At what gestational age is corticosteroid administration recommended for pregnant women with preterm premature rupture of membranes (PPROM)?

Corticosteroid Administration in Preterm Premature Rupture of Membranes (PPROM)

Antenatal corticosteroids should not be administered in previable and periviable PPROM until the time when neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient. 1

Gestational Age-Based Recommendations

Before 23 weeks

• Corticosteroids are not routinely recommended before 23 weeks gestation in PPROM 1
• Administration should be based on shared decision-making regarding neonatal resuscitation plans 1

23 0/7 - 23 6/7 weeks

• Corticosteroids may be considered starting at 23 0/7 weeks based on family's decision regarding resuscitation 2, 3
• Administration should align with the plan for neonatal resuscitation and intensive care 1

24 0/7 - 33 6/7 weeks

• A single course of corticosteroids is strongly recommended for pregnant women at risk of preterm delivery within 7 days 2, 3
• Benefits include reduced risks of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and neonatal death 4, 5

34 0/7 - 36 6/7 weeks

• Betamethasone may be considered for women at risk of late preterm birth within 7 days who have not received previous corticosteroids 1, 2
• Recommended dosing: 2 doses of 12 mg intramuscular betamethasone 24 hours apart 1

Clinical Decision Algorithm

1. Assess gestational age and viability:

   • <23 weeks: Generally not recommended unless resuscitation is planned 1
   • ≥23 weeks: Consider based on resuscitation plans 2, 3
   • ≥24 weeks: Recommended if delivery anticipated within 7 days 4, 2

2. Evaluate risk of delivery within 7 days:

   • If delivery is imminent (within hours), benefits may be limited 1
   • Maximum benefit occurs when corticosteroids are administered 24 hours to 7 days before delivery 2, 3

3. Consider previous corticosteroid exposure:

   • If previous course was administered >14 days ago and gestational age is <34 weeks, a single repeat course may be considered 2, 3
   • For late preterm (34-36 6/7 weeks), only consider if no previous course was given 1

Important Clinical Considerations

• Corticosteroid administration in PPROM does not increase risk of maternal or neonatal infection when appropriate antibiotic coverage is provided 4
• Antibiotics should be administered according to gestational age guidelines (recommended at ≥24 weeks, considered at 20-23 6/7 weeks) 1, 6
• The decision to administer corticosteroids should align with plans for neonatal resuscitation and intensive care 1
• Avoid administering corticosteroids when there is no intention to provide neonatal resuscitation, as this exposes the mother to medication risks without benefit 1

Pitfalls to Avoid

• Administering corticosteroids when delivery is not anticipated within 7 days 1, 2
• Using corticosteroids before viability without a plan for neonatal resuscitation 1
• Failing to provide appropriate antibiotic coverage with corticosteroid administration in PPROM 6, 4
• Delaying corticosteroid administration when indicated, as maximum benefit requires at least 24 hours before delivery 2, 3