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ORIGINAL RESEARCH |
From the American College of Obstetricians and Gynecologists, Washington, DC; Mcmaster University, Department of Psychology, Hamilton, Ontario, Canada; and Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, California.
Address reprint requests to: Jay Schulkin, PhD American College of Obstetricians and Gynecologists Department of Research 409 12th Street, SW Washington, DC 20024-2188 E-mail: jschulkin{at}acog.org
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Abstract |
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Methods: Questionnaires mailed to 1020 ACOG Fellows included items on demographics, knowledge, clinical practice patterns, and educational background regarding antenatal corticosteroids.
Results: The survey response rate was 47.8%. Almost all respondents (94%) reported administering antenatal corticosteroids, with reduction of respiratory distress syndrome (82%) as the primary reason for antenatal corticosteroid administration. Most (59.2%) were unaware of newly recognized associations between multiple administrations of corticosteroids and fetal growth restriction. In hypothetical clinical situations, responses by physicians who completed their residency training before 1970 indicated less likelihood to administer corticosteroids when administration is relatively indicated per National Institutes of Health (NIH) and ACOG guidelines than those trained later (P < .001). Only 8% of the entire sample rated their knowledge of antenatal corticosteroids as comprehensive; most (68%) rated it as adequate. Respondents rated residency training as a much better source of antenatal corticosteroid knowledge than medical school.
Conclusion: Most obstetrician-gynecologists reported using antenatal corticosteroids; however, in general, many were not aware of more recent information regarding potential risks. This survey suggests that a multipronged educational approach is warranted to update obstetrician-gynecologists about antenatal corticosteroids.
Preterm births are associated with medical complications, such as respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis as well as other long-term morbidities. Antenatal corticosteroids are an effective treatment to reduce those neonatal complications.1 Adverse effects that might be associated with antenatal corticosteroid administration include increased risk of infection in the mother when premature rupture of membranes occurs, the potential for poor fetal growth in cases of multiple administrations, and subsequent developmental abnormalities.2–4 However, medical experts have advised that the neonatal benefits outweigh the maternal risks; hence, the National Institutes of Health (NIH) and ACOG published guidelines for the use of a single course of antenatal corticosteroids in obstetric practice.1,5
This study investigated the clinical decisions, knowledge, opinions, and education of obstetrician-gynecologists with respect to clinical circumstances that would predispose them toward or mitigate against antenatal corticosteroid administration. The survey also investigated their knowledge of new associations regarding potential side effects of corticosteroid administration. Because corticosteroid use has increased, it is important to know physicians’ practice patterns when administering corticosteroids, their knowledge of possible adverse effects in the mother and infant, and their usual source of knowledge for clinical information leading to changes in clinical practice. This information will help in developing educational tools for informing obstetrician-gynecologists about the evolving clinical effects of antenatal corticosteroid administration.
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Materials and Methods |
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AbstractMaterials and MethodsResultsDiscussionReferences |
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The survey was primarily in the form of multiple-choice questions pertaining to physicians’ practices and knowledge about antenatal corticosteroids and potential adverse effects. The questionnaire also contained items concerning demographic information, educational background, and clinical practice patterns related to steroid administration. Clinical scenarios designed to elicit physician responses in a Likert response format were also presented. Many cases were designed to simulate clinical scenarios described in the NIH Consensus Conference statement in which antenatal corticosteroid administration was clearly or relatively indicated. We also included case descriptions that called for more clinical judgment (less clearly indicated) in an effort to elicit a range of responses (eg, steroids before 24 weeks or after 34 weeks with a documented immature lung profile). Finally, we included survey items about popular myths or misperceptions regarding corticosteroid administration (eg, selective administration based on fetal sex) to determine the need for updated educational tools.
