What is the recommended steroid therapy regimen in preterm labor?

Steroid Therapy in Preterm Labour

Recommended Regimen

Administer betamethasone 12 mg intramuscularly as two doses given 24 hours apart to women at risk of preterm delivery between 24 and 34 weeks of gestation. 1, 2

Standard Protocol by Gestational Age

24-34 Weeks (Standard Indication)

• Betamethasone 12 mg IM × 2 doses, 24 hours apart is the preferred regimen 1, 2
• Alternative: Dexamethasone 6 mg IM × 4 doses, 12 hours apart, or dexamethasone 12 mg IM × 2 doses, 24 hours apart 3
• This represents a GRADE 1A recommendation with high-certainty evidence 1, 2
• Maximum benefit occurs when delivery happens 24 hours to 7 days after administration 2
• Even a single dose should be given if delivery is imminent, as this improves neurodevelopmental outcomes 3

34⁰⁄₇ to 36⁶⁄₇ Weeks (Late Preterm)

• Offer betamethasone 12 mg IM × 2 doses, 24 hours apart to women with singleton pregnancies who meet ALL of the following criteria: 1
  • High risk of delivery within the next 7 days
  • Expected delivery before 37 weeks
  • Specific high-risk conditions: preterm labor with cervical dilation ≥3 cm or ≥75% effacement, spontaneous rupture of membranes, or medical indications (e.g., preeclampsia) 4
• This reduces respiratory support needs (11.6% vs 14.4%; RR 0.80) and severe respiratory morbidity (8.1% vs 12.1%; RR 0.67) 1, 4

22-23 Weeks (Periviable Period)

• Consider administration only when active neonatal resuscitation is planned and delivery is anticipated within 7 days 3
• Survival benefit is clear, but neurological and long-term outcomes remain uncertain 3
• Decision should incorporate parental wishes 3

Absolute Contraindications

Do NOT Administer in These Situations:

• Pregestational diabetes mellitus - significantly increases neonatal hypoglycemia risk (GRADE 1C recommendation) 1, 4
• Low likelihood of delivery before 37 weeks - risks outweigh benefits when delivery is unlikely (GRADE 1B recommendation) 1
• Beyond 37 weeks gestation - no proven benefit and unknown long-term effects, even for scheduled cesarean delivery 3

Special Populations

Multiple Gestations

• Use same dosing as singletons, but reserve for pregnancies at genuinely high risk of delivery within 7 days 3
• Consider for multiple gestations reduced to singleton on or after 14 weeks 1, 4

Preterm Prelabor Rupture of Membranes (PPROM)

• Administer standard course - same benefits without increased infection risk 5

Gestational Diabetes (NOT Pregestational)

• Not a contraindication - proceed with standard dosing 3

Critical Clinical Benefits

The evidence demonstrates that antenatal corticosteroids reduce:

• Perinatal death by 15% (RR 0.85) 6
• Neonatal death by 22% (RR 0.78) 6
• Respiratory distress syndrome by 29% (RR 0.71) 6
• Intraventricular hemorrhage by 42% (RR 0.58) 6
• Developmental delay in childhood by 49% (RR 0.51) 6

Repeat Dosing

• Single course only is recommended for standard practice 2
• A single repeat course may be considered if: 3
  • Gestational age <34 weeks
  • Previous course completed >7 days earlier
  • Renewed imminent delivery risk
• Routine repeat or "rescue" courses are NOT advised 2

Common Pitfalls to Avoid

Timing Errors

• Administering when delivery is unlikely before 37 weeks wastes medication and exposes patients to unnecessary risks 1
• Withholding when delivery is truly imminent - even one dose provides benefit 3

Monitoring Failures

• Neonatal hypoglycemia monitoring is mandatory after betamethasone administration 2, 4
• 93% of hypoglycemia cases are mild and self-limited, resolving within 24 hours 2, 4
• Risk is substantially higher with pregestational diabetes - this is why it's contraindicated 1

Patient Counseling Gaps

• Must inform patients that long-term neurodevelopmental effects remain uncertain (GRADE 1C recommendation) 1
• This is particularly important for late preterm administration 1