What are the guidelines for using steroids during pregnancy?

Guidelines for Using Steroids During Pregnancy

Steroids should be used during pregnancy only when the potential benefit justifies the potential risk to the fetus, with specific considerations for type, timing, and indication of steroid therapy. 1, 2

Types of Steroid Use During Pregnancy

Antenatal Corticosteroids for Fetal Lung Maturity

• Recommended for women at risk of preterm birth between 24+0 and 33+6 weeks gestation when delivery is anticipated within 7 days, as they reduce neonatal mortality and morbidity 3, 4
• In selected cases, may be extended to 34+6 weeks gestation 4
• Either betamethasone (12 mg IM twice, 24 hours apart) or dexamethasone (6 mg IM four times, 12 hours apart) may be used 4
• Consider administration between 22+0 and 23+6 weeks when active newborn life support is indicated 4
• A single repeat course can be considered in pregnancies <34+0 weeks if the previous course was completed more than 7 days earlier and there is renewed risk of imminent delivery 4

Maternal Corticosteroid Therapy

• Short bursts of oral corticosteroids may be used after the first trimester for severe conditions, especially if causing exacerbation of asthma 3
• Consultation with the patient's obstetrician is recommended before initiating therapy 3
• First trimester use carries the greatest risk of potential teratogenicity 3, 2
• Maternal diabetes should be assessed before use, as steroids can cause hyperglycemia 3

Topical/Intranasal Corticosteroids

• Modern nasal corticosteroids (budesonide, fluticasone, mometasone) are safe to use at recommended doses during pregnancy 3
• Off-label use of budesonide irrigations or corticosteroid nasal drops is not recommended during pregnancy 3

Risks and Considerations

Maternal Risks

• Corticosteroids can cause maternal side effects including:
  • Hyperglycemia and potential gestational diabetes 3
  • Hypertension and increased risk of preeclampsia 3
  • Adrenal suppression with prolonged use (>5 mg prednisolone daily for >3 weeks) 3

Fetal/Neonatal Risks

• Animal studies have shown increased incidence of cleft palate with corticosteroid use during pregnancy 1, 2
• Potential risks include:
  • Slightly increased risk for cleft lip with or without cleft palate 3
  • Increased incidence of preterm birth 3
  • Low birth weight infants 3
  • Neonatal hypoglycemia (particularly with late preterm steroid use) 4, 5

Special Situations

Immunosuppression After Organ Transplantation

• Azathioprine, cyclosporine, tacrolimus, and prednisolone should not be stopped in pregnant transplant recipients 3
• Mycophenolate mofetil is teratogenic and should be stopped at least 12 weeks before conception 3
• Women taking cyclosporine and tacrolimus should be monitored closely for hypertension and preeclampsia throughout pregnancy 3

Rheumatic and Musculoskeletal Diseases

• Continue low-dose prednisone if needed for disease control 3
• Taper high-dose prednisone with addition of pregnancy-compatible drugs if needed 3
• For cesarean delivery, stress-dose steroids are recommended 3

Cholestatic Liver Diseases

• Prednisolone is considered low risk during pregnancy but is associated with increased risk of cleft palate in first trimester use 3
• Ursodeoxycholic acid (UDCA) can be administered in cholestatic liver disease when the pregnant woman is symptomatic during second or third trimesters 3

Breastfeeding Considerations

• Prednisone or nonfluorinated steroid equivalent <20 mg daily is compatible with breastfeeding 3
• For prednisone ≥20 mg daily, discard breast milk obtained within 4 hours following medication 3
• The American Academy of Pediatrics considers oral steroids to be compatible with breastfeeding 3

Common Pitfalls to Avoid

• Avoid using steroids without clear indications - benefits must outweigh potential risks 2, 6
• Avoid first trimester use when possible due to potential teratogenic effects 3, 1
• Avoid mycophenolate mofetil during pregnancy due to high risk of congenital malformations 3
• Avoid "treatment creep" - using antenatal corticosteroids in patients who don't meet strict criteria 5
• Monitor for maternal hyperglycemia when administering corticosteroids 3

By following these guidelines and weighing the benefits against potential risks, clinicians can make informed decisions about steroid use during pregnancy to optimize both maternal and fetal outcomes.