Discussion
From 2011 to 2015, we observed an increase in the proportion of women
with pre-gestational diabetes who received ACS prior to elective
caesarean section. However, the proportion of women receiving ACS prior
to elective caesarean section declined after this until 2019. This
decline may have resulted from the publication of the Australian and New
Zealand Clinical Practice Guideline in 2015, which did not recommend
administration of ACS to this population.13 When
comparing women who received ACS to those that did not, we did not find
a statistically significant difference in the proportion of neonates who
required admission to high level nursery care, that had respiratory
distress, hypoglycaemia or sepsis, however we did observe some
potentially clinically significant findings which are biologically
plausible and consistent with previous observational studies.
A number of studies have indicated reductions in the rates of newborn
respiratory morbidity in infants born to women who received ACS prior to
elective caesarean section at term2-4 or late
preterm.16 A small retrospective case-control study
investigating the use of ACS prior to elective caesarean section in
women with gestational diabetes showed a significantly reduced risk of
special care nursery admission for respiratory distress but a higher
rate of neonatal hypoglycaemia requiring treatment.17Of note, all women who received ACS were treated with intravenous
insulin and dextrose infusions to prevent maternal
hyperglycaemia.17 Our larger retrospective study was
unable to confirm the findings with respect to the neonatal outcomes.
Previous randomised trials have largely excluded women with
pre-gestational diabetes, however, clinicians have extrapolated the
findings of those studies to include women with pre-gestational
diabetes. Women with pre-gestational diabetes have higher risks of
adverse pregnancy outcomes and thus frequently require elective birth at
late pre-term or early term gestations. Despite the paucity of robust
scientific evidence for the benefit of ACS in this cohort, clinicians
have shown an enthusiasm in prescribing ACS prior to elective caesarean
section in this study despite the lack of
evidence.18,19