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OBSTETRICS

Evaluation of strategies regarding

management of imminent preterm delivery
before 32 weeks of gestation: a regional cohort
study among 1375 women in the Netherlands
Merel Boesveld, MD; Martijn A. Oudijk, PhD; Steven V. Koenen, PhD;
Hens A. A. Brouwers, PhD; Erik Van Beek, PhD; Janine Boon, PhD; Addy Drogtrop, PhD;
Robert Euser, MD; Inge M. Evers, PhD; Cora A. Fiedeldeij, MD; Karst Y. Heida, MD;
Anjoke J. M. Huisjes, MD; Guido J. J. M. Muijsers, PhD; Jaap M. Schierbeek, MD;
Anneke Kwee, PhD
OBJECTIVE: To evaluate the management of imminent preterm delivery with respect to prescription of antenatal corticosteroids (ACS)
and referral to a tertiary center.
STUDY DESIGN: A retrospective cohort study existing of 1 perinatal

center and 9 referring hospitals. All women who received their first
dose of ACS in 1 of the 10 hospitals between 240 and 320 weeks
of gestation and/or delivered before 32 weeks of gestation from 2005
until 2010. Patients were identified using the electronic database of
hospital pharmacies. Main outcome measures were time interval from
administration to delivery for different indications and number of
women who were not referred in time to a tertiary center.
RESULTS: In total, 1375 women received ACS. Main indications were
suspected preterm labor (44.7%), preterm prelabor rupture of membranes (15.9%), maternal indication (12.8%), fetal indication (9.2%)

and vaginal blood loss (8.4%). Overall, 467 (34.0%) women delivered
7 days after ACS administration; 8.7% of women with vaginal blood
loss and 54.5% of women with maternal indication. Among the 931
women who received ACS in the secondary hospitals, 452 (48.5%)
women were referred to a tertiary hospital and 89 (6.5%) women
delivered in a secondary hospital with a gestational age of less than 32
weeks.
CONCLUSION: One-third of all women receiving ACS delivered within 7

days and half of the women who received ACS in a secondary hospital
were referred to a tertiary center. There seems to be room for
improvement regarding the timing of ACS administration and subsequently referral to a tertiary center.
Key words: antenatal corticosteroids, pregnancy, preterm birth,
referral policy, time interval

Cite this article as: Boesveld M, Oudijk MA, Koenen SV, et al. Evaluation of strategies regarding management of imminent preterm delivery before 32 weeks of gestation:
a regional cohort study among 1375 women in the Netherlands. Am J Obstet Gynecol 2015;212:348.e1-7.

rematurity is still a major cause of

morbidity and mortality. Preterm
infants are at an increased risk of
neonatal death, respiratory distress syndrome, intraventricular hemorrhage,
and necrotizing enterocolitis. Treatment
with antenatal corticosteroids (ACS) has

major advantages in the outcome of

preterm neonates, especially in infants
born before 34 weeks of gestation.1,2
Because of these great benets, it is recommended that all women at risk of
delivery between 24 0 and 34
0 weeks should receive a single course of

From the Departments of Obstetrics and Gynecology (Drs Boesveld, Oudijk, Koenen, Heida, and
Kwee) and Pediatrics (Dr Brouwers), University Medical Center Utrecht, Utrecht, and the
Departments of Obstetrics and Gynecology, Diakonessen Hospital (Dr Boon), Utrecht; St. Antonius
Hospital (Dr van Beek), Nieuwegein; Twee Steden Hospital (Dr Drogtrop) and St. Elisabeth Hospital
(Dr Fiedeldeij), Tilburg; Beatrix Hospital (Dr Euser), Gorinchem; Meander Medical Center (Dr Evers),
Amersfoort; Gelre Hospital (Dr Huisjes), Apeldoorn; Rivierenland Hospital (Dr Muijsers), Tiel; and
Deventer Hospital (Dr Schierbeek), Deventer, the Netherlands.
Received July 2, 2014; revised July 29, 2014; accepted Oct. 7, 2014.
The authors report no conict of interest.
Corresponding author: Anneke Kwee, PhD. a.kwee@umcutrecht.nl
0002-9378/$36.00  2015 Elsevier Inc. All rights reserved.  http://dx.doi.org/10.1016/j.ajog.2014.10.014

348.e1 American Journal of Obstetrics & Gynecology MARCH 2015

ACS.3,4 Furthermore, women at risk for

preterm delivery and a gestational age
between 24 0 and 32 0 weeks should
be transferred to a perinatal center with a
neonatal intensive care unit (NICU).5,6
The optimal effect of ACS is achieved
within a time interval between administration and delivery of 1 to 7 days.7-9
Because preterm birth is difcult to
predict a signicant number of women
will receive ACS too early, too late, or not
at all. As a consequence, some women
are unnecessarily treated with this drug
whereas others unjustly did not receive
treatment with ACS. Approximately
50% of women given a rst course of
ACS remain pregnant and at risk for
preterm birth after an interval of 7
days.10 The safety and additional benet
of multiple ACS courses is still debated.

