Question 56

Women with twin and higher-order multiple pregnancies who are genuinely at risk of preterm birth should receive targeted antenatal corticosteroids in line with the recommendations used for singleton pregnancies. Multiple pregnancy alone is not an indication for an untargeted prophylactic course at a predetermined gestation, because many women will not deliver during the period in which benefit is greatest. In this case the woman is at 30+4 weeks and is already in established preterm labour with birth considered likely within 48 hours, so the risk is sufficiently immediate to justify treatment. There is no recommendation to double the corticosteroid dose because two fetuses are present, nor is treatment limited to monochorionic pregnancies or pregnancies complicated by fetal growth restriction. The objective is to time a standard course to a genuine risk of preterm birth. Therefore, the most appropriate management is a targeted course using the same principles that apply to singleton pregnancy.

A) Targeted antenatal corticosteroids are recommended in multiple pregnancy when preterm birth is likely.

B) Routine untargeted administration to all twin pregnancies at a fixed gestation is not recommended.

C) Fetal growth restriction is not required before corticosteroids can be offered in twins.

D) Treatment is not confined to monochorionic twin pregnancies.

E) The standard corticosteroid regimen is not doubled because of fetal number.

G) Treatment is not restricted to planned caesarean birth.

H) Birth should not be delayed for seven days solely to maximise corticosteroid exposure.

Stock SJ, Thomson AJ, Papworth S, on behalf of the Royal College of Obstetricians and Gynaecologists. Antenatal corticosteroids to reduce neonatal morbidity and mortality. BJOG. 2022;129:e35–e60. RCOG Green-top Guideline No. 74. doi:10.1111/1471-0528.17027.