Evidence-Based Clinical Recommendations For The Use Of Antenatal Corticosteroids

Abstract

Antenatal corticosteroid (ACS) therapy is one of the most effective evidence-based interventions for improving neonatal survival and reducing major short-term morbidities associated with prematurity in pregnancies at risk of preterm birth. However, the clinical benefit of ACS largely depends on accurate patient selection, appropriate gestational age, and the reliable prediction of delivery timing. The most pronounced benefit is achieved when delivery occurs within 1-7 days after the initial dose; outside this window, efficacy decreases and the risk of unnecessary fetal exposure increases. Current evidence strongly supports the administration of ACS in pregnancies between 24+0 and 33+6 weeks of gestation with a high risk of preterm birth within the following seven days. Within this gestational window, ACS significantly reduces neonatal mortality as well as major morbidities such as respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. In contrast, the 22+0–23+6 weeks of gestation represent the most sensitive period for the use of ACS, and administration should be considered only in selected cases in which delivery is expected imminently and aggressive neonatal care is planned, within a shared decision-making process. The administration of ACS is not recommended in pregnancies below 22+0 weeks of gestation. The use of ACS in the late preterm period (34+0-36+6 weeks of gestation) remains controversial, and no survival benefit has been demonstrated. Although ACS may modestly reduce the need for respiratory support during this period, it increases the risk of neonatal hypoglycemia, and uncertainties persist regarding long-term neurodevelopmental outcomes. Therefore, ACS should not be used routinely but should be considered only in selected cases where a clear potential benefit is evident. There is insufficient evidence to support the use of prophylactic ACS prior to planned cesarean delivery at ≥37 weeks of gestation. Although repeated courses of ACS may provide short-term respiratory benefits, their use should be carefully limited due to concerns regarding fetal growth and potential long-term effects associated with increased exposure. Overall, ACS should be administered using a targeted, selective, and individualized approach.