Prophylactic corticosteroids for high-risk gestation: a pound of prevention?

Abstract

Objective: To compare, in twin pregnancies, a uniform policy of administering corticosteroids only for specific indications with theoretic prophylactic administration policies. Methods: We reviewed records of all twin gestations managed in our system from January 1996 to April 2000. Steroids were given from 24 to 31 weeks with ruptured membranes, and from 24 to 33 weeks with intact membranes when delivery, indicated or spontaneous, threatened. Steroids were neither given prophylactically nor repeated arbitrarily. Results: One hundred sixty-three pregnancies were assessed: 43 (26%) delivered before 34 weeks. Of these, 24 (56%) received the first steroid injection at least 48 hours before delivery, 25 (58%) at least 24 hours before, and 27 (63%) at least 12 hours before. The median number of steroid courses was 1 (range 1–2.5). Only 7 women (16%) delivered without receiving steroids. Of the 120 women (74%) delivered at or beyond ≥34 weeks, only 16 (13%) received steroids. In the entire cohort, 128 women (79%) received appropriate therapy: the 24 delivered before 34 weeks and at least 48 hours after the first steroid dose, and the 104 delivered at or beyond ≥34 weeks and not exposed to steroids. In contrast, a policy of single-course prophylactic steroid administration to ensure that all women delivering before 34 weeks did so at least 48 hours after the first steroid dose would have required treating 104 additional women to benefit—at most—19, and would have resulted in only a 26% rate of appropriate treatment. A policy of repetitive weekly courses from 24–34 weeks would have led to the administration of an excess 1,040 courses in our cohort. Conclusion: Reserving steroids for clinical indications results in a high rate of appropriate therapy and a low rate of unnecessary therapy. In light of the unproven safety and efficacy of repetitive steroids, these data support the use of steroids only for threatened spontaneous delivery or indicated preterm delivery.