) and physical growth between multiple and single course groups. Multiple courses of antenatal dexamethasone resulted in a significant decrease in severe forms of RDS and they did not cause adrenal suppression, decreased growth or impaired neuro-development.

Single Versus Repeat Courses of Antenatal Steroids to Improve Neonatal Outcomes: Risks and Benefits

Recent additions to the literature provide evidence supporting the use of repeat courses of antenatal steroids. Both human and animal studies offer evidence that repeat courses of corticosteroids improve neonatal pulmonary outcomes, especially for the infants delivered at earlier gestational ages. Although there is also evidence to suggest altered neuronal maturation and intrauterine growth restriction in animals treated with repeat steroids, randomized controlled studies in humans have shown that birth weight reduction was only seen in those infants treated with 4 or more courses of corticosteroids. In addition, the reduction in neonatal birth weight and head circumference seen after multiple courses of antenatal corticosteroids normalizes by the time of hospital discharge. Studies are ongoing to investigate the 24-month post delivery physical and neurodevelopmental outcomes in infants exposed to repeat courses of antenatal corticosteroids. Although there is evidence demonstrating the safety of a single repeat, or 'rescue', dose of antenatal corticosteroids, this must be tempered against the adverse effects seen after multiple courses of weekly repeat steroids. Randomized controlled trials are needed to determine the optimal number of courses of antenatal steroids to reduce the frequency of neonatal respiratory distress syndrome (RDS) without adversely affecting other neonatal outcomes.

Animal models for small for gestational age and fetal programming of adult disease

Fetal growth retardation is a fetal adaptation in response to inadequate supply of oxygen and/or nutrients. Animal models of intrauterine growth retardation are an invaluable tool to question the genetic, molecular and cellular events that determine fetal growth and development. Rodent and non-litter bearing animals are mammalian system with similar embryology,anatomy and physiology to humans. Utilization of these systems has led to a greater understanding of the pathophysiology and consequences of intrauterine growth retardation. These observations are comparable to that observed in humans born small for gestational age, and are of interest because of the known association between poor fetal growth and development of adult disease. All the experimental manipulations described here have altered a number of metabolic and physiological variables, but the pattern of alterations seems to vary with the procedure and species employed. This review describes animal models for intrauterine growth retardation and assesses their potentials and limitations at aiming to improve strategies for the prevention of adult disease.

Randomized trial of a single repeat dose of prenatal betamethasone treatment in imminent preterm birth

BACKGROUND

A single dose of prenatal betamethasone treatment decreases neonatal morbidity rates when administered within 7 days before preterm delivery. A single repeat dose or booster dose of betamethasone before delivery has been proposed to be effective, but its efficacy has not been subjected to a randomized, blinded trial.

METHODS

Women with imminent delivery before 34.0 gestational weeks were eligible if they remained without delivery for >7 days after a single course of betamethasone. After stratification, a single repeat dose of betamethasone (12 mg) or placebo was administered. The primary outcome was survival without respiratory distress syndrome or severe intraventricular hemorrhage (grade 3 or 4).

RESULTS

A total of 249 mothers had been enrolled by the time the study was discontinued. All of the 159 infants in the betamethasone group and 167 in the placebo group were born before 36 weeks of gestation. The intact survival rate was unaffected and was lower than anticipated, because the gestational age-adjusted incidence of respiratory distress syndrome was higher than the population incidence. The requirement for surfactant therapy in respiratory distress syndrome was increased in the betamethasone group. According to posthoc analysis of the data for 206 infants who were delivered within 1 to 24 hours, the betamethasone booster tended to increase the risk of respiratory distress syndrome and to decrease intact survival rates.

CONCLUSIONS

According to this study, a single booster dose of betamethasone just before preterm birth may perturb respiratory adaptation. These results caution against uncontrolled use of a repeat dose of glucocorticoid in high-risk pregnancies.

