ANTENATAL

CORTICOSTEROIDS

Dr. MAHALAKSHMI VENKATESAN

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

 INTRODUCTION

• Over two dozen randomised trials have

con rmed that a course of antenatal
corticosteroid therapy (ACS) administered
to women at risk for preterm delivery
reduced the incidence and severity of
respiratory distress syndrome (RDS) and
mortality in offspring.

• Subsequent trials have shown that ACS

also improves circulatory stability in
preterm neonates, resulting in lower rates
of intraventricular haemorrhage and
necrotizing enterocolitis compared with
unexposed preterm neonates.
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MECHANISM OF ACTION

• ACS accelerates development of type 1 and type 2

pneumocytes, leading to structural and biochemical changes
that improve both lung mechanics and gas exchange (eg,
surfactant production).

• Other effects include induction of pulmonary beta-receptors,

which play a role in surfactant release and absorption of
alveolar uid when stimulated; induction of fetal lung antioxidant
enzymes; and upregulation of genes for mediators of pulmonary
epithelial sodium and liquid absorption, which are important for
postnatal absorption of lung uid.
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TIMING BEFORE DELIVERY  

• Ideally, ACS is timed so that maximum ef cacy is achieved before

delivery, and this window is two to seven days after
administration of the rst dose. Observational data suggest
neonatal bene ts begin to accrue within a few hours of ACS
administration.

• Infants who received one dose of ACS in utero, but delivered

before the second dose was given, had better outcomes than
infants who did not receive any dose.
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CHOICE OF DRUG, DOSING, AND SIDE
EFFECTS
BETAMETHASONE OR DEXAMETHASONE?

Either betamethasone or dexamethasone administered parenterally is acceptable.

These steroids are preferred over other steroids because they are less extensively
metabolized by the placental enzymes (11β -hydroxysteroid dehydrogenase type 2)

DOSING  
Betamethasone sodium
phosphate+acetate
two doses of 12 mg IM 24
hours apart or
Dexamethasone sodium
phosphate four doses
of 6 mg IM 12 hours apart.

In INDIA, the salt Betamethasone sodium phosphate+acetate is

not available. Only the shorter acting betamethasone phosphate
is available hence DEXAMETHASONE IS PREFFERED.
MATERNAL SIDE EFFECTS

• Transient hyperglycemia occurs in many women; the

steroid effect begins approximately 12 hours after the rst dose
and may last for ve days. Screening for gestational diabetes, if
indicated, should be performed either before ACS administration
or at least ve days after the rst dose.

• The total leukocyte count increases by approximately 30

percent within 24 hours after ACS injection, and the lymphocyte
count signi cantly decreases. These changes return to baseline
within three days but may complicate the diagnosis of infection
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FETAL SIDE EFFECTS
• 22+0 to 34+6 weeks Likely to reduce
birthweight if birth occurs more
than 7 days after steroids. May increase
psychiatric and behavioural diagnoses if
children born at term

• 35+0 to 36+ 6  weeks - Likely to

increase neonatal hypoglycaemia

• Before planned caesarean birth at term

37–39 week - May reduce
educational attainment at
school age
.

• Fetal heart rate (FHR) and biophysical

parameters – decrease in variability
on days 2 and 3 after administration, which
alone is not an indication for delivery.
Reduced fetal breathing and body
movements can result in a lower
biophysical pro le score or non-
reactive NST.

• Doppler ow studies – A transient

improvement in umbilical artery
end-diastolic ow (EDF) after ACS
administration has been described in 63 to
71 percent of patients in some studies. The
improvement began approximately eight
hours after the rst dose of ACS and lasted
a median of three days (range 1 to 10 days).
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CANDIDATES FOR A FIRST ACS COURSE BY
GESTATIONAL AGE

22+0 to 22+6 weeks — After thorough counselling between the

patient and maternal-fetal medicine and neonatology specialists
ONLY if the patient is requesting aggressive neonatal intervention

One key concept at this gestational age is that ACS may provide a
survival bene t, but the risk of major long-term morbidity
in survivors is high. Major morbidities included severe
intraventricular haemorrhage, cystic periventricular leukomalacia,
necrotizing enterocolitis, culture-con rmed infection, severe
retinopathy of prematurity, and chronic lung disease.
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23+0 to 33+6 weeks — In agreement all the guidelines

recommends administration of ACS for all pregnant patients at
23+0 to 33+6 weeks of gestation who are at increased risk of
preterm delivery within the next seven days. At this gestational age,
ACS improves neonatal survival and reduces major short-term
morbidity, although long-term neurodevelopmental issues remain a
concern

34+0 or more weeks —The use of ACS at ≥34+0 weeks is

controversial given the absence of a survival bene t, less absolute
respiratory bene t due to the lower risk of serious respiratory
problems at this gestational age, and greater concern about
potential long-term harm.
.

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PRIOR TO ELECTIVE SECTION

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RCOG/NICE

ACO DOES NOT

RECOMMEND

WH

FIGO consider for

cases before 39
weeks
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USE OF RESCUE (SALVAGE, BOOSTER) ACS

• RCOG, NICE GUIDELINES DOES NOT RECOMMEND.

• The American College of Obstetricians and Gynecologists (ACOG) recommends
considering a single repeat course of ACS in patients <34+0 weeks of gestation who are
at high risk of preterm delivery within the next seven days if ACS was administered
more than 14 days previously

• WHO recommends a single repeat course of ACS in patients <34+0 weeks of gestation
if ACS was administered more than 7 days previously

Some clinicians prefer to withhold rescue steroids if the rst ACS course was
administered after 28 weeks, but this exception is based on limited evidence

Multiple courses of steroids (>1 rescue course) - After 32 weeks of gestation,

placental weight was signi cantly less, decrease in fetal growth and Increased incidence of
cerebral palsy in the repeat ACS group and was related inversely to the number of
courses. And in no circumstance should be exceeding 3 rescue doses.
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SPECIAL POPULATIONS
• Frank Chorioamnionitis ACS is
CONTRAINDICATED.

• Multiple gestation — The same dosing schedule

is recommended for singleton and multiple
gestations.

• Hypertension —Betamethasone and

dexamethasone have low mineralocorticoid activity
compared with other corticosteroids; therefore,
hypertension is not a contraindication to therapy

• Diabetes — ACS should not be withheld from

women with diabetes when indicated. The steroid
effect on glucose levels begins approximately 12
hours after the rst dose and may last for ve days

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RELATED TRIALS

• ASTECS TRIAL (Antenatal steroids for term elective C-

Section) : No adverse effects was seen on health, behaviour and
academic achievement of children born following a a single
course of ACS at term. ACS did not reduce the prevalence of
asthma and allergy following elective C-Section.

• WHO ACTION - 2 TRIAL Antenatal dexamethasone did

not result in a reduction in neonatal death, stillbirth or severe
neonatal respiratory distress in this trial

 TAKE HOME MESSAGE

1) GESTATIONAL AGE: Between 24 weeks and 34 completed weeks of gestation
who are at risk of preterm delivery within 7 days

2) LATE PRETERM: A single course of ACS is recommended between 34 completed

weeks and 37 weeks of gestation who are at risk of preterm delivery within 7
days and who have not received a previous course of ACS.

3) REPEAT DOSE: A single repeat course of ACS should be considered in women

less than 34 weeks of gestation who are at risk of preterm delivery within 7 days
and whose prior course of ACS was administered more than 7-14 days previously.

4) PRIOR TO ELECTIVE LSCS: Do NOT routinely administe

5) Which steroids? - DEXAMETHASONE

.

THANK YOU