Dr. Somendra shukla is a one of the best Pediatrician & neonatologist at Gurgaon. He has vast expierence of 9 yrs in neonatology & pediatrics. He has cleared the prestigious Diplomate of National Board (DNB) and royal college of pediatrics, london (MRCPCH) examinations in pediatrics. He has worked and honed up her skills with some of the top corporates institutes of India such as Fortis hospital, moolchand medcity and paras hospital. He has also done his Fellowship in neonatology awarded by prestigious National neonatology forum of India.He is a member of IAP and NNF and has attended various seminars and workshops and has presented several papers in various national conferences and conducted CMEs. He is an expert in newborn intensive care including care of ventilated and extremely low birth weight babies (<1000g><750g). His area of interest are childhood vaccination, growth and development and childhood asthma.

1. ANTENATAL STEROIDS
Dr. Somendra Shukla
Neonatologist & Pediatrician

2. Mechanism of
Action of Antenatal
Corticosteroids

3. Antenatal Corticosteroids
How do corticosteroids work?
Increase the amount of lung surfactant (+/-)
Decrease the inflammatory process from trauma
Decrease vascular permeability
Increase tissue compliance & thus lung volume
Improve the response to surfactant that is present
Enhance the clearance of lung water

4. A. Respiratory Action
 Antenatal corticosteroid therapy leads to architectural and biochemical changes
that improve both lung mechanics and gas exchange. These changes are
primarily the result of accelerated morphologic development of type 1 and type 2
pneumocytes. Type 1 pneumocytes are responsible for gas exchange in the
alveoli, while type 2 pneumocytes are responsible for production and secretion of
surfactant.
 Antenatal corticosteroids also alter production of surfactant binding proteins and
enhance fetal lung antioxidant enzymes.
 However, for these changes to occur the lungs need to have reached a stage of
development that is biologically responsive to corticosteroids.

5. B. Circulatory Action
 Antenatal corticosteroid therapy improves circulatory stability in
preterm neonates, resulting in less intraventricular hemorrhage
and necrotizing enterocolitis.

6. Betamethasone Vs Dexamethasone
Betamethasone half life – 72 hours with a larger
volume of distribution
Dexamethasone half life – 60 hours
Both freely cross the placenta
Differ by a single methyl group

7. Betamethasone Vs Dexamethasone
Baud et al. NEJM 1999 – Less PVL with betamethasone vs.
dexamethasone or untreated controls
Van Marter et al. Pediatrics 1990 – Less BPD with betamethasone vs.
other corticosteroids
Lee et al. Pediatrics 2008 – less impaired neurodevelopment at 18 to
22 months in betamethasone group over dexamethasone
Betamethasone fewer dosages and less time to complete
Elimian et al. Obstet Gynecol 2007 – Less IVH with dexamethasone
vs. betamethasone

8. Antenatal Corticosteroids Dosing Schedule
What steroid should be used and what should the
injection schedule be?
Betamethasone 12 mg IM x 2 doses Q 24 hours
or
Dexamethasone 6 mg IM x 4 doses Q 12 hours
But if felt to be needed
Betamethasone 12 mg IM x 2 doses Q 12 hours can be
administered

9. Rationale for
Repeating antenatal
corticosteroids

10. Rationale for Repeating
antenatal corticosteroids
 The biologic rationale for repeating antenatal corticosteroid
therapy is based upon the observation that biochemical
stimulation of surfactant production appears to be reversible in
cell culture models i.e. surfactant protein mRNA levels decline to
control levels after cortisol is removed.
 However, other beneficial effects, such as cytostructural
maturation, persist after steroid exposure is withdrawn.

11. Advantages
& Disadvantages of Repeated
Antenatal Corticosteroids

12. Advantages
 Repeated doses are associated with better neonatal lung function
than single course of corticosteroids, particularly among infants
delivered before 32 weeks of gestation.
 Also, less need for mechanical ventilation, continuous positive airway
pressure, and surfactant use. There was also a reduction in the
frequency of pneumothorax.
 However, there is NO SIGNIFICANT BENEFIT in reduction of severe
respiratory distress syndrome, grade III or IV intraventricular
hemorrhage, chronic lung disease or periventricular leukomalacia.

13. Disadvantages
 Repeated doses are associated with lower birth weight than the
single course, and appear to cause IUGR.
 However, it was found that repeating a SINGLE RESCUE DOSE
or COURSE, does not affect fetal growth.
 Some studies reported increased incidence of cerebral palsy.
 Regarding late term effects, some studies showed affection of
neurological development in early childhood.

14. Disadvantages
 In animals: studies have shown decreased brain size, altered
nerve growth, a delayed rate of myelination, altered retinal
development, a decrease in the number of neurons and a dose-
dependent degeneration of neurons in the hippocampus.
Also it may be associated with increased incidence of
hypertension.

15. ANS – Evidence Based Guidelines:
Repeat Courses
Weekly repetitive courses of antenatal steroids are no
longer recommended because of concerns for fetal head
and somatic growth. The effect is generally seen after
>=3 courses or >=4 courses.
The 2000 NIH Consensus Conference reaffirmed the 1994
Consensus recommendations and further stated that
repeat courses of corticosteroids should not be used
routinely, but should be reserved for patients enrolled in
randomized controlled trials.