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Although repeated courses of ACS may
decrease perinatal mortality and
morbidity, several studies have shown
harmful neonatal effects, such as
decreased length, weight, head circumference, and adverse behavior.11-15 To
ensure that every woman at risk for
preterm delivery is treated adequately it
is necessary to optimize the timing of the
rst course of ACS. Therefore, it is
essential to evaluate prescribing patterns
of ACS as well as the referral patterns of
secondary hospitals to improve care for
women at risk of preterm delivery. The
aim of our study was to evaluate these
issues in the referral area of the University Medical Center Utrecht (UMCU).

M ATERIALS

AND

M ETHODS

Setting
We performed a retrospective cohort
study in the catchment area of the
UMCU, a level 3 regional, referral, and
university teaching hospital. The NICU
of the UMCU is 1 of 10 Dutch level 3
NICUs, which cares for 13% of all neonates in need of intensive care in the
Netherlands. There are 10 hospitals in
the region, 7 nonuniversity teaching
hospitals and 3 general hospitals, that
refer pregnant women at risk for delivery
before 32 weeks to the UMCU. Of these
hospitals, 3 have a postintensive care/
high-care facility. If a woman remains
pregnant, she is referred back to her own
hospital when there is no indication for
admission to a level 3 hospital anymore.
Nine of these 10 hospitals participated in
the study. The region of Utrecht is a
geographical area in the middle of the
Netherlands with approximately 21,000
deliveries a year.
Population
We identied 2 groups of women. Firstly,
all women receiving ACS, at least 1 dose
of 12 mg of betamethasone (Celestone
Chronodose; Schering-Plough, Kenilworth, NJ), between 24 0 and 32
0 weeks of gestation were included.
Patients were identied using the
electronic database of the hospital
pharmacies.16 Because the aim of our
study was to evaluate the prescribing
patterns and referral patterns of these 10
hospitals, we included only women who

received their rst dose of ACS in one of

these hospitals.
Secondly, all women delivering between 24 0 and 32 0 weeks of
gestation who did not receive ACS were
identied as well. We excluded women
with an intrauterine fetal death, lethal
congenital anomalies, and women who
underwent a termination of pregnancy
for maternal reasons in combination
with a poor prognosis of the child (eg,
severe early onset preeclampsia with severe: intrauterine growth restriction
[IUGR]).

Data collection
Data were collected from January 2005
until December 2010. The medical
charts were reviewed for maternal,
pregnancy and neonatal characteristics.
If information on follow-up was not
available in the medical charts, a questionnaire was sent to the medical practitioner or midwife. We recorded the
following characteristics: maternal age,
multiple pregnancy, parity, previous
preterm delivery, gestational age at
administration of ACS, reason of suspected preterm birth, subsequent antenatal courses, transfer to a perinatal
center, gestational age at delivery, interval from administration to delivery,
mode of delivery, location of delivery,
birthweight, sex, and admission to the
NICU. Previous preterm delivery was
dened as a delivery between a gestational age of 24 0 and 37 0 weeks. (4)
A complete course of ACS was dened as
2 doses of 12 mg betamethasone. The
indications for administration were
categorized as: (1) suspected preterm
labor with intact membranes (PTL), (2)
preterm prelabor rupture of membranes
(PPROM), (3) maternal indication, (4)
fetal indication, (5) vaginal blood loss
(VBL), (6) multiple indications.
Maternal indications included: pregnancy induced hypertension, preeclampsia (PE), and HELLP-syndrome
(hemolysis, elevated liver enzymes, and
low platelet count). Fetal indications
included: IUGR, with or without
Doppler abnormalities, and suspected
fetal distress (abnormalities of the cardiotocogram). VBL included: blood loss
because of placenta previa or bleeding of

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unknown origin. The reasons for no

administration of ACS were also noted
and categorized as: (1) acute fetal
distress, (2) poor prognosis regarding
viability, (3) advanced delivery, and (4)
no specic reason. It was categorized
as acute fetal distress if there was an
indication for an emergency cesarean
delivery because of fetal reasons, including a suspicion of abruption of the
placenta, abnormal cardiotocography, or
prolapsed cord. Women who did not
receive ACS because of major congenital
anomalies, a gestational age, or estimated fetal weight below viability were
included in the indication poor prognosis. Advanced delivery included
women with advanced cervical dilatation. All cases that could not be included
in one of these categories and without a
clear reason for not administering ACS
in the medical chart, were categorized as
no specic reason. Outcome measures
were: number of women who received
ACS and delivered within 7 days after
ACS administration and the time interval between ACS administration and
delivery with different indications.

