Single Course Of Corticosteroids Research Articles

EVALUATION OF LONG TERM OUTCOMES ASSOCIATED WITH PRETERM EXPOSURE TO ANTENATAL CORTICOSTEROIDS : A SYSTEMATIC REVIEW

The aim: This study aims to show about evaluation of long term outcomes associated with preterm exposure to antenatal corticosteroids. Methods: By comparing itself to the standards set by the Preferred Reporting Items for Systematic Review and Meta Analysis (PRISMA) 2020, this study was able to show that it met all of the requirements. So, the experts were able to make sure that the study was as up to date as it was possible to be. For this search approach, publications that came out between 2013 and 2023 were taken into account. Several different online reference sources, like Pubmed and SagePub, were used to do this. It was decided not to take into account review pieces, works that had already been published, or works that were only half done. Result: In the PubMed database, the results of our search brought up 117 articles, whereas the results of our search on SagePub brought up 112 articles. The results of the search conducted for the last year of 2013 yielded a total 91 articles for PubMed and 66 articles for SagePub. The result from title screening, a total 2 articles for PubMed and 11 articles for SagePub. In the end, we compiled a total of 8 papers. We included five research that met the criteria. Conclusion: Numerous studies have shown no evidence of long-term harm (and in fact showed improved survival and neurodevelopmental outcomes with long-term pulmonary and others benefit), particulary as it relates to a single course of corticosteroids administered at less than 34 weeks of gestation.

Administration of Antenatal Corticosteroids: Current State of Knowledge.

The administration of a single course of corticosteroids before week 34 + 0 of gestation in cases with impending preterm birth is now standard procedure in obstetric care and firmly established in the guidelines of different countries. But despite the apparently convincing data, numerous aspects of this intervention have not yet been properly studied. It is still not clear which corticosteroid achieves the best results. There are very few studies on what constitutes an appropriate dose, circadian rhythms, the time frame in which corticosteroids are effective, and the balance between the risks and benefits of repeat administration. As the existing studies have rarely included patients before week 24 + 0 of gestation, we have very little information on the possible benefits of administering corticosteroids before this timepoint. If corticosteroids are administered antenatally after week 34 + 0 of gestation, the short-term benefit may be offset by the long-term adverse effect on psychomotor development. This present study summarizes the current state of knowledge regarding these issues.

EFFICACY OF PROPHYLACTIC CORTICOSTEROIDS PRIOR TO CESAREAN SECTION TO PREVENT RESPIRATORY COMPLICATION

Background: Cesarean section (CS) is a risk factor for the development of neonatal respiratory complications, mostly respiratory distress syndrome (RDS) and transient tachypnea of the new-born, both in term and preterm infants. Infants born at term by elective cesarean delivery are more likely to develop respiratory morbidity than infants born vaginally. Objective: To assess the effect of prophylactic corticosteroid administration before elective cesarean section at term, as compared to usual management without corticosteroids, in reducing neonatal respiratory morbidity and admission to special care with respiratory complications. Patients and methods: This was a prospective study that was conducted on 200 women from the Out-Patient Clinic at Al-Hussein Hospital, Al-Azhar University from September 2018 to November 2019. Randomized controlled trials comparing prophylactic antenatal corticosteroid administration (dexamethasone) with placebo or with no treatment, given before elective cesarean section at term (at or after 37 weeks of gestation). Results: PG represented 60% of 1st group while represented 50% of 2nd group without significant difference between them. There was no significant difference between groups as regard co-morbidity. There was no significant difference between groups regard causes of CS, and the major causes were previous CS and placenta previa. There was no significant difference between groups as regard postpartum hemorrhage or maternal complication in general. APGAR1 was significantly higher among corticosteroid group. Overall respiratory complication was significantly lower among corticosteroid group, respiratory distress (RD), need of neonatal intensive care unit (NICU) and mechanical ventilation and mortality were lower among the same group than control but not significantly. Conclusion: A single course of corticosteroids (four 6mg doses of dexamethasone administered intramuscular every 12 hours) should be considered for women undergoing planned cesarean at 37 or more weeks’ gestation.

