When to give antenatal steroids in a high-risk obstetric case?

Question

Hello doctor,

This is a high-risk obstetric case. The patient is a 31-year-old female who is 32 weeks pregnant with severe scrub typhus. There are multiple eschars, with ARDS requiring 6L of oxygen. I started Azithromycin (Doxycycline is not recommended). Preterm labor is developing, with fetal distress being recognized. Platelets are decreasing (now at 40K), while LFTs are increasing. A recent echocardiogram revealed myocarditis. She needs an urgent delivery. What is the steroid timing for fetal lungs versus maternal health?

Kindly suggest.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query and understand your concern.

This is an extremely high-risk obstetric emergency. The key challenges are balancing maternal stability with fetal viability while deciding the timing of urgent delivery.

Progressive ARDS (acute respiratory distress syndrome) and myocarditis increase the risk of deterioration; maternal oxygenation may worsen rapidly. Worsening thrombocytopenia causes a high risk of DIC (disseminated intravascular coagulation) and postpartum hemorrhage (PPH).

If fetal heart tracing is non-reassuring or the maternal condition worsens, urgent delivery is justified.

Steroids (Betamethasone 12 mg IM (intramuscular) 12 hourly) ideally need 48 hours for full effect. Steroids can exacerbate maternal sepsis, ARDS, and thrombocytopenia. If maternal status is stable for 24 to 48 hours, administer steroids. If you notice rapid deterioration, prioritize urgent delivery.

If both the mother and fetus are stable and labor is progressing, vaginal delivery should be done to avoid surgical risks with low platelets.

If there is severe fetal distress, worsening ARDS, or the mother is unable to tolerate labor, go for a C-section. If the platelet count is less, do a platelet transfusion before the C-section.

Continue Azithromycin since Doxycycline is contraindicated in pregnancy. Administer IV (intravenous) fluids cautiously to avoid worsening pulmonary edema. Mechanical ventilation can be introduced if oxygen levels worsen or oxygen requirements increase. Monitor liver function, coagulation, and platelets closely as there is a risk of HELLP (hemolysis, elevated liver enzymes, and low platelet levels) overlap.

Ensure these:

1. If fetal distress is severe or maternal status declines, deliver the baby.

2. If stable, aim for 24 to 48 hours to allow the steroid effect.

3. Ensure platelet transfusion if a C-section is needed.

4. Monitor closely for DIC, PPH, and worsening ARDS.

I hope this helps.

Take care.