In Response

We thank Dr Jain for his letter about the antenatal corticosteroid recommendation in the 2014 SOGC guidelines, “Antenatal corticosteroids may be considered for women delivered by elective Caesarean delivery at≤38+6 weeks’ gestation to reduce respiratory morbidity (1-B; low quality of evidence/weak recommendation).”1.Magee L.A. Pels A. Helewa M. Rey E. von Dadelszen P. SOGC Hypertension Guideline Committee. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. SOGC Clinical Practice Guideline no. 307, May 2014.J Obstet Gynaecol Can. 2014; 36: 416-438Abstract Full Text Full Text PDF PubMed Scopus (293) Google Scholar, 2.Magee L.A. Pels A. Helewa M. Rey E. von Dadelszen P. on behalf of the Canadian Hypertensive Disorders of Pregnancy (HDP) Working Group Diagnosis, evaluation and management of the hypertensive disorders of pregnancy.Pregnancy Hypertens. 2014; 4: 105-145PubMed Scopus (269) Google Scholar We would like to emphasize that the strength of the recommendation was graded as “weak,” consistent with use of “may be considered” rather than “should be considered.” The magnitude of bias introduced by lack of blinding in the trial of Stutchfield et al. is unknown, but the trial nevertheless provides randomized trial evidence supporting use of corticosteroids before elective Caesarean.3.Stutchfield P. Whitaker R. Russell I. Antenatal Steroids for Term Elective Caesarean Section (ASTECS) Research Team. Antenatal betamethasone and incidence of neonatal respiratory distress after elective caesarean section: pragmatic randomised trial.BMJ. 2005; 331: 662Crossref PubMed Scopus (299) Google Scholar We included information on antenatal corticosteroids for acceleration of fetal pulmonary maturity in our 2014 guideline after debate within the committee. In the end, we put more weight on having a guideline that was a comprehensive source of information for maternity care providers caring for women with a hypertensive disorder of pregnancy (HDP), and less weight on mentioning aspects of care that are not the focus of HDP care. We were happy to reference other SOGC guidelines for detailed guidance about aspects of care that are not the focus of HDP care. However, the SOGC guideline on antenatal corticosteroids is out of date, having been published in 2002, and so we referenced more recent guidance related to care in the Royal College of Obstetricians and Gynaecologists Green-Top Guideline “Antenatal corticosteroids to reduce neonatal morbidity.”4.Royal College of Obstetricians and Gynaecologists Antenatal corticosteroids to reduce neonatal morbidity. RCOG, London (GB)2010Google Scholar We are uncertain why our recommendation “… has increasingly become a source of confusion for obstetricians and other practitioners involved in peripartum care of pregnant women.” The guideline is specifically about the HDPs, and it would be repetitive to re-state in every section that recommendations pertain only to women with one or more of the HDPs. Also, if any woman requires delivery for maternal or fetal reasons, and waiting 24-48 hours after corticosteroid administration is not deemed to be of greater benefit than risk, the woman should be delivered. This is true at 28+4 weeks before an emergency Caesarean section (for eclampsia, for example) or at 38+4 weeks before an elective Caesarean section in a woman with chronic hypertension. Dr Jain questions why antenatal corticosteroids would be beneficial before elective Caesarean section and not also for labour induction or even before spontaneous labour. The literature has already spoken to the benefits of labour in preparing the neonate for respiratory health postpartum, and administration of antenatal corticosteroids before something that is spontaneous (by definition) would represent not only an impossible challenge but one without supporting evidence. Importantly, there is no randomized trial evidence that pertains to delivery plans other than elective Caesarean section. Where we agree wholeheartedly with Dr Jain is in the need for an updated guideline on antenatal corticosteroids, to which Dr Jain could contribute his knowledge of the topic. We will be happy to update our recommendation and reference that document when it is published.