Data were analyzed using a personal computer-based software package, SPSS 9.0 (SPSS, Inc., Chicago, IL). Descriptive statistics were computed for the measures used in the analyses. Two-tailed t tests and analysis of variance were used to compare group means between the two groups. Differences on categorical measures were assessed using 
2 tests. Group differences on ordinal measures were assessed using the Mann-Whitney U test. All analyses were tested for significance using an alpha of .05. Given the emergence of corticosteroid administration as a new treatment paradigm, we divided the sample into three groups on the basis of residency year to evaluate the influence of education and training period on clinical practice patterns. Research on antenatal corticosteroids began in the early 1970s. Therefore, our first group completed their residencies between 1940 and 1970 (1940–1970 group). This group was not exposed to information about the use of antenatal corticosteroids during medical school or residency. Antenatal corticosteroids were not used regularly in North America until the 1980s, so the second group completed their residency training between 1971 and 1985 (1971–1985 group). We hypothesized that this group would have received some exposure to antenatal corticosteroid use during medical school or residency. The third group completed their residency training between 1986 and 2000 (1986–2000 group) and should have had more exposure to antenatal corticosteroid administration during their training than those who completed their residency in earlier years.
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Results |
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Most of the obstetrician-gynecologists practice in suburban (36.1%) or urban non-inner-city (31.7%) locations. The remainder were from urban inner-city (12.6%), rural (12.8%), military (2.5%), or other (2.9%) practice locations. Types of practice included obstetric-gynecologic partnership or group (43.9%), solo practice (22.3%), multispecialty group (13.4%), university faculty and practice (10.7%), health maintenance organization (3.1%), military (2.1%), and other (2.7%).
Almost all (94.4%) respondents reported that they administer antenatal corticosteroids in their practice and there was no difference in rate of antenatal corticosteroid administration between network and non-network respondents. Seventy percent of respondents reported that they have used an accelerated dosage regimen for antenatal corticosteroids, and 75.1% indicated that they administer multiple doses. Median number of deliveries reported by the sample was 15 per month (range 1–300), and respondents reported administering antenatal corticosteroids a median of once per month (range 0–80). Upper ranges are high because some respondents supervised large numbers of deliveries in their positions as full-time university faculty members. Almost all respondents (99.5%) reported that they most often administer antenatal corticosteroids between 25 and 34 weeks’ gestation. Only 0.4% indicated that they administer corticosteroids at an earlier gestational age, and none administer corticosteroids later than 35 weeks’ gestation.
Respondents ranked the indications for which they most frequently administer antenatal corticosteroids. Choices were prevention of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and neonatal mortality. The primary reasons given for administration of antenatal corticosteroids were prevention of respiratory distress syndrome (81.8%). The questionnaire included items regarding how soon or late after administration that the benefits of antenatal corticosteroids could be seen. Respondents did not agree on the timing. Some (27.9%) reported that benefits could be seen as early as 12 hours. Some (39.5%) reported that benefits could be seen between 13 and 24 hours. Others (27.3%) reported that benefits could be seen only 24 hours after administration. When asked how late the benefits of corticosteroids could be seen, 55.2% reported as late as 5–9 days. A few respondents (13.7%) indicated that benefits can be seen as late as 10–13 days, and 18% reported that benefits can be seen after as many as 14 days.
Six clinical vignettes of hypothetical situations describing patients at risk for preterm delivery were included in the questionnaire (Table 1
). Respondents were asked to indicate whether they would administer antenatal corticosteroids in each of those situations. The primary purpose of the questions was to determine the range of clinical practices in relatively common clinical situations. In all but situation 6, most respondents would administer antenatal corticosteroids; for situation 6, most would not administer them (Table 1).
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contains the percentages of obstetrician-gynecologists within each training-year category who responded "yes," "no," and "don’t know" to each clinical vignette. There were statistically significant differences in reported decisions to administer corticosteroids in four of the six situations. The differences reflect more reports of "don’t know" by obstetrician-gynecologists in the 1940–1970 group. Moreover, compared with physicians who completed training more recently, a larger number of physicians in the 1940–1970 group also reported that they would not administer antenatal corticosteroids in two of the clinical situations. Respondents were asked about their opinions on the more recently recognized association between antenatal corticosteroid administration and fetal growth restriction. More than half (59.2%) reported that they do not believe that antenatal corticosteroid administration is associated with fetal growth restriction. Only 12.6% reported they believed there was a relationship between antenatal corticosteroids and fetal growth restriction, whereas 18.6% indicated that they did not know whether a relationship exists.
