- Design
- Systematic review and meta-analysis of 1 randomised trial 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); RDS RR 1.11 (0.81–1.52)
A systematic review and meta-analysis pooled one randomised trial and 15 observational studies, covering 18,367 twin neonates, of whom 8,723 were exposed to antenatal corticosteroids. The primary outcomes were neonatal death and neonatal hypoglycaemia.
Steroid exposure was not clearly linked to fewer neonatal deaths; the estimate pointed towards benefit but the interval reached no effect. There was no overall reduction in respiratory distress syndrome, including when births before and after 34 weeks were analysed separately. Exposure was linked to more neonatal hypoglycaemia, more need for supplemental oxygen and more neonatal unit admission, and the hypoglycaemia signal was consistent across gestational ages.
Twins have mostly been a small part of the singleton trials behind steroid recommendations, and twin pregnancies may clear steroids differently. This review suggests the benefit in twins is less certain than many clinicians assume, especially late preterm.
The certainty of evidence was moderate to low and most data are observational, where sicker pregnancies are more likely to be given steroids. Current guidelines on antenatal corticosteroids have not changed and this review is not a reason to depart from them. It is a reason to be deliberate about timing, to avoid courses where birth is unlikely within a week, and to plan neonatal glucose monitoring after exposure.
- Follow current guidance on antenatal corticosteroids for twins; this review has not changed it.
- Give steroids when birth is genuinely expected within seven days, not as a precaution weeks ahead.
- Tell the neonatal team when twins were exposed so glucose monitoring is planned.
- Discuss the uncertain benefit openly when considering late-preterm steroids in twins.
- Expect more data: an adequately powered twin trial is the missing piece.
Why it matters
It challenges the assumption that the singleton benefit of antenatal steroids carries over intact to twins.
Don't overread it
Mostly observational evidence of moderate to low certainty; it does not show steroids are harmful or useless in twins.
The statistics, in plain English
For neonatal death the relative risk was 0.77, but its confidence interval (0.59 to 1.01) just includes 1.0, so no effect remains possible. For hypoglycaemia the RR of 1.80 (1.30 to 2.51) excludes 1.0, so the increase is more secure. Because most included studies were observational, women given steroids may have differed from those who were not, and that can bias both directions.
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