This updated review has included the results of four long-term, in multiple pregnancies. However, authors of previous stu follow-up studies into childhood( Collaborative 1981; Kari 1994; encouraged to provide further information as the use of antenatal Liggins 1972b; Schutte 1980)and two into adulthood (Liggins corticosteroids in such pregnancies may be able to be answered 1972b: Schutte 1980). Results suggest that antenatal corticos- without the need for further randomised controlled trials. Follow- teroids result in less neurodevelopmental delay and possibly less up studies in adulthood should be undertaken to confirm the long cerebral palsy in childhood. This probably reflects the lower neu- term effects of this treatment. Future studies are needed to deter- rological and respiratory morbidity experienced by corticosteroid mine the optimal dose and drug for this purpose, and to determine reated infants in the neonatal period. Concern regarding long. the risks and benefits of repeat courses of corticosteroids term neurological function has largely come from animal stud- ies showing decreased brain growth after antenatal corticosteroid exposure(Huang 1999: Jobe 1998). However, follow up of two FEEDBACK studies(Liggins 1972b; Schutte 1980), which only used a single course of antenatal corticosteroids, into adulthood. has failed to Nachum, September 2002 demonstrate any psychological differences between those exposed corticostero Exposure to excess corticosteroids before birth is hypothesised Are there enough data to indicate the efficacy of antenatal steroids be a key mechanism underlying the feral origins of adult disease in twins? hypothesis( Barker 1998; Benediktsson 1993). Increased insulin (Summary of comment received from Zohar Nachum, Septembe release has been found 30 minutes following a 75 g oral glucose 2002. tolerance test in one follow-up study conducted at age 30(Liggi 1972b). However, the same study found no difference in blood pressure, fasting lipids, body size, hypothalamo-pituitary-adrenal Only two small trials report outcome following a multiple preg- Thus, while the finding of increased insulin resistance in adult. the use of corticosteroids in multiple pregnancy. Nevertheles o? he prevalence of diabetes or cardiovascular disease. nancy. Therefore there is currently not enough evidence to suppe hood provides support to excess corticosteroids as a mechanism view of the strength of the overall evidence, it would seem sensi- underlying the fetal origins of adult disease hypothesis, it should ble to offer a single course of steroids to women with a multiple ot be seen as a reason to withhold antenatal corticosteroids given pregnancy at risk of preterm birth the large and clinically substantial benefits seen in the neonatal (Sumn om Devender roberts and Stuart Dalziel May2006) AUTH。Rs, CONCLUSI。Ns Zohar Nachum The evidence from this new review supports the continued use of Unmap sust 2002 a single course of antenatal corticosteroids to accelerate fetal lung It is unclear whether quasi-randomised trials should be included maturation in women at risk of preterm birth. Treatment with The abstract states they are included, types of studies says they tenatal corticosteroids reduces the risk of neonatal death, respi- are excluded, and a quasi-randomised study has been included ratory distress syndrome, cerebroventricular haemorrhage, necro. ( Morales 198 tising enterocolitis, infectious morbidity, need for respiratory sup- Also some data appear to be missing from the meta-analysis. Silver port and neonatal intensive care unit admission. There is evidence 1995 does not contribute any information to the outcome neona- from 26 tal death, yet the data are reported in the abstract you reference to 34+6 weeks and in the current era of neonatal practice. F (7/54 deaths on dexamethasone, 8/42 deaths on placebo) thermore, there is evidence to suggest benefit in the subgroups of women with premature rupture of membranes and those with hy- (Summary of comments received from Carol Preston, August pertension syndromes. A single course of antenatal corticosteroids 2002) lould be considered routine for preterm delivery. Implications for research The protocol for the updated review excluded quasi-randomised There is no need for further trials of a single course of antena. studies, and Morales 1986 has therefore been excluded. The data tal corticosteroids versus placebo in singleton pregnancies. Data for neonatal deaths in Silver 1995 are now included in the meta- are sparse regarding risks and benefits of antenatal corticosteroids Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth( Rev Copyright @2006 The Cochrane Collaboration. Published by John wiley& Sons, LtdThis updated review has included the results of four long-term, follow-up studies into