Gastrointestinal perforation in very low-birthweight infants

BACKGROUND

Spontaneous isolated gastrointestinal perforation (SIP) in very low-birthweight infants has been reported as a different disease entity from necrotizing enterocolitis (NEC). The objective of this study was to investigate the incidence and risk factors of NEC and SIP.

METHODS

The authors reviewed the medical records of very low-birthweight infants who were admitted to Toho University Perinatal Center, Tokyo, Japan, between 1 January 1991 and 31 December 2002. The diagnosis of NEC was made with the finding of bloody gastric fluid or stool, abdominal distention, and abnormal abdominal X-ray findings such as pneumatosis intestinalis or fixed dilated intestinal loops. SIP was defined at laparotomy as the presence of an isolated gastrointestinal perforation surrounded by normal appearing bowel.

RESULTS

A total of 556 very low-birthweight infants were included in this study. Of those, 15 infants were excluded because of major anomalies. Out of 541 infants, 14 were diagnosed to have NEC or gastrointestinal perforation. In total, 13 infants had gastrointestinal perforation and 10 were confirmed as SIP. Two SIP suggestive cases were included in SIP cases. There was only one case of NEC (0.2%) during 12 years in the authors' institute. Eight SIP cases had antenatal nonsteroidal anti-inflammatory drugs (NSAID). The treatment with antenatal NSAID was significantly associated with the incidence of SIP (p<0.001).

CONCLUSION

The authors experienced only one proven case of NEC (0.2%), 12 cases of SIP (2.2%) among 556 very low-birthweight infants admitted during 12 years. Antenatal NSAID were strongly associated with SIP.

[Antenatal exposure to corticosteroids for fetal lung maturation and its repercussion on weight, length and head circumference in the newborn infant]

BACKGROUND AND OBJECTIVE

To study the effects of antenatal corticosteroids treatment to promote fetal lung maturation, on fetal growth, depending on the number of the courses administered.

PATIENTS AND METHOD

The study was based on data from the Spanish Collaborative Study of Congenital Malformations (ECEMC), analysing a sample of 29,557 singleton liveborn infants without congenital defects. An stratified analysis by gestational age was performed to compare the weight, length and head circumference at birth, in the exposed and unexposed infants to dexamethasone/betamethasone. To control confounding factors (year of birth, maternal age, gestational age, parity, maternal smoking and/or alcohol consumption, gestational diabetes, non-gestational diabetes and other maternal chronic diseases) we used a general linear model with random effects, being the randomised variable the place of birth.

RESULTS

The exposure to more than one course of antenatal corticosteroids resulted in a significant reduction of birth weight, length and head circumference in singleton preterm infants. The birth weight decreased by 22% (p < 0.0001), the length 5% (p = 0.002) and the head circumference 6% (p = 0.0005). The treatment with only one course reduced also significantly the weight and length but not the head circumference. In addition, we observed a significant interaction between the treatment and gestational age at birth indicating that the effect of corticosteroids is stronger in the most premature babies.

CONCLUSIONS

In this retrospective analysis, the antenatal exposure to corticosteroids to promote fetal maturation is associated with diminished weight, length and head circumference in the premature newborn infant. This negative effect was greater in those premature babies exposed to multiple courses.

Antenatal steroid therapy: have we undervalued the risks?

Antenatal corticosteroid therapy to enhance fetal lung maturation in pregnancies at risk for preterm delivery is used commonly, based on the assumption that its established benefits outweigh associated risks. Corticosteroid treatment does confer some risks, particularly with respect to restricted brain growth and disordered neuronal development. These alterations have the potential for long-term effects on health. They deserve further study, and should not be undervalued. Corticosteroid therapy should be applied selectively in those situations in which the risk of preterm birth is very high and the likelihood of severe respiratory distress syndrome substantial.

Normal neuropsychological development in children with congenital complete heart block who may or may not be exposed to high-dose dexamethasone in utero

BACKGROUND

Antenatal and postnatal treatment with dexamethasone (DEX) may negatively affect the neuropsychological development in children. Maternal anti-Ro/Sjögren's syndrome A (SSA) antibodies may also be associated with learning disabilities in offspring.