EFFICACY OF PROPHYLACTIC CORTICOSTEROIDS PRIOR TO CESAREAN SECTION TO PREVENT RESPIRATORY COMPLICATION

Background: Cesarean section (CS) is a risk factor for the development of neonatal respiratory complications, mostly respiratory distress syndrome (RDS) and transient tachypnea of the new-born, both in term and preterm infants. Infants born at term by elective cesarean delivery are more likely to develop respiratory morbidity than infants born vaginally. Objective: To assess the effect of prophylactic corticosteroid administration before elective cesarean section at term, as compared to usual management without corticosteroids, in reducing neonatal respiratory morbidity and admission to special care with respiratory complications. Patients and methods: This was a prospective study that was conducted on 200 women from the Out-Patient Clinic at Al-Hussein Hospital, Al-Azhar University from September 2018 to November 2019. Randomized controlled trials comparing prophylactic antenatal corticosteroid administration (dexamethasone) with placebo or with no treatment, given before elective cesarean section at term (at or after 37 weeks of gestation). Results: PG represented 60% of 1st group while represented 50% of 2nd group without significant difference between them. There was no significant difference between groups as regard co-morbidity. There was no significant difference between groups regard causes of CS, and the major causes were previous CS and placenta previa. There was no significant difference between groups as regard postpartum hemorrhage or maternal complication in general. APGAR1 was significantly higher among corticosteroid group. Overall respiratory complication was significantly lower among corticosteroid group, respiratory distress (RD), need of neonatal intensive care unit (NICU) and mechanical ventilation and mortality were lower among the same group than control but not significantly. Conclusion: A single course of corticosteroids (four 6mg doses of dexamethasone administered intramuscular every 12 hours) should be considered for women undergoing planned cesarean at 37 or more weeks’ gestation.

Comparison between two doses of betamethasone administration with 12 hours vs. 24 hours intervals on prevention of respiratory distress syndrome: a randomised trial

The purpose of the present study was to compare the effect of a two-dose administration of betamethasone with 12 hours interval vs. 24 hours interval on neonatal respiratory distress syndrome (RDS). The study was performed as a randomised clinical trial on 201 pregnant women with a gestational age of 26–34 weeks. In one group 12 mg of betamethasone every 12 hours for two doses and in the other group 12 mg of betamethasone every 24 hours for two doses were prescribed intramuscularly. There were no significant differences between the two groups according to maternal age, parity, gravidity, BMI, neonatal sex, need to surfactant, NICU admission, NICU stay, neonatal death, neonatal sepsis and Apgar score at minutes 1 and 5, but the gestational age at the beginning of the study and delivery receiving complete course of betamethasone and neonatal weight were lower in 24 hours group. RDS, necrotising enterocolitis, intra-ventricular haemorrhage and chorioamnionitis were more in the 24 hours’ group. Multiple regression analysis showed that RDS and IVH (p = .022, RR = 0.07, CI95% 0.006–0.96 and p = .013; RR = 0.9, CI95% 0.1–0.89, respectively) were more in the 24 hours group and neonatal death (p = .034, RR = 4.7, CI95% 1.07–16.2) and NEC (p = 0.038, RR = 2.5, CI95% 1.7–3.7), were more in the 12 hours group. In conclusion, it seems that 12 hours interval betamethasone therapy may be considered as an alternative treatment in the case of preterm labour for acceleration of lung maturity; however, it is suggested that more studies should be performed on this issue and various morbidities.IMPACT STATEMENTWhat is already known on this subject: Administration of a single course of corticosteroids in all women with a gestational age of 24–34 weeks of pregnancy who are at risk for preterm labour and delivery has been recommended. The accepted regimen by National Institutes of Health (NIH) is an injection of betamethasone for two doses with 24 hours interval.What do the results of this study add: Twelve hours interval betamethasone therapy may be considered as an alternative treatment in the cases of preterm labour for acceleration of lung maturity.What are the implications of these findings for clinical practice and/or further research: Prescription of two doses (complete regimen) is more important than the interval between two doses for obtaining the maximum effect in a preterm birth.

