Maternal, fetal, and neonatal outcomes associated with long-term use of corticosteroids during pregnancy

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 5 – A N T E N ATA L C A R E

Maternal, Fetal & Neonatal Outcomes of Long-Term Corticosteroid Use in Pregnancy AlSaad D et al. Maternal, fetal, and neonatal outcomes associated with long-term use of corticosteroids during pregnancy. TOG 2019;21:117–125. doi:10.1111/tog.12556

3-fold 5–10× OR 3.35 RISE IN MATERNAL CORTISOL IN PREGNANCY ↑GESTATIONAL DIABETES RISK, CHRONIC ORAL CLEFTS, 1ST-TRIMESTER EXPOSURE STEROIDS

DO N' T-M IS S FA C TS

1. Chronic maternal corticosteroid use does NOT replace a standard fluorinated ACS course if preterm delivery threatens at 24–34 weeks

2. ACS regimens: betamethasone 12 mg IM ×2 (24h apart) or dexamethasone 6 mg IM ×4 (12h apart); RCOG accepts any regimen totalling 24 mg in 24–48h

3. Dexamethasone/betamethasone cross placenta readily (poor 11β-HSD2 substrates, only 1.8%/7.1% inactivated) vs cortisol (67% inactivated) and prednisolone (51% inactivated)

4. ACS ↓RDS: RR 0.66 (95% CI 0.59–0.73) from 21 studies/4269 infants; serial (>2) courses not recommended

5. 1st-trimester corticosteroid exposure: possible ↑oral clefts (OR 3.35) – but large Danish registry found no increased risk; evidence conflicting

6. Chronic corticosteroid use → 5–10-fold ↑gestational diabetes risk – offer GTT

7. Avoid betamethasone in breastfeeding; prefer prednisolone, avoid feed for 4h post-dose

8. Mifepristone + long-term corticosteroids (e.g. post-transplant) is contraindicated

PLACENTAL TRANSFER AT A GLANCE

Cross readily: dexamethasone, betamethasone (fluorinated) More placenta-metabolised: cortisol, prednisolone

ABBREVIATION KEY

HPA — hypothalamic–pituitary–adrenal (axis) OR — odds ratio

CRH — corticotrophin-releasing hormone CI — confidence interval

ACTH — adrenocorticotrophin hormone RCOG — Royal College of Obstetricians and Gynaecologists

11β-HSD2 — 11β-hydroxysteroid dehydrogenase type 2 ACOG — American College of Obstetricians and Gynecologists

RDS — respiratory distress syndrome GTT — glucose tolerance test

ACS — antenatal corticosteroids NICU — neonatal intensive care unit

RR — risk ratio

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — 2019;21:117–125. doi:10.1111/tog.12556

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