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North American Journal of Medical Sciences | February 2014 | Volume 6 | Issue 2 | 71
Review Article
Introduction
Glucocorticoids are drugs, which have multiple effects on
carbohