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- [00:01]
A
Podcast family. I am so thankful for Tona Activewear. Yep, it's our brand new sponsor and what that means to you is that you get 16% off. That's 1 6, 16% off anything that you buy on Tona Activewear through the link in our show notes. Again that link is tonaactive.com discount chopanospinobg the link is in our show notes. Tonaactive.com discount choppa no spinobg altogether. Again, the link is in our show notes. 16% off for premium leggings that you can wear to the gym or every day because it's the same designers from Lululemon. So Tona Activewear, thank you for your sponsorship. Thank you for being part of our podcast community. Go to tonaactive.com discount chopano spinobg for your 16 discount. Well, well, well Podcast family. You know you listen to the show for a variety of reasons. Our charming wit, of course, our pointless banter. Well, it's not always pointless, just some of the time. And of course I hope you listen to the show because we are always telling you what is hot hot hot in press. Like what we're covering today that just came out on June 4, 2026. By point of reference, we're still doing this at the end of the first week of June of 2026. This is a brand new systematic review and meta analysis covering something that's near and dear to my heart. You all know that a special interest of focus of research for us, for me, is antenatal corticosteroids. And this has to do with the use of acs, antenatal corticosteroids in twins. Now, I know what you're thinking. Wait a minute, what's the big deal there? We already have guidance that. That's ACOG's practice bul1 and indeed it is. That is the one on multifetal gestation, twin triplet and higher order multiple pregnancies. We get that. However, even though in that practice bulletin it states, quote, based on the improved outcome reported in singleton gestations, the NIH recommends that unless a contraindication exists, a course of antonetocorticosteroids should be administered to all patients who are at risk of delivery within seven days and who are between 24 and 34 weeks of gestation. Here it is guys. Irrespective of the fetal number, end quote. However, a brand new meta analysis that just came out again on June 4, 2026 is saying the exact opposite. Yeah, it said not only does it likely not help But. But it maybe could cause some harm.
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B
Say it ain't so, Joe. Say it ain't so.
- [03:00]
A
Oh, Joe. Say it ain't so. So we're gonna get into it. I don't even know what that movie. That's what's from. What is that? Eight Men Out? Never heard of it. Not a sponsor anyway. So, yes, this new systematic review meta analysis has some shocking, shocking, shocking findings. And. And it's going to make you say,
- [03:21]
B
say it ain't so, Joe. Say it ain't so.
- [03:25]
A
But the authors themselves, before we all get our underwear in wad, the authors themselves gives you what to do with this heartbreaking, disappointing and shocking data. At the end of the manuscript, it's going to tell you, I'm going to read it to you exactly. So we all can stop hyperventilating and nothing really is going to change as of yet. So even though this new publication is going to have you asking a couple of questions, including say it ain't so, Joe.
- [03:55]
B
Say it ain't so.
- [03:57]
A
Just say it ain't so, Joe. I don't know who Joe is. Eight Men Out. I've never heard of this movie. What is it a comedy? Is it a drama? I don't know. Anyway, all to say, we're going to tackle this brand new systematic review and meta analysis, the title of which is called oh, I lost my thing. Michael, Michael, help me. Help me. Here it is. Wow, there's a lot of authors on this. It is anti corticosteroid used in twin pregnancies is systematic review and meta analysis. That's what I waited for. That was anticlimactic. All right, everybody, now that I've kind of laid it all out, we'll be right back after this intro.
- [04:31]
B
It ain't so, Joe. Say it ain't so.
- [04:35]
A
We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast.
- [04:44]
C
No one goes to Hanks for spreadsheets. They go for a darn good pizza. Lately, though, the shop's been quiet, so Hank decides to bring back the $1 slice. He asks co pilot in Microsoft Excel to look at his sales and costs, help him see if he can afford it. Copilot shows Hank where the money's going and which little extras make the dollar slice work. Now Hanks has a line out the door. Hank makes the pizza copilot handles the spreadsheets. Learn more@m365copilot.com work.
