Steroid Use in Pregnancy

Indications for Antenatal Steroid Use

The American College of Obstetricians and Gynecologists recommends administering two doses of betamethasone 12 mg intramuscularly, 24 hours apart, to pregnant women between 24+0 and 33+6 weeks of gestation who are at high risk of preterm delivery within 7 days 1
Specific indications include preterm labor with intact membranes and cervical dilation ≥3 cm or cervical thinning 75%, spontaneous rupture of membranes, or planned preterm delivery for other indications (gestational hypertension, preeclampsia, fetal growth restriction, oligohydramnion) 1
For late preterm pregnancies (34-36 weeks), consider betamethasone administration if there is a high risk of delivery within 7 days and before 37 weeks 1, 2
The American College of Obstetricians and Gynecologists recommends against the use of antenatal corticosteroids for women with a low probability of delivery before 37 weeks 1, 2
Diabetes mellitus is an absolute contraindication for antenatal corticosteroid use in late preterm pregnancies due to the risk of worsening neonatal hypoglycemia 1, 2, 3

Steroid Use for Maternal Conditions

The American Academy of Allergy, Asthma, and Immunology recommends continuing nasal corticosteroid sprays (budesonide, fluticasone, mometasone) for chronic rhinitis and rhinosinusitis during pregnancy at recommended doses 4, 5, 6, 7
Budesonide intranasal is the preferred choice if starting new therapy during pregnancy (category B with extensive safety data) 7
Short courses of oral corticosteroids can be used after the first trimester for severe asthma or exacerbations, especially if they threaten maternal respiratory status 4, 5, 6

Risks and Side Effects

Maternal risks include hyperglycemia, potential gestational diabetes, hypertension, and increased risk of preeclampsia 4, 5
Fetal/neonatal risks include a slight increase in the risk of cleft lip with or without cleft palate, increased incidence of preterm birth and low birth weight, and neonatal hypoglycemia (especially with late preterm steroids) 1, 2, 3, 4, 5
The greatest risk of teratogenicity is associated with first-trimester use 4, 5

Breastfeeding

Oral corticosteroids are considered compatible with breastfeeding 4, 5
Prednisone or non-fluorinated steroids <20 mg per day are compatible with breastfeeding 4, 5
Very little of the corticosteroid consumed by the mother enters the breast milk 4, 5

Patient Counseling

Patients at risk of late preterm delivery should receive comprehensive counseling about the potential risks and benefits of antenatal corticosteroid administration, with an explanation that long-term risks are still uncertain 1, 2

Steroid Use During Pregnancy

Benefits and Risks

The European Society of Cardiology recommends antenatal corticosteroids for women at risk of preterm birth between 24+0 and 33+6 weeks gestation, as they reduce neonatal mortality and morbidity 8
The American Academy of Pediatrics considers oral steroids to be compatible with breastfeeding, and prednisone or nonfluorinated steroid equivalent <20 mg daily is compatible with breastfeeding 9, 10
Short bursts of oral corticosteroids may be used after the first trimester for severe conditions, especially if causing exacerbation of asthma, according to the European Respiratory Society 9, 11
Modern nasal corticosteroids (budesonide, fluticasone, mometasone) are safe to use at recommended doses during pregnancy, as stated by the American College of Allergy, Asthma, and Immunology 9, 12

Maternal and Fetal Risks

Corticosteroids can cause maternal side effects including hyperglycemia and potential gestational diabetes, hypertension and increased risk of preeclampsia, and adrenal suppression with prolonged use, according to the American College of Obstetricians and Gynecologists 8, 9, 13
Potential fetal/neonatal risks include slightly increased risk for cleft lip with or without cleft palate, increased incidence of preterm birth, and low birth weight infants, as reported by the American Academy of Pediatrics 9

Special Situations

Azathioprine, cyclosporine, tacrolimus, and prednisolone should not be stopped in pregnant transplant recipients, and mycophenolate mofetil is teratogenic and should be stopped at least 12 weeks before conception, according to the European Society of Transplantation 13
Continue low-dose prednisone if needed for disease control in rheumatic and musculoskeletal diseases, and taper high-dose prednisone with addition of pregnancy-compatible drugs if needed, as recommended by the American College of Rheumatology 10
Prednisolone is considered low risk during pregnancy but is associated with increased risk of cleft palate in first trimester use, according to the European Association for the Study of the Liver 14

