Do you administer dexamethasone (corticosteroid) in a preterm labor patient at 35 weeks gestation?

Corticosteroid Administration at 35 Weeks Gestation

Yes, administer betamethasone 12 mg intramuscularly in two doses 24 hours apart to patients at 35 weeks gestation who have a singleton pregnancy and are at high risk of delivery within the next 7 days and before 37 weeks. 1, 2

Who Qualifies for Treatment

You should offer corticosteroids when all three criteria are met: 1, 2

• Singleton pregnancy (including twin pregnancies reduced to singleton before 14 0/7 weeks) 1
• Gestational age between 34 0/7 and 36 6/7 weeks 1, 2
• High probability of delivery within 7 days, demonstrated by:
  • Preterm labor with cervical dilation ≥3 cm OR cervical effacement ≥75% 1, 2
  • Spontaneous rupture of membranes 1, 2
  • Expected preterm delivery for medical indications (preeclampsia, fetal growth restriction, oligohydramnios) 1, 2

Preferred Medication and Dosing

Betamethasone is the first-line agent, not dexamethasone. 2, 3 Give betamethasone 12 mg intramuscularly, two doses separated by 24 hours. 1, 2, 3 Dexamethasone 12 mg intramuscularly in two doses 24 hours apart is acceptable only if betamethasone is unavailable. 2, 3

Clinical Benefits at 35 Weeks

The evidence from the ALPS trial demonstrates significant respiratory benefits: 1, 2

• 20% reduction in need for respiratory support (11.6% vs 14.4%; RR 0.80) 1, 2
• 33% reduction in severe respiratory morbidity (8.1% vs 12.1%; RR 0.67) 1, 2

These benefits are substantial enough to justify treatment despite the late preterm timing. 1

Absolute Contraindications

Do not administer corticosteroids if: 2, 3

• Pregestational diabetes mellitus is present - this significantly increases the risk of severe neonatal hypoglycemia and is an absolute contraindication 2, 3
• Low likelihood of delivery before 37 weeks - corticosteroids should not be used "just in case" without genuine high risk 1, 2

Note that gestational diabetes alone is not a contraindication - only pregestational diabetes excludes treatment. 2

Timing Considerations

Maximum benefit occurs when delivery happens 24 hours to 7 days after administration. 2, 4 Both doses should ideally be completed for optimal effect, though even partial courses provide some benefit. 2 Do not delay medically indicated delivery to complete the steroid course. 3

Neonatal Monitoring Requirements

Neonates require blood glucose monitoring after birth, particularly in the first 24 hours. 2 While neonatal hypoglycemia occurs more frequently with corticosteroid exposure, 93% of cases resolve within 24 hours and are mild and self-limited. 1, 2 Infants with hypoglycemia were actually less likely to have prolonged NICU stays than those without hypoglycemia. 1

Special Populations to Consider

You may consider corticosteroid administration in select populations not included in the original ALPS trial, though the evidence is weaker (GRADE 2C): 1, 2

• Multiple gestations reduced to singleton on or after 14 0/7 weeks 1, 2
• Pregnancies with fetal anomalies 1, 2
• Patients expected to deliver in <12 hours 1, 2

Critical Pitfalls to Avoid

Do not use dexamethasone as first-line - betamethasone has the strongest evidence base and is the preferred agent. 2, 3 Do not administer corticosteroids without genuine high risk of delivery within 7 days - overuse exposes infants to unnecessary risks without benefit. 2, 3 Do not withhold treatment based on gestational diabetes alone - only pregestational diabetes is a contraindication. 2