More Steroid Stuff (July 2026)

Summary

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Podcast Summary: “More Steroid Stuff (July 2026)”

Dr. Chapa’s OBGYN Clinical Pearls
Date: June 24, 2026
Host: Dr. Chapa
Main Topic: Real-life challenges and new evidence regarding the optimal timing of antenatal corticosteroid administration in threatened preterm labor

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Episode Overview

This episode dives into the clinical conundrum of timing antenatal corticosteroids for women at risk of preterm delivery, focusing on the ‘Goldilocks’ challenge: not too early, not too late—just right. The discussion is anchored around a newly published (July 2026) retrospective study by Clapp et al (with notable contributor Cynthia Gyamphi Bannerman) in Obstetrics and Gynecology (the Green Journal), examining how often clinicians achieve optimally timed steroid doses in real-world practice.

Dr. Chapa addresses:

• The difficulty of predicting preterm birth
• SMFM and FIIGO guidelines for optimal steroid timing
• Real-world outcomes from the new study
• Risks of both overuse and underuse, including neurodevelopmental impact

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Key Discussion Points & Insights

1. The “Goldilocks Problem” in Antenatal Steroid Timing

[02:17, 08:09]

• Analogy: Timing steroids is like choosing the “just right” porridge in Goldilocks—too early, benefits fade; too late, there’s no benefit.
• Real-world challenge: Predicting exactly when a patient will deliver preterm is extremely difficult; many clinical factors defy accurate timing.

“If you give them too early, then the benefits fade, and if you give them too late and the patient delivers very quickly, then they don't have time to work.”
— Dr. Chapa [02:17]

2. New Study Spotlight: Clapp et al., Green Journal, July 2026

[03:10, 08:09, 09:52]

• Study design: Retrospective, two large academic hospitals, 2016–2024, only singletons, focused on betamethasone use.
• Cohort: 1,694 patients who delivered before 34 weeks.
• Aim: Quantify how often steroids are timed optimally, too early, or too late, using SMFM quality metrics.

3. What is “Optimal Timing”? Redefining Clinical Practice

[08:09]

• Old teaching: Optimal benefit at 24 hours after second dose (or 48 hours after first dose) of betamethasone.
• SMFM 2022 quality metric:
  • Optimal: Delivery occurs 6 hours to 7 days after first dose
  • Too early: <6 hours after first dose
  • Too late: >7 days after first dose

“According to SMFM, the quality metric for giving a steroid, quote, end quote, optimally timed ... is delivery six hours to seven days after the first dose. That is per the SMFM quality metric.”
— Dr. Chapa [08:09]

4. Real-World Results: How Often is Steroid Timing “Just Right”?

[12:30]

• Among those delivering preterm (<34 weeks):

  • 57% received optimally timed steroids
  • 19% received steroids too early (delivered >7 days after injection)
  • 10% (9.6%) received steroids too late (delivered <6 hrs after injection)
  • 15% did not receive any steroids despite delivering early

• Among all who received steroids preterm:

  • 25.9% (about 1 in 4) were exposed but ultimately delivered at term (≥37 weeks)

“So among those who actually needed it, about half or nearly half did not receive steroids when they should have ... And 25% actually went on to deliver at term.”
— Dr. Chapa [12:30]

5. Risks and Controversies: Overuse and Underuse

[06:30, 13:45]

• Potential harm of overuse: Epigenetic imprinting, neurodevelopmental and psychosocial effects (noted in Finnish and Danish cohorts), especially if steroids are given and the baby is born at term.
• Guideline (FIGO): Do not use a “just in case” strategy; clinical judgment is crucial to reduce unnecessary exposures.

“This is why Figo says, look, you should not give steroids quote unquote, just in case she may deliver early, because that's over calling it and is exposing kids to steroids that they may not need.”
— Dr. Chapa [06:30]

6. Clinical Takeaways & Practical Advice

[13:45, 15:29]

• Predicting preterm delivery remains one of the hardest clinical challenges.
• Using the SMFM window (6 hours–7 days) is the current best standard.
• Don’t stress when optimal timing isn't achieved—the unpredictability is universal.

