(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.
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.
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 .
*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.