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Society for Maternal-Fetal Medicine Consult Series #58: Use of antenatal corticosteroids for individuals at risk for late preterm delivery: a response

  • Society for Maternal-Fetal Medicine, Publications Committee
Published:January 24, 2022DOI:https://doi.org/10.1016/j.ajog.2022.01.016
      The Society for Maternal-Fetal Medicine (SMFM), Publications Committee appreciates Dr Vidaeff and colleagues’ interest in the SMFM Consult Series #58, “Use of antenatal corticosteroids for individuals at risk for late preterm delivery,”
      • Reddy U.M.
      • Deshmukh U.
      • Dude A.
      • Harper L.
      • Osmundson S.S.
      Society for Maternal-Fetal Medicine (SMFM)
      Society for Maternal-Fetal Medicine Consult Series #58: use of antenatal corticosteroids for individuals at risk for late preterm delivery: replaces SMFM Statement #4, Implementation of the use of antenatal corticosteroids in the late preterm birth period in women at risk for preterm delivery, August 2016.
      which reviews the available and often conflicting evidence regarding potential long-term neurodevelopmental risks of antenatal corticosteroids. We recommend that “patients at risk of late preterm delivery be thoroughly counseled regarding the potential risks and benefits of antenatal corticosteroid administration and be advised that the long-term risks remain uncertain,” which is correctly acknowledged by Dr Vidaeff. We recommend offering antenatal corticosteroids to patients who meet the antenatal late preterm steroids (ALPS) trial criteria and against offering late preterm corticosteroids to patients with pregestational diabetes mellitus and those unlikely to deliver before 37 weeks of gestation.
      Dr Vidaeff’s concern is offering antenatal corticosteroids to “select populations” excluded from the ALPS trial, “where the overwhelming majority of gestations will deliver after 37 weeks.” Specific populations were excluded from the ALPS trial to reduce the complexity of assessing the relationship between the intervention and main outcome, which may have been impacted directly by the qualifying conditions, not because of the expectation of different biologic mechanisms or potential harm with these populations. However, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) 2C recommendation was recognized as weak with low-quality, indirect evidence for which there is significant uncertainty in the estimates of benefits, risks, and burdens. When making clinical decisions, it is critical to consider the GRADE of each recommendation.
      We agree that the risks associated with antenatal late preterm corticosteroids may be higher for term neonates. We recommended that “clinicians should carefully select candidates for late preterm corticosteroids who are likely to deliver preterm,”
      • Reddy U.M.
      • Deshmukh U.
      • Dude A.
      • Harper L.
      • Osmundson S.S.
      Society for Maternal-Fetal Medicine (SMFM)
      Society for Maternal-Fetal Medicine Consult Series #58: use of antenatal corticosteroids for individuals at risk for late preterm delivery: replaces SMFM Statement #4, Implementation of the use of antenatal corticosteroids in the late preterm birth period in women at risk for preterm delivery, August 2016.
      even if all other criteria for steroid administration are met. After applying these strict criteria, the rate of term delivery in the ALPS trial was only 16.4%.
      • Gyamfi-Bannerman C.
      • Thom E.A.
      • Blackwell S.C.
      • et al.
      Antenatal betamethasone for women at risk for late preterm delivery.
      We believe that the ALPS trial demonstrated respiratory benefits. These findings were supported in a systematic review and meta-analysis.
      • Saccone G.
      • Berghella V.
      Antenatal corticosteroids for maturity of term or near term fetuses: systematic review and meta-analysis of randomized controlled trials.
      Therefore, we disagree with the assertion that there is “absence of efficacy data.” We believe that despite the limitations in the available data, the demonstrated benefits of antenatal late preterm steroids outweigh the as yet unproven risks. Lastly, we respectfully disagree with the suggestion that providers are not likely to adequately communicate the potential risks of late preterm corticosteroids. However, we believe that providers can and should review the available evidence with their patients, to make a shared and informed decision.

      References

        • Reddy U.M.
        • Deshmukh U.
        • Dude A.
        • Harper L.
        • Osmundson S.S.
        • Society for Maternal-Fetal Medicine (SMFM)
        Society for Maternal-Fetal Medicine Consult Series #58: use of antenatal corticosteroids for individuals at risk for late preterm delivery: replaces SMFM Statement #4, Implementation of the use of antenatal corticosteroids in the late preterm birth period in women at risk for preterm delivery, August 2016.
        Am J Obstet Gynecol. 2021; 225: B36-B42
        • Gyamfi-Bannerman C.
        • Thom E.A.
        • Blackwell S.C.
        • et al.
        Antenatal betamethasone for women at risk for late preterm delivery.
        N Engl J Med. 2016; 374: 1311-1320
        • Saccone G.
        • Berghella V.
        Antenatal corticosteroids for maturity of term or near term fetuses: systematic review and meta-analysis of randomized controlled trials.
        BMJ. 2016; 355: i5044

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