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221: Steroid administration, fetal monitoring, and timing of delivery in monoamniotic twins

      Objective

      To determine the optimum steroid administration strategy for monoamniotic twins.

      Study Design

      We assembled a retrospective cohort of monoamniotic twin pregnancies at or beyond 24 weeks managed at a single tertiary care center from 2007 to 2017. All patients in the cohort were admitted between 24 to 28 weeks gestation for either twice or three times daily fetal heart rate monitoring with additional monitoring as deemed necessary by the managing provider. We classified patients according to whether steroids were administered on admission, at a predetermined gestational age, or for a change in clinical status. Our primary outcome of interest was receipt of steroids within 7 days of delivery. We next recorded daily hours on the fetal monitor for each patient and analyzed each patient-week of hospitalization as a separate observation. We used logistic regression to examine associations between fetal monitoring characteristics and risk of delivery in the hospital week of interest.

      Results

      Twenty-four patients comprised 150 patient-weeks of inpatient observation. The median gestational age at delivery was 32.3 weeks (range 28.1-35.3) with no stillbirths observed. The 54% of patients (n=13) receiving steroids on admission had a 0% rate of receiving this course within a week of delivery. A repeat course, given due to clinical concern increased this rate to 69.2%. Twenty-one percent (n=5) of patients received steroids at an empirical gestational age and had a 60.0% rate of timely administration. The 25% of patients (n=6) receiving steroids for change in clinical status had a 66.7% rate of receipt of steroids within a week of delivery. In an analysis adjusted for gestational age, women experiencing delivery within the week were more likely to spend more time on the fetal monitor compared to those who remained undelivered (Table). If steroids were routinely given at 32 weeks or when a patient spends more than 5 hours on the monitor 79% of patients would have received steroids within 7 days of delivery, without using the option of a repeat course.

      Conclusion

      Routine administration of steroids on admission never leads to receipt of a first course of steroids within 7 days of delivery. Withholding the first course of steroids until 32 weeks gestation or until an objective change in fetal monitoring duration may optimize steroid timing in monoamniotic twins.
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