Potential missed opportunities for antenatal corticosteroid exposure and outcomes among periviable births: Observational cohort study

Objective

To test the hypothesis that potential missed opportunities for antenatal corticosteroids increase as gestational age decreases and are associated with adverse outcomes.

Design

Observational cohort study.

Setting

Twenty-four US centers in the Neonatal Research Network.

Population

Actively treated infants at 22–25 weeks of gestation and with birthweight 401–1000 g, without major birth defects, born 2006–18.

Methods

Potential missed opportunity was defined as no antenatal corticosteroids but did have prenatal antibiotics, and/or magnesium sulphate, and/or prolonged rupture of membranes. Poisson regression models adjusted for baseline characteristics.

Main outcome measures

Antenatal corticosteroid exposure, mortality and severe intracranial haemorrhage or periventricular leucomalacia.

Results

A total of 6966 (87.5%) infants were exposed to antenatal corticosteroids, 454 (5.7%) had no exposure but potential missed opportunities for antenatal corticosteroid exposure, and 537 (6.7%) had no exposure and no evidence of potential missed opportunities. Compared with infants born at 25 weeks, potential missed opportunities for antenatal corticosteroid exposure were more likely at 22 weeks (adjusted relative risk [aRR] 11.06, 95% confidence interval [CI] 7.52–16.27) and 23 weeks (aRR 3.24, 95% CI 2.44–4.29) but did not differ at 24 weeks (aRR 1.08, 95% CI 0.82–1.42). Potential missed opportunities for antenatal corticosteroids decreased over time at 22–23 weeks of gestation. Antenatal-corticosteroid-exposed infants had lower risk of death (31.0% versus 54.8%; aRR 0.77, 95% CI 0.70–0.84) and survivors had lower risk of severe brain injury (25.0% versus 44.5%; aRR 0.64, 95% CI 0.55–0.73) compared with infants with potential missed opportunities.

Conclusion

Potential missed opportunities for antenatal corticosteroid exposure increased with decreasing gestational age and were associated with higher rates of death and severe brain injury among actively treated periviable births.