Systemic Corticosteroids in Pregnancy — OBRx

Antenatal corticosteroids (fetal lung maturation)

Standard regimens for women at risk of preterm birth within 7 days

Go to betamethasone / dexamethasone

Immune thrombocytopenia (ITP) in pregnancy

Common first-line therapies: prednisone/prednisolone or methylprednisolone (± IVIG); coordinate with hematology

Prednisone/Prednisolone • Methylprednisolone • IVIG

Common platelet targets used for planning (individualize)

Vaginal delivery: often ≥30 × 10⁹/L (institution dependent)
Cesarean delivery: commonly target ≥50 × 10⁹/L
Neuraxial anesthesia: commonly target ≥70 × 10⁹/L (SOAP: risk likely very low at ≥70K in typical obstetric etiologies, including ITP, if platelet count is stable and no other coagulopathy)

Coordinate platelet goals with anesthesia and hematology.

Prednisone / Prednisolone (common first-line)

Expect clinically useful platelet rise in ~1 week; peak response often 2–4 weeks

~0.5–1 mg/kg/day PO (often 20–60 mg/day), then taper to lowest effective dose

Aim for the minimum effective dose to reduce maternal adverse effects (e.g., hyperglycemia, hypertension).

Methylprednisolone (alternative first-line example)

~0.5–1 mg/kg/day PO/IV, then taper to lowest effective dose

May be used when prednisone/prednisolone is not tolerated or a different route is needed.

High-dose methylprednisolone (pulse; specialist-directed)

1 g/day IV × 3 days

Kashiwagi H et al. note platelets may begin to rise by ~day 3, with response in many cases but often temporary; maintenance oral therapy is typically used afterward with taper.

IVIG (often quickest/predictable rise within ~1–3 days)

1 g/kg IV daily × 1–2 days

Alternative: 0.4 g/kg/day × 5 days if not urgent.

Medication labels (DailyMed + FDA)

Prednisone
DailyMed search: labels • FDA (Drugs@FDA search): search

Prednisolone
DailyMed search: labels • FDA (Drugs@FDA search): search

Methylprednisolone sodium succinate (Solu-Medrol and generics)
DailyMed: label • FDA (Drugs@FDA search): Solu-Medrol

Common supplied forms include injectable suspension (20/40/80 mg/mL) and powder for injection (e.g., 40/125/500/1000/2000 mg).

Refractory hyperemesis gravidarum (last-resort steroid therapy only if ≥9–10 weeks GA)

Use only after standard antiemetic strategies fail; consider gestational timing

Methylprednisolone

Clinical note

Corticosteroids may help in severe refractory HG, but are generally reserved for rescue therapy due to adverse effects. Coordinate inpatient management (hydration, electrolytes, thiamine, nutrition support) with current HG guidance.

Methylprednisolone (example rescue regimen)

16 mg PO or IV q8h × 3 days

If no clear improvement by 72 hours → STOP (response after that is unlikely). If beneficial, taper over ~2 weeks to the lowest effective dose; avoid prolonged courses when possible.

Taper (example ~2 weeks):

8 mg q8h × 3 days (24 mg/day)
4 mg q8h × 3 days (12 mg/day)
4 mg BID × 3 days (8 mg/day)
4 mg daily × 3 days, then stop

Continue only as long as needed; many protocols recommend limiting total duration (e.g., ≤6 weeks) if ongoing benefit.

Medication labels (DailyMed + FDA)

Methylprednisolone sodium succinate (Solu-Medrol and generics)
DailyMed: label • FDA (Drugs@FDA search): Solu-Medrol

Methylprednisolone (Medrol)
DailyMed: label • FDA label PDF: Medrol

Common supplied forms: tablets 2, 4, 8, 16, 32 mg; injectable vials vary by product.

Bell’s palsy (idiopathic peripheral facial nerve palsy)

First-line: oral corticosteroids within 72 hours (± antiviral); eye protection is essential

Prednisone • (± Valacyclovir)

Prednisone regimen (EMR-ready)

Prednisone 50–60 mg PO daily × 5 days, then taper over 5 days

Example taper: Day 6: 50 mg • Day 7: 40 mg • Day 8: 30 mg • Day 9: 20 mg • Day 10: 10 mg, then stop.

Common supplied forms: tablets 1, 2.5, 5, 10, 20 mg (varies by product).

Antiviral adjunct (optional)

Valacyclovir 1 g PO TID × 7 days

Combination therapy may reduce synkinesis rates; use clinical judgment and severity assessment.

Eye protection (do not skip)

Artificial tears PRN during the day
Lubricating ointment at bedtime
Consider patch/taping eyelid closed at night if incomplete closure
Consult an otolaryngologist or neurologist for patients with unclear diagnosis, rash, persistent paralysis, prolonged weakness of the facial muscles, or recurrent weakness.