“If somebody tries to throw you under the bus for not giving appropriately timed steroids, go, ‘Yeah, well, I'm in good company because of the problem of the predictability of preterm birth.’”
— Dr. Chapa [15:29]

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Notable Quotes and Memorable Moments

• “It is the problem of the unpredictability for preterm birth. Yeah, I came up with that. That's a lot of P's, but y' all get that.” — Dr. Chapa [13:31]
• “We’re just trying to fulfill our life calling and our mission. This is Dr. Chapa’s OBGYN no Spin podcast.” — Dr. Chapa [07:27]
• “The title of which this study is, is Maximizing benefit from Antenatal Steroid use while Avoiding Overuse.” — Dr. Chapa [03:10]

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Important Timestamps

• 02:17: Goldilocks analogy and introduction to timing steroids
• 03:10: New study details and contributor shout-outs
• 08:09: Review of SMFM 2022 steroid timing definition
• 09:52: Study methodology: years, sample, inclusion criteria
• 12:30: Real-world outcomes, percentages for timing accuracy
• 13:45: Discussion about overuse and imprinting risks
• 15:29: Main clinical take-home messages

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Summary Table: Steroid Timing Outcomes (Clapp et al., 2026 Study)

| Category | % of Patients (N=1,694) Delivering <34wks | |-------------------------------------------|------------------------------------------| | Optimally timed (6 hrs–7 days after dose) | 57% | | Too early (>7 days after dose) | 19% | | Too late (<6 hours after dose) | 10% | | No steroids before preterm delivery | 15% | | Received steroids but delivered at term | 26% * |

*Of all patients who received antenatal steroids before 34 weeks, 1 in 4 ultimately delivered at term

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Overall Tone & Closing

Dr. Chapa keeps the episode accessible, evidence-based, and a little playful—reminding listeners that the unpredictability of preterm birth frustrates even seasoned clinicians. The episode balances practical summary with pearls of wisdom, advocating for clinical judgement while recognizing the difficulty—and imperfection—of timing antenatal steroids.

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Useful for:
Medical students, residents, and OBGYN providers seeking practical, current, and evidence-based advice for perinatal care.

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Transcript

[Dr. Chapa]

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[Jordan]

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[Dr. Chapa]

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[Jordan]

You remember the Goldilocks and the three Bears. Like the porridge. One was too hot, one was too cold, and one was just right. You remember the last time that you timed something perfectly. I mean, maybe you played baseball and it was that perfect swing of the bat and you hit that ball just right. Or you perfectly time a flight you have to catch in a commute and you make it with perfect timing to walk right onto the plane. Or maybe it's a higher stakes game that you time perfectly Y', all, that's what we're talking about here, getting the timing correctly. And nothing says that better in that example of not too early and not too late and just in that sweet spot like antenatal steroids, man, oh man, is that tough to figure out. If you give them too early, then the benefits fade and if you give them too late and the patient delivers very quickly, then they don't have time to work. So this is why we're covering this brand new study in the Green Journal in Obstetrics and Gynecology by Clapp et al that looks at this real world difficult situation. It's a retrospective study and the balancing act of pushing the trigger too fast or not pushing it fast enough and missing out on the sweet spot. Now there's several key points here that we're gonna point out. Number one, this is part of this authorship is Cynthia Gyamphi, who is phenomenal. We've talked about her in the past. She is a friend, she was part of the Alps leadership and good job for her and this team. The title of which this study is, is Maximizing benefit from Antenatal Steroid use while Avoiding Overuse. So couple of take home messages I'm going to give you here, but the first is if you're ever brought to your hospital peer review committee with the question or the accusation rather being why didn't you time steroids better? Then the short answer is because nobody can. Because it's one of the hardest things to predict is when a patient will actually deliver preterm. Now there are some factors there that some do better than other in terms of clinical criteria. For example, if she's got preeclampsia with severe features and she's under 34 weeks, you know that she's gonna, you gotta get her delivered as soon as possible. You can time that a little bit better. But there's some things that maybe are harder to predict, like a patient with threatened preterm labor. We know that anywhere from 30 to 40% of those are gonna deliver at term anyway. So it's very difficult to figure these things out. This brand new retrospective study, again From July of 2026, takes a look at this real difficulty and gives numbers to this. Who had optimal timing of steroids, who had it too early, who had it too late. And we're going to redefine and remember, remind everybody here of what SMFM says is optimal timing. Now we all learned that it was, oh, it's 24 hours after the second dose of betamethasone or 48 hours from the first, that's where you get maximal benefits. Maybe, but that's not really in the overall bigger banner of optimally timed. That's much broader than just 24 hours after the second dose of betamethasone or 48 hours after the first dose. It's a lot broader than that. So we're going to remind everybody of the SMFM quality metric from 2022 that talked about this. That was in their special statement on the quality metric for the administration of corticosteroids. And we're going to give you the percentages of who had this perfectly timed and who fell out of range. And some surprising numbers here. This is why, remember, we've covered this before. As you all know, steroids is one of my pet projects. And this is why Figo says, look, you should not give steroids quote unquote, just in case she may deliver early, because that's over calling it and is exposing kids to steroids that they may not need. And especially if they go on to term. We know that there's some concern there about epigenetic imprin printing and psychological and neurodevelopmental delays that's been found over a variety of studies. One of them was a Finnish study, another one is a Danish study. We've talked about all of these in the past. When you expose kids in utero to steroids and then they go on to deliver at term, there is potentially, even though it's controversial, potentially, this increased risk of neuropsychological and neurodevelopmental delays in those term born children. We've covered this in the past. That shouldn't be, you know, surprising to anybody. So in this episode, we're going to cover this brand New July of 2026 publication from the Green Journal from Clap et al. And Cynthia Gayamhi Bannerman is in this as well, talking about the real world difficulty of getting steroids timed correctly. So if somebody tries to throw you under the bus for mistiming steroids, go, well, do you have a better way? Because until we have the syn Quinn on test synchron, remember, is Latin for without doubt. Unless we have that test that says I know when she's going to deliver, then it really is the Goldilocks game in obstetrics. You don't want to give it too soon, you don't want to give it too late. You want to find that perfect spot, that sweet spot in the middle. So let's cover the July 2026 brand new study on more steroid stuff. Here we go. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast. I do realize that the Little Goldilocks song at the beginning was pretty darn creepy. You think that was creepy? You should see the little cartoon that goes with it.

