Letter

Giving steroids before elective caesarean section: Authors respond to editorial

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7530.1475-a (Published 15 December 2005) Cite this as: BMJ 2005;331:1475
  1. P R Stutchfield, consultant paediatrician (DrPeter.Stutchfield{at}cd-tr.wales.nhs.uk)1,
  2. R Whitaker, trial statistician2
  1. 1 Conwy and Denbighshire NHS Trust, Glan Clwyd Hospital, Rhyl, Denbighshire LL18 5UJ
  2. 2 Institute of Medical and Social Care Research, University of Wales Bangor LL57 2PX

    EDITOR—We reported the outcome of a randomised trial of antenatal betamethasone before elective caesarean section at term, showing a reduction of more than 50% in admission with respiratory distress for babies delivered at 37-39 weeks (BMJ 24 September, p 662). Of the 35 babies admitted with respiratory distress, 19 control babies had transient tachypnoea and five had respiratory distress syndrome, compared with 10 babies with transient tachypnoea and one with respiratory distress syndrome in the intervention group. Fourteen control babies required intensive care, three with respiratory distress syndrome requiring ventilation for two to five days, with a 12-18 day stay, whereas only two in the intervention group received intensive care.

    We postulated that the reduced incidence of transient tachypnoea with antenatal betamethasone may result from an effect on the expression of the epithelial channel gene allowing the lung to switch from fluid secretion to fluid absorption. Fiori's electronic response to our paper provides evidence for an additional factor, enhanced surfactant production. The presence of lung fluid is likely to delay surfactant production, leading to a further decrease in lung compliance seen in transient tachypnoea.

    In the accompanying editorial Steer raises concerns about the long term consequences of giving antenatal steroids by reporting the outcome of follow-up studies where multiple two weekly courses of antenatal steroids were given from 24 weeks' gestation onwards and high dose intravenous postnatal courses of corticosteroid were prescribed for the very preterm to prevent chronic lung disease.1 He then raised the spectre of thalidomide and diethyl-stilbestrol in pregnancy, in which mass prescribing and the lack of long term follow-up research led to well reported serious consequences. These drugs were used early in pregnancy during early embryogenesis. Steer concludes that “giving steroids…even as a single course, remains questionable.”

    Although we understand Steer's concern, the Cochrane review in 2003 and the evidence based guideline of the Royal College of Obstetricians and Gynaecologists on the use of antenatal corticosteroids to prevent respiratory distress syndrome conclude that a single course of antenatal corticosteroid has no adverse effect on physical growth, neurological or cognitive outcome, or infection in child or mother.2 3 The royal college's guideline synthesises five papers following more than 1500 survivors from randomised trials or cohort studies of antenatal corticosteroids for up to 20 years. We have reviewed all five papers, together with another published since the guideline and Dalziel et al's paper extending follow-up to 31 years.4 5 We find the college guideline rigorous and appropriate.

    The risk of Steer's recommendation is discouraging others from discussing and offering a simple, safe, and effective evidence based preventive measure to women who, for whatever reason, require or plan an elective section before 39 weeks.

    Footnotes

    • Competing interests None declared.

    References

    1. 1.
    2. 2.
    3. 3.
    4. 4.
    5. 5.
    View Abstract

    Sign in

    Log in through your institution

    Free trial

    Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
    Sign up for a free trial

    Subscribe