Antenatal Corticosteroids and Preterm Neonatal Morbidity and Mortality among Women with and without Diabetes in Pregnancy

European guidelines on perinatal care: corticosteroids for women at risk of preterm birth

of recommendationsCorticosteroids should be administered to women at a gestational age between 24⁺⁰ and 33⁺⁶weeks, when preterm birth is anticipated in the next seven days, as these have been consistently shown to reduce neonatal mortality and morbidity. (Strong-quality evidence; strong recommendation). In selected cases, extension of this period up to 34⁺⁶weeks may be considered (Expert opinion). Optimal benefits are found in infants delivered within 7 days of corticosteroid administration. Even a single-dose administration should be given to women with imminent preterm birth, as this is likely to improve neurodevelopmental outcome (Moderate-quality evidence; conditional recommendation).Either betamethasone (12 mg administered intramuscularly twice, 24-hours apart) or dexamethasone (6 mg administered intramuscularly in four doses, 12-hours apart, or 12 mg administered intramuscularly twice, 24-hours apart), may be used (Moderate-quality evidence; Strong recommendation). Administration of two "all" doses is named a "course of corticosteroids".Administration between 22⁺⁰ and 23⁺⁶weeks should be considered when preterm birth is anticipated in the next seven days and active newborn life-support is indicated, taking into account parental wishes. Clear survival benefit has been observed in these cases, but the impact on short-term neurological and respiratory function, as well as long-term neurodevelopmental outcome is still unclear (Low/moderate-quality evidence; Weak recommendation).Administration between 34 + 0 and 34 + 6 weeks should only be offered to a few selected cases (Expert opinion). Administration between 35⁺⁰ and 36⁺⁶weeks should be restricted to prospective randomized trials. Current evidence suggests that although corticosteroids reduce the incidence of transient tachypnea of the newborn, they do not affect the incidence of respiratory distress syndrome, and they increase neonatal hypoglycemia. Long-term safety data are lacking (Moderate quality evidence; Conditional recommendation).Administration in pregnancies beyond 37⁺⁰weeks is not indicated, even for scheduled cesarean delivery, as current evidence does not suggest benefit and the long-term effects remain unknown (Low-quality evidence; Conditional recommendation).Administration should be given in twin pregnancies, with the same indication and doses as for singletons. However, existing evidence suggests that it should be reserved for pregnancies at high-risk of delivering within a 7-day interval (Low-quality evidence; Conditional recommendation). Maternal diabetes mellitus is not a contraindication to the use of antenatal corticosteroids (Moderate quality evidence; Strong recommendation).A single repeat course of corticosteroids can be considered in pregnancies at less than 34⁺⁰weeks gestation, if the previous course was completed more than seven days earlier, and there is a renewed risk of imminent delivery (Low-quality evidence; Conditional recommendation).

Antenatal corticosteroids in specific groups at risk of preterm birth: a systematic review

OBJECTIVE

This study aimed to synthesise available evidence on the efficacy of antenatal corticosteroid (ACS) therapy among women at risk of imminent preterm birth with pregestational/gestational diabetes, chorioamnionitis or fetal growth restriction (FGR), or planned caesarean section (CS) in the late preterm period.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science and Global Index Medicus was conducted for all comparative randomised or non-randomised interventional studies in the four subpopulations on 6 June 2021. Risk of Bias Assessment tool for Non-randomised Studies and the Cochrane Risk of Bias tool were used to assess the risk of bias. Grading of Recommendations Assessment, Development and Evaluations tool assessed the certainty of evidence.

RESULTS

Thirty-two studies involving 5018 pregnant women and 10 819 neonates were included. Data on women with diabetes were limited, and evidence on women undergoing planned CS was inconclusive. ACS use was associated with possibly reduced odds of neonatal death (pooled OR: 0.51; 95% CI: 0.31 to 0.85, low certainty), intraventricular haemorrhage (pooled OR: 0.41; 95% CI: 0.23 to 0.72, low certainty) and respiratory distress syndrome (pooled OR: 0.59; 95% CI: 0.45 to 0.77, low certainty) in women with chorioamnionitis. Among women with FGR, the rates of surfactant use (pooled OR: 0.38; 95% CI: 0.23 to 0.62, moderate certainty), mechanical ventilation (pooled OR: 0.42; 95% CI: 0.26 to 0.66, moderate certainty) and oxygen therapy (pooled OR: 0.48; 95% CI: 0.30 to 0.77, moderate certainty) were probably reduced; however, the rate of hypoglycaemia probably increased (pooled OR: 2.06; 95% CI: 1.27 to 3.32, moderate certainty).