Statistical analysis
Statistical analysis was performed using
SPSS software version 20.0 (IBM Corporation, Armonk, NY). We counted the
number of women delivering 7 days
and >7 days after ACS administration.
Pearson c3 tests and independent sample
t tests were used to evaluate whether
there was a signicant difference in
characteristics between the groups. The
median time from the rst ACS administration to delivery was calculated for
the different indications. A KaplanMeier plot was made to express time to
delivery per indication. Data were
censored after 30 days, because there is
no benecial effect of ACS expected
anymore after this period. The study was
approved by the medical ethical committee of the participating hospitals.

R ESULTS
During the study period 90,248 women
delivered in the participating hospitals of
the region Utrecht.
The total number of women who
received ACS from 2005 until 2010 in the

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FIGURE 1

Flowchart

Boesveld. Evaluation of strategies regarding management of imminent preterm delivery. Am J Obstet Gynecol 2015.

participating hospitals in Utrecht was

1421. Of these women 40 (2.8%) women
were lost to follow-up and were excluded
from further analysis. Furthermore, 6
women were excluded because an intrauterine fetal death had occurred, or
because of pregnancy termination for
maternal and/or fetal reasons with an
unviable fetus (ACS administration unjustied). In total 1375 women were
analyzed (Figure 1).
Overall, 1269 (1.4%) women delivered between 24 0 and 32 0 weeks of
gestation, 1074 (84.6%) women in the
UMCU, and 195 (15.4%) women in the
referring hospitals. Of the 1269 women,
193 (15.2%) did not receive ACS before
delivery: 94 women in the UMCU and 99
women in the referring hospitals. Reasons for not receiving ACS were as follows: acute fetal distress (n 68; 35.2%),
poor prognosis regarding viability (n
43; 22.3%), advanced delivery (n 59;
30.6%), and no specic reason in 23
(11.9%) women. The main differences
between the reasons for not administering ACS between the UMCU and the
referring hospitals was a higher percentage of the reason poor prognosis
regarding viability in the UMCU than
the referring hospitals and a lower

percentage of no specic reason.

Furthermore, there were small differences between the reasons in the
different referring hospitals. Maternal,
pregnancy, and infant characteristics for
the women receiving ACS are shown in
Table 1. The main indications for ACS
administration were suspected PTL in
614 (44.7%) women, PPROM in 219
(15.9%) women, maternal indication in
176 (12.8%) women, fetal indication in
127 (9.2%) women, and VBL in 115
(8.4%) women. The remaining 124
(9.0%) women had multiple indications
for the administration of ACS. Among
women with VBL, 56 (48.7%) women
had placenta previa and 59 (51.3%)
women had an unknown cause of VBL.
Delivery within 7 days after ACS
administration occurred more often in
nulliparous women than in multiparous
women (P < .05). Furthermore, women
who delivered more than 7 days after
ACS administration had more often a
history of preterm birth (P <.05). There
were more cesarean deliveries in the
group of women who delivered within 7
days after ACS administration (P < .05).
Among the 931 women who received
ACS in a level 2 hospital, 452 (48.5%)
women were referred to a hospital with a

