What are the guidelines for using high dose steroids, such as prednisolone (corticosteroid), in pregnant women?

From the Guidelines

High-dose corticosteroids like prednisolone should be used during pregnancy only when the potential benefits outweigh the risks to the mother and fetus, and the lowest effective dose for the shortest duration possible should be used. When medically necessary for serious conditions such as severe asthma exacerbations, autoimmune disorders, or inflammatory conditions, prednisolone is generally considered safer than other corticosteroids because it is partially metabolized by the placenta 1. The recommended approach is to use the lowest effective dose for the shortest duration possible, and for acute conditions requiring high-dose therapy, prednisolone may be given at 40-60 mg daily for 3-7 days with a rapid taper afterward. For chronic conditions, maintenance doses should be kept below 20 mg daily when possible, as recommended by the 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases 1.

Some key points to consider when using high-dose steroids during pregnancy include:

• Timing is important, as administration during the first trimester carries a small increased risk of cleft palate (0.2-0.3%), while third-trimester use may be associated with intrauterine growth restriction and adrenal suppression in the newborn 1.
• Patients should receive supplemental calcium and vitamin D during treatment, and blood glucose monitoring is recommended as corticosteroids can worsen or precipitate gestational diabetes 1.
• The decision to use high-dose steroids during pregnancy should always involve shared decision-making between the patient and healthcare provider, carefully weighing the severity of the maternal condition against potential fetal risks 1.
• Nonfluorinated glucocorticoids, such as prednisolone, should be used when needed, but substitution of steroid-sparing pregnancy-compatible immunosuppressive therapy is desirable when high-dose or prolonged use is required 1.
• Continuing low-dose glucocorticoid treatment (≤10 mg daily of prednisone or nonfluorinated equivalent) during pregnancy is conditionally recommended if clinically indicated, and tapering higher doses of nonfluorinated glucocorticoids to <20 mg daily of prednisone is strongly recommended 1.

Overall, the use of high-dose corticosteroids during pregnancy requires careful consideration of the potential benefits and risks, and should be guided by the most recent and highest quality evidence, such as the 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases 1.

From the FDA Drug Label

Usage in Pregnancy: Since adequate human reproduction studies have not been done with corticosteroids, use of these drugs in pregnancy or in women of childbearing potential requires that the anticipated benefits be weighed against the possible hazards to the mother and embryo or fetus Infants born of mothers who have received substantial doses of corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism.

The use of high dose steroids, such as prednisolone, in pregnant women requires careful consideration of the potential benefits and risks. Key considerations include:

• Weighing the anticipated benefits against the possible hazards to the mother and fetus
• Carefully observing infants born to mothers who have received substantial doses of corticosteroids during pregnancy for signs of hypoadrenalism 2

From the Research

Guidelines for High Dose Steroids in Pregnant Women

• The use of high dose steroids, such as prednisolone, in pregnant women should be carefully considered, weighing the benefits and potential risks to both the mother and the fetus 3, 4.
• Systemic corticosteroids are not teratogenic, but pregnant women receiving corticosteroid therapy may experience side effects and benefits similar to those of non-pregnant women 3.
• Clinical experience suggests that usual doses of prednisone and methylprednisolone throughout pregnancy do not cause abnormalities in children, but premature rupture of amniotic membranes and low birthweight babies may occur 3.
• Betamethasone and dexamethasone are used to treat the fetus, and the effect on the fetus of bolus doses of methylprednisolone is unknown 3.
• Corticosteroid therapy in pregnancy is appropriate to control clinically active maternal illness, treat an in utero infant suffering from neonatal lupus-associated carditis, and induce fetal lung maturation 3, 5.

Specific Considerations

• Inhaled corticosteroids (ICS) should be continued throughout pregnancy at low to moderate doses sufficient to control asthma symptoms and prevent exacerbations, but caution must be taken with doses greater than 1000 µg/d 6.
• A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation who are at risk of preterm delivery within 7 days 5.
• Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation who are at risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids 5.

Safety and Efficacy

• Most biological agents are safe to use in pregnancy, but glucocorticoids may increase the risk of gestational diabetes and gestational hypertension/preeclampsia 4.
• Nonsteroidal medication should only be used during the first trimester and for a short period during the second trimester 4.
• Limited experience with tumor necrosis factor-α inhibitor medications suggests minimal risk, but methotrexate, mycophenolate, and leflunomide are contraindicated during pregnancy 4.