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Use of steroids in the perinatal period
1Royal Maternity Hospital, and Department of Child Health, Queen's University of Belfast, Belfast, Northern Ireland. h.halliday@qub.ac.uk
Insights
Prenatal corticosteroids offer significant benefits for preterm infants, reducing mortality and lung issues. However, postnatal corticosteroid use should be minimized due to serious adverse effects, with exceptions for ventilator-dependent infants.
Area of Science:
- Neonatal Medicine
- Perinatal Pharmacology
- Pediatric Pulmonology
Background:
- Corticosteroids are utilized prenatally for fetal lung maturation and postnatally for chronic lung disease (CLD) management.
- Randomized controlled trials (RCTs) have investigated the efficacy and safety of perinatal corticosteroid administration.
Purpose of the Study:
- To evaluate the cost-benefit ratios of prenatal and postnatal corticosteroid therapy.
- To synthesize evidence from systematic reviews of RCTs on the benefits and risks of corticosteroids in perinatal care.
Main Methods:
- Systematic reviews of RCTs from the Cochrane Library were analyzed.
- Outcomes were quantified using Numbers Needed to Treat (NNT) and Numbers Needed to Harm (NNH) with 95% confidence intervals (CI).
Main Results:
- Prenatal betamethasone (single course) significantly reduces respiratory distress syndrome (RDS), surfactant use, intraventricular hemorrhage, and neonatal mortality.
- Postnatal corticosteroids show benefits in preventing/treating CLD, including earlier extubation, but are associated with significant short-term (hyperglycemia, hypertension, hypertrophic cardiomyopathy, GI bleeding, growth failure) and long-term adverse effects (cerebral palsy, developmental delay, abnormal neurological examination).
- Adverse effects of postnatal steroids are more pronounced with early treatment (<96 hours) but can occur later.
Conclusions:
- A single prenatal course of betamethasone is beneficial for fetuses likely to be born preterm; repeated courses may be harmful.
- Postnatal corticosteroid use should be avoided unless absolutely necessary, potentially in very low doses for ventilator-dependent infants at high risk of mortality.
Introduction:
Corticosteroids can be used prenatally to mature the fetal lungs and postnatally to treat or prevent chronic lung disease (CLD). Randomised controlled trials have been performed to evaluate the benefits and risks of perinatal corticosteroid therapy.
Methods:
Systematic reviews of randomised controlled trials of prenatal and postnatal corticosteroids in the Cochrane Library were examined to determine the cost-benefit ratios of treatment. Outcomes are given as numbers needed to treat (NNT) or numbers needed to harm (NNH) with 95% confidence intervals (CI).
Results:
Prenatal corticosteroids reduce the risk of RDS (NNT 11; 95% CI 9-16), surfactant use (NNT 9; 95% CI 5-62), intraventricular haemorrhage (NNT 9; 95% CI 6-19) and neonatal mortality (NNT 23; 95% CI 16-42). There are no short-term or long-term adverse effects of a single course of prenatal betamethasone. However, repeated courses of prenatal steroids could be harmful and should be avoided outside of a randomised controlled trial. Postnatal corticosteroids can be used to prevent CLD (early use) or to treat it (late use). Beneficial effects include earlier extubation (typical NNT 5; 95% CI 4-10), reduced CLD (typical NNT 10; 95% CI 8-17) and avoidance of late steroids (NNT 7; 95% CI 6-10). However, there are significant adverse short-term effects such as hyperglycaemia (typical NNH 8; 95% CI 6-10), hypertension (typical NNH 10; 95% CI 8-14). Hy- pertrophic cardiomyopathy (typical NNH 5; 95% CI 4-11), gastrointestinal bleeding (typical NNH 17; 95% CI 11-33) and growth failure (NNH 2; 95% CI 1-2). More important are long-term adverse effects of cerebral palsy (typical NNH 8; 95% CI 6-17), developmental delay (typical NNH 7; 95% CI 4-33) and abnormal neurological examination (typical NNH 4; 95% CI 2-14). These adverse effects are more pronounced with early (<96 h) treatment but probably also occur when steroids are given later in the postnatal period.
Conclusions:
A single course of prenatal betamethasone has clear benefits for the fetus who is likely to be born preterm but repeated courses may be harmful. Postnatal steroids should be avoided if at all possible. They might be indicated in very low doses for ventilator-dependent infants who might otherwise die without them.
