A Randomized Trial Comparing the Impact of One Versus Two Courses of Antenatal Steroids (ACS) on Neonatal Outcome

• Composite Neonatal Morbidity < 34 Weeks Gestation at Time of Birth. [ Time Frame: From birth to 28 days of life ] [ Designated as safety issue: Yes ]
  This outcome measured the total number of neonates with Composite Neonatal morbidity who delivered at < 34 weeks gestation. Composite Morbidity consisted of respiratory distress syndrome, bronchopulmonary dysplasia, severe intraventricular hemorrhage, periventricular leukomalacia, proven sepsis, necrotizing enterocolitis, or perinatal death
  
  

• Gestational Age at (@) Delivery [ Time Frame: gestational age at delivery in weeks of gestation ] [ Designated as safety issue: Yes ]
  Reported the average/mean Neonatal gestational age (GA) (reported in weeks of pregnancy) at the time of birth for both groups (ACS vs. Placebo).
  
  
• Neonatal Birth Weight Reported in Grams [ Time Frame: At time of Birth ] [ Designated as safety issue: Yes ]
  Measured mean Birth weights of Neonates in each arm as reported in grams on the birth record.
  
  
• Interuterine Growth Restriction (IUGR) or Small for Gestational Age(SGA)in Babies Delivering at < 34 Weeks Gestation. [ Time Frame: Measured at birth. ] [ Designated as safety issue: Yes ]
  Noted as the total number of Neonates delivering at < 34 weeks gestation for which their weights fell within the 10th percentile at time of birth.
  
  
• Neonatal Head Circumference Taken at Time of Birth. [ Time Frame: Birth ] [ Designated as safety issue: Yes ]
  Reported as the average of all neonatal head circumferences (HC) taken at time of birth in each group.
  
  
• Number of Babies Who Required Ventilatory Support Within the First 28 Days of Life. [ Time Frame: birth to 28 days of life ] [ Designated as safety issue: Yes ]
  The number of babies who required ventilatory support within the first 28 days of life. Equal to or great than 12 hours was considered one day.
  
  
• Number of Neonates Who Required Surfactant Therapy After Birth. [ Time Frame: Birth to 28 days of life ] [ Designated as safety issue: Yes ]
  The Number of neonates who required surfactant therapy within the first 28 days after birth.
  
  
• Number of Neonates With Pneumothorax [ Time Frame: birth to 28 days of life ] [ Designated as safety issue: Yes ]
  Total number of neonates with pneumothorax diagnosed postpartum.
  
  
• Maternal Infectious Morbidity. [ Time Frame: Up to 28 days after giving birth ] [ Designated as safety issue: Yes ]
  Total number of Mothers having Maternal infectious morbidity (e.g. endometritis & maternal sepsis) noted from birth through 28 days after birth
  
  

This is a randomized double-blinded placebo-controlled trial. The objective of this study is to evaluate the impact of one versus two courses of antenatal steroids on the incidence of major neonatal morbidity including respiratory distress syndrome in patients delivering prior to 34 weeks' gestation in a randomized prospective fashion.

Preterm delivery occurs in approximately 10% of all deliveries in the United States. Preterm birth is the cause of 75% of neonatal mortality not mentioning the significantly increased morbidity from respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and sepsis. Numerous studies have evaluated the safety and efficacy of antenatal corticosteroid (ACS) administration in threatened preterm labor.

National Institutes of Health (NIH) first consensus conference in 1994 evaluated the research in this field. Conclusions included the clear evidence that antenatal corticosteroids decrease the incidence of RDS in infants born at 29-34 weeks gestation, with a decrease in RDS severity for infants born at 24-28 weeks gestation and a decrease in the incidence of intraventricular hemorrhage in infants born at 24-28 weeks gestation without harm to mother or fetus. Their recommendation was to give a single course of corticosteroids to all pregnant women between 24 and 34 weeks gestation who are at risk of preterm delivery within 7 days.

Since the studies on the duration of the effects of antenatal corticosteroids in the fetus are not conclusive, many obstetricians repeat corticosteroids weekly or bi-weekly to patients continuing to be at risk for preterm delivery. Lacking scientific evidence, many investigators have performed retrospective analyses regarding the effects of single-course versus multiple-course antenatal corticosteroids.

The NIH consensus panel reconvened in 2000 and concluded that studies regarding repeated courses of corticosteroids are suggestive of possible benefits, especially in reduction of RDS, however, design flaws limit their validity.

The more recent publication from Caughey and Parer examined the literature for evidence regarding a dose response of the benefits and detriments of antenatal corticosteroids. Based on their complex mathematical analysis they recommend all fetus' between 24 and 34 weeks' gestation at risk for preterm delivery should be given a first course of ANC. If the risk of preterm delivery persists the next course should be given 2 weeks later, for a maximum of two courses. Consistent with all previous articles, the call for a well designed randomized, controlled trial is made.