Episode 155 Antenatal Steroids

What if the treatments we believe to be beneficial in Obstetrics aren't as helpful as we thought? Or worse, might they bring along hidden risks for mothers and babies? As your host, Florence, I invite you to journey with me as we explore the complex world of antenatal steroids, a commonly used intervention for preterm labor and planned cesarean births. This episode will not only shed light on the perceived positives, like improved baby outcomes, but also dissect the potential downsides, such as its impact on diabetic control for mothers. We'll also delve into emerging evidence that raises questions about the true scale of these benefits.

Let's take a closer look at the long-term implications of administering antenatal steroids. Is it possible that even a single course of these steroids could lead to a higher chance of mental or behavioral disorders later in life for the baby? Or increase the risk of serious infections in their first year? Informed discussions between doctors and parents are crucial when it comes to this controversial topic. Drawing to a close, we'll talk about how you, our dedicated listeners, can support this podcast and ensure its accessibility to all, and how to propose topics for our future episodes. Prepare to have your perceptions challenged and your understanding deepened as we navigate the evolving realm of Obstetrics.

Want to know more
https://www.rcog.org.uk/media/karfqj1i/corticosteroids-in-pregnancy-patient-information-leaflet.pdf
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.17027
https://www.bmj.com/content/382/bmj-2023-075835

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
Keeping my podcast running without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to support theobspod please head over to my buy me a coffee page https://bmc.link/theobspodV any donation very gratefully received however small.
Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...

Transcript

Speaker 1: 0:00

Hello, my name is Florence. Welcome to the ObsPod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, anyone else that's interested, the ObsPod is for you.

Speaker 1: 0:49

Episode 155, antinatal steroids. For a long time certainly as long as I can remember in my career, one of the first things we would do when a woman was admitted in possible pre-term labour is give her two doses of steroids, either dexamethasone or betamethasone. Two injections 12 or 24 hours apart. It was pretty much the first thing we'd do as she came through the door give steroids, because that was the single biggest thing we could do to make a difference if she was going to deliver pre-term. We knew there were lots of benefits for the baby's lungs if we could get those steroids in and give them a little bit of time to work, and much of the treatment we used to try and slow down pre-term labour was not aimed at stopping pre-term labour, because that's well my impossible, but to bias time, to give us a bit of time to get those steroid injections into the woman and for them to be effective for her baby. The evidence was very compelling, that it improved outcomes. It was a no-brainer and that's how we did that.

Speaker 1: 2:24

Things got extrapolated as they so often do. It's extremely difficult to predict accurately when a woman might deliver preterm and the best benefit of the steroids would be 24 hours to a week after we'd given those doses. So if we mistimed it, we might give her steroids and they might not be of use. Either we'd given them too late, we'd missed the point at which they would be most effective, or we might have given them too early, everything settled down and she didn't go on to give birth. Or in a situation where we were more in control of the preterm birth, such as when there's a very, very growth restricted baby or a woman has severe preeclampsia, we might not time things correctly. So it was routine practice when I was junior in my career to regularly give steroids to those women that we thought were having a high chance of giving birth prematurely. We would give steroids and if she hadn't delivered in the next couple of weeks, we would repeat, give those steroids a couple of weeks later. No downside, we thought, and certainly we will have benefited very many babies over the years by this course of action.

Speaker 1: 4:08

Then we started to look at babies born closer to their due date, particularly those born by cesarean. It's well recognised that one of the complications of a planned cesarean is something called transient tachypnea of the newborn, literally fast breathing of a newborn baby. And this is because babies born by cesarean haven't been down the birth canal, they haven't had their chest compressed by lots of contractions, they haven't had the lung liquid squeezed out and therefore when they're born their lungs are wet, they're full of amniotic fluid and it takes them time to get rid of that fluid. People often describe cesarean babies as being very mucusy and you may see liquid actually pour out of their mouths Most of the time. Ttn, as we like to shorten it, is quite innocuous. If you leave the baby skin to skin with its mother, it will settle down over the first hour or so and sort itself out. But for some babies it won't and this will necessitate admission to the neonatal unit and perhaps oxygen and some respiratory support, some help with breathing.

