April 4, 2016
The American Academy of Pediatrics endorses this document.
The recently published Antenatal Late Preterm Steroids (ALPS) trial demonstrated that administration of antenatal betamethasone may be of benefit for pregnancies at high risk of late preterm birth between 34 0/7 and 36 6/7 weeks of gestation (1). The primary outcome impacted by administration of antenatal corticosteroids was the decreased need for respiratory support, as well as decreases in severe respiratory complications, transient tachypnea of the newborn (TTN), bronchopulmonary dysplasia (BPD), a composite of respiratory distress syndrome, TTN and apnea, the use of postnatal surfactant, and the need for immediate postnatal resuscitation. There was also a decrease in the proportion with prolonged Neonatal Intensive Care Unit (NICU) stays. Adverse outcomes, including proven sepsis, chorioamnionitis (intrauterine infection), or endometritis, were not increased in the group receiving antenatal steroids. Hypoglycemia was more common in the infants exposed to betamethasone; however, there were no reported adverse events related to hypoglycemia, and hypoglycemia was not associated with an increased length of hospital stay. Monitoring of neonatal blood glucose is therefore recommended for infants exposed to antenatal corticosteroids administered during the late preterm period. However, monitoring neonatal blood glucose in these neonates should not be viewed as a change in practice since the American Academy of Pediatrics (AAP) recommends monitoring of neonatal blood glucose for late preterm infants since late preterm birth is a known risk factor for hypoglycemia (2).
There are important considerations related to the administration of corticosteroids in the late preterm period. Antenatal steroids given during this time should not be given if there has already been a course of corticosteroids administered for fetal benefit in the current pregnancy (i.e., administration of betamethasone in the late preterm period should not be used as a repeat, or "rescue", course) (3). Additionally, late preterm administration of antenatal corticosteroids is not indicated in women diagnosed with chorioamnionitis (intrauterine infection) (3). Furthermore, tocolysis should not be used in an attempt to delay delivery in order to administer antenatal corticosteroids in the late preterm period, nor should an indicated late preterm delivery (such as for preeclampsia with severe features) be postponed for steroid administration (3). It is also important to note that the ALPS trial did not include women with multiple gestation, diabetes, previous exposure to steroids during pregnancy, or pregnancies with major non-lethal fetal malformations; additional data are needed to determine if late preterm antenatal corticosteroids provide benefit in these settings. ACOG is reviewing these topics and will issue any updated clinical guidance as appropriate.
- With the release of this new data and until further guidance is released, administration of betamethasone may be considered in women with a singleton pregnancy between 34 0/7 and 36 6/7 weeks gestation at imminent risk of preterm birth within 7 days.
- Monitoring of neonatal blood glucose is recommended for late preterm infants since late preterm birth is a risk factor for hypoglycemia; these same guidelines should be followed for infants exposed to antenatal corticosteroids administered during the late preterm period.
- Late preterm antenatal corticosteroid administration should not be used in women diagnosed with chorioamnionitis (intrauterine infection).
- Tocolysis should not be used in order to delay delivery to allow for administration of late preterm antenatal corticosteroids, nor should an indicated late preterm delivery (such as for preeclampsia with severe features) be postponed for steroid administration.
- Administration of late preterm antenatal corticosteroids should not be given if the pregnancy was already exposed to antenatal corticosteroids.
- Because the ALPS trial excluded pregnant women with diabetes, multifetal gestations, previous exposure to steroids during pregnancy, or pregnancies with major non-lethal fetal malformations, ACOG is reviewing these topics and will issue any updated clinical guidance as appropriate.
- Gyamfi-Bannerman C, Thom EA, Blackwell SC, Tita AT, Reddy UM, Saade GR, et al. Antenatal betamethasone for women at risk for late preterm delivery. NICHD Maternal-Fetal Medicine Units Network. N Engl J Med 2016; DOI: 10.1056/NEJMoa1516783.
- Adamkin DH. Postnatal glucose homeostasis in late-preterm and term infants. Committee on Fetus and Newborn. Pediatrics 2011;127:575-9.
- SMFM Publications Committee. SMFM Statement: Implementation of the use of antenatal corticosteroids in the late preterm birth period in women at risk for preterm delivery. Am J Obstet Gynecol 2016; DOI: 10.1016/j.ajog.2016.03.013.
This Practice Advisory was developed by the American College of Obstetricians and Gynecologists in collaboration with Christopher M. Zahn, MD; Cynthia Gyamfi-Bannerman, MD, MSc; Yasser Y. El-Sayed, MD; and Ann E. Borders, MD.
A Practice Advisory is issued when information on an emergent clinical issue (e.g. clinical study, scientific report, draft regulation) is released that requires an immediate or rapid response, particularly if it is anticipated that it will generate a multitude of inquiries. A Practice Advisory is a brief, focused statement issued within 24-48 hours of the release of this evolving information and constitutes ACOG clinical guidance. A Practice Advisory is issued only online for Fellows but may also be used by patients and the media. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal or incorporation into other ACOG guidelines.
This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.