We asked obstetrician-gynecologists to provide likelihood ratings regarding possible consequences of antenatal glucocorticoid administration on serum metabolic and hematologic factors. Likelihood ratings included a five-point Likert-type scale ranging from "very unlikely" to "very likely." Respondents rated the likelihood that antenatal corticosteroids can alter laboratory reports of glucose, potassium, and sodium levels and white blood count. Most agreed that it was somewhat likely or very likely to alter determinations of glucose (74.0%) and white blood count (70.1%). "Neither likely nor unlikely" was the modal rating for both the likelihood of potassium (35.7%) or sodium (37.1%) determination being altered. However, 30.8% believed it is somewhat or very unlikely for potassium, and 34.8% responded it is somewhat or very unlikely that antenatal corticosteroids can alter laboratory determinations of sodium. Respondents also provided likelihood ratings for higher risk of infection for women exposed to corticosteroids, higher risk of infection in women with PROM when exposed to corticosteroids, more difficulty diagnosing infection because corticosteroids mask signs of infection, and antenatal corticosteroids increasing the risk of pulmonary edema in the mother. For each risk, the modal rating by obstetrician-gynecologists was "somewhat likely" (26.4–39.0%). Although this was the modal response for each item, close inspection of the response rates found that, for three of the four items (higher risk of infection, corticosteroids masking signs of infection, and increased risk of pulmonary edema), slightly more obstetrician-gynecologists gave ratings on the "unlikely" side of the scale than on the "likely" side of the scale.
Most respondents rated their knowledge of antenatal corticosteroids as adequate (68.3%), and only 7.8% rated their knowledge as comprehensive. Of the remaining respondents, 13.4% rated their knowledge as marginal, and 1.7% rated their knowledge as inadequate.
When asked to rate their training in using antenatal corticosteroids during medical school, 6.0% of obstetrician-gynecologists rated their training as comprehensive, 12.0% rated their training as adequate, 17.5% as marginal, and 32.6% rated their training as inadequate. Thirty-two percent did not respond to this question. Ratings of training during their residency were much more positive. Fifty percent rated their residency training in antenatal corticosteroids as comprehensive, 15.7% as adequate, 4.9% as marginal, and 8.5% as inadequate. Twenty-one percent did not respond to this question. Ratings of continuing medical education courses were also good; 30.9% rated continuing medical education training as comprehensive, 28.5% as adequate, 8.7% as marginal, and 6.6% as inadequate. Twenty-five percent did not rate their continuing medical education course training.
Respondents rated the importance of various possible sources of information regarding antenatal corticosteroids. For each possible source, the rating scale provided was: 1 = an important source of knowledge; 2 = a source of knowledge; 3 = a minor source of knowledge; 4 = not a source of knowledge. Few (18.0%) considered medical school a source or an importance source of knowledge. Many (65.4%) obstetrician-gynecologists considered residency training and other sources of knowledge, such as continuing medical education courses (59.4%), ACOG publications (68.2%), journal articles (70.3%), and textbooks (49.0%) as sources or important sources of knowledge on antenatal corticosteroid use.
As hypothesized, knowledge and training about antenatal corticosteroids also varied based on the year residency training was completed. Although most (57.9%) obstetrician-gynecologists in the 1940–1970 group rated their knowledge of antenatal corticosteroids as adequate, members of this group were more likely to rate their knowledge as marginal (31.6%) or inadequate (7.9%) than those who completed residency training more recently (2 = 30.33, P < .001). Although most obstetrician-gynecologists in the 1940–1970 group reported that they administer antenatal corticosteroids in their practice (85.4%), members of this group were more likely to not use antenatal corticosteroids than those who completed residency training in more recent years (2 = 18.91, P < 001).
Obstetrician-gynecologists in the 1940–1970 group were more likely than those in the other groups to rank medical school as not a source of knowledge of antenatal corticosteroids (2 = 14.07, P = 029). Those in the 1986–2000 group were more likely than those who received their training in earlier years to rate their residency training as comprehensive (2 = 135.86, P < 001). Similarly, textbooks were more likely to be a source or an important source of knowledge for those in the 1986–2000 group than those who received their training earlier (2 = 19.40, P = 004). Continuing medical education courses are more likely to be an important source of knowledge for those in the 1940–1970 and the 1971–1985 groups than for those who received their training after 1985 (2 = 21.15, P = 002), although many (40.4%) who received their training since 1985 rated continuing medical education courses as a source of knowledge. Most respondents in each residency group rated journal articles and ACOG publications as sources or important sources. Many obstetrician-gynecologists who received their residency training before 1985 rated other sources of information as important; many of these other sources are conversations with colleagues, especially neonatologists.