OBJECTIVE

To assess neuropsychological development in babies exposed to very high dosages of DEX in utero, whose mothers were anti-Ro/SSA positive.

METHODS

13 children with congenital complete heart block (CHB) (11 exposed and 2 not exposed to DEX) and 3 healthy siblings, all of anti-Ro/SSA-positive women, were evaluated. 11 preschool-aged children (5 boys) were assessed using Griffiths Mental Development Scales. 5 school-aged children (2 boys) were examined using Wechsler Intelligence Scale for Children-Revised to check IQ and reading tests to explore the existence of learning disabilities or dyslexia. None of the children had had major neonatal complications, although those with CHB had to be paced at different intervals from birth.

RESULTS

The children had been exposed in utero to a mean total dose of 186.6 mg DEX. IQ levels were always normal (mean IQ 105.1, standard deviation (SD) 9.5). Only one child had a learning disability, of borderline clinical significance, but this child had never been exposed to DEX.

CONCLUSION

No negative effects were found on the neuropsychological development in this cohort of children, even if they had been exposed to maternal anti-Ro/SSA antibodies and to very high dosages of DEX (much higher than those used to improve fetal lung maturity). These findings might be of interest in view of the large number of infants exposed in the past to repeated antenatal courses of steroids.

The effectiveness of adrenocorticotropin repeated doses in high risk pregnancies

OBJECTIVE

The aim of this study was to assess the effect of two kinds of adrenocorticotropin (ACTH)-depot repeated doses administered to pregnant women who underwent infertility treatment.

MATERIAL AND METHODS

The study population included 424 pregnant women with singletons. Two hundred and forty-two women received repeated 0.5 mg doses of ACTH, whereas 182 women also were treated for infertility but did not receive any therapy. The ACTH-treated patients were subdivided into two subgroups: (1) 142 patients received only series of three 0.5 g ACTH-depot injections every other day in the first and/or second trimester with occasionally single ACTH-depot doses in the third trimester, (2) 100 patients received only single 0.5 mg ACTH-depot doses for the entire duration of pregnancy. Clinical symptoms of threatened abortion and preterm delivery as well as very low or decreasing levels of serum oxytocinases were indications for the hormonal therapy. Low oxytocinase serum levels, recurrent abortion and preterm delivery characterize pregnant women with hypothalamic insufficiency.

RESULTS

Women who received only single doses of the ACTH-therapy for the entire duration of pregnancy had a statistically significant longer gestation, and higher newborn mass and length than patients who received a series of three hormonal injections as well as control women who had no clinical or laboratory indication for such therapy.

CONCLUSIONS

ACTH-depot injection results in the oxytocinase increased serum level, a decreased number of abortion and preterm deliveries and prolonged duration of pregnancy. Single repeated doses of the ACTH-depot therapy had statistically significant better results in the prolongation of pregnancy, newborn mass and length than a serial hormonal dosage.

Effects of antenatal magnesium sulfate and corticosteroid therapy on sleep states of preterm infants

This exploratory longitudinal study was designed to compare the neonatal illness severity, sleep-wake, and respiratory sleep behaviors of preterm infants whose mothers received prenatal corticosteroids and/or magnesium sulfate (MgSO4) with those of infants whose mothers did not receive these medications. The 134 infants were divided into four groups: those whose mothers received MgSO4 only, those who received steroids only, those who received both MgSO4 and steroids, and those who received neither. The groups did not differ on infant characteristics or illness severity. Infants exposed to MgSO4 had more active sleep without rapid eye movement, indicating poorly organized active sleep. The MgSO4 -only group had higher quiet sleep regularity scores and fewer state changes. These findings suggest that fetal exposure to MgSO4 may subtly affect the central nervous system.

