Corticosteroids in the Management of Pregnant Patients With Coronavirus Disease (COVID-19).

Abstract

We read with interest the commentary by Saad et al1 in the October 2020 issue of Obstetrics & Gynecology. We wish to provide an alternative perspective regarding the administration of corticosteroids for coronavirus disease 2019 (COVID-19) in critically ill pregnant patients. The authors reference the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial’s demonstrating a mortality benefit with dexamethasone for patients with COVID19 who are on supplemental oxygen or mechanical ventilation.2 They describe how dexamethasone crosses the placenta and thus recommend methylprednisolone for the treatment of COVID-19 in pregnant and breastfeeding women, citing the efficacy of methylprednisolone in non–COVID19 acute respiratory distress syndrome. This recommendation presumes that the efficacy of methylprednisolone in acute respiratory distress syndrome translates into reducing mortality in COVID19. However, the data evaluating methylprednisolone in COVID-19 are limited. A subsequent meta-analysis investigating corticosteroids in critically ill patients with COVID-19 found that corticosteroids were associated with a statistically significant mortality reduction (odds ratio [OR] 0.66; 95%CI0.53–0.82), supporting a class effect among corticosteroids.3 Importantly, 57% of the study data came from the RECOVERY trial, and 77% of the combined data came from trials using dexamethasone. Three studies, contributing to 20% of the data, used hydrocortisone and found a similar pooled estimate of benefit to dexamethasone but did not reach statistical significance (OR 0.69; 95% CI 0.43–1.12). The single study of methylprednisolone was small and underpowered, not finding a statistically significant difference in mortality (OR 0.91; 95% CI 0.29–2.87). Furthermore, the METCOVID (Methylprednisolone as Adjunctive Therapy for Patients Hospitalized With Coronavirus Disease 2019) trial failed to demonstrate a mortality benefit with methylprednisolone in patients with COVID-19.4 Unfortunately, most of the studies evaluating hydrocortisone and methylprednisolone have been stopped early in light of the RECOVERY trial findings. Although it is biologically plausible, we believe that it is unclear from these data whether other corticosteroids offer the same mortality benefit that dexamethasone does in critically ill patients with COVID-19. We also acknowledge that the generalizability of these findings to critically ill pregnant women is unknown. However, given the significant morbidity and mortality associated with critically ill patients with COVID-19, the best available evidence should be used. We recommend that the primary care team collaborate with the local obstetric team to discuss the risks and benefits of dexamethasone with pregnant patients with COVID-19 and give due consideration for a course of dexamethasone as in the RECOVERY trial. Financial Disclosure: Hilary Rowe disclosed the following: Salary: Fraser Health Authority; Honoraria: University of British Columbia (UBC) Continuing Education, Canadian Society of Hospital Pharmacists (CSHP); Consulting Fees/Royalties: UBC Continuing Professional Development, Springer Publishing. The other authors did not report any potential conflicts of interest.