AFJOG

REVIEW INTRODUCTION In 1972, Liggins and Howie in a sentinel study, evaluated the benefits of administering synthetic antenatal corticosteroids (ACS) to accelerate foetal lung maturation in women at risk of imminent premature birth. 1 Their findings demonstrated marked reductions in neonatal respiratory distress, morbidity and mortality. 1 Furthermore, additional benefits such as prevention of neonatal intraventricular haemorrhage and a decrease in hospital stay for neonates have been confirmed by multiple clinical trials. 1-4 This has led to the administration of ACS becoming a global standard of clinical care to mitigate against the adverse effects of prematurity in pregnancies less than 33 weeks plus 6 days gestational age in both high and low-and-middle income countries. 2 In these instances, a single course of ACS is recommended for women with gestational ages between 24 0/7 weeks and 33 6/7 weeks, who are at risk of delivery within the next 7 days. 3 A follow-up study on the effects in children 6 to 11 years born at term who received a single dose of ACS revealed elevated cortisol reactivity to acute psychological stress. 4 In addition, a longitudinal study conducted in extremely low birth weight babies (<1000g) reported that children exposed to ACS may develop anxiety in adulthood. 5 USE OF ANTENATAL CORTICOSTEROIDS IN LATER GESTATIONS For advanced gestational ages, a 2017 Cochrane review of 30 randomised control trials (RCTs) (7,774 women and 8,158 infants) showed that ACS improved all perinatal outcomes, including perinatal deaths (2.3% fewer), neonatal deaths (2.6% fewer) and respiratory distress syndrome (4.3% fewer) in both late preterm labour ( 34 – 36 weeks gestational age) and early term labours (>37 weeks gestational age). 6, 7 However, with regards to the use of ACS for elective caesarean sections between 37-39 weeks of gestational age, the data is less clear despite a separate Cochrane review of four RCTS which showed a strong reduction in the incidence of respiratory distress syndrome (RDS) (RR 0.48:95% CI 0.27 to 0.87), but there was no statistically significant reduction in perinatal deaths (RR 0.67:95%; CI 0.11-4.10) and an increased incidence of neonatal hypoglycaemia was found. 2, 3, 6, 7 Furthermore, some authors have raised questions about the quality of the studies included in the Cochrane reviews. 8, 9 Despite this, the use of ACS for scheduled caesarean deliveries at 37 weeks gestational age and greater is increasing and becoming integrated into regional and national guidelines in some countries. 10 It has been noted that respiratory morbidity in the new-born reduces as the gestation increases, and that the beneficial effect of ACS wane after the 38th week of gestation. As a result, it is recommended that elective caesarean deliveries be scheduled in the 39th week of gestation. 2, 9 The ASTECS study, a RCT of 1000 women at 37 weeks of gestation or more administered Betamethazone 48 hours before elective caesarean sections. They found a rate of respiratory distress and the need for admission to neonatal intensive care unit (NICU) to be 5.1% in the control compared to 2.4% of the treated babies, (p=0.02), with the number needed to treat of 37, in order to prevent one admission to the NICU. Recently there has been an increasing number of publications indicating that foetal exposure to antenatal steroids, particularly in late preterm and early term pregnancies, may be associated with short- and long-term harms such as growth impairment, physical, and neurodevelopmental disorders in childhood. 2-5, 11-13 Such data, albeit observational, have raised concerns about the “off-label” use of ACS. A systematic review and meta- HM Sebitloane 1 , NE Tabane 2 , OP Khaliq 2 , J Moodley 3 1 Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa 2 Department of Paediatrics and Child Health, School of Clinical Medicine, The University of the Free State, Bloemfontein, South Africa 3 Women’s Health and HIV Group, Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa CORRESPONDENCE: Dr HM Sebitloanem| Email: Sebitloanem@ukzn.ac.za Antenatal Glucocorticoids for Foetal Lung Maturation: Increasing concerns of physical, mental, and developmental disorders in children: Strengthening Benefits versus Preventing Potential Harms ABSTRACT The use of antenatal corticosteroids (ACS) is a global standard of clinical care to mitigate against respiratory adverse effects of prematurity in pregnancies < 33 weeks plus six days of gestational age. Antenatal corticosteroids are administered to these women to enhance foetal lung maturation. There is good evidence that the appropriate use of ACS for foetal lung maturity leads to a significant decrease in neonatal distress, morbidity and mortality. However, recent reports have suggested that inappropriate use of ACS i.e., at wrong gestational ages-in term pregnancies or repeated doses may lead to childhood physical and neurodevelopmental disorders. To minimize long term adverse effects, administration of ACS should be done during the appropriate gestational age. Further investigations are required to improve the outcomes of premature babies without causing harm in childhood. African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 2 | 2023 | 17