Antenatal corticosteroid administration in periviable twin pregnancies between 22 and 25 weeks: a nationwide-based...

Twin pregnancies are markedly increased risk of preterm birth, with a growing proportion delivering at periviable gestational ages. While antenatal corticosteroid administration improves neonatal outcomes in singleton pregnancies, evidence specific to twins at the threshold of viability remains limited.

To evaluate trends in antenatal corticosteroid administration and compare neonatal outcomes between antenatal corticosteroid-exposed and unexposed twin pregnancies delivered between 22 and 26 weeks' gestation.

A cross-sectional study using the National Center for Health Statistics and Centers for Disease Control and Prevention natality dataset (2016-2022). Twin pregnancies delivered between 22 and 26 weeks' gestation were included. Singletons, higher-order multiples, neonates delivering outside of this gestational age window, and those missing antenatal corticosteroid data were excluded. The primary outcome was neonatal survival; secondary outcomes included 10-minute Apgar score <7, prolonged ventilation, surfactant therapy, suspected neonatal sepsis, and composite adverse outcomes defined as ventilation, 10-minute Apgar score <7, or death. Adjusted odds ratios were estimated using multivariable logistic regression.

Among 15,833 twin births at 22 to 26 weeks, 6982 (44%) were exposed to antenatal corticosteroid, while 8851 (56%) were unexposed. Antenatal corticosteroid administration was linked to higher neonatal survival at 22 to 23 weeks (55.9% vs 26.8%; adjusted odds ratio, 3.66; 95% confidence interval, 2.95-4.55), 23 to 24 weeks (74.1% vs 65.6%; adjusted odds ratio, 1.53; 95% confidence interval, 1.30-1.79), and 24 to 26 weeks (85.4% vs 82.2%; adjusted odds ratio, 1.21; 95% confidence interval, 1.02-1.44). The odds of a 10-minute Apgar score <7 were lower with antenatal corticosteroid at 22 to 23 weeks (53.0% vs 66.8%; adjusted odds ratio, 0.56; 95% confidence interval, 0.45-0.69), 23 to 24 weeks (30.6% vs 36.5%; adjusted odds ratio, 0.84; 95% confidence interval, 0.72-0.98), and 24 to 26 weeks (17.4% vs 23.2%; adjusted odds ratio, 0.68; 95% confidence interval, 0.58-0.80). When the analysis was limited to neonates who received active postnatal intervention (n=9118), the survival benefit of antenatal corticosteroid remained significant at both 22 weeks (adjusted odds ratio, 2.5; 95% confidence interval, 1.77-3.54) and 23 weeks (adjusted odds ratio, 1.56; 95% confidence interval, 1.26-1.94). Between 2016 and 2022, antenatal corticosteroid utilization increased significantly across all gestational ages, particularly at 22 weeks' gestation, where antenatal corticosteroid use rose from 13.5% to 42.9%, a more than 3-fold increase (P<.0001). This upward trend in antenatal corticosteroid use was statistically significant when comparing the periods before and after the release of the American College of Obstetricians and Gynecologists advisory in 2021 on periviable corticosteroid administration, most pronounced at 22 weeks, with a rise from 26.1% in 2020 to 42.9% in 2022 (P<.0001).

Antenatal corticosteroid administration in twin pregnancies at periviable gestational ages is associated with improved neonatal survival, especially at 22 and 23 weeks, and with lower odds of short-term neonatal adverse outcomes. The survival benefit persists among neonates receiving active postnatal intervention, suggesting that antenatal corticosteroid use confers benefit when intensive neonatal care is planned. However, these findings are limited to short-term neonatal outcomes and should be interpreted within the constraints of the available data.