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