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Am J Perinatol 2022; 39(11): 1159-1165
DOI: 10.1055/a-1785-9290
SMFM Fellowship Series Article

Indication Creep of Antenatal Late Preterm Steroids

Eliza R. McElwee 
1   Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical University of South Carolina, Charleston, South Carolina
,
Kyla Wilkinson
1   Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical University of South Carolina, Charleston, South Carolina
,
Rebecca Crowe
1   Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical University of South Carolina, Charleston, South Carolina
,
Jill C. Newman
2   Department of Medicine, Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
,
Mallory Alkis
1   Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical University of South Carolina, Charleston, South Carolina
,
Rebecca Wineland
1   Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical University of South Carolina, Charleston, South Carolina
,
Matthew M. Finneran
1   Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical University of South Carolina, Charleston, South Carolina
› Author Affiliations Funding None.
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Abstract

Objective While antenatal corticosteroids (ACS) administered in the late preterm period have been shown to reduce respiratory morbidity, this finding was demonstrated in a well-designed randomized controlled trial (the Antenatal Betamethasone for Women at Risk for Late Preterm Delivery [ALPS]) with strict inclusion/exclusion criteria that may differ from clinical practice. The aim of this study was to investigate whether there has been indication creep since use of late preterm ACS became standard of care.

Study Design Retrospective cohort study of pregnant women who received late preterm ACS between 2016 and 2019 were identified and separated into epochs of 2016 to 2017 and 2018 to 2019 based on year of exposure. The primary outcome was rate of inappropriate ACS exposure, defined as nonadherence to the inclusion/exclusion criteria of the ALPS trial. Secondary outcomes were rates of nonoptimal ACS exposure (delivery >7 days from ACS or term delivery). Logistic regression was used to generate adjusted odds ratios (aORs) between epochs for the primary outcome adjusting for confounders.

Results There were 660 women who received late preterm ACS during the study period with 229 (34.6 %) deemed inappropriate exposures. The most common reason for inappropriate treatment was preterm premature rupture of membrane (PPROM; 29.0%) with exclusionary cervical examination or contraction frequency. No difference was observed in inappropriate ACS exposure between epochs (aOR = 0.83, 95% confidence interval [CI]: 0.59–1.2). However, there was a reduction in nonoptimal exposure over time (aOR = 0.67, 95% CI: 0.47–0.97) . Women receiving inappropriate ACS were more likely to deliver at term if indicated for maternal/fetal status (50.0 vs. 19.5%, p < 0.001) and preterm labor (66.0 vs. 41.9%; p = 0.015). Further, inappropriate exposure in preterm labor had higher rates of exposure latency >7 days (62.3 vs. 39.1%, p = 0.006) with a longer latency to delivery (3 vs. 16 days; p < 0.001).

Conclusion Over one-third of women received late preterm ACS for an indication that could be classified as indication creep. Depending on indication, inappropriate administration is associated with higher rates of nonoptimal exposure.

Key Points

  • There is potential for indication creep of ACS administration.

  • One third of late preterm ACS exposures in our study were inappropriate.

  • Utilizing clinical criteria can aid in identifying patients who best benefit from late preterm ACS.

Keywords

late preterm steroids - indication creep - preterm labor

Note

This research was presented virtually at the Society of Maternal-Fetal Medicine Annual Meeting on January 2021, poster no.: 804.




Publication History

Received: 20 August 2021

Accepted: 18 February 2022

Accepted Manuscript online:
02 March 2022

Article published online:
10 June 2022

© 2022. Thieme. All rights reserved.

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