Committee Opinion No. 713 Summary: Antenatal Corticosteroid Therapy for Fetal Maturation.

Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation who are at risk of preterm delivery within 7 days, including for those with ruptured membranes and multiple gestations. It also may be considered for pregnant women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family's decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation who are at risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids. A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. Continued surveillance of long-term outcomes after in utero corticosteroid exposure should be supported. Quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are encouraged.

Committee Opinion No. 713: Antenatal Corticosteroid Therapy for Fetal Maturation.

Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation who are at risk of preterm delivery within 7 days, including for those with ruptured membranes and multiple gestations. It also may be considered for pregnant women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family's decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation who are at risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids. A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. Continued surveillance of long-term outcomes after in utero corticosteroid exposure should be supported. Quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are encouraged.

Antenatal corticosteroids for maturity of term or near term fetuses: systematic review and meta-analysis of randomized controlled trials

Objective To evaluate the effectiveness of antenatal corticosteroids given at ≥34 weeks’ gestation.Design Systematic review with meta-analysis.Data sources Electronic databases were searched from their inception to February 2016.Eligibility criteria for...

Committee Opinion No.677: Antenatal Corticosteroid Therapy for Fetal Maturation.

Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation, including for those with ruptured membranes and multiple gestations. It also may be considered for pregnant women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family's decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation at imminent risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids. A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who have an imminent risk of preterm delivery within the next 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. Continued surveillance of long-term outcomes after in utero corticosteroid exposure should be supported. Quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are encouraged.

Committee Opinion No. 677 Summary: Antenatal Corticosteroid Therapy for Fetal Maturation

Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation, including for those with ruptured membranes and multiple gestations. It also may be considered for pregnant women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family's decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation at imminent risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids. A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who have an imminent risk of preterm delivery within the next 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. Continued surveillance of long-term outcomes after in utero corticosteroid exposure should be supported. Quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are encouraged.

Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes.

It has been unclear whether repeat dose(s) of prenatal corticosteroids are beneficial. To assess the effectiveness and safety of repeat dose(s) of prenatal corticosteroids. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 January 2015), searched reference lists of retrieved studies and contacted authors for further data. Randomised controlled trials of women who had already received a single course of corticosteroids seven or more days previously and considered still at risk of preterm birth. We assessed trial quality and extracted data independently. We included 10 trials (a total of 4733 women and 5700 babies) with low to moderate risk of bias. Treatment of women who remain at risk of preterm birth seven or more days after an initial course of prenatal corticosteroids with repeat dose(s), compared with no repeat corticosteroid treatment, reduced the risk of their infants experiencing the primary outcomes respiratory distress syndrome (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.75 to 0.91, eight trials, 3206 infants, number needed to treat to benefit (NNTB) 17, 95% CI 11 to 32) and serious infant outcome (RR 0.84, 95% CI 0.75 to 0.94, seven trials, 5094 infants, NNTB 30, 95% CI 19 to 79).Treatment with repeat dose(s) of corticosteroid was associated with a reduction in mean birthweight (mean difference (MD) -75.79 g, 95% CI -117.63 to -33.96, nine trials, 5626 infants). However, outcomes that adjusted birthweight for gestational age (birthweight Z scores, birthweight multiples of the median and small-for-gestational age) did not differ between treatment groups.At early childhood follow-up, no statistically significant differences were seen for infants exposed to repeat prenatal corticosteroids compared with unexposed infants for the primary outcomes (total deaths; survival free of any disability or major disability; disability; or serious outcome) or in the secondary outcome growth assessments. In women, for the two primary outcomes, there was no increase in infectious morbidity of chorioamnionitis or puerperal sepsis, and the likelihood of a caesarean birth was unchanged. The short-term benefits for babies of less respiratory distress and fewer serious health problems in the first few weeks after birth support the use of repeat dose(s) of prenatal corticosteroids for women still at risk of preterm birth seven days or more after an initial course. These benefits were associated with a small reduction in size at birth. The current available evidence reassuringly shows no significant harm in early childhood, although no benefit.Further research is needed on the long-term benefits and risks for the woman and baby. Individual patient data meta-analysis may clarify how to maximise benefit and minimise harm.