Speaker 1: 5:30

So in situations where we knew we were going to need a baby to be born early by cesarean, even though it was beyond, strictly speaking, what we would call preterm, we started to think maybe steroids would be of benefit here too. We could give steroids to women who needed to have their cesarean at 37 weeks and that would counteract the higher chance of TTN at that stage of pregnancy and the baby would be able to stay with its mum and have less chance of admission to the neonatal unit result. So we started offering steroids to women having planned cesareans if they were at higher chance of their babies requiring admission because they were having it a bit early. We also offered steroids to women having a planned cesarean who had diabetes. There's a link between diabetes and surfactant production. Surfactant is the chemical that helps with the surface tension in the lungs, helping the lungs inflate, and we know that babies of diabetic mums do not have as good surfactant production so are a bit more likely to get respiratory breathing problems after birth when born by cesarean. So it makes total sense to give mums with diabetes steroids before their planned cesarean birth.

Speaker 1: 7:17

So far this all stands quite straightforward right. So why have I chosen to do an episode on this. Well, the answer is it isn't quite as straightforward as we thought. Let's start with those women with diabetes. Giving a large dose of steroids actually can completely throw off their diabetic control. So we would have women admitted to have steroids and then we would see their blood sugars soar, usually 12 to 24 hours after that dose of steroids. And that would often need them to be on a sliding scale, a drip of insulin and sugar solution, with regular testing of their blood sugars hourly for us to try and help them maintain a normal blood sugar. Big swings in their blood sugars are not good for them, but equally not good for their baby that's about to be born. So this was an obvious downside, but the benefit seemed to be worth it. But slowly, little by little, we started to see evidence that actually steroids were not as great as we thought, that there might be some downsides. We stopped giving them out like smarties to any woman that literally walked in the door in threatened pre-term labor or who we thought might deliver early, and we certainly stopped those repeated doses.

Speaker 1: 8:56

There have been some advances in how we might or might not predict or try and predict preterm birth. I've talked about it a little bit in my episode 1, 2, 3 Transfer, about in-neutrary transfers. What we're trying to do these days is use these tools to try and give us the best possible chance of identifying that 24 hours to one week time period in which the steroids will be of the most benefit, so that we don't take the risks of giving doses of steroids too early when they won't be of use. And we also try not to take the risk of giving steroids to women that actually, although it looks like they might be in preterm labour, are actually not going to birth their baby preterm. But everything is going to settle down and stop. But it can be incredibly hard as an obstetrician, even with the tools we now have, such as fetal fibronectin or cervical length, to try and accurately predict who are the women that are going to give birth to their baby prematurely. It can be a hard call to make. So why are we now hesitating?

Speaker 1: 10:36

Well, there's quite a bit of new evidence come to light about the negative aspects of giving steroids preterm, and that's why I've chosen to do a whole episode on it today. For me, my conscious awareness started with an excellent infographic from a team up in Edinburgh, which has now been incorporated into the Royal College of Obstetricians and Gynecologists Green Top Guidance. This infographic focused on the benefits or disadvantages of giving steroids for babies born by Planned Caesarean at term, so more than 37 weeks. It's a nice decision-making tool and something that I now often give women if they're making that decision, or if we're making that decision together, particularly if they've maybe had steroids in a past situation, and I'm explained to them why practice has changed and that I might not be offering them steroids anymore. It talks about the potential downside in terms of the baby's blood sugars immediately after birth, but, more importantly, it talks about the fact that there may be some impact on the baby's brain development and that this may have an effect on the baby as it goes through its developmental milestones or education. It also discusses the fact that there's less evidence that steroids can definitely be beneficial for breathing issues at term, whereas the evidence for help with breathing issues preterm is compelling. So for the last few years, we've really been raining back in and using far less steroid injections prior to Planned Caesarean Definitely seen a shift in practice, but what about preterm birth? What should we be doing then? Well, the reason I've chosen to record this episode today is because of a recent excellent article in the BMJ and I've put a link to that and the infographic I just mentioned in the show notes for today.