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Discussion |
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Knowledge about potential adverse effects of corticosteroid administration on serum metabolic and hematological factors (changes in glucose levels and white blood count) was adequate. This is not surprising given the concern about masking infection and the tendency to follow serial white blood cell counts of patients with preterm labor or PROM.2,7,8 Despite theoretical concerns,3 antenatal corticosteroids do not appear to mask infection, and PROM is not a contraindication.1,5,9
With regard to more recently recognized potential complications, respondents had definite opinions about fetal growth restriction. Although reports about fetal growth restriction in humans are relatively isolated, most respondents indicated that they did not believe it is associated with corticosteroid administration. This understanding appears to be supported in the early literature,9,10 but recent studies found decreased growth in humans when steroids were used before 28 weeks or when multiple doses of glucocorticoids were administered.4,11 Unfortunately, the survey question did not specify single or multiple injections of corticosteroids. The opinion of the respondents might be related to their knowledge that the association is specific to multiple administrations.
The tendency to re-treat emerged based on the original data of Liggins and Howie12 that the beneficial effect of corticosteroids did not persist after 7 days, but more recent studies suggested a persistent beneficial clinical effect after treatment.9 More importantly, Banks et al13 reported that the incidence of respiratory distress syndrome between 25 and 32 weeks was the same for patients receiving one course of corticosteroids compared with two or more courses. In light of evolving data regarding potential harm of repetitive dosing, risks and benefits of additional doses should await prospective randomized human clinical trials as discussed in the recent NIH guidelines conference.14
With regard to the six clinical vignettes, the likelihood of the two older groups of physicians to administer corticosteroids decreased as the indications became more relative. This result might be due to their experience with antenatal corticosteroid administration, leading to more caution in clinical decision-making. Those who completed residency training after 1986 were the most likely to administer antenatal corticosteroids in all cases presented. In two vignettes indications were clearly based on the NIH consensus statement, in two other vignettes indications were relatively based on high likelihood of delivery before 34 weeks’ gestation, and in two cases no guidelines were available. Seventy to 90% of respondents would give corticosteroids in the clear indication vignettes.
Obstetrician-gynecologists trained before 1970 were less likely to give steroids in cases of PROM at 27 weeks, which could reflect overall training and experience regarding corticosteroids or the clinical opinion pervasive during the 1970s and early 1980s of decreased risk of respiratory distress syndrome in infants born after PROM.15,16 Training during that time period might explain the apparent hesitancy of those physicians to administer corticosteroids despite more recent publications regarding improved neonatal benefit.9,17
Two cases involved medical complications placing the patient at risk of preterm delivery and therefore had relative indications for antenatal corticosteroid administration. In these situations, 40–80% of respondents would administer corticosteroids, and there was a strong relationship with era of residency training. In the last two cases the respondents as a group would give a second dose of steroids to a woman at high risk, whereas few would give it after 35 weeks, even when fetal lung immaturity was present. Again, the linear training effect was apparent, with more physicians in the 1986–2000 group responding that they would administer corticosteroids.
Differences in reported antenatal corticosteroid administration practices were reflected in self-reported knowledge of antenatal corticosteroids, with physicians trained in earlier years less likely to rate their knowledge as adequate than those who completed training more recently. Respondents reported obtaining information on steroid administration from continuing medical education courses, journal articles and ACOG publications, and other sources. Concerted effort should be made to providing information about antenatal corticosteroid administration.
Finally, previous studies were not able to demonstrate an impact on physician practices after expert policy statements,18,19 but sequential studies of antenatal corticosteroid administration demonstrated increased use since publication of the NIH and ACOG statement.20,21 This study suggests that antenatal corticosteroids might be underused in some clinical situations (eg, PROM or medically indicated preterm births) and overused in others (eg, repetitive dosing). Information from survey participants indicated that a multi-pronged educational approach is warranted to reach as many obstetrician-gynecologists as possible because physicians obtain knowledge in different ways, some of which may be age dependent.
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Footnotes |
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Received July 10, 2000. Received in revised form September 28, 2000. Accepted October 12, 2000.
