Antenatal Corticosteroids at the Limits of Fetal Viability

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Antenatal Corticosteroids at the Limits of Fetal Viability

Infants exposed in utero to corticosteroids and born at 23 to 25 weeks' gestation demonstrated survival advantages.

Faced with threatened extreme preterm delivery, clinicians and parents must decide whether to intervene, given poor outcomes of such infants. Data are lacking on the efficacy of antenatal corticosteroids administered at the limits of fetal viability. To examine benefits of maternal corticosteroid administration, investigators conducted a large observational cohort study among 10,541 infants born at 22 to 25 weeks' gestation at one of several National Institute of Child Health and Human Development Neonatal Research Network centers from 1993 through 2009. Three quarters of infants were born to mothers who received antenatal steroids ("exposed" infants). Infants who died postnatally within the first 12 hours without having received neonatal resuscitation were excluded.

Nonblack women of higher socioeconomic status who were older than 19 and those who underwent cesarean deliveries were more likely to have received steroids. Exposed infants were less likely to die by age 18 to 22 months, even after adjustment for maternal sociodemographic and clinical factors (37% vs. 57%; adjusted odds ratio, 0.6). This benefit was noted among infants born at 23 to 25 weeks' gestation but not earlier. Exposed infants also were less likely to have neurodevelopmental impairment at ages 18 to 22 months (39% vs. 49%; AOR, 0.8).

Comment: Parents and caregivers are increasingly faced with decision making at the edge of fetal viability. This large, rigorous prospective cohort study demonstrates significant benefits of antenatal corticosteroids in extremely preterm infants. Although residual confounding (e.g., difficult-to-measure factors that contribute to willingness to administer steroids) could contribute to the association, a causal relation between corticosteroids and improved outcomes is likely. Nonetheless, outcomes at these early gestational ages remain dismal: Almost 70% of infants whose mothers received corticosteroids had either died or exhibited neurodevelopmental impairment by ages 18 to 22 months. Antenatal steroids (or other interventions) at very early gestational ages should be offered equitably and with respect for parental preferences regarding appropriate care.

— , MD, MPH

Published in Journal Watch Women's Health December 15, 2011

Citation(s):

Carlo WA et al. Association of antenatal corticosteroids with mortality and neurodevelopmental outcomes among infants born at 22 to 25 weeks' gestation. JAMA 2011 Dec 7; 306:2348.

http://womens-health.jwatch.org/cgi/content/full/2011/1215/1?q=topic_pregnancy

Gail Neuman RNC BSN CPHW, Notary Public

certified in high risk OB

childbirth/lactation educator & student nurse practitioner

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Perinatal Nurse Associates

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