[Dr. Chapa]

Okay.

[Jordan]

But it does make the point. I mean, it is Goldilocks and the Three Bears. This whole steroid business, because you gotta time it just right. If you give it too early, doesn't work as well. If you, you know, give it too late and she delivers well, then. But you don't get any benefit. So even though we've learned a lot, remember we've covered this in the past, that there's. There's some benefit to a steroid as early as three to six hours. That's why SMFM defines optimally timed guys as broader than just 24 hours after betamethasone or 48 hours after the first dose. It's broader. According to SMFM, the quality metric for giving a steroid, quote, end quote, optimally timed, and that's what they used in this retrospective study, is delivery six hours to seven days after the first dose. That is per the SMFM quality metric. So you give a shot. And even if they deliver at six hours to within seven days, that is called optimally timed. If they deliver less than six hours or more than seven days, that is called suboptimally dosed. So according to smfm, if you give a dose of steroid and they deliver between six hours to seven days later, six hours to seven days later, that is optimally timed. Now, the whole thing of, you know, 48 hours after the first dose or 24 hours after the second of betamethasone, that's. Yes, that is true. You tend to get a peak effect there. But there's still benefit at six hours to seven days after the first dose. So that's what these authors tried to do. So this is what Cynthia and Clapp tried to figure out retrospectively. They said, look, from 2016 through 2024, right? July 2016 to December 2024. That's a lot of years, guys. At two large academic hospitals. These are all level four four NICUs. And by the way, they only use beta methasone, no dex. So it's a beta methasone issue. Most people use beta methazone because it's easier to administer versus, you know, the four shots in 48 hours. You just need two. They said, let's take a look at the sweet spot. When it's non controversial. 24 and 0 to 33 and 6. That is the sweet spot for steroids. Nobody argues that. Okay? 24 and 0 to 33 and 6. ACOG and SMFM say that is recommended. Okay? Remember, under that it's, you know, maybe you might could. And then afterwards you get into the whole Alps deal. That's controversial. So 24 to 33 and 6. The non controversial. How many patients with threatened preterm labor or whatever other indication that they might deliver early. And that includes previa, that includes an accreta, that includes pprom, oligohydramna, fetal growth restriction, whatever, but not, not twins. These were only in singletons. Let's see how many had optimally timed steroids. Remember, delivery six hours to seven days after the first dose. That is straight out of the SMFM Quality Metrics Report, the special statement in 2022. Now, we want to do this in rapid fashion, okay? I just want to give you the stats to drill in three main concepts here. Remember, three main concepts. Number one, it's hard to predict who's actually going to deliver under 34 weeks. Number two, what? The definition of optimal steroid timing. We've already talked about that. And then number three, the percent in this retrospective study who we thought was gonna deliver early, under 34 weeks, and then ends up going to term. All right, so that's another issue, because we don't wanna expose children in utero to medication that they don't need, especially one that's kind of controversial, like antinetocorticosteroids. And then they go to term. And the potential, again, I'm just saying that because it is controversial, the potential for imprinting and them taking a hit in psychosocial and neurodevelopmental delays, which has been very well published in both Danish and Finnish cohorts, and we've talked about that in previous episodes. So first of all, among close to 1700, if you want the actual N, it's 1694 close to 1700 patients who did deliver before 34 weeks. So let's take a look at that cohort first, and then we'll take a look of the percentage that went to term. But of those who actually did deliver before 34 weeks, who actually needed the medicine, the good news is that 57% had optimally timed antinetocorticosteroids. So you're thinking, Hey, 57%, that's not bad. And I agree with that, except that the rebuttal is 43% of those who needed it did not get optimally timed steroids. So you see, it depends on how you look at it. All right, so 57% had optimally timed antinetocorticosteroids. Remember, this is the cohort who actually did deliver early. Now those who delivered before 34 weeks, there was a group that was 15% who didn't receive any steroids at all. Well, you don't wanna be in that camp. I mean there's like, well, we got time. And then boom, she delivered again. Unpredictability in the actual prognosis here for preterm delivery. So 57% had optimally timed. 