Corticosteroid Use in Pregnancy

Antenatal Corticosteroids for Fetal Lung Maturation

The European Society of Cardiology recommends that steroids should not be used routinely for elective cesarean delivery at term 15, 16
The European Society of Cardiology suggests that one additional rescue course of steroids can be given if the initial course was >14 days ago, gestational age remains ≤34 weeks, and delivery is now imminent 15, 16
Avoid repeated rescue courses beyond one additional dose—they reduce infant birthweight and head circumference 15, 16
For women with pre-eclampsia at ≤34 weeks, the European Society of Cardiology recommends giving corticosteroids if delivery is anticipated within 7 days 15, 16
The American College of Obstetricians and Gynecologists recommends against giving steroids for HELLP syndrome specifically—six guidelines explicitly recommend against this 17

Steroids for Maternal Medical Conditions During Pregnancy

The European Association for the Study of the Liver recommends continuing azathioprine, cyclosporine, tacrolimus, and prednisolone in pregnant transplant recipients—do not stop these medications 18
The European Association for the Study of the Liver suggests stopping mycophenolate mofetil at least 12 weeks before conception due to teratogenicity (49% miscarriage rate, 23% structural anomalies) 18
Monitor for hyperglycemia and gestational diabetes—screen all women on glucocorticoids for GDM 18
Watch for hypertension and increased preeclampsia risk, especially with cyclosporine and tacrolimus 18
Women taking >5 mg prednisolone daily for >3 weeks are at risk for adrenal suppression—consider stress-dose steroids at delivery and for intercurrent illness, vomiting, or hyperemesis 18
Only 10% of maternal corticosteroid dose reaches the developing fetus with non-fluorinated steroids 18

Maternal and Fetal Risks

Slight increase in cleft lip with or without cleft palate with first-trimester exposure (though recent data are more reassuring than older studies) 18
The European Association for the Study of the Liver recommends screening for gestational diabetes in all women receiving glucocorticoids 18
Monitor blood pressure closely in women on cyclosporine or tacrolimus throughout pregnancy 18
Consider intramuscular or parenteral glucocorticoid replacement if severe hyperemesis or intercurrent infection develops 18

Hydrocortisone Use in Pregnancy

For Women with Adrenal Insufficiency

The American College of Physicians recommends increasing hydrocortisone by 2.5-10 mg daily during the third trimester due to physiologic increases in corticosteroid-binding globulin and free cortisol levels 19
The Endocrine Society suggests fludrocortisone dose often needs to be increased during late pregnancy due to progesterone's anti-mineralocorticoid effects 19
Monitoring should be done using salt cravings, blood pressure, and serum electrolytes rather than plasma renin activity, which normally increases during pregnancy, as recommended by the Journal of Internal Medicine 19

Delivery Management

The American College of Obstetricians and Gynecologists recommends administering 100 mg hydrocortisone (Solu-Cortef) IV as a bolus at delivery, repeated every 6 hours if necessary 19
The Society for Maternal-Fetal Medicine suggests doubling the oral dose for 24-48 hours postpartum 19

Regarding Pregnancy-Induced Hypertension

The European Society of Cardiology recommends that corticosteroids are not indicated for treating pregnancy-induced hypertension or preeclampsia itself, and instead suggests using methyldopa, labetalol, and nifedipine as antihypertensive agents during pregnancy 20, 21, 22, 23
The American Heart Association suggests that for severe hypertension (≥170/110 mmHg), IV labetalol, oral methyldopa, or oral nifedipine should be used, rather than corticosteroids 21, 24, 25

Critical Pitfall to Avoid

The Journal of Internal Medicine warns against confusing the indication for hydrocortisone replacement in adrenal insufficiency with treatment of PIH, and recommends that women with adrenal insufficiency who develop PIH need both their replacement hydrocortisone and appropriate antihypertensive therapy with methyldopa, labetalol, or nifedipine 19, 21, 25