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Indication Creep of Antenatal Late Preterm Steroids

Eliza R McElwee1, Kyla Wilkinson1, Rebecca Crowe1

  • 1Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical University of South Carolina, Charleston, South Carolina.

American Journal of Perinatology
|March 2, 2022
PubMed

Insights

Over one-third of women received late preterm antenatal corticosteroids (ACS) inappropriately, indicating potential "indication creep." This inappropriate use is linked to higher rates of nonoptimal exposure, highlighting the need for strict adherence to clinical criteria.

Area of Science:

  • Obstetrics and Gynecology
  • Neonatal Medicine
  • Clinical Pharmacology

Background:

  • Antenatal corticosteroids (ACS) are crucial for reducing respiratory morbidity in preterm infants.
  • The Antenatal Betamethasone for Women at Risk for Late Preterm Delivery (ALPS) trial established strict criteria for ACS use in the late preterm period.
  • The widespread adoption of late preterm ACS as standard care raises concerns about potential deviations from original trial criteria.

Purpose of the Study:

  • To investigate the phenomenon of "indication creep" in the administration of late preterm antenatal corticosteroids (ACS).
  • To assess the rate of inappropriate ACS exposure based on ALPS trial criteria since its widespread adoption.
  • To evaluate the association between inappropriate ACS administration and nonoptimal exposure outcomes.

Main Methods:

  • Retrospective cohort study analyzing data from 2016-2019.
  • Identified pregnant women who received late preterm ACS.
  • Defined inappropriate exposure as nonadherence to ALPS trial inclusion/exclusion criteria; analyzed nonoptimal exposure (delivery >7 days from ACS or term delivery).
  • Used logistic regression to compare epochs and assess confounders.

Main Results:

  • Out of 660 women, 229 (34.6%) received inappropriate late preterm ACS.
  • Preterm premature rupture of membranes (PPROM) was the most common reason for inappropriate use (29.0%).
  • No significant difference in inappropriate exposure rates was found between 2016-2017 and 2018-2019 epochs (aOR=0.83).
  • A reduction in nonoptimal exposure was observed over time (aOR=0.67).
  • Inappropriate ACS use was associated with higher rates of term delivery and preterm labor, and longer latency to delivery in cases of preterm labor.

Conclusions:

  • A significant proportion of late preterm ACS administrations may represent "indication creep," deviating from evidence-based criteria.
  • Inappropriate ACS administration is associated with increased nonoptimal exposure, particularly in specific clinical scenarios like preterm labor.
  • Adherence to established clinical criteria is essential to ensure optimal benefit and minimize potential risks associated with late preterm ACS.
Abstract

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