15% didn't receive steroids at all. That leaves those that had it too early. In other words, they had waning benefit because the patient delivered more than seven days. That was 19%. And then 10%, actually 9.6% who received the first dose delivered less than six hours before delivery. So they had it too late. Podcast family, I'm inviting you to elevate your coffee routine with the strong coffee company that is striving to reach our natural greatness. I use it, it's coffee 2. It has protein MCTS for energy and mental clarity and adaptogens. This is one of my favorite coffees. It comes in regular black and latte mixes. And now you get 20% off when you go through the link in our show notes. That's right. Just for being a podcast family member, go to strongcoffeecompany.com discount chopa no spinobg for your 20% discount. The link is in our show notes. So just as a reminder, remember, these are the children that did deliver before 34 weeks who had optimally timed steroids. 57% versus 15% who didn't have any steroids at all. 19% who delivered more than seven days after the first dose and 10% who delivered before the six hour mark. But the authors also balanced this out. They wanted to see who was exposed to steroids and then went on to deliver at term. And here's the other surprising things, guys. Among all patients who received antennaocorticosteroids before 34 weeks, 1 out of 4, 25%, actually 25.9% ultimately delivered at term. So at or after 37 weeks. So that's a substantial population exposed to anti endocorticosteroids without any benefit, maybe with the potential negative impact on neurocognitive and social development, as once again we have covered in the past. So do you all see this, guys? So among those who actually needed it, about half or nearly half did not receive steroids when they should have. And 10% received it way too late so they delivered beforehand. 19% had more than seven days and 15% didn't have it at all. And 25% actually went on to deliver at term. All this has to do, guys, just to prove the unbelievable problem of the predictability of preterm birth. Yeah, I came up with that. That's a lot of P's, but y' all get that it is the problem of the unpredictability for preterm birth. So what's the take home message here? Number one, according to Figo, remember that's in their best practice for steroids. Don't just give steroids willy nilly just in case because there is some concern about those children going on to terminate and that imprinting. So as of now, try to use your best clinical judgment. For those who have optimally timed steroids, remember that is delivery at six hours but no more than seven days. Now, just to be clear, there is some starting benefit as early as three to four hours. There is data for that, but it actually starts to increase the fastest at six hours. And there is benefit still after seven days up until 14. That is true. So at the two extremes of delivery within six hours and and then delivery from seven to 14 days, there is benefit. I don't want to make it seem like there isn't, but the optimal timing according to SMFM is delivery six hours to seven days after the first dose. Podcast family this is coming out July 2026 for my friend Cynthia G and Clap et al in the Green Journal, just showing how difficult it is. So again, if somebody tries to throw you under the bus for not giving appropriately timed steroids, go. Yeah, well, I'm in good company because of the problem of the predictability of preterm birth. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast family. Now that we've done all that. Michael, let's take it home.

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[Jordan]

This is Dr. Chapma's obgyn no spin podcast. Sam.