Influence of a single course of antenatal betamethasone on the maternal-fetal insulin-IGF-GH axis in singleton pregnancies

OBJECTIVE

We examined the hypothesis that a single course of antenatal betamethasone influences the maternal-fetal insulin-IGF-GH axis.

DESIGN

A prospective, observational, pilot study consisting of four groups of pregnant women: (I) received betamethasone and delivered <2 weeks post treatment; (II) received betamethasone and delivered >2 weeks post treatment; (III) untreated women who delivered <37 weeks (preterm controls); (IV) untreated women who delivered >37 weeks (term controls). Maternal and mixed umbilical cord blood was collected at delivery and analyzed for insulin, glucose, IGF-I, IGF-II, IGFBP-1, IGFBP-3, GH, and GHBP.

RESULTS

Betamethasone increased maternal insulin, glucose and IGF-I levels without affecting IGFBPs. In the fetal compartment, betamethasone treatment was associated with a delayed suppressive effect on GH and a sustained suppressive effect on IGF-II levels. There were no differences in infant size or neonatal morbidities between patients who delivered <2 weeks or >2 weeks post betamethasone treatment. In Group IV, birth weight correlated positively with cord IGF-I levels (r2=0.41, p=0.0098) and negatively with cord IGFBP-1 levels (r2=0.51, p=0.0039), and ponderal index correlated negatively with cord IGFBP-1 levels (r2=0.27, p<0.05).

CONCLUSIONS

A single course of antenatal betamethasone influences the maternal-fetal insulin-IGF-GH axis, particularly fetal IGF-II levels, without measurable anthropometric changes at birth. Whether these effects have implications beyond the neonatal period remains to be determined.

Anti-inflammatory and immunosuppressive drugs and reproduction

Rheumatic diseases in women of childbearing years may necessitate drug treatment during a pregnancy, to control maternal disease activity and to ensure a successful pregnancy outcome. This survey is based on a consensus workshop of international experts discussing effects of anti-inflammatory, immunosuppressive and biological drugs during pregnancy and lactation. In addition, effects of these drugs on male and female fertility and possible long-term effects on infants exposed to drugs antenatally are discussed where data were available. Recommendations for drug treatment during pregnancy and lactation are given.

Perinatal corticosteroid effect on amygdala and hippocampus volume during brain development in the rat model

Exposure of the fetus to corticosteroid during brain development has been suggested to cause permanent change in brain structure and has been associated with long term cognitive, behavioral and emotional impairment. We evaluated the effect of perinatal corticosteroid, at a dose similar to that which human fetuses are exposed, on cerebral cortex, corpus collosum, hippocampus, dentate gyrus and amygdala in a rat model. Rat pups were given betamethasone at day 1 (P1). Brain sections from the rat pups at postnatal day 45 (P45) were then analyzed. No differences were noted in the volumes of cerebral cortex, corpus collosum, hippocampus, dentate gyrus, or three nuclei of the amygdala compared to the control and sham groups. We concluded that a single course of betamethasone, at a comparable dose to that which the human fetus is exposed in clinical practice, had no effect on these regional brain volumes at this stage of development.

Use of systemic glucocorticosteroids in pregnancy: Be alert but not alarmed

SUMMARY Concerns have been raised regarding the use of repeated courses of systemic glucocorticosteroids given to pregnant women with threatened premature labour to improve fetal lung maturity. Most worrying are animal studies showing detrimental effects on the developing brain, though human data to date are conflicting. Additional concerns relate to the fetal origins of adult diseases, particularly vascular diseases such as hypertension and atherosclerosis. It is currently recommended that obstetricians give only a single course of antenatal corticosteroids to pregnant women to enhance lung maturity instead of giving repeated doses, which was previously a common practice. Other clinicians including dermatologists, gastroenterologists and rheumatologists may have reason to provide systemic glucocorticosteroids to pregnant women. Although systemic glucocorticosteroids all cross the placenta to some degree, the extent to which they do so depends on the drug involved. The choice of systemic glucocorticosteroid for the pregnant women in light of this evolving literature is discussed.