Antenatal Corticosteroids – When to Administer?

The appropriate use of antenatal corticosteroids improves neonatal outcomes, including decreased severity and/or frequency of respiratory distress syndrome (RDS), intracranial hemorrhage, necrotizing enterocolitis and death. Antenatal corticosteroids, when appropriate, are administered in a clinical setting where patients are at risk for preterm delivery within 7 days, irrespective of membrane status and fetal number.

Clinical Actions:

Risk of preterm delivery within 7 days

Between 24w0d to 33w6d – ‘Recommended’

• • Single course of corticosteroids

Between 22w0d and 23w6d – ‘May be Considered’

• 23w0d to 23w6d
  • Single course of corticosteroids
• 22w0d to 22w6d
  • Single course of corticosteroids

Note: ACOG and SMFM revised recommendation states

Antenatal corticosteroids may be considered at 22 0/7 weeks to 22 6/7 weeks of gestation if neonatal resuscitation is planned and after appropriate counseling

Some families may choose to forgo resuscitation and support after appropriate counseling

Between 20w0d and 21w6d – ‘Not Recommended’

• Antenatal corticosteroids are not recommended due to lack of data suggesting benefit

Late preterm (34w0d – 36w6d)

ACOG 

• If no previous corticosteroids
  • Single course of betamethasone
  • Not indicated in women diagnosed with clinical chorioamnionitis

SMFM 

• Single course of betamethasone in specific populations
  • Population included in ALPS trial: Recommended
    • Nonanomalous singleton gestation
    • High risk for preterm delivery (medically indicated or spontaneous)
    • No prior antenatal steroids
  • Select populations not in the original ALPS trial: Suggest consideration for use in the following clinical scenarios
    • Multiple gestations reduced to a singleton gestation ≥14w0d
    • Fetal anomalies
    • Expected to deliver in less than 12 hours
  • Low likelihood of delivery <37 weeks: Recommend against
  • Pregestational diabetes: Recommend against due to risk for worsening neonatal hypoglycemia

Repeat or Rescue Courses

• Regularly scheduled repeat courses or serial (> 2) courses
  • Not recommended
• If a patient has received one prior course of corticosteroids > 14 days ago, is less than 34w0d gestation and is at risk of preterm delivery within 7 days
  • a single repeat course of corticosteroids should be considered (change from previous ‘may’)
  • Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario (based on Cochrane meta-analysis)
• Preterm prelabor rupture of membranes (PPROM)
  • There is insufficient evidence to make a recommendation for or against repeat or rescue courses

Dose and Regimen: give first dose even if 2nd dose unlikely

• Betamethasone: 12 mg IM, 2 doses 24 hours apart
• Dexamethasone:  6 mg IM, 4 doses 12 hours apart

Learn More – Primary Sources

ACOG Committee Opinion 713: Antenatal Corticosteroid Therapy for Fetal Maturation

ACOG Practice Advisory: Use of Antenatal Corticosteroids at 22 Weeks of Gestation

ACOG Practice Bulletin No. 171 : Management of Preterm Labor

Society for Maternal-Fetal Medicine (SMFM) Consult #58: Use of Antenatal Corticosteroids for Individuals at Risk for Late Preterm Delivery

Society for Maternal-Fetal Medicine Special Statement: Quality metrics for optimal timing of antenatal corticosteroid administration – American Journal of Obstetrics & Gynecology (ajog.org)

Results of the BUMPES Trial: Sitting Up or Lying Down to Promote Vaginal Delivery with an Epidural in the 2nd Stage of Labor?

BACKGROUND AND PURPOSE:

• Recent Cochrane Review did not demonstrate a difference between upright or recumbent when assessing the chance of a spontaneous vaginal birth in women with epidural anesthesia
• Brockehurst et al. (BMJ, 2017) sought to determine whether the  upright position  during the second stage of labor increases the chance of spontaneous vaginal birth in women with a low-dose epidural

METHODS:

• Birth in the Upright Maternal Position with Epidural in Second stage (BUMPES) Trial
• Multicenter randomized controlled trial (RCT)
• Inclusion Criteria
  • ≥ 16 years, ≥ 37 weeks gestation, nulliparous, singleton cephalic presentation, and intended to have a spontaneous vaginal birth
  • 2^nd stage with low dose epidual in situ
• Subjects were assigned to the following groups:
  • Upright position
    • Maintain pelvis in as vertical a plane as possible
    • Walking, kneeling, sitting etc. all acceptable
  • Lying down position
    • Up to 30 degrees inclination
  • Groups were stratified by center
    • Blinding of participants or clinicians not possible
  • Primary outcome was spontaneous vaginal birth
  • Secondary outcomes were
    • mode of birth, perineal trauma, infant Apgar score <4 at 5 minutes, admission to a neonatal unit
    • longer term outcomes included maternal physical and psychological health, incontinence, and infant gross developmental delay

RESULTS:

• 1,556 participants were in the upright group and 1,537 in the lying down group
• Primary Outcome
  • There were significantly fewer spontaneous vaginal births in the upright group (35.2%) vs the lying down group (41.1%) with adjusted risk ratio (RR) 0.86 (95% CI 0.78 to 0.94)
• Secondary Outcomes
  • No evidence of difference for most of the secondary maternal, neonatal, or longer term outcomes including
    • Vaginal delivery, obstetric anal sphincter injury, infant Apgar score <4 at five minutes and maternal fecal incontinence at one year

CONCLUSION:

• There is a 5.9% absolute increase in the chance of spontaneous vaginal birth in the lying down group
• Authors recognize limitations of the study
  • Inability to mask
  • Unless there is an indication to do otherwise, guidance and practice promote women using any position they find more comfortable and may have resulted in superior adherence in the upright group
• No obvious mechanism to explain findings
• When adding this current cohort of approximately 3,000 well randomized women to previous data, sum of evidence strengthens findings in this paper
  • Combining present results with previous data, odds ratio of upright vs lying down is 0.80 (95% CI 0.70 to 0.92)

Learn More – Primary Sources:

Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomized controlled trial