Rescue corticosteroids in twin pregnancies and short‐term neonatal outcomes

To estimate the efficacy of a rescue course of antenatal corticosteroids in twin pregnancies. Retrospective cohort study. Tertiary-care centre. Twins born from 24 to <34 weeks of gestation in a single maternal and fetal medicine practice from 2006 to 2011. We compared neonatal outcomes in 88 twins exposed to a single course of corticosteroids with outcomes in 42 twins exposed to two courses of corticosteroids: the initial course and a single rescue course. Analyses were adjusted to control for correlation between twins born to the same mother. Short-term neonatal respiratory morbidity. Rescue corticosteroids were associated with fewer days of mechanical ventilation (7.3 ± 3.3 versus 33.9 ± 25.3 days, P = 0.003), fewer days with a fraction of inspired oxygen of >21% (6.3 ± 4.3 versus 33.3 ± 25.8 days, P = 0.003), a lower incidence of mechanical ventilation >14 days or death while on mechanical ventilation (0 versus 12.5%, P = 0.016), and a lower incidence of retinopathy of prematurity (0 versus 12.5%, P = 0.016). The proportion of neonates with respiratory distress syndrome did not differ between the groups (adjusted odds ratio 1.28, 95% confidence interval 0.50-3.26). There were no differences found for birthweight, head circumference and length. In twins born before 34 weeks of gestation, exposure to rescue corticosteroids may be associated with improved neonatal outcomes. Further studies are warranted to assess the effect of rescue corticosteroids in twin pregnancies.

Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes.

It has been unclear whether repeat dose(s) of prenatal corticosteroids are beneficial. To assess the effectiveness and safety of repeat dose(s) of prenatal corticosteroids. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011), searched reference lists of retrieved studies and contacted authors for further data. Randomised controlled trials of women who had already received a single course of corticosteroids seven or more days previously and considered still at risk of preterm birth. We assessed trial quality and extracted data independently. We included 10 trials (more than 4730 women and 5650 babies) with low to moderate risk of bias. Treatment of women who remain at risk of preterm birth seven or more days after an initial course of prenatal corticosteroids with repeat dose(s), compared with no repeat corticosteroid treatment, reduced the risk of their infants experiencing the primary outcomes respiratory distress syndrome (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.75 to 0.91, eight trials, 3206 infants, numbers needed to treat (NNT) 17, 95% CI 11 to 32) and serious infant outcome (RR 0.84, 95% CI 0.75 to 0.94, seven trials, 5094 infants, NNT 30, 95% CI 19 to 79).Treatment with repeat dose(s) of corticosteroid was associated with a reduction in mean birthweight (mean difference (MD) -75.79 g, 95% CI -117.63 to -33.96, nine trials, 5626 infants). However, outcomes that adjusted birthweight for gestational age (birthweight Z scores, birthweight multiples of the median and small-for-gestational age) did not differ between treatment groups.At early childhood follow-up no statistically significant differences were seen for infants exposed to repeat prenatal corticosteroids compared with unexposed infants for the primary outcomes (total deaths; survival free of any disability or major disability; disability; or serious outcome) or in the secondary outcome growth assessments. The short-term benefits for babies of less respiratory distress and fewer serious health problems in the first few weeks after birth support the use of repeat dose(s) of prenatal corticosteroids for women still at risk of preterm birth seven days or more after an initial course. These benefits were associated with a small reduction in size at birth. The current available evidence reassuringly shows no significant harm in early childhood, although no benefit.Further research is needed on the long-term benefits and risks for the woman and baby. Individual patient data meta-analysis may clarify how to maximise benefit and minimise harm.

