Elsevier

Seminars in Perinatology

Volume 37, Issue 6, December 2013, Pages 410-413
Seminars in Perinatology

Antenatal corticosteroids for periviable birth

https://doi.org/10.1053/j.semperi.2013.06.024Get rights and content

Abstract

Antenatal corticosteroids have been proven to accelerate fetal lung development and reduce neonatal morbidity and mortality when given between 28 and 34 weeks of gestation. However, there is only limited research to guide their use in the periviable period (22–26 weeks). Laboratory studies suggest that it is biologically plausible for antenatal steroids to be effective in this gestational period. In addition, cohort studies have demonstrated the efficacy of antenatal corticosteroids in reducing neonatal mortality and IVH. Follow-up studies performed between 18 and 22 months of age also suggest a long-term benefit to antenatal use in this period. Based on this information, antenatal corticosteroids should be used in appropriate patients at high risk for preterm birth at 23–26 weeks of gestation. An advantageous outcome to treatment at 22 weeks is less certain.

Section snippets

Biologic plausibility for efficacy of antenatal corticosteroids in the periviable period

Antenatal corticosteroids work through multiple mechanisms to prepare the fetal lung for air breathing. The most well-known of these mechanisms is the induction of proteins and enzymes, including increased tissue and alveolar surfactant production. However, there are a number of other important biochemical effects including accelerated antioxidant production and induction of beta-receptor expression in the alveolar cells.2., 3. An equally important effect of antenatal corticosteroids is the

Cohort studies of antenatal corticosteroids in the periviable period

Table 1 demonstrates the experience of the NICHD Neonatal Network evaluating neonatal morbidity and mortality at 22–25 weeks of gestation in steroid-exposed vs. nonsteroid-treated infants.1 The study demonstrated a significant reduction in mortality in exposed neonates born in weeks 23, 24, and 25. Neonates delivered at 22 weeks showed a reduced mortality rate, which did not meet statistical significance. Overall, an odds ratio of 0.5 (95% CI: 0.52–0.65) was demonstrated for neonates born in

Choice of antenatal steroid in the periviable period

Cohort studies have compared dexamethasone and betamethasone for periviable steroid treatment. A study, of infants weighing between 400 and 1500 g, from the Neonatal Network of betamethasone.6 The 18–22 month follow-up of these infants (birth weight 400–1000 g) evaluating neurodevelopmental outcomes showed reductions in most neurodevelopmental outcomes with betamethasone treatment compared to dexamethasone.7 This difference was found to only be statistically significant for deafness. This work

Conclusion

While further study would be beneficial, the information that we presently have strongly suggests that antenatal corticosteroids have value when given in the periviable period and should be offered when clinically appropriate. This benefit is clear from 23 weeks on. It is less certain whether they should be utilized at 22 weeks or less. Because of the uncertainty in gestational age prediction, it is suggested that they should be used at this gestational age if preterm birth appears to be

References (13)

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This work has, in part, been supported by the Multicenter Maternal–Fetal Medicine Unit (MFMU) Research Network Grant: U10 HD040585.

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