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References |
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2. Taeusch HW Jr. Glucocorticoid prophylaxis for respiratory distress syndrome: A review of potential toxicity. J Pediatr 1975;87:617–23.[Medline]
3. Jobe AH, Wada N, Berry LM, Ikegami M, Ervin MG. Single and repetitive maternal glucocorticoid exposures reduce fetal growth in sheep. Am J Obstet Gynecol 1998;178:880–5.[Medline]
4. French NP, Hagan R, Evans SF, Godfrey M, Newnham JP. Repeated antenatal corticosteroids: Size at birth and subsequent development. Am J Obstet Gynecol 1999;180:114–21.[Medline]
5. American College of Obstetricians and Gynecologists. Antenatal corticosteroid therapy for fetal maturation. ACOG committee opinion no. 210, Washington, DC: American College of Obstetricians and Gynecologists, 1998.
6. Ikegami M, Polk D, Jobe A. Minimum interval from fetal beta-methasone treatment to postnatal lung responses in preterm lambs. Am J Obstet Gynecol 1996;174:1408–13.[Medline]
7. Denison FC, Elliott CL, Wallace EM. Dexamethasone-induced leukocytosis in pregnancy. Br J Obstet Gynaecol 1997;104:851–3.[Medline]
8. Ohlsson A, Wang E. An analysis of antenatal tests to detect infection in preterm premature rupture of the membranes. Am J Obstet Gynecol 1990;162:809–18.[Medline]
9. Crowley PA. Antenatal corticosteroid therapy: A meta-analysis of the randomized trials 1972 to 1994. Am J Obstet Gynecol 1995;173: 322–35.[Medline]
10. Smolders-de-Hass H, Neuvel J, Schmand B, Treffers PE, Kopp JG, Hoeks J. Physical development and medical history of children who were treated antenatally with corticosteroids to prevent respiratory distress syndrome: A 10- to 12-year follow up. Pediatrics 1990;86:65–70.
11. Bennet L, Kozuma S, McGarrigle HH, Hanson MA. Temporal changes in fetal cardiovascular, behavioural, metabolic and endocrine responses to maternally administered dexamethasone in the late gestation fetal sheep. Br J Obstet Gynaecol 1999;106:331–9.[Medline]
12. Liggins GC, Howie RN. A controlled trial of antepartum glucocorticoid treatment for prevention of the respiratory distress syndrome in premature infants. Pediatrics 1972;50:515–25.
13. Banks BA, Cnaan A, Morgan MA, Parer JT, Merrill JD, Ballard PL, et al. Multiple courses of antenatal corticosteroids and outcome in premature neonates. North American Thyrotropin-Releasing Hormone Study Group. Am J Obstet Gynecol 1999;181:709–17.[Medline]
14. National Institutes of Health. Antenatal corticosteroids revisited: Repeat courses. NIH Consensus Statement 2000;17:1–10.[Medline]
15. Sell EJ, Harris TR. Association of premature rupture of membranes with idiopathic respiratory distress syndrome. Obstet Gynecol 1977;49:167–9.
16. Thibeault DW, Emmanouilides GC. Prolonged rupture of fetal membranes and decreased frequency of respiratory distress syndrome and patent ductus arteriosus in preterm infants. Am J Obstet Gynecol 1977;129:43–6.[Medline]
17. Morales WJ, Diebel ND, Lazar AJ, Zadrozny D. The effect of antenatal dexamethasone administration on the prevention of respiratory distress syndrome in preterm gestations with premature rupture of membrane. Am J Obstet Gynecol 1986;159:591–5.
18. Soliman SR, Burrows RF. Cesarean section: Analysis of the experience before and after the National Consensus Conference on Aspects of Cesarean Birth. CMAJ 1993;148:1315–20.[Abstract]
19. Grilli R, Lomas J. Evaluating the message: The relationship between compliance rate and the subject of a practice guideline. Med Care 1994;32:202–13.[Medline]
20. Bronstein JM, Goldenberg RL. Practice variation in the use of corticosteroids: A comparison of eight data sets. Am J Obstet Gynecol 1995;173:296–8.[Medline]
21. Leviton LC, Goldenberg RL, Baker CS, Schwartz RM, Freda MC, Fish LJ, et al. Methods to encourage the use of antenatal corticosteroid therapy for fetal maturation: A randomized controlled trial. JAMA 1999;281:46–52.
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