Committee Opinion No. 475: Antenatal Corticosteroid Therapy for Fetal Maturation

A single course of corticosteroids is recommended for pregnant women between 24 weeks and 34 weeks of gestation who are at risk of preterm delivery within 7 days. A single course of antenatal corticosteroids should be administered to women with premature rupture of membranes before 32 weeks of gestation to reduce the risks of respiratory distress syndrome, perinatal mortality, and other morbidities. The efficacy of corticosteroid use at 32–33 completed weeks of gestation for preterm premature rupture of membranes is unclear, but treatment may be beneficial, particularly if pulmonary immaturity is documented. Sparse data exist on the efficacy of corticosteroid use before fetal age of viability, and such use is not recommended. A single rescue course of antenatal corticosteroids may be considered if the antecedent treatment was given more than 2 weeks prior, the gestational age is less than 32 6/7 weeks, and the women are judged by the clinician to be likely to give birth within the next week. However, regularly scheduled repeat courses or multiple courses (more than two) are not recommended. Further research regarding the risks and benefits, optimal dose, and timing of a single rescue course of steroid treatment is needed.

The effect of maternal body mass index on neonatal outcome in women receiving a single course of antenatal corticosteroids

The aim of this study was to determine the effect of maternal body mass index on the incidence of neonatal prematurity morbidities in those who receive corticosteroids. This was a secondary analysis of a trial of corticosteroids in women at risk for preterm birth. Women receiving a single course of corticosteroids were classified by their prepregnancy body mass index (<25 and > or = 25) and compared on a composite outcome comprised of several neonatal morbidities and on each individual outcome. Of 183 eligible women, 96 (52.5%) had a body mass index of <25 and 87 (47.5%) had a body mass index of > or = 25. The composite outcome occurred more frequently in the body mass index of > or = 2 5 group (28.7%), compared with those with a body mass index of <25 (18.8%), although this was not statistically significant (odds ratio, 1.75; 95% confidence interval, 0.83-3.72). Body mass index was not associated with outcomes after adjusting for confounding. Maternal body mass index did not affect neonatal prematurity morbidities in those receiving corticosteroids.

Effects of Multiple Courses of Antenatal Corticosteroids on Blood-Brain Barrier Permeability in the Ovine Fetus

To test the hypothesis that multiple courses of antenatal corticosteroids accentuate the decreases in blood-brain barrier permeability observed after a single course of corticosteroids in preterm ovine fetuses. Chronically instrumented 106-day gestation ovine fetuses were studied after single and multiple courses of dexamethasone or placebo were given to ewes beginning at 104 to 106 or 76 to 78 days of gestation, respectively. In the single-course groups, the ewes received dexamethasone (6 mg, n = 6) or placebo (n = 6) as four intramuscular injections every 12 hours over 48 hours. In the multiple course groups, the ewes received the same treatment (dexamethasone, n = 9, or placebo, n = 8), once per week for 5 weeks starting at 76 to 78 days of gestation. Blood-brain barrier permeability was quantified with the blood-to-brain transfer constant (K(i)) for alpha-aminoisobutyric acid (AIB) in the brain regions of the fetuses 12 hours after the last injection of dexamethasone was given to the ewes at 106 to 107 days of gestation. Both single (analysis of variance [ANOVA]; main effects for dexamethasone treatment, F = 5.92, P <.04) and multiple (ANOVA; main effects for dexamethasone treatment, F = 4.74, P <.04) courses of antenatal corticosteroids were associated with decreases in blood-brain barrier permeability in the brain regions of the ovine fetus. However, the multiple courses did not accentuate (ANOVA; main effects for single versus multiple courses, F = 1.06, P = .32) the decreases in permeability observed after a single course. Contrary to our hypothesis, antenatal treatment with a 5-week course of corticosteroids did not accentuate the reductions in blood-brain barrier permeability that we observed after a single course of corticosteroids in the fetus.

