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Steroids - plenty of benefits, but not without risk.

L 1969 study with sheep found improved survival for preterm delivered lambs after corticosteroid exposure.1 This work paved the way for one of the most important developments in antenatal care for patients at risk for preterm delivery. The subsequent randomized, placebocontrolled trial, which demonstrated reduced respiratory distress syndrome for pregnancies given betamethasone, likely changed antenatal care forever, as practices around the world incorporated antenatal steroids into their treatment protocols.2,3 The increased usage of steroids to decrease the frequency of respiratory distress syndrome, as well as severe intraventricular hemorrhage and necrotizing enterocolitis, has improved neonatal survival.2 Unfortunately, with all the benefits steroids provide to the fetus, one must consider their effects on the mother. For most, there is little effect, but for a few, serious consequences can arise. A number of trials have investigated an association between steroid administration and maternal infection.3,4 Although it is well described that there is a profound increase in white blood cell counts after steroid administration,3 risks for maternal infections (either antenatal or postdelivery) are either nonexistent, or only slightly increased.3,4 Significant maternal pulmonary edema also has been described.3 Muddying the water, many preterm labor patients treated with steroids also receive tocolytic therapy. Before tocolytic or steroid therapy, patients frequently are hydrated with large fluid boluses. Preparations should be made for prompt treatment of pulmonary edema for patients receiving steroids, particularly if they also receive tocolytic therapy with either beta agonists or magnesium sulfate, have coexisting cardiac disease, multiple pregnancies, or a high suspicion for an underlying subclinical infection. A well-established observation associated with steroid administration is some degree of maternal hyperglycemia.5 Glucose screens done within 5–7 days of steroid administration frequently will be abnormal, indicating a need for repeat testing 7–10 days after the initial testing.5,6 Most repeat studies will be found to be normal after a 7-day waiting period.5,6 Both betamethasone and dexamethasone exacerbate peripheral insulin resistance.7 This has been proposed as an explanation for this abnormal laboratory finding. Risks for diabetic ketoacidosis after steroid administration are well known for known diabetic patients, but diabetic ketoacidosis has also been described in patients with no prior history of glucose intolerance.8 Twins pregnancies have a greater mean glucose the first 24 hours after dexamethasone administration than singletons, so one should exercise appropriate preventive care.5 Evaluations of serum glucose and urine ketones after steroid administration would seem prudent so as to allow for preventive care, thus avoiding this life-threatening problem. See related article on page 433.