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 (95% CI 0.59–1.01); hypoglycaemia RR 1.80 (1.30–2.51)

A meta-analysis published in June combined one randomised trial with observational studies — 16 studies and 18,367 twin neonates, 8,723 of them exposed to antenatal corticosteroids — comparing exposure with none.

Steroid exposure was not significantly associated with lower neonatal mortality (RR 0.77, 95% CI 0.59 to 1.01) or less respiratory distress syndrome (RR 1.11, 0.81 to 1.52), and splitting by gestation below or above 34 weeks did not change that. Exposure was associated with more neonatal hypoglycaemia (RR 1.80), more need for supplemental oxygen (RR 1.72) and more NICU or special care admission (RR 1.33). The hypoglycaemia finding held across gestational ages.

Certainty was rated moderate to low, and most of the data are observational, where sicker or earlier twins are more likely to receive steroids. This does not overturn current guidance on steroids for threatened preterm twin birth, which has not changed. It does strengthen the case for neonatal glucose monitoring after exposure, and for caution about late-preterm courses in twins.

• Follow current guidance on antenatal steroids for threatened preterm birth in twins; it has not changed.
• Alert the neonatal team to steroid exposure so that glucose is checked after birth.
• Weigh the late-preterm course in twins carefully; benefit was not shown above 34 weeks.
• Time courses to likely delivery rather than giving them early on low-certainty threat.
• Discuss the uncertain balance of benefit and harm with parents when the course is elective.

Why it matters

Twin steroid practice has been borrowed from singleton trials, and this is the clearest sign the balance may differ.

Don't overread it

Certainty is moderate to low and mostly observational; this is not a reason to withhold steroids from preterm twins.

The statistics, in plain English

For mortality, the interval runs from 0.59 to 1.01 — it just includes 1, so a benefit is possible but not shown. For hypoglycaemia, RR 1.80 means about 80% more babies affected in relative terms, and that interval does not include 1. Much of this comes from observational studies, so the steroid group may simply have been sicker.

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