Neonatal adrenal function after repeat dose prenatal corticosteroids: A randomized controlled trial

Do repeat prenatal corticosteroids suppress neonatal cortisol concentrations? Randomized controlled trial of women given weekly repeat corticosteroids or saline placebo, while at risk of preterm birth, until 32 weeks' gestation. Cord serum cortisol concentrations in infants exposed to repeat corticosteroids were similar compared with infants exposed to a single course of corticosteroids (mean difference -26 nmol/L (95% CI -57, 5 nmol/L, P = .10), as were prestress salivary cortisol concentrations on day 3 (median 16.5 vs 15.3 nmol/L, P = .96). The adrenal response to a stressor on day 3 was lower in the repeat corticosteroid group compared with the single course group (median 11.9 vs 21.4 nmol/L, P = .02). Cortisol concentrations were lower in the repeat corticosteroid group on day 7 (median 11.7 vs 18.2 nmol/L, P = .04), but not on days 14 and 21. The short- or long-term clinical impact, if any, of these changes in adrenal function needs to be determined.

Repeat courses of antenatal corticosteroids: The controversy continues

confirming the initial findings. 1 Despite what appears to be overwhelming evidence that a single course of antenatal corticosteroids improves outcomes and has a highly favorable risk to benefit ratio, obstetricians throughout the world slowly incorporated the use of corticosteroids into their practice. The reluctance to use corticosteroids was based on the risk of infection, inability to identify the pregnancies that would benefit most, and data from several animal models that suggested that exposure to exogenous corticosteroids resulted in intrauterine growth restriction and permanent damage to the central nervous system. In an attempt to review the scientific evidence and dispel unfounded myths regarding corticosteroids, the National Institutes of Health (NIH) held a consensus conference in 1994. The panel published a consensus statement that strongly supported the use of a single course of corticosteroids in pregnancies between 24 and 34 weeks gestation at risk for delivery within 7 days. 3 They also presented longterm pediatric follow-up data to prove its safety. After the dissemination of the NIH consensus statement, clinical practice appeared to change overnight. Administration of antenatal corticosteroids became the ‘‘standard of care’’ for women at risk for preterm birth and the use of repeat courses of corticosteroids became commonplace. 4 The practice of repeat courses was not

Antenatal Corticosteroid Therapy for Fetal Maturation

The National Institute of Child Health and Human Development and the Office of Medical Applications of Research of the National Institutes of Health convened consensus conferences in 1994 and 2000 that recommended giving a single course of corticosteroids to all pregnant women between 24 and 34 weeks of gestation who are at risk of preterm delivery within 7 days. Because of insufficient scientific evidence, the consensus panel also recommended that repeat corticosteroid courses, including so-called "rescue therapy", should not be routinely used but should be reserved for women enrolled in clinical trials. Betamethasone and dexamethasone have been most widely studied and have generally been the preferred corticosteroids for antenatal treatment to accelerate fetal organ maturation. The American College of Obstetricians and Gynecologists' Committee on Obstetric Practice supports the conclusions of the consensus conferences.

Contact sensitization pretransplantation predicts acute hepatic allograft rejection.

The loss of hepatic allografts to the rejection processes is now relatively rare, and the reduction of adverse effects related to immunosuppressive therapy is becoming more important as patients survive longer after transplantation. We therefore investigated the response to a contact neoantigen before liver transplantation as a predictor of acute rejection after transplantation. Forty-one patients with chronic liver disease were sensitized with 0.1% diphenylcyclopropenone while on the waiting list for orthotopic liver transplantation. Fourteen days later an elicitation reaction was performed with 5 different concentrations of diphenylcyclopropenone. Nineteen responded to diphenylcyclopropenone (score range, 1-9). Twenty-two patients had no response. Three patients died before transplantation (all nonresponders). Twelve (63%) of 19 responders had treatment for acute rejection compared with 1 of 19 nonresponders (P < .0001). In addition univariate analysis revealed recipient age, donor age, Child-Pugh class, and immunosuppressive agent to be associated with acute rejection. On multivariate analysis only skin test response was a significant predictor of acute rejection (P = .02). All nonresponders had no or only mild rejection on biopsy, but 12 of 19 responders had moderate or severe acute rejection on biopsy. All patients requiring additional therapy to a single course of corticosteroids for acute rejection had skin test scores greater than 1. We concluded that patients who do not respond to diphenylcyclopropenone sensitization before transplantation develop at most mild acute rejection and that skin test scores identify patients with troublesome rejection. Evaluation of skin test responses to a contact neoantigen may facilitate tailoring of immunosuppressive therapy.