348.e3 American Journal of Obstetrics & Gynecology MARCH 2015

NICU. This differed per hospital from

35.2% to 64.0% (Table 2 and Figure 2).
Of the 479 women not referred to a
tertiary center, 331 (69.1%) women had
a gestational age between 30 0 and
32 0 weeks of which 109 (32.9%)
women were hospitalized in a center
with a postintensive care/high-care
facility.
Of the 452 women referred to a tertiary center, 343 (75.9%) women delivered in this tertiary hospital and 191
(42.3%) women delivered within 7 days
after ACS administration. In total 89
(6.5%) women delivered in a level 2
hospital with a gestational age of less
than 32 weeks after treatment with ACS;
69 (77.5%) women with a gestational age
between 30 and 32 weeks of which 30
(43.5%) women delivered in a center
with a postintensive care/high-care
facility.
Table 3 shows that the proportion of
women who delivered within 7 days after
administration of ACS is different for
each indication. The highest incidence of
delivery 7 days after ACS administration was found in women with a
maternal indication (54.5%). The lowest
incidence of delivery 7 days after ACS
administration was found in women
with VBL (8.7%); 7 (12.5%) women
with a placenta previa; and 3 (5.1%)
women with an unknown cause of VBL
delivered within 7 days. The median
time from ACS administration to delivery is 20 days (interquartile range
[IQR], 4e50) and differs for the
different indications. This is illustrated
in the Kaplan-Meier plot in Figure 3.
Women with VBL had the longest median time interval, with an interval of 43
days (IQR, 24e66). The shortest median
time interval was found in women with
maternal indication, with an interval of 6
days (IQR, 3e18).

C OMMENT
Main findings
In case of imminent preterm delivery
before 32 weeks of gestation, the guideline of the Dutch society of Obstetrics
and Gynecology advises to refer the
woman to a tertiary hospital and
administer ACS.3-6,17 In addition, timing
of ACS administration is of utmost

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TABLE 1

Baseline table of women who received ACS

Characteristics

Woman delivering 7 d Woman delivering >7 d

(n [ 467)
(n [ 908)
P value

Maternal age

30 (5.1)

30 (5.3)

.816

Multiple pregnancy

79 (16.9)

147 (16.2)

.793

306 (65.5)

460 (50.7)

.000a

143

.004a
.000a

Nulliparity
Previous delivery 37 wks

48

Indication for administration

Suspected PTL

159 (34.0)

455 (50.1)

PPROM

106 (22.7)

113 (12.4)

Maternal indication

96 (20.6)

80 (8.8)

Fetal indication

31 (6.6)

96 (10.6)

VBL

10 (2.1)

105 (11.5)

Multiple indications

65 (13.9)

59 (6.5)

29 3 (15)

29 0 (15)

24-26 wks

42 (9.0)

90 (9.9)

26-28 wks

59 (12.6)

174 (19.2)

28-30 wks

116 (24.8)

260 (28.6)

30-32 wks

249 (53.3)

376 (41.4)

GA on admission

.017

ACS course
Course not completed

115 (24.6)

0 (0.0)

1 complete course

352 (75.4)

830 (91.4)

2 complete courses

0 (0.0)

78 (8.6)

Vaginal delivery

220 (47.1)

506 (55.7)

Cesarean delivery

247 (52.9)

402 (44.3)

.000a

Birth

GA at delivery

29 6 (23)

35 0 (32)

.007a
.000a

Infant characteristicsb
Birthweight

1347 (401)

2271 (893)

.000a

Male sex

286 (52.2)

536 (50.6)

.447

Admission to NICU

410 (74.8)

325 (30.8)

.000a

Data are expressed as number (%) or mean ( SD).

ACS, antenatal corticosteroids; PTL, preterm labor with intact membranes; PPROM, premature prolonged rupture of membranes; VBL, vaginal blood loss; GA, gestational age; NICU, neonatal intensive care unit.
a

A significant difference between women delivering 7 d and women delivering >7 d; b Date missing for 10 infants.

Boesveld. Evaluation of strategies regarding management of imminent preterm delivery. Am J Obstet Gynecol 2015.

importance because of the optimal

effectiveness period and the possible
harmful neonatal effects of multiple
courses of corticosteroids.8-10 In this
study, we showed that one third of all
women receiving ACS delivered within 7
days and that half of the women who

received ACS in a secondary hospital

were not referred to a tertiary center.
Furthermore, there are substantial differences in these outcomes between
hospitals. In total, 89 (6.5%) women
delivered in a secondary hospital with a
gestational age of less than 32 weeks, the