16. ANS – Evidence Based Guidelines:
Repeat Courses
In mothers likely to deliver beyond 2 weeks from the primary
course and before 34 weeks gestation, a single “rescue”
course of antenatal corticosteroids appears to provide
additional benefit. The same medication regimens would be
utilized.
Rescue course of ANS simply means the administration of a
second course to patients whose pregnancies continue more
than a week or 2 from their original course and only in whom,
in the judgment of the clinician, delivery has again become
likely.

17. ANS – Evidence Based Guidelines:
Rescue Courses
Research has shown that choosing to administer a rescue course
of antenatal corticosteroids in pregnant women treated
initially >2 weeks prior, and who are judged by the clinician to
be likely to deliver within the next week and before 34 weeks
gestation, is a beneficial approach that significantly decreases
respiratory complications of prematurity and is without
apparent immediate or short-term adverse effects to the
mother or infant.

19. Antenatal Corticosteroids
ACOG – Committee Opinion # 475 – Feb 2011
ACOG (overall) supports the conclusions of the
1994 & 2000 NIH consensus conferences
All women at risk for PTD from 24 to 34 weeks
gestation (or 24 to < 32 weeks with PPROM) are
candidates for a single course of corticosteroids
A single repeat rescue course may be considered if
the gestational age is < 32 6/7 weeks, it has been
more than 2 weeks from the prior treatment, and
delivery is likely within the next 7 days

20. Antenatal Corticosteroids
ACOG – Committee Opinion # 475 – Feb 2011
For PPROM 32 to 33 6/7 weeks treatment is ??
but may be beneficial in cases with documented
pulmonary immaturity
Regularly scheduled courses (more than 2) are
not recommended
Betamethasone 12mg IM x 2 doses Q24 hours
(24 hour treatment time)
Dexamethasone 6mg IM x 4 doses Q12 hours (36
hour treatment time)

21. Antenatal Corticosteroids
ACOG and AAP Joint Statement 2007 Antenatal
Corticosteroid Administration
ACOG – Practice Bulletin # 127-June 2012
Management of Preterm Labor
ACOG – Practice Bulletin #139-October 2013
Management of PPROM
All state administering a single course of
corticosteroids for 240/7
to < 34 weeks gestation

22. ANS - Repeat Courses: References
Antenatal Corticosteroids Revisited: Repeat Courses. NIH
Consensus Statement 2000; 17(2): 1-10.
Antenatal corticosteroid therapy for fetal maturation.
ACOG Committee Opinion No. 273. Obstet
Gynecol 2002; 99: 871-873.
Wapner RJ, Sorokin Y, Thom EA, Johnson F, Dudley DJ,
Spong CY, et al. Single versus weekly courses of
antenatal corticosteroids: Evaluation of safety and
efficacy. Am J Obstet Gynecol 2006; 195(3): 633-42.
Crowther CA, Harding JE. Repeat doses of prenatal
corticosteroids for women at risk of preterm birth for
preventing neonatal respiratory disease. Cochrane
Database of Systematic Reviews 2007, Issue 3. Art
No.: CD003935. DOI:
10.1002/14651858.CD003935.pub2.

23. ANS – Evidence Based Guidelines:
Timing
All fetuses between 24 and 34 weeks gestation at risk of
preterm delivery should be considered candidates for
antenatal treatment with corticosteroids.
There are no recommendations concerning routine early
treatment with antenatal corticosteroids.
In selected situations beyond 34 weeks gestational age with
an indicated delivery (e.g., placenta previa, prior uterine
rupture) in the presence of an immature fetal lung profile,
treatment with antenatal corticosteroids can be effective.
The same medication regimens would be utilized.

25. Corticosteroids after
34 weeks gestation
Haas et al. 2012 – retrospective study of 110 cases
with a –FLM between 340/7
and 370/7
weeks gestation
where 69 received corticosteroids and 41 did not
Rate of RDS, TTN, hypoglycemia, NICU admission
and hyperbilirubinemia were the same

26. Corticosteroids after
34 weeks gestation
Feitosa Porto et al. 2011 – randomized trial of
antenatal corticosteroids in late preterm infants
320 patients between 34 & 36 weeks randomized
to betamethasone or placebo 2008 to 2010
43 discharged / 2 SB / 2 excluded – total 47 lost
143 steroid group – 2 cases RDS
130 in placebo group – 1 case RDS
No benefit seen

27. Corticosteroids after
34 weeks gestation
Stutchfield et al. 2005 – Antenatal Steroids for Term
Elective Cesarean Section (ASTECS)
942 patients for C-section randomized to
betamethasone or regular care 1995 to 2002
467 treated – 11 (2.4%) to NICU for RDS
475 controls – 24 (5.1%) to NICU for RDS
P = 0.02

28. RATIONALE
• 3 out of 4 preterm delivery b/w 34-37 wks
• Incidence of RDS
34 wks --- 50%
35 wks --- 15%
36 wks --- 8%

29. MECHANISM OF ACTION
• No role of surfactant deficiency
• Helps in fluid reabsorption
• Via E- Na channel
• TTNB

30. Recommendation
• Not recommended routinely
• Not received prior steroid
• Not in cases with prior labor delivery
• Indication
 34- 35+6 wks
 Elective LSCS
 without prior labor

31. ACTECS (Antenatal Steroid for Term
Elective Cesarean section)
• After 37 wks- 39 wks
• No significant reduction in respiratory distress

32. W- Hospital by Pratiksha
Golf course Ext Road
Gurgaon
Phone no.: 0124-4131000