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Use of Antenatal Corticosteroids at 22 Weeks of Gestation

  • Practice Advisory PA
  • September 2021

(Reaffirmed October 2022)

This Practice Advisory was developed by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine in collaboration with Alison G. Cahill, MD, MSCI; Anjali J. Kaimal, MD, MAS; Jeffrey A. Kuller, MD; and Mark A. Turrentine, MD.

Background

Corticosteroid administration before preterm birth is an important antenatal therapy available to improve newborn outcomes. In the setting of periviable birth, if neonatal resuscitation is planned after appropriate counseling (see Periviable Birth and Perinatal Palliative Care), antenatal corticosteroids have been recommended at 24 0/7 weeks to 25 6/7 weeks of gestation and may be considered at 23 0/7 weeks to 23 6/7 weeks of gestation 1 .

At 20 0/7 weeks to 22 6/7 weeks of gestation, previous studies demonstrated no significant reduction in neonatal death and neurodevelopmental impairment with the administration of antenatal corticosteroids 1 2 . More recent retrospective, observational data suggest that antenatal corticosteroid administration, in combination with resuscitation efforts, improves rates of survival at 22 weeks of gestation, although there is little overall impact on the absolute rate of survival without major morbidities.

A 2021 systematic review and meta-analysis that included 31 retrospective, observational studies of 2,226 infants who were delivered at 22 0/7 weeks to 22 6/7 weeks of gestation found that survival among infants born to pregnant individuals receiving antenatal corticosteroids was twice that of infants born to pregnant individuals not receiving antenatal corticosteroids (39.0% versus 19.5%; P<.01) 3 . One multicenter observational cohort that analyzed over 1,000 live births at 22 0/7 weeks to 22 6/7 weeks of gestation found that infants who received antenatal corticosteroids with postnatal life support were more likely to survive than infants who received postnatal life support alone [38.5% versus 17.7% (adjusted risk ratio, 2.11; 95% CI, 1.68–2.65)] 4 . While survival without a major morbidity was improved with antenatal corticosteroids, the absolute rate of survival without major morbidities still remained very low [4.4% versus 1.0% (adjusted risk ratio, 4.35; 95% CI, 1.84–10.28)] 4 . It is important to note that there are significant limitations in these data, including selection bias in choosing to intervene and confounding by indication.

Updated Recommendation

Based on this new literature, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine are revising their recommendation regarding antenatal corticosteroid administration at 22 weeks of gestation: Antenatal corticosteroids may be considered at 22 0/7 weeks to 22 6/7 weeks of gestation if neonatal resuscitation is planned and after appropriate counseling (2C; weak recommendation, low-quality evidence) Table 1. The recommendation regarding antenatal corticosteroid administration at 20 0/7 weeks to 21 6/7 weeks of gestation remains unchanged: Antenatal corticosteroids are not recommended during this time period because of the absence of data to suggest benefit 1 .

Use of Antenatal Corticosteroids at 22 Weeks of Gestation

*Survival of infants born in the periviable period is dependent on resuscitation and support. Between 22 0/7 weeks and 25 6/7 weeks of gestation, there are several factors in addition to gestational age that affect the potential for survival, survival without major morbidities, and the determination of viability. (Therefore, the studies discussed above do not indicate a changing assessment of the determination of viability between 22 0/7 weeks and 25 6/7 weeks of gestation, which remains dependent on multiple factors.) Some families may choose to forgo resuscitation and support after appropriate counseling.

†Grading based on the Society for Maternal-Fetal Medicine’s grading approach, found at https://www.ajog.org/article/S0002-9378(20)32576-X/fulltext.

‡See Obstetric Care Consensus 6 on Periviable Birth for a full list of clinical recommendations during the periviable period.

 

Counseling and Special Considerations

As with all decisions in the setting of periviable birth, appropriate counseling will be critical in determining whether or not to administer antenatal corticosteroids at 22 0/7 weeks to 22 6/7 weeks of gestation. A decision regarding whether or not to administer antenatal corticosteroids will be linked to the decision regarding resuscitation and support and should be considered in that context. Appropriate counseling and discussion with the family regarding individual risks and benefits of management options in addition to alternate approaches should be undertaken before any decision regarding intervention is made 1 . Specifics regarding counseling are well outlined in ACOG guidance (see Periviable Birth and Perinatal Palliative Care), and clinicians should refer to these documents for more information.

