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The clinical use of corticosteroids in pregnancy: Corticosteroid use in Pregnancy

Research output: Contribution to journalArticle

  • Matthew W. Kemp
  • John P. Newnham
  • J.P. Challis
  • Alan H. Jobe
  • Sarah Stock

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Original languageEnglish
JournalHuman Reproduction Update
Early online date20 Nov 2015
DOIs
Publication statusPublished - 16 Feb 2016

Abstract

Background: The use of antenatal steroid therapy is common in pregnancy. In early pregnancy, steroids may be used for the treatment of recurrent miscarriage, or fetal abnormalities such as congenital hyperplasia. In mid-late pregnancy, the antenatal administration of corticosteroids to mothers in anticipation of preterm birth is one of the most important advances in perinatal medicine; from initial observations made nearly half a century ago in a sheep model of pregnancy, antenatal corticosteroids are now standard of care for pregnancies at risk of premature delivery in high- and middle-income countries. The widespread uptake of this therapy is due to a compelling body of evidence demonstrating improved neonatal outcomes following antenatal corticosteroid exposure, stemming most notably from corticosteroid-driven maturation of fetal pulmonary function. As we approach the 50th anniversary of landmark work by Liggins and Howie showing that corticosteroids promoted maturation of the fetal lung, it is apparent that much remains to be understood with regards to how we might best apply antenatal corticosteroid therapy to improve pregnancy outcomes in both early and mid-late pregnancy gestations.
Methods: Drawing on advances in laboratory science, pre-clinical and clinical studies, we performed a narrative review of the scientific literature to provide a timely update on the benefits, risks and uncertainties of antenatal corticosteroid use in pregnancy. Three, well-established therapeutic uses of antenatal steroids, namely: recurrent miscarriage; congenital hyperplasia; and preterm birth were selected to frame the narrative review.
Results: Even the most well-established antenatal steroid therapies lack the comprehensive pharmacokinetic and dose response data necessary to optimise dosing regimens. New insights into complex, tissue specific corticosteroid signalling by genomic-dependent and independent mechanisms have not been used to inform corticosteroid treatment strategies. There is growing evidence that some fetal corticosteroid treatments are either ineffective, or may result in adverse outcomes in addition to lasting epigenetic changes in a variety of homeostatic mechanisms. Nowhere is the need to better understand the intricacies of corticosteroid therapy better conveyed than in the findings of Althabe and colleagues (Althabe et al. 2015) who recently reported an increase in overall neonatal mortality and maternal morbidity in association with antenatal corticosteroid administration in low-resource settings.
Conclusions: New research to clarify the benefits and potential risks of antenatal corticosteroid therapy is urgently needed, especially with regards to corticosteroid use in low-resource environments. We conclude that there is both significant scope and an urgent need for further research-informed refinement to the use of antenatal corticosteroids in pregnancy.

ID: 21855433