Speaker 1: 13:24

They looked at a nationwide cohort in Taiwan, looking at nearly two million mother and child pairs to look at what proportion of women who received steroids in their pregnancy, ready for preterm birth, actually didn't go on to birth their babies preterm. And it was interesting to discover that actually 40% of women given steroids because of an anticipated preterm birth did not actually go on to birth their baby until they were full term, and that's really quite a high proportion. They then looked at the short term and long term outcomes of those babies. So if, as a baby, you'd been exposed to steroids before 34 weeks and you were then born at more than 37 weeks, so what? What was the impact? And these are the results that make you stop and think. So what they showed in terms of short term outcome was that these babies had a slightly higher chance of admission to a neonatal unit, more chance of needing breathing support, such as being intubated that means being on a ventilator but also an impact on a higher chance of having some sort of mental or behavioral disorder later in life.

Speaker 1: 15:14

I always find the data on mental and behavioral development quite difficult, because how do you decide cause and effect? I mean I know people doing studies do take that into consideration, confounding factors but it always seems to me a little bit difficult to attribute something back directly to a single intervention. But the other impact that they discovered in longer term outcomes was that infants that had been exposed to antenatal steroids in the womb had significantly higher chance of infection, serious infection in the first year of life, and I'm talking things needing admission to hospital such as pneumonia, sepsis and acute gastroenteritis with increased chances, what they call a hazard ratio 1.4 to 1.74. So significant differences in the first six months or year of life. I think this is important. Not that the other possible impact on brain development isn't important, it totally is but this is the first time I've seen clear evidence of what appears to be a definite downside, a definite disadvantage, if we give steroids and the woman then doesn't go on to birth her baby preterm.

Speaker 1: 17:15

So overall they said antenatal corticosteroids one course so not even the repeated courses we used to give, but one course showed a significantly associated risk of 1.2 to 1.4 of overall serious infection in the first six to twelve months of life and we need to be open and honest with couples about this information. But equally we need parents to be aware of this information so that if we have given antenatal steroids, they know to inform doctors and people caring for those children during that first year of life that they do have this background increased chance and therefore in that first year of life, professionals dealing with that baby and that family need to understand the need for perhaps increased vigilance and parents themselves need to be aware that those common childhood illnesses perhaps may be a little bit more for that particular baby, still far more likely that that baby won't have complications and problems, but their background risk is higher than if those steroids had never been given. So what is my zesty bit? My zesty bit is where we can I know it's difficult in the throes of labour but where we can, where we're planning a preterm birth or we do have time and we can have a proper, good conversation.

Speaker 1: 19:07

We need to be a little less blasé about giving steroids and we need to have a better conversation with parents about the potential downsides. There is some really good information for parents which I've put in the show notes and I think, when you've got time to discuss and talk to people, we really need to use that good information to say, yes, on balance, I think steroids would benefit your baby and these are the reasons why. But rather than just brushing it away which, to be honest, I have done in the past rather than brushing it away and saying there is no downside, we need to say, well, there could be a downside. There definitely is a downside in terms of blood sugar stability after birth and possible infection, and then on top of that, there is this potential for perhaps mental and behavioural developmental issues in the future. So it's not anything like as clear cut as I think it was or seemed at the beginning of my career and as a woman. If you're listening to this, or a couple listening to this, then read there's a really nice RCOG patient information leaflet and have a think yes, steroids are still incredibly beneficial, particularly if your baby is very pre-term, so we're talking 23 to 28 weeks. So I'm not saying don't have steroids, but I'm saying understand there are benefits and downsides, just like with most things in life, and don't be frightened to ask questions about those downsides so that you can make a really well informed decision about what you feel is best for yourself and your family.

Speaker 1: 21:33

I very much hope you found this episode of the Obspod interesting. If you have, it be fantastic if you could subscribe, rate and review, on whatever platform you find, your podcasts, as well as recommending the Obspod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalog from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary.

Speaker 1: 22:32

If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the program notes, where I've attached some links. If you want to get in touch to suggest topics for future episodes, you can find me at the Obspod, on Twitter and Instagram, and you can email me theobspod at gmailcom. Finally, it's very important to me to keep the Obspod free and accessible to as many people as possible, but it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and by chance, you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link, to buy me a coffee, don't feel under any obligation, but if you'd like to contribute, you now can. Thank you for listening.