This Practice Advisory serves as an interim update to all of ACOG’s guidance and materials regarding antenatal corticosteroid administration.

References

  1. Periviable birth. Obstetric Care Consensus No. 6. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e187–99. doi: 10.1097/AOG.0000000000002352.
    Article Locations:
    Article LocationArticle LocationArticle LocationArticle Location
  2. Carlo WA, McDonald SA, Fanaroff AA, Vohr BR, Stoll BJ, Ehrenkranz RA, et al. Association of antenatal corticosteroids with mortality and neurodevelopmental outcomes among infants born at 22 to 25 weeks' gestation. Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. JAMA 2011;306:2348–58. doi: 10.1001/jama.2011.1752.
    Article Locations:
    Article Location
  3. Backes CH, Rivera BK, Pavlek L, Beer LJ, Ball MK, Zettler ET, et al. Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis. Am J Obstet Gynecol 2021;224:158–74. doi: 10.1016/j.ajog.2020.07.051.
    Article Locations:
    Article Location
  4. Ehret DE, Edwards EM, Greenberg LT, Bernstein IM, Buzas JS, Soll RF, et al. Association of antenatal steroid exposure with survival among infants receiving postnatal life support at 22 to 25 weeks' gestation. JAMA Netw Open 2018;1:e183235. doi: 10.1001/jamanetworkopen.2018.3235.
    Article Locations:
    Article LocationArticle Location

A Practice Advisory is a brief, focused statement issued to communicate a change in ACOG guidance or information on an emergent clinical issue (e.g., clinical study, scientific report, draft regulation). A Practice Advisory constitutes ACOG clinical guidance and is issued only online. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal or incorporation into other ACOG guidelines.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.

While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Publications of the American College of Obstetrician and Gynecologists are protected by copyright and all rights are reserved. The College's publications may not be reproduced in any form or by any means without written permission from the copyright owner.

The American College of Obstetricians and Gynecologists (ACOG), is the nation's leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women's health care. www.acog.org 

Topics
Counseling Gestational age Infant mortality Infant, newborn Intrapartum care Obstetric delivery Palliative care Patient care Periviable birth Pregnancy Premature obstetric labor Resuscitation Steroids
Figures & Tables

Figures & Tables

Updated Guidance Regarding Antenatal Corticosteroid Administration for Threatened and Imminent Periviable Birth by Best Estimate of Gestational Age*†‡ *Survival of infants born in the periviable period is dependent on resuscitation and support. Between 22 0/7 weeks and 25 6/7 weeks of gestation, there are several factors in addition to gestational age that affect the potential for survival, survival without major morbidities, and the determination of viability. (Therefore, the studies discussed above do not indicate a changing assessment of the determination of viability between 22 0/7 weeks and 25 6/7 weeks of gestation, which remains dependent on multiple factors.) Some families may choose to forgo resuscitation and support after appropriate counseling. †Grading based on the Society for Maternal-Fetal Medicine’s grading approach, found at https://www.ajog.org/article/S0002-9378(20)32576-X/fulltext. ‡See Obstetric Care Consensus 6 on Periviable Birth for a full list of clinical recommendations during the periviable period.

Updated Guidance Regarding Antenatal Corticosteroid Administration for Threatened and Imminent Periviable Birth by Best Estimate of Gestational Age*†‡ *Survival of infants born in the periviable period is dependent on resuscitation and support. Between 22 0/7 weeks and 25 6/7 weeks of gestation, there are several factors in addition to gestational age that affect the potential for survival, survival without major morbidities, and the determination of viability. (Therefore, the studies discussed above do not indicate a changing assessment of the determination of viability between 22 0/7 weeks and 25 6/7 weeks of gestation, which remains dependent on multiple factors.) Some families may choose to forgo resuscitation and support after appropriate counseling. †Grading based on the Society for Maternal-Fetal Medicine’s grading approach, found at https://www.ajog.org/article/S0002-9378(20)32576-X/fulltext. ‡See Obstetric Care Consensus 6 on Periviable Birth for a full list of clinical recommendations during the periviable period.

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