Antenatal corticosteroids: an assessment of anticipated benefits and potential risks
Antenatal corticosteroids: an assessment of anticipated benefits and potential risks
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DOI：
10.1016/j.ajog.2018.04.007
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发表时间：
2018-07-01
影响因子：
9.8
通讯作者：
Goldenberg, Robert L.
中科院分区：
文献类型：
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作者：
Jobe, Alan H.;Goldenberg, Robert L.
产前皮质类固醇是孕周 24-34 周有早产风险的妊娠的标准治疗方法。最近的试验表明，产前皮质类固醇对于晚期早产和选择性剖宫产有一定的益处，并且应在家庭讨论的情况下考虑用于围产期的产前皮质类固醇。然而，许多患有先兆早产的女性在产前接受皮质类固醇治疗，但直到 34 周以上或足月时才分娩。净效应是很大一部分分娩人群将接触产前皮质类固醇。由于随机对照试验是在大约 1990 年之前进行的，妊娠期通常>28 周，因此对产前皮质类固醇的益处的准确评估存在差距。母亲和婴儿生存的护理做法与今天不同。随机对照试验数据也没有强烈支持从产前皮质类固醇治疗到分娩的最佳间隔为 1-7 天。基于流行病学的研究使用了超过 85% 的高危妊娠接受产前皮质类固醇治疗的大型队列，可能高估了产前皮质类固醇的益处。尽管大多数与早产相关的死亡发生在资源匮乏的环境中，但产前皮质类固醇在这些环境中的有效性和安全性仍有待评估。产前皮质类固醇对于高资源环境中高危妊娠的短期益处无疑证明了产前皮质类固醇的合理性，因为多年来已发现的风险很少。然而，在大型动物模型和暴露于产前皮质类固醇的儿童群体中已发现心血管和代谢异常，这与胎儿对成人疾病的规划一致。产前皮质类固醇的这些后期影响表明，在 24-34 周的高危妊娠之外扩大使用产前皮质类固醇应谨慎。前进的一个方向是开发无创胎儿评估，以确定更广泛胎龄的妊娠，这些妊娠可能受益于产前皮质类固醇。
Antenatal corticosteroids are standard of care for pregnancies at risk of preterm delivery between 24-34 weeks' gestational age. Recent trials demonstrate modest benefits from antenatal corticosteroids for late preterm and elective cesarean deliveries, and antenatal corticosteroids for periviable deliveries should be considered with family discussion. However, many women with threatened preterm deliveries receive antenatal corticosteroids but do not deliver until >34 weeks or at term. The net effect is that a substantial fraction of the delivery population will be exposed to antenatal corticosteroids. There are gaps in accurate assessments of benefits of antenatal corticosteroids because the randomized controlled trials were performed prior to about 1990 in pregnancies generally >28 weeks. The care practices for the mother and infant survival were different than today. The randomized controlled trial data also do not strongly support the optimal interval from antenatal corticosteroid treatment to delivery of 1-7 days. Epidemiology-based studies using large cohorts with >85% of at-risk pregnancies treated with antenatal corticosteroids probably overestimate the benefits of antenatal corticosteroids. Although most of the prematurity-associated mortality is in low-resource environments, the efficacy and safety of antenatal corticosteroids in those environments remain to be evaluated. The short-term benefits of antenatal corticosteroids for high-risk pregnancies in high-resource environments certainly justify antenatal corticosteroids as few risks have been identified over many years. However, cardiovascular and metabolic abnormalities have been identified in large animal models and cohorts of children exposed to antenatal corticosteroids that are consistent with fetal programming for adult diseases. These late effects of antenatal corticosteroids suggest caution for the expanded use of antenatal corticosteroids beyond at-risk pregnancies at 24-34 weeks. A way forward is to develop noninvasive fetal assessments to identify pregnancies across a wider gestational age that could benefit from antenatal corticosteroids.