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majority (77.5%) with a gestational age

between 30 0 and 32 0 weeks.
Overall, 193 women did not receive ACS
before delivery, the majority with a clear
and insuperable reason. Only a negligible percentage of women delivering
32 weeks (1.8%) did not receive ACS
without an apparent reason. Apparently,
administration of ACS is standard policy
for women with a suspected preterm
delivery 32 weeks of gestation in the
Netherlands. Adequate prediction of
those women who will deliver prematurely may be difcult and is dependent
on the indication for ACS administration. As a consequence, overtreatment of
women at risk for premature delivery is
present. However, it remains the question what the most appropriate number
needed to treat is with the current diagnostic tools, and which at the other hand
also not leads to undertreatment.
Table 2 shows that the proportion of
women who delivered within 7 days after
ACS administration is different for each
indication. The highest incidence was
found in women with a maternal indication (54.5%), mainly preeclampsia.
The lowest incidence was found in
women with VBL (8.7%). The median
time from ACS administration to delivery is 20 days (IQR, 4e50) and differs
for the different indications.
A difference between women who
delivered 7 days compared with
women who delivered >7 days after ACS
administration was that the latter group
contained more multiparous women.
This might be explained by the higher
incidence of maternal and multiple indications among nulliparous women
and a higher incidence of PTL and VBL
among multiparous women. This can
also be the reason for the higher rate of
cesarean deliveries in the group women
who delivered within 7 days after ACS
administration. Another difference between these groups of women was that
women who delivered more than 7 days
after ACS administration had more often
a previous preterm birth. This might be
explained by a lower threshold for prescribing ACS administration considering
the higher chance of a recurrent preterm
birth in these women.

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TABLE 2

Referral policy for women with ACS in the secondary hospitals

Referred to tertiary hospital

Hospitals

Total
deliveries

Total ACS

Total

Delivery in
tertiary
hospital

Delivery 7 d

Delivery <32 wks

Time interval
Median (IQR)

9.909

125 (1.3)

44 (35.2)

32 (72.7)

15 (34.1)

27 (61.4)

11 (6e36)

12.376

110 (0.9)

50 (45.5)

43 (86.0)

19 (38.0)

33 (66.0)

16 (3e39)

6.857

77 (1.1)

35 (45.5)

31 (88.6)

17 (48.6)

30 (85.7)

9 (4e21)

8.348

89 (1.1)

46 (51.7)

33 (71.7)

20 (43.5)

31 (67.4)

9 (4e41)

7.308

79 (1.1)

35 (44.3)

27 (77.1)

16 (45.7)

24 (68.6)

8 (4e20)

4.959

77 (1.6)

35 (45.5)

30 (85.7)

18 (51.4)

25 (71.4)

6 (2e19)

6.752

85 (1.3)

41 (48.2)

35 (85.4)

18 (43.9)

29 (70.7)

8 (4e24)

9.430

153 (1.6)

79 (51.6)

45 (57.0)

26 (32.9)

44 (55.7)

21 (4e49)

12.820

136 (1.1)

87 (64.0)

69 (79.3)

42 (48.3)

59 (67.8)

9 (3e27)

Data are expressed as number (%).

ACS, antenatal corticosteroids; IQR, interquartile range.
Boesveld. Evaluation of strategies regarding management of imminent preterm delivery. Am J Obstet Gynecol 2015.

Strengths and limitations

To appreciate the present results a few
issues need to be addressed. The
strengths of this study are the large
sample size and the small loss to follow-

up. Although ACS administration is

regulated by national guidelines, the
decision to prescribe ACS is made by the
obstetrician. Because of its retrospective
nature, it was not always clear what the

FIGURE 2

Referral policy for women with ACS administration in a secondary

hospital

ACS, antenatal corticosteroids.

Boesveld. Evaluation of strategies regarding management of imminent preterm delivery. Am J Obstet Gynecol 2015.

348.e5 American Journal of Obstetrics & Gynecology MARCH 2015

motivation was to administer ACS at that

specic time and/or to refer a woman to
a perinatal center. Another limitation is
that our data are from one region in the
Netherlands. However, we believe that
the region of Utrecht does not differ
much from other regions, making these
results generalizable to other parts of the
Netherlands and probably also other
countries.

Interpretation
With respect to the prescription pattern
of ACS our results are comparable to a
recent study from 2 Dutch perinatal
centers.7 In this study, the time interval
between ACS administration and delivery was calculated for women with a
completed course of ACS. The median
time interval for women with VBL was
41 days and for women with PTL 25
days. In our study, these numbers were
35 days for women with VBL and 19 days
for women with PTL. This difference is
probably the result of another inclusion
criterion; we also included women with
an incomplete ACS course.7 In the
studies of Lee et al18 and Howell et al,19
characteristics associated with not
receiving ACS were analyzed. The percentages of eligible mothers that did not
receive ACS before delivery were 23.1%

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TABLE 3

Numbers of women who received ACS and delivered 7 days categorized

by indication
Preterm delivery
etiology

Number who
delivered 7 d, n (%)

Time to delivery (d),

Median (IQR)

Suspected PTL

159 (25.9)

40 (7e63)