Medication labels (DailyMed + FDA)

Prednisone
DailyMed search: labels • FDA (Drugs@FDA search): search

Valacyclovir
DailyMed search: labels • FDA (Drugs@FDA search): search

Acyclovir
DailyMed search: labels • FDA (Drugs@FDA search): search

Asthma exacerbation (systemic steroids)

Pregnancy: treat exacerbations promptly; systemic steroids used for moderate–severe episodes

Methylprednisolone • Prednisone

Methylprednisolone (IV/IM example)

40–80 mg/day IV or IM (1–2 divided doses)

Continue until clinical improvement / peak flow ~70% predicted or personal best.

Prednisone (PO example)

40–60 mg PO daily × 5–7 days

Typical outpatient “burst” duration varies by severity; tailor to response and local protocol.

Medication labels (DailyMed + FDA)

Prednisone
DailyMed search: labels • FDA (Drugs@FDA search): search

Methylprednisolone sodium succinate
DailyMed: label • FDA (Drugs@FDA search): Solu-Medrol

Congenital adrenal hyperplasia (CAH) / adrenal insufficiency in pregnancy

Maintenance therapy + pregnancy adjustments + labor/cesarean stress-dose regimen

Hydrocortisone • Prednisone/Prednisolone • Fludrocortisone

For maternal replacement therapy in CAH/adrenal insufficiency, hydrocortisone, prednisone, and prednisolone are preferred because placental 11β-HSD2 limits fetal exposure. Dexamethasone is not inactivated by the placenta and is generally reserved only when a fetal effect is specifically desired.

Baseline management (typical)

Continue pre-pregnancy glucocorticoid replacement (commonly hydrocortisone or prednisone/prednisolone).
Continue mineralocorticoid (fludrocortisone) if used pre-pregnancy.
Avoid switching to dexamethasone for routine maternal treatment (increased fetal exposure).

Dose and schedule are individualized; coordinate with Endocrinology/MFM.

Pregnancy dosing adjustments (practical)

No routine change is required in early pregnancy unless symptoms suggest under-replacement.
Many patients require a 20–40% increase in glucocorticoid replacement in the third trimester (clinical status drives decisions).
Mineralocorticoid needs may rise; titrate fludrocortisone using blood pressure and potassium (renin is less reliable during pregnancy).

Sick-day / vomiting precautions (high yield)

Intractable vomiting, febrile illness, trauma, or inability to tolerate oral meds → risk for adrenal crisis.
Use parenteral hydrocortisone + IV fluids per institutional protocol.

Do not delay treatment if adrenal crisis is suspected.

Labor / delivery “stress dose” regimen (common protocol)

Hydrocortisone 100 mg IV (or IM) at onset of active labor (or prior to C-section)

then either:

Hydrocortisone 200 mg/24 h continuous infusion, or
Hydrocortisone 50 mg IV q6h

After delivery, taper back toward baseline promptly if uncomplicated (institution-dependent).

Prenatal dexamethasone for fetal virilization prevention

Prenatal dexamethasone to prevent virilization in an affected female fetus remains controversial and is not routine. The Endocrine Society suggests pursuing prenatal therapy only through IRB-approved protocols at centers able to collect outcomes data.

Medication labels (DailyMed + FDA)

Hydrocortisone sodium succinate (Solu-Cortef and generics)
DailyMed search: labels • FDA (Drugs@FDA search): Solu-Cortef

Hydrocortisone (oral)
DailyMed search: labels • FDA (Drugs@FDA search): search

Fludrocortisone
DailyMed search: labels • FDA (Drugs@FDA search): search

Prednisone / Prednisolone
DailyMed: prednisone • prednisolone

Perioperative / “stress-dose” steroids

For patients with adrenal insufficiency or risk of HPA-axis suppression

Hydrocortisone

Who may need supplementation?

Patients with known adrenal insufficiency, or those with possible HPA-axis suppression from chronic glucocorticoids.

Treatment with more than 5 mg of prednisone (or its steroid equivalent) for more than 3 weeks may cause adrenal cortical atrophy as a result of chronic suppression of ACTH production. Complete recovery of the hypothalamic-pituitary-adrenal (HPA) axis may take up to 12 months after glucocorticoid treatment has been discontinued . During this recovery time the ability to increase cortisol production is limited, and stressful situations that increase the demand for cortisol may trigger adrenal insufficiency. Supplementation of the glucocorticoid dosage during stressful situations (stress dose) such as surgery and critical illness has been advised to prevent vascular collapse due to secondary adrenal insufficiency. The stress doses recommended depend on the intensity and duration of the stress.