- [05:14]
A
All right, so let me just put it out there. Right at the beginning. This is disappointing. It's shocking. And before you go to your water cooler tomorrow, Monday, because we're doing this at the end of Sunday on July, on June 7, 2026. Before you go, hey, did you hear the new systematic review and meta analysis that steroids don't work in twins and could maybe be harmful? Hold on now. Yes, yes, that is what this new systematic review and analysis found. But there's a lot of issues, a lot of issues. And I'm not being mean. I mean, the authors themselves say, hold on here, let's not throw the baby out with the bath water here on this one because there's some big issues here. One, I commend the authors for doing this because we need data in twins. And right now, smfm, acog, major global professional societies all agree to give steroids irregardless. Is that a word? Irregardless or regardless. Did I just mess that up? Irregardless. Regardless. How about regardless, y'? All? I was. Let me. Just for those of you who are new to the show, I was raised on the border, all right? So I. My English sometimes gets in the way of my brain. What? Whatever, man. Look, regardless of fetal number, give steroids. Give steroids. Especially between the sweet spot, 24 to 34 weeks. I'm going to tell you what the issues are here, and the authors are very clear. Before you say, let's not do this, which is against, again most global and national recommendations for preterm birth, regardless of fetal number here, the authors say we should consider this quote, hypothesis generating, end quote. Now, if you don't know what that means, okay, in medical literature, when something is found to be interesting and hypothesis generating, that means you're like, oh, that's weird. Maybe we should study that somehow. That's all that that means, is hypothesis generated. Let's make another hypothesis and study this where the data isn't so heterogeneous. Now, let me explain why it's heterogeneous. Because there's not that many twin studies here. And in this, again, it's just looking at twins, not triplets or quads. In twins, they had to expand the pool of what they looked at, remember systematic review and meta analysis? So they included. They started out with like 5,500 records. 5,500. They whittled that down in their first pass to like 4,500. And then they got to like 75. Yeah, guys, you all see the whittling down? Is that amazing or what? So they're like at 75 like, woo, we're doing something. And. And then they ended up with two RCTs, 2 and 14 observational studies. Now, when you mix observational studies with RCTs, not brain rocket science here, guys, to figure out, you're going to have some, some lot of heterogeneity here because RCTs are kind of like level one and then the observations are level two. And so it muddies the entire results. But you got to do that to get the numbers and that that are needed, right? So 14, 14 total observational studies to RCTs. Okay, let me just give you the results here because there's a lot to cover. And I'm just giving you the big bummer here, which is something that I've already been saying for the last two years, that I've been studying antinetocorticosteroids as part of my research focus. One of my research focuses, which is the thing that messes up the data the most, especially when you're doing something like this, putting a lot of studies in together for a systematic review and meta analysis, is steroids in the late preterm interval, guys, and I'm not bashing Alps again. Cynthia Gamfi, big mentor. I think she's phenomenal, past president of S mfm. But yeah, it throws things off because there's a little bit of benefit and a lot more possible concern, mainly with hypoglycemia. And the authors state that very, very thing in this publication. I'm going to read it exactly as they say, the warning that they have for this late preterm use that may have really muddied the water here. Okay, so let me just give you the results and then their conclusions and then we can start wrapping this up. I want you to have kind of a, a big high level, you know, synopsis here of what this is. So if somebody tries to blindside you that we're not going to give steroids anymore in twins, your answer should be, yeah, yeah, we are. We're still going to do it because that is still standard practice. And this study had a lot of issues, okay? Issues, as one of my friends says, with his lisp. All right, so here it is in this publication that the thought was that it was going to confirm what was found in singletons. It absolutely did not. Let me read you the results and then we're going to brace ourselves and dry our tears for what we read and then go from there. So here it is. Quote, exposure to antenatal corticosteroids was not significantly associated with a reduction in neonatal mortality. So already that's a big bummer. So it didn't reduce the biggest thing that we know it does in singletons, which is neonatal morbidity. Pardon me, mortality. They go on to say, quote, antenatal corticosteroid use was not associated with a reduction in respiratory distress. What like. Well that's a bummer. Actually the relative risk was 1.11. It went the opposite way. So up a little bit. And gestational age stratified analyses were non significant. Now here's where it gets even more disappointing. So that's like, yeah, it didn't help. It actually maybe got a