What are the guidelines for using steroids, such as prednisone (corticosteroid), during pregnancy?

Guidelines for Using Steroids During Pregnancy

Corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus, with careful consideration of timing, dose, and indication. 1, 2

General Principles for Systemic Corticosteroids

• Oral corticosteroids in short bursts may be safe after the first trimester, with use better justified in severe conditions, especially if causing exacerbation of asthma 3
• First trimester use carries the greatest risk of potential teratogenicity, with animal studies showing increased incidence of cleft lip with or without cleft palate 1, 2
• Low-dose glucocorticoid treatment (≤10 mg daily of prednisone or nonfluorinated equivalent) can be continued during pregnancy if clinically indicated 3, 4
• Higher doses of corticosteroids should be tapered to <20 mg daily of prednisone when possible, adding a pregnancy-compatible glucocorticoid-sparing agent if necessary 3, 4
• Women taking glucocorticoid treatment should be screened for gestational diabetes mellitus due to increased risk of hyperglycemia 3, 4
• Women taking >5 mg prednisolone per day for more than 3 weeks are at increased risk of adrenal suppression and should receive increased glucocorticoid doses during delivery, intercurrent infection, vomiting, or hyperemesis gravidarum 3, 4

Topical and Inhaled Corticosteroids

• Modern nasal corticosteroids including budesonide, fluticasone, and 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
• Inhaled corticosteroids for asthma are considered safe during pregnancy, with budesonide having the most safety data (pregnancy category B) 3, 4

Antenatal Corticosteroids for Fetal Lung Maturation

• Antenatal corticosteroids should be administered to women at gestational age between 24+0 and 33+6 weeks when preterm birth is anticipated within 7 days 5, 6
• Either betamethasone (12 mg IM twice, 24 hours apart) or dexamethasone (6 mg IM in four doses, 12 hours apart) may be used 5, 6
• Administration between 22+0 and 23+6 weeks should be considered when active newborn life-support is indicated 6
• Administration between 34+0 and 34+6 weeks should only be offered in selected cases 6
• Administration beyond 37+0 weeks is not indicated, even for scheduled cesarean delivery 6

Risks and Monitoring

• Maternal risks include hyperglycemia, increased incidence of preeclampsia, and adrenal suppression with prolonged use 3
• Fetal/neonatal risks include slightly increased risk for cleft lip with or without cleft palate, increased incidence of preterm birth, and low birth weight 3, 4
• Patients should undergo diabetes testing prior to use, especially if a longer course of corticosteroids is being considered 3, 4
• Consultation with the patient's obstetrician is recommended when considering corticosteroid use during pregnancy 3

Special Situations

• In rheumatic and musculoskeletal diseases, medications such as hydroxychloroquine, azathioprine, colchicine, and sulfasalazine are compatible for use throughout pregnancy 3
• For transplant recipients, azathioprine, cyclosporine, tacrolimus, and prednisolone should not be stopped during pregnancy 3
• Mycophenolate mofetil is teratogenic and should be stopped at least 12 weeks before conception 3
• The American Academy of Pediatrics considers oral steroids to be compatible with breastfeeding 3, 4

Common Pitfalls and Caveats

• Avoid first trimester use of systemic corticosteroids when possible due to increased risk of cleft palate 1, 2
• Do not use multiple repeat courses of antenatal corticosteroids for fetal lung maturation, as this may affect fetal growth 6
• Monitor for maternal hyperglycemia and hypertension when using systemic corticosteroids 3, 4
• Remember that the benefits of treating severe maternal conditions (like asthma) often outweigh the potential risks of corticosteroid use 3
• Consider the lowest effective dose of corticosteroids to minimize maternal and fetal risks 3, 4