Am J Obstet Gynecol. 2025 Nov 15:S0002-9378(25)00853-1. doi: 10.1016/j.ajog.2025.11.017. Online ahead of print.
ABSTRACT
BACKGROUND: Twin pregnancies are markedly increased risk of preterm birth, with a growing proportion delivering at periviable gestational ages. While antenatal corticosteroid (ACS) administration improves neonatal outcomes in singleton pregnancies, evidence specific to twins at the threshold of viability remains limited.
OBJECTIVE: To evaluate trends in ACS administration and compare neonatal outcomes between ACS-exposed and unexposed twin pregnancies delivered between 22 and 26weeks’ gestation.
STUDY DESIGN: A cross-sectional study utilizing the National Center for Health Statistics and CDC natality dataset (2016-2022). Twin pregnancies delivered between 22 and 26 weeks’ gestation were included. Singletons, higher-order multiples, neonates delivering outside of this gestational age window, and those missing ACS data were excluded. The primary outcome was neonatal survival; secondary outcomes included 10-minute Apgar score <7, prolonged ventilation, surfactant therapy, suspected neonatal sepsis, and composite adverse outcomes defined as either ventilation, 10-minute Apgar score <7, or death. Adjusted odds ratios (aOR) were estimated using multivariable logistic regression.
RESULTS: Among 15,833 twin births at 22-26 weeks, 6,982 (44%) were exposed to ACS, while 8,851 (56%) were unexposed. ACS administration was linked to higher neonatal survival at 22-23 weeks (55.9% vs. 26.8%; aOR 3.66, 95% CI 2.95-4.55), 23-24 weeks (74.1% vs. 65.6%; aOR 1.53, 95% CI 1.30-1.79), and 24-26 weeks (85.4% vs. 82.2%; aOR 1.21, 95% CI 1.02-1.44). The odds of a 10-minute Apgar score <7 were lower with ACS at 22-23 weeks (53.0% vs. 66.8%; aOR 0.56, 95% CI 0.45-0.69), 23-24 weeks (30.6% vs. 36.5%; aOR 0.84, 95% CI 0.72-0.98), and 24-26 weeks (17.4% vs. 23.2%; aOR 0.68, 95% CI 0.58-0.80). When the analysis was limited to neonates who received active postnatal intervention (n=9118), the survival benefit of ACS remained significant at both 22 weeks (aOR 2.5, 95% CI 1.77-3.54) and 23 weeks (aOR 1.56, 95% CI 1.26-1.94). Between 2016 and 2022, ACS utilization increased significantly across all gestational ages, particularly at 22 weeks’ gestation, where ACS use rose from 13.5% to 42.9%, a more than threefold increase (p<0.0001). This upward trend in ACS use was statistically significant when comparing the periods before and after the release of the ACOG advisory in 2021 on periviable corticosteroid administration, most pronounced at 22 weeks, with a rise from 26.1% in 2020 to 42.9% in 2022 (p<0.0001).
CONCLUSION: ACS administration in twin pregnancies at periviable gestational ages is associated with improved neonatal survival, especially at 22 and 23 weeks, and with lower odds of short-term neonatal adverse outcomes. The survival benefit persists among neonates receiving active postnatal intervention, suggesting that ACS use confers benefit when intensive neonatal care is planned. However, these findings are limited to short-term neonatal outcomes and should be interpreted within the constraints of the available data.
PMID:41248783 | DOI:10.1016/j.ajog.2025.11.017
