Antenatal corticosteroids for fetal lung maturation
- Studies that have shown worse outcomes for infected patients with the prolonged use of high-dose corticosteroids did not consider baseline morbidity. However, in an antenatal setting, the doses are much smaller and the exposure is not prolonged.
- Antenatal steroids must be used with prudence particularly in critically ill pregnant women in the ICU.
- The use of antenatal steroids should be discussed with a multidisciplinary team.
- The decision to administer antenatal corticosteroids should be individualized based on potential maternal risks and fetal benefits according to gestational age. MFM consultation is recommended.
- Antenatal steroids for late preterm and rescue doses are not recommended in the pandemic setting.
- Recommendations differ slightly according to gestational age. Usage of antenatal steroids in this setting after 32 weeks is debatable.
- No administration after 32 0/7 weeks in COVID-19 positive patients or patients under investigation.
- Boelig et al. (according to severity of respiratory symptoms)
- < 32 weeks: Administer if mild to moderate. Discuss risk and benefits if severe.
- 32-34 weeks: Consider if mild to moderate. Avoid if severe.
- 34-36 weeks: Avoid antenatal steroids
Magnesium sulfate for fetal neuroprotection
- The decision to administer magnesium should consider the fetal neuroprotection benefits based on gestational age and the potential risks of maternal respiratory depression given the baseline respiratory condition.
- Dosage and fluid quantity should be adjusted based on renal function as per usual.
- Administration of a 4g bolus is an option in mild respiratory distress particularly for imminent delivery at < 31 weeks.
- In cases of mild to moderate respiratory symptoms, usual indications (gestational age < 32 weeks) can be followed. Risks and benefits should be balanced in severe cases bearing in mind that respiratory complications are possible.
- In infected patients or patients under investigation not receiving steroids, tocolysis is not recommended.
- Indomethacin is most beneficial in terms of steroid effectiveness. The FDA has declared that there is no evidence to modify the usage of NSAIDS.
- Nifedipine is an alternative; it is not an appropriate choice in cases of hypotension or tachycardia.
- Magnesium is not as effective and requires fluid administration.
- Betamimetics are not an appropriate choice in infected patients; they cause hypotension, tachycardia and pulmonary edema.
- Recommendations according to gestational age and severity of respiratory symptomatology:
- Boelig at al.
- < 32 weeks: Consider Indomethacin if mild to moderate. Use Nifedipine if severe.
- 32-34 weeks: Use nifedipine in all cases.
- 34-36 weeks: Tocolysis is not indicated.
- Boelig at al.
Boelig et al. wrote an expert review regarding various steps of the labour and delivery process, including a section on the use of obstetric medications. McIntosh provided recommendations for the use of antenatal corticosteroids in light of the association between corticosteroid use and worse outcomes of infection. This clinical opinion article also provides recommendations on tocolysis. Poon et al. issued recommendations on several aspects regarding the care of infected pregnant women from the International Federation of Gynecology and Obstetrics (FIGO) and other organizations, including a portion on intrapartum care. The Society for Maternal-Fetal Medicine and The Society for Obstetric Anesthesia and Perinatology issued recommendations for labour and delivery with a section on the use of corticosteroids and magnesium sulfate. Stephens et al. provided guidelines for labour and delivery including sections on antenatal steroids and magnesium sulfate.
Boelig R.C., Manuck T., Oliver E.A. et al. (March 25, 2020). Labor and Delivery Guidance for COVID-19. American Journal of Obstetrics and Gynecology MFM. https://doi.org/10.1016/j.ajogmf.2020.100110
McIntosh J.J. (April 9, 2020). Corticosteroid Guidance for Pregnancy during COVID-19 Pandemic. The American Journal of Perinatology. https://doi.org/10.1055/s-0040-1709684
Poon L.C., Yang H., Kapur A. et al. (April 4, 2020). Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: Information for healthcare professionals. International Journal of Gynecology & Obstetrics. https://doi.org/10.1002/ijgo.13156
The Society for Maternal-Fetal Medicine and The Society for Obstetric Anesthesia and Perinatology (March 27, 2020). Labor and Delivery COVID-19 Considerations. Retrieved from: https://www.smfm.org/covidclinical
Stephens A.J., Barton J.R., Ankumah Bentum N.-A. et al. (April 28, 2020). General Guidelines in the Management of an Obstetrical Patient on the Labor and Delivery Unit during the Covid-19 Pandemic. American Journal of Perinatology. https://doi.org/10.1055/s-0040-1710308