What are the effects of prednisone (corticosteroid) on pregnancy?

From the Guidelines

Prednisone can be used during pregnancy when the benefits outweigh the risks, but it should be prescribed at the lowest effective dose for the shortest duration possible, with a recommended dose of ≤10 mg daily of prednisone or nonfluorinated equivalent, as conditionally recommended by the 2020 American College of Rheumatology guideline 1.

Effects of Prednisone on Pregnancy

The use of prednisone during pregnancy is a common practice, especially for managing conditions like severe asthma, lupus, or inflammatory bowel disease.

• The medication helps reduce inflammation and suppress the immune system, which can be crucial for managing these conditions in pregnant women.
• Potential risks to the fetus include low birth weight and adrenal suppression, as noted in the 2020 American College of Rheumatology guideline 1.
• To minimize risks, doctors may taper the dose towards the end of pregnancy, and newborns whose mothers took prednisone during pregnancy should be monitored for signs of adrenal insufficiency.

Recommended Dosage and Monitoring

• The recommended dose of prednisone during pregnancy is ≤10 mg daily of prednisone or nonfluorinated equivalent, as conditionally recommended by the 2020 American College of Rheumatology guideline 1.
• Higher doses of nonfluorinated glucocorticoids should be tapered to <20 mg daily of prednisone, and a pregnancy-compatible glucocorticoid-sparing agent may be added if necessary, as strongly recommended by the 2020 American College of Rheumatology guideline 1.
• For breastfeeding mothers, prednisone is generally considered safe, as only small amounts pass into breast milk, but high doses may potentially affect infant growth, so monitoring is recommended, as noted in the 2007 EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases 1.

Important Considerations

• Always consult with your obstetrician and the prescribing physician to weigh the benefits and risks for your specific situation.
• The use of prednisone during pregnancy should be carefully monitored, and the dose should be adjusted as needed to minimize risks to the fetus and the mother.
• The 2020 American College of Rheumatology guideline provides conditional recommendations for the use of prednisone during pregnancy, and these recommendations should be followed to ensure the best possible outcomes for both the mother and the fetus 1.

From the FDA Drug Label

Pregnancy Teratogenic Effects Pregnancy Category C Corticosteroids have been shown to be teratogenic in many species when given in doses equivalent to the human dose Animal studies in which corticosteroids have been given to pregnant mice, rats, and rabbits have yielded an increased incidence of cleft palate in the offspring. There are no adequate and well-controlled studies in pregnant women. Corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus Infants born to mothers who have received substantial doses of corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism.

The effects of prednisone on pregnancy include:

• Teratogenic effects: Corticosteroids have been shown to be teratogenic in many species, with an increased incidence of cleft palate in offspring.
• Potential risk to the fetus: Corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
• Risk of hypoadrenalism: Infants born to mothers who have received substantial doses of corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism. 2

From the Research

Effects of Prednisone on Pregnancy

• The use of prednisone during pregnancy may lead to adverse pregnancy outcomes, including placental morphological changes and altered nutrient transport function 3.
• A study found that prenatal prednisone exposure caused a decrease in placental weight and a decrease in the placenta junctional zone/labyrinth zone ratio, but no changes were observed in the fetuses 3.
• Another study investigated the effects of prednisone use in pregnant women with rheumatoid arthritis on insulin resistance in offspring and found no increased risk for insulin resistance in children exposed to prednisone in utero 4.
• A systematic review of the literature on the side effects of antenatal predniso(lo)ne and dexamethasone use found that antenatal predniso(lo)ne use may be associated with lower gestational age, but was not associated with miscarriages, stillbirths, congenital abnormalities, or other adverse outcomes 5.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that the decision to use any agent during pregnancy should be based on the clinical context, risks associated with individual medications, and gestational age, and that low-risk medications like prednisone can be continued in pregnancy or initiated during pregnancy as needed 6.
• A review of immunosuppressive drug use during pregnancy found that corticosteroids like prednisone have been used extensively and safely in pregnant patients with systemic lupus erythematosus and rheumatoid arthritis, with no reports of congenital malformations in exposed infants 7.

Placental Effects

• Prenatal prednisone exposure can cause placental morphological changes, including a decrease in placental weight and a decrease in the placenta junctional zone/labyrinth zone ratio 3.
• The effects of prednisone on the placenta may be dose-, stage-, and sex-dependent, with the highest dose of 1 mg/kg causing the most significant changes 3.
• Prednisone exposure can also alter nutrient transport function in the placenta, with changes in gene expression and cell proliferation markers 3.

Fetal Effects

• There is no evidence to suggest that prednisone use during pregnancy increases the risk of congenital malformations or other adverse fetal outcomes 3, 5, 7.
• One study found that children exposed to prednisone in utero had no increased risk for insulin resistance at the age of approximately 7 years 4.
• Another study found that antenatal predniso(lo)ne use was not associated with differences in blood pressure, low blood glucose levels, or low bone mass in offspring 5.