CONCLUSIONS

There is a paucity of evidence on ACS for women who have diabetes. ACS therapy may have benefits in women with chorioamnionitis and is probably beneficial in FGR. There is limited direct trial evidence on ACS efficacy in women undergoing planned CS in the late preterm period, though the totality of evidence suggests it is probably beneficial.

PROSPERO REGISTRATION NUMBER

CRD42021267816.

The effect of time interval between antenatal corticosteroid administration and delivery on outcomes in late preterm neonates born to mothers with diabetes: a retrospective cohort study

Objectives

The study aims to investigate whether the time interval between administering antenatal corticosteroids (ACS) and delivery influences the neonatal outcomes in late preterm (LPT) neonates (34 + 0 to 36 + 6 weeks) born to mothers with diabetes.

Study design

This retrospective cohort study included women with any type of diabetes who gave birth between 34 + 0 weeks and 36 + 6 weeks of gestation. Based on the time interval between the first dose of corticosteroid and delivery, the cases were stratified into the following groups: <2, 2-7, and >7 days. Women unexposed to ACS served as the control group. The primary outcomes included the incidence of neonatal hypoglycemia and respiratory distress syndrome/transient tachypnea of the newborn. Multivariate logistic regression was used to assess the relationship between the time interval and neonatal outcomes and adjust for potential confounders.

Results

The study enrolled a total of 636 parturients. Among them, 247 (38.8%) delivered within 2 days after ACS administration, 169 (26.6%) within 2-7 days, and 126 (19.8%) at >7 days. Baseline characteristics such as type of diabetes, methods of glycemic control, preterm premature rupture of membrane, placenta previa, cesarean delivery, indication for delivery, percentage of large for gestational age, birth weight, and HbA1c in the second or third trimester were significantly different among the four groups. The multivariate analysis showed no statistically significant difference in the incidence of primary or secondary neonatal outcomes between the case and control groups.

Conclusions

ACS treatment was not associated with neonatal hypoglycemia and respiratory outcomes in LPT neonates born to diabetic mothers, regardless of the time interval to delivery.

Time Interval From Early-Term Antenatal Corticosteroids Administration to Delivery and the Impact on Neonatal Outcomes

OBJECTIVES

To determine the association between the time interval from antenatal corticosteroids administration to delivery and neonatal complications in diabetic mothers undergoing early term (37+0 to 38+6 weeks) scheduled cesarean section (ETSCS).

STUDY DESIGN

A retrospective cohort study of women with any form of diabetes in pregnancy undergoing ETSCS was included. Cases were stratified into the following groups based on the time interval from the first dose of corticosteroids administration to delivery: <2, 2-7, and >7 days. Women undergoing ETSCS, who did not receive corticosteroids were included as controls. We assessed the association between the time interval and neonatal outcomes in a multivariate regression model that controlled for potential confounders. Primary outcomes were the incidence of respiratory distress syndrome (RDS)/transient tachypnea of the newborn (TTN) and neonatal hypoglycemia.

RESULTS

The study cohort comprised 1,165 neonates. Of those, 159 (13.6%) were delivered within 2 days of maternal corticosteroids administration, 131 (11.2%) were delivered within 2-7 days after maternal corticosteroids administration, and 137 (11.8%) delivered more than 7 days after maternal corticosteroids administration. The remaining 738 (63.3%) were not exposed to corticosteroids. Multivariate analysis demonstrated that delivery within any time of antenatal corticosteroids administration was not associated with decreased risks of RDS/TTN. The risk of neonatal hypoglycemia was highest in the delivery of <2 days group (adjusted odds ratio [aOR]: 2.684, 95% confidence interval [CI]: 1.647-4.374 for control group; aOR: 2.827, 95% CI: 1.250-6.392 for delivery 2-7 days group; aOR:2.975, 95% CI: 1.265-6.996 for delivery >7 days group).

