Antenatal Corticosteroids in Preterm Premature Rupture of Membranes (PPROM)
Antenatal corticosteroids are not contraindicated in PPROM but should only be administered when neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient. 1
Timing of Antenatal Corticosteroids in PPROM
- Administration of antenatal corticosteroids is not recommended in previable and periviable PPROM until the time when a trial of neonatal resuscitation and intensive care would be considered appropriate (GRADE 1B) 1
- The benefits of antenatal corticosteroids in reducing neonatal respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death are well-established in PPROM cases without increased risk of maternal or neonatal infection 2
- For gestations between 24-34 weeks with PPROM, antenatal corticosteroids should be administered when delivery is anticipated and neonatal resuscitation would be pursued 3
Clinical Decision-Making Framework
- For previable PPROM (<20 weeks): Antenatal corticosteroids are not recommended as neonatal resuscitation is typically not pursued at this gestational age 1
- For periviable PPROM (20-23 6/7 weeks): Antenatal corticosteroids should be withheld until the gestational age when neonatal resuscitation would be considered 1, 3
- For PPROM ≥24 weeks: Antenatal corticosteroids are recommended when delivery is anticipated within 7 days, as the benefits outweigh potential risks 3, 2
Benefits vs. Risks
- Benefits: Reduction in respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and neonatal death 2, 4
- Historical concerns about increased infection risk with corticosteroids in PPROM have not been substantiated by evidence 2, 4
- Decision analysis studies indicate that the benefit of reducing severe intraventricular hemorrhage outweighs the potential risk of increasing neonatal sepsis 5
Special Considerations
- In patients with COVID-19 infection and PPROM, antenatal corticosteroids remain beneficial between 24-30 weeks despite potential maternal risks, but may have less favorable risk-benefit ratio at 31-32 weeks 6
- The combination of antenatal corticosteroids with appropriate antibiotic therapy is the standard of care for PPROM at viable gestational ages 3
Common Pitfalls to Avoid
- Administering antenatal corticosteroids too early (before the period when neonatal resuscitation would be considered) provides no benefit and may expose the mother to unnecessary risks 1
- Withholding antenatal corticosteroids in appropriate candidates (≥24 weeks) due to unfounded concerns about infection risk 2, 4
- Using multiple courses of antenatal corticosteroids, which may increase risks without clear additional benefits 1