ACTH stimulation test (quick note)

For uncertain chronic steroid exposure/adrenal reserve, an ACTH stimulation test may be used (baseline cortisol, ACTH 250 mcg IV, cortisol at 30 and 60 minutes). Interpretation and pregnancy adjustments vary; follow institutional endocrinology guidance.

Many modern perioperative guidelines favor physiologic supplementation rather than very high “stress doses,” depending on procedure severity and clinical status.
Example perioperative hydrocortisone supplementation (adapt to local protocol)

Stress level / example	Suggested supplementation (in addition to usual dose)	Duration / taper
Minor e.g., colonoscopy, minor procedures	Hydrocortisone 25 mg IV at induction	Single dose, then resume usual regimen
Moderate e.g., major laparoscopy, hysterectomy	Hydrocortisone 50–100 mg IV at induction then 25 mg IV q6–8h for 24h	Return to usual dose over 24–48h if stable
Major e.g., cardiac/major abdominal surgery, critical illness	Hydrocortisone 100 mg IV at induction then 200 mg/24h (continuous) OR 50 mg IV q6h	Wean to baseline over 1–3 days as clinically improves

Pregnancy note: for known adrenal insufficiency in labor/cesarean, many protocols use hydrocortisone 100 mg IV then 50 mg IV q6h for ~24h, then resume baseline dosing (institution-dependent).

Medication labels (DailyMed + FDA)

Hydrocortisone sodium succinate (Solu-Cortef and generics)
DailyMed search: labels • FDA (Drugs@FDA search): Solu-Cortef

Approximate glucocorticoid equivalents

Helpful for conversions when hydrocortisone substitution is needed

Conversion table

Steroid	Approx. biologic half-life	Approx. equivalent anti-inflammatory dose
Cortisone	8–12 hours	25 mg
Hydrocortisone (cortisol)	8–12 hours	20 mg
Prednisone	18–36 hours	5 mg
Prednisolone	18–36 hours	5 mg
Methylprednisolone	18–36 hours	4 mg
Triamcinolone	18–36 hours	4 mg
Dexamethasone	36–54 hours	0.75 mg
Betamethasone	36–54 hours	0.75 mg

REFERENCES (Click to expand)

ACOG Practice Bulletin No. 189. Nausea and vomiting of pregnancy. Obstet Gynecol. 2018. PMID: 29266076

Clark SM. Inpatient Management of Hyperemesis Gravidarum. 2024. PMID: 38301258

Matusiak K, et al. A practical approach to immune thrombocytopenia in pregnancy. Hematology Am Soc Hematol Educ Program. 2025. PMID: 41347968

Kashiwagi H, et al. Reference guide for management of adult immune thrombocytopenia in Japan: 2019 revision. Int J Hematol. 2020;111(3):329–351. PMID: 31897887

Fogerty AE, et al. ITP in pregnancy: diagnostics and therapeutics in 2024. Hematology Am Soc Hematol Educ Program. 2024. ASH full text

Bauer ME, et al. SOAP Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia. Anesth Analg. 2021. PMID: 33861047

Dalrymple SN, et al. Bell Palsy: Rapid Evidence Review. Am Fam Physician. 2023. PMID: 37054419

Pofi R, Tomlinson JW. Glucocorticoids in pregnancy. Obstet Med. 2020. PMID: 32714437 • PMCID: PMC7359660

Woodcock T, et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. 2020. PMID: 32017012

Miggelbrink LA, et al. Peri-operative corticosteroid supplementation guideline. 2025 (open access PMC): PMC11885097

Bornstein SR, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. 2016. PMCID: PMC4880116

Cera G, et al. Pregnancy and Prenatal Management of Congenital Adrenal Hyperplasia. J Clin Med. 2022. PMID: 36294476 • PMCID: PMC9605322

Speiser PW, et al. Endocrine Society. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: clinical practice guideline. J Clin Endocrinol Metab. 2010. PMID: 20823466

Jabbour SA. Steroids and the surgical patient. Med Clin North Am. 2001 Sep;85(5):1311-7. PMID:11565501

Lamberts SW, Bruining HA, de Jong FH.Corticosteroid therapy in severe illness. N Engl J Med. 1997;337(18):1285-92. PMID:9345079

Brunt MJ and Melby JC Adrenal Gland Disorders In: Noble J, ed. Textbook of Primary Care Medicine.3rd ed St. Louis, Mo: Mosby, Inc; 2001: 397-402.

Jacobi j. Corticosteroid replacement in critically ill patients.Crit Care Clin2006;22(2):245-53, PMID:16677998

Salem M, Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem.Ann Surg. 1994;219(4):416-25. PMID:8161268

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