CONCLUSIONS

Corticosteroids treatment for diabetic mothers undergoing ETSCS was not associated with beneficial neonatal respiratory outcomes. In addition, delivery, <2 days after antenatal corticosteroids administration was associated with an increased risk of neonatal hypoglycemia.

Association of antenatal steroids with surfactant administration in moderate preterm infants born to women with diabetes mellitus and/or hypertension

BACKGROUND

Randomized trials of antenatal steroid administration (ANS) for extreme or moderate preterm pregnancies excluded women with diabetes mellitus (DM) and included few with preeclampsia.

METHODS

Cohort study (n = 1,813) including moderate preterm births [29^0/7-33^6/7wks' gestational age GA)] before (Epoch-1) and after (Epoch-2) expansion of ANS administration to women with hypertensive disorders (HTN) and/or DM. We compared surfactant administration in Group-1 (neither HTN nor DM), Group-2a (HTN not DM), Group-2b (DM not HTN) and Group-2c (DM and HTN).

RESULTS

Surfactant administration was less frequent after ANS in Group-1 [adjusted odds ratio (aOR) 0.54, 95% confidence interval (CI) 0.31, 0.93, P = 0.03], Group-2a (aOR 0.36, CI 0.22, 0.58, P < 0.001) and Group-2c (aOR 0.29, CI 0.12, 0.71, P = 0.007) but not Group-2b (P = 0.64).

CONCLUSIONS

ANS administration was independently associated with less surfactant administration in moderately preterm neonates whose mothers had neither HTN nor DM, and those with HTN, but not those with DM without HTN.

Neonatal hypoglycemia after antenatal late preterm steroids in individuals with diabetes

OBJECTIVE

To establish whether administration of antenatal late preterm steroids to pregnant people with diabetes resulted in higher risk of neonatal hypoglycemia.

STUDY DESIGN

This is a retrospective cohort study of individuals with pre-gestational or gestational diabetes admitted between 34 0/7-36 6/7 weeks' gestation before and after introduction of an antenatal late preterm steroids protocol. The primary outcome was any neonatal blood glucose ≤ 60 mg/dL in the first 24 h of life.

RESULTS

Of 123 mother-neonate pairs, 52.8% (N = 65) delivered during the post-protocol period; 75.4% of those (N = 49) received late preterm steroids. 59.7% (N = 34) of the pre-protocol neonates and 81.5% (N = 53) of the post-protocol neonates had hypoglycemia (p = 0.008). After controlling for gestational age at delivery and mode of delivery, neonates in the post-protocol group had increased odds of hypoglycemia (adjusted odds ratio 2.96, 95% confidence interval 1.29-6.82).

CONCLUSION

Neonates born to mothers with diabetes who received late preterm corticosteroids experienced greater odds of hypoglycemia.

Association of antenatal steroids with neonatal mortality and morbidity in preterm infants born to mothers with diabetes mellitus and hypertension

BACKGROUND

Randomized trials of antenatal steroids (ANS) included women at 24-33 weeks gestational age (GA); however, few women had preeclampsia and women with diabetes mellitus (DM) were excluded.

METHODS

Cohort study including preterm births at 230/7-286/7 weeks GA before (Epoch-1) and after (Epoch-2) expansion of ANS administration to women with DM and hypertensive disorders (HTN). We compared Group-A (neither DM nor HTN) and Group-B (DM and/or HTN).

RESULTS

Among 747 neonates the adjusted odds ratio (aOR) for surfactant administration, in-hospital mortality, severe intraventricular hemorrhage (IVH) and death or severe IVH were lower in ANS-exposed neonates than unexposed neonates. In Group-B, ANS administration was independently associated with less severe IVH and less death or severe IVH, but not less surfactant use or mortality.

CONCLUSIONS

Increased ANS administration in women with DM and/or HTN was independently associated with less severe IVH and less death or severe IVH but without decrease in surfactant administration.