Antenatal steroids in twins: no clear benefit, more hypoglycaemia

Design

Systematic review and meta-analysis, 1 RCT and 15 observational studies

Population

18,367 twin neonates, 8,723 exposed to antenatal corticosteroids

Primary outcome

Neonatal mortality and neonatal hypoglycaemia

Effect

Mortality RR 0.77 (0.59-1.01); hypoglycaemia RR 1.80 (1.30-2.51)

A systematic review and meta-analysis pooled 16 studies of twin pregnancies, one randomised trial and the rest observational, covering 18,367 neonates of whom 8,723 were exposed to antenatal corticosteroids. It was published in June 2026, not this week.

Steroid exposure was not clearly associated with fewer neonatal deaths (RR 0.77, 95% CI 0.59 to 1.01) and showed no reduction in respiratory distress syndrome (RR 1.11, 0.81 to 1.52), including when split by gestation below or above 34 weeks. Exposed babies had more neonatal hypoglycaemia (RR 1.80, 1.30 to 2.51), more supplemental oxygen (RR 1.72) and more admissions to neonatal or special care (RR 1.33). The authors rated certainty moderate to low.

Twins were under-represented in the trials that built the case for antenatal steroids, so this question is fair. But observational exposure data are prone to confounding by indication: the twins given steroids were the ones clinicians expected to deliver early and sick. Current guidance has not changed on this review, and it should not be abandoned on observational data. What it does support is a careful look at late-preterm courses in twins, where the benefit is least certain, and a hypoglycaemia plan for any exposed baby.

• Follow your current guidance for twins at high risk of early preterm birth; this review does not change it.
• For late-preterm twins, weigh the uncertain respiratory benefit openly with the parents before a course.
• Tell the neonatal team when twins were exposed, so glucose checks start early after birth.
• Avoid repeated or rescue courses in twins unless delivery within a week is genuinely likely.

Why it matters

The benefit assumed for twins was borrowed from singleton trials, and these data do not confirm it.

Don't overread it

Most included studies were observational; this cannot show that steroids cause harm in twins.

The statistics, in plain English

A risk ratio of 0.77 for death with an interval running to 1.01 means the data are compatible with anything from a 41% reduction to no effect at all. The hypoglycaemia result, RR 1.80 with an interval of 1.30 to 2.51, does not cross 1 and was consistent across gestations, so it is the firmer finding.

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