childhood (Collaborative 1981; Kari 1994; Liggins 1972b; Schutte 1980) and two into adulthood (Liggins 1972b; Schutte 1980). Results suggest that antenatal corticos￾teroids result in less neurodevelopmental delay and possibly less cerebral palsy in childhood. This probably reflects the lower neu￾rological and respiratory morbidity experienced by corticosteroid treated infants in the neonatal period. Concern regarding long￾term neurological function has largely come from animal stud￾ies showing decreased brain growth after antenatal corticosteroid exposure (Huang 1999; Jobe 1998). However, follow up of two studies (Liggins 1972b; Schutte 1980), which only used a single course of antenatal corticosteroids, into adulthood, has failed to demonstrate any psychological differences between those exposed to antenatal corticosteroids and those exposed to placebo. Exposure to excess corticosteroids before birth is hypothesised to be a key mechanism underlying the fetal origins of adult disease hypothesis (Barker 1998; Benediktsson 1993). Increased insulin release has been found 30 minutes following a 75 g oral glucose tolerancetest in one follow-up study conducted at age 30 (Liggins 1972b). However, the same study found no difference in blood pressure, fasting lipids, body size, hypothalamo-pituitary-adrenal axisfunction orthe prevalence of diabetes orcardiovascular disease. Thus, while the finding of increased insulin resistance in adult￾hood provides support to excess corticosteroids as a mechanism underlying the fetal origins of adult disease hypothesis, it should not be seen as a reason to withhold antenatal corticosteroids given the large and clinically substantial benefits seen in the neonatal period. A U T H O R S ’ C O N C L U S I O N S Implications for practice The evidence from this new review supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. Treatment with antenatal corticosteroids reduces the risk of neonatal death, respi￾ratory distress syndrome, cerebroventricular haemorrhage, necro￾tising enterocolitis, infectious morbidity, need for respiratory sup￾port and neonatal intensive care unit admission. Thereis evidence to suggest benefit across a wide range of gestational ages from 26 to 34 + 6 weeks and in the current era of neonatal practice. Fur￾thermore, there is evidence to suggest benefit in the subgroups of women with premature rupture of membranes and those with hy￾pertension syndromes. A single course of antenatal corticosteroids should be considered routine for preterm delivery. Implications for research There is no need for further trials of a single course of antena￾tal corticosteroids versus placebo in singleton pregnancies. Data are sparse regarding risks and benefits of antenatal corticosteroids in multiple pregnancies. However, authors of previous studies are encouraged to provide further information as the use of antenatal corticosteroids in such pregnancies may be able to be answered without the need for further randomised controlled trials. Follow￾up studies in adulthood should be undertaken to confirm thelong￾term effects of this treatment. Future studies are needed to deter￾minethe optimal doseand drug for this purpose,and to determine the risks and benefits of repeat courses of corticosteroids. F E E D B A C K Nachum, September 2002 Summary Arethere enough data to indicate the efficacy of antenatal steroids in twins? (Summary of comment received from Zohar Nachum, September 2002.) Author’s reply Only two small trials report outcome following a multiple preg￾nancy.Thereforethereiscurrently notenough evidenceto support the use of corticosteroids in multiple pregnancy. Nevertheless, in view of the strength of the overall evidence, it would seem sensi￾ble to offer a single course of steroids to women with a multiple pregnancy at risk of preterm birth. (Summary of responsefrom Devender Robertsand Stuart Dalziel, May 2006.) Contributors Zohar Nachum Preston, August 2002 Summary It is unclear whether quasi-randomised trials should be included. The abstract states they are included, types of studies says they are excluded, and a quasi-randomised study has been included (Morales 1986). Also some data appear to be missing from the meta-analysis. Silver 1995 does not contribute any information to the outcome neona￾tal death, yet the data are reported in the abstract you reference (7/54 deaths on dexamethasone, 8/42 deaths on placebo). (Summary of comments received from Carol Preston, August 2002.) Author’s reply The protocol for the updated review excluded quasi-randomised studies, and Morales 1986 has therefore been excluded. The data for neonatal deaths in Silver 1995 are now included in the meta￾analysis. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth (Review) 14 Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd 第 108 页