Twin steroid benefits remain uncertain

In twin pregnancies, antenatal corticosteroids did not clearly reduce neonatal death or breathing illness and were linked to more low blood sugar.
*Systematic review/meta-analysis of mostly cohort studies; Level 2.

Citation

Felippe CA, Ruiz SdosSC, de Souza RF, et al. Antenatal Corticosteroid Use in Twin Pregnancies: A Systematic Review and Meta-analysis. Obstet Gynecol. 2026;148:434-444. doi:10.1097/AOG.0000000000006344

Background

Steroids before preterm birth improve newborn outcomes in single pregnancies, but twins may respond differently. This review assessed benefits and harms specifically in twin pregnancies.

Patients

Twin pregnancies at risk of preterm birth; studies without twin-specific data, higher-order multiples, postnatal steroids, maternal-only steroid use, or unclear comparators were excluded.

Intervention

Antenatal corticosteroids, usually betamethasone or dexamethasone, before delivery.

Control

No antenatal corticosteroid exposure.

Outcome

Newborn death, breathing illness, low blood sugar, oxygen need, neonatal unit admission, apnea, and low Apgar score.

Follow-up Period

Birth hospitalization; long-term outcomes were not assessed.

Results

Sixteen studies included 18,367 newborns; 8,723 were exposed to antenatal corticosteroids. Evidence certainty was moderate to low. Neonatal death and respiratory distress were not significantly reduced.

Outcome Finding
Low blood sugar RR 1.80 (95% CI 1.30 to 2.51)
Oxygen requirement RR 1.72 (95% CI 1.07 to 2.74)
Neonatal unit admission RR 1.33 (95% CI 1.07 to 1.64)
Apnea RR 4.99 (95% CI 1.49 to 16.79)
Apgar score less than 7 RR 0.63 (95% CI 0.42 to 0.93)

RR: risk ratio; CI: confidence interval; Apgar: newborn condition score.

Numbers needed to harm could not be calculated from the reported pooled data. Most evidence came from observational studies, so treatment-selection bias is possible.

Limitations

Most studies were retrospective and varied in steroid timing, delivery timing, and patient risk. Few adjusted well for reasons steroids were given. Long-term child outcomes were not evaluated.

Funding

Funding not reported; no conflicts disclosed.

Clinical Application

Do not assume singleton benefits apply to twins; individualize steroid use, especially late preterm or when delivery timing is uncertain.