little bit worse. But. But wait, there's more. Quote, when we took a look at the RCTs by themselves, they found that higher risk of RDS among ACS exposed neonates was higher and exposure to ACS was associated with increased supplemental oxygen requirement, increased neonatal hypoglycemia and NICU or special care admission, end quote. So yeah, the whole thing of maybe can do some kind of good, which is the hypothesis that has been for 20 years, that was completely exnate here. So not only did it not help, it caused more RDs, it caused more oxygen requirement, it caused more neonatal hypoglycemia and more trips to the nicu. This is shocking. Not what was thought to have been found based on all of the other data, including past single observational studies that showed that, yeah, this might could help. So the authors concluded, quote, in twin pregnancies, remember just twins, ACS exposure was not consistently associated with improved neonatal outcomes, with no overall reduction in RDS and no reduction in neonatal mortality. End quote. However, even though that is a big boo hoo moment, quote, given the moderate to low certainty of the available evidence, here it is, guys. These findings should be interpreted cautiously. Cautiously. Now, back at the end or in their last paragraph of this manuscript, they say, don't go changing your practice. This should be considered again, hypothesis generating. Just ask yourself some good questions here and maybe be. Here it is, guys. Maybe be more restrictive and thoughtful of how we give steroids. Hello, that's exactly what I've been saying in most of my podcasts. Episodes that have covered antenatal corticosteroids. Acss have said that don't just give them willy nilly. Don't do that. Especially with the potential here in the late preterm interval to cause some issues. We don't want to do that. Now let me read you this issue specifically before you think I'm throwing the ALF Traut under the bus, here's exactly what these authors say and what may have muddied the water here. Because when you include late preterm intervals 34 up to 36 and 6, it kind of messes up things. Quote, the data support a more selective approach to ACS use in twins particularly. Here it is guys, brace yourselves. Particularly in the late preterm period or when delivery timing is uncertain. In other words, just give it because why not? She got twins, she may go into preterm labor. No, they should be at risk of delivering within seven days and ideally should be between 2024 and 34 weeks. And this concern of late preterm interval exposure is problematic. Okay, so again, I'm not saying that the authors say this themselves. Most of the concern here and what may have drawn these into a negative finding was late preterm exposure. So the authors state, quote, given the heterogeneicity and lack of patient level data, findings should be considered hypothesis generating until further high quality studies are done to define optimal patient selection and to clarify risk benefit ratio in this population. Okay, so again, I'm not putting words in anybody's mouth. I'm reading to you exactly what the authors state and I'm going to give you this final quote and we're going to call it a day. So good, so good, so good. New markdowns up to 70% off are at Nordstrom rack stores now. Stock up instead. Save big on shoes, tops, dresses, accessories and more must haves for summer. Join the NordicLub to unlock exclusive discounts. Shop new arrivals first and more. Plus buy online and pick up at your favorite rack store for free. Great brands, great prices. That's why you rack quote. Clinically this supports a more individualized approach. I already said that. Particularly in the late preterm interval when the balance between benefits and harms. Here it is, guys. Is more uncertain, end quote. I have been saying that for the last two years and especially when Alps first came out, you know, the data kind of simmer and then as you've, if you've been following the show, I've got plenty on steroids and late preterm interval calling attention to be very cautious with that. As the authors state here, quote, when the balance between benefits and harms is more uncertain, end quote. So yes, it's disappointing. Yes, it's super concerning. Yes, it really does make us say
- [15:50]
B
say it ain't so, Joe. Say it ain't so.
- [15:53]
A
Oh, say it ain't so.
- [15:55]
B
Say it ain't so, Joe. Say it ain't so.
- [15:58]
A
I mean, it is what it is. So again, if. If your attending says, did you read the systematic review and meta analysis, Sarah? Joan, Working twins. And I know that because I read the abstract, then you say, well, sir or madam, in the remainder of the paper it says, yeah, let's not do any changes yet because we need hypothesis generating until we have further high quality data. So disappointing, shocking, heartbreaking and sad. I guess sad was thrown in there somewhere. I guess that was implied. But the truth is, yes, this is confusing, yes, it's disappointing, but we shouldn't be changing our practice just as of yet. So, podcast family, now that we've done all that, Michael, I think we've wrapped up what we're supposed to do. As always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that.
- [16:48]
B
Say it ain't so, Joe. Say it ain't so, Michael.
- [16:52]
A
Let's take it home. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OB GYN no Spin podcast.