PPROM

106 (48.4)

8 (2e26)

Maternal indication

96 (54.5)

6 (3e18)

Fetal indication

31 (24.4)

21 (8e35)

VBL

10 (8.7)

43 (24e66)

VBL eci

3 (5.1)

55 (33e73)

Placenta previa

7 (12.5)

40 (16e53)

65 (52.4)

7 (3e15)

467 (34.0)

20 (4e50)

Multiple indications
Total

ACS, antenatal corticosteroids; eci, e causa ignota; IQR, interquartile range; PTL, preterm labor with intact membranes;
PPROM, premature prolonged rupture of membranes; VBL, vaginal blood loss.
Boesveld. Evaluation of strategies regarding management of imminent preterm delivery. Am J Obstet Gynecol 2015.

and 19.6%, respectively. In our study a

slightly lower percentage was observed
15.2% of eligible mothers did not receive
ACS therapy before delivery. Howell
et al19 demonstrated that 43% of the

women without ACS delivered more

than 2 hours after admission and 33% of
the women delivered more than 4 hours
after admission. Unfortunately, we did
not analyze the exact time in hours from

FIGURE 3

Kaplan-Meier plot showing the time interval from ACS administration to

delivery in women with different medical indications

ACS, antenatal corticosteroids; eci, e causa ignota; PTL, suspected preterm labor with intact membranes; PPROM, premature prolonged
rupture of membranes; VBL, vaginal blood loss.
Boesveld. Evaluation of strategies regarding management of imminent preterm delivery. Am J Obstet Gynecol 2015.

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admission to delivery in our study.

However, data from the studies of Lee
et al18 and Howell et al19 and probably
our study indicates there might be sufcient time for treatment with ACS in
part of these women. Especially, since we
know that the rst effects of ACS are seen
within some hours after administration
of the rst dose.18,20,21
Although there are some studies
which have evaluated the prescribing
patterns of ACS, this is the rst study
evaluating the referral policy for women
at risk of preterm delivery in the
Netherlands. In our study, only half of
the women who received ACS were
referred and it differed per institution
(35.2-64.0%). At rst sight this percentage seems too low, because when
there is a need to prescribe ACS, indicating an imminent preterm delivery, it
seems logical to refer a woman to a
perinatal center. On the other hand, the
number of women delivering within 7
days after receiving ACS in a level 2
hospital is also not very high (6.5%).
This could imply that obstetricians use
additional/other tools to estimate the
risk that a woman will deliver within 7
days. However, then the question arises if
this woman really needed administration
of ACS.
Predicting preterm birth is difcult,
especially in women with VBL and suspected PTL. The introduction of additional screening, including bronectine
screening and measurement of the cervical length may give a reduction in
overtreatment of women with suspected
PTL, without increasing the number of
preterm deliveries without ACS administration.22,23 During the study period
these diagnostic tools were not routinely
used.
Women with early onset preeclampsia
are at increased risk of preterm delivery,
and it is therefore recommended they
should receive ACS.24,25 The benecial
effect of ACS in the preterm growth
restricted neonate remains controversial.
Until more information is available, it is
recommended to administer ACS.3,26
Timing is based on the severity of
IUGR, Doppler ndings, rate of progression, and the presence of comorbid
conditions. However, there seems to be

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room for improvement because only

25.5% delivered within 7 days. Although
we could not analyze the exact reasons
for giving ACS at that specic time, we
suppose that with a more strict protocol
on timing of ACS we can improve ACS
administration in this group in a substantial number of cases. Improving the
timing of ACS in women with VBL is
even more difcult. The fear for acute
placental abruption can lead to a low
threshold of ACS administration. Additional screening in these women is
limited. Nevertheless, only 8.7% of
women with VBL delivered 7 days after
ACS administration, and we therefore
should be more critical toward the necessity of ACS administration in this
subgroup of women.
In conclusion, the treatment of
women at risk of preterm delivery with
ACS has great benets. However, the
results of this study show that there is a
high probability of treatment with ACS
in women who will not proceed into
subsequent preterm delivery, especially
in women with VBL.
Considering the potential harmful effects of multiple courses of ACS, administration should be considered carefully.
Therefore, clinicians should develop
better approaches to predict preterm deliveries to improve the prescribing
and referral patterns, making management of imminent preterm delivery more
cost-effective. Furthermore, we would
recommend every hospital to monitor
and evaluate their own policies.
REFERENCES
1. Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for
women at risk of preterm birth. Cochrane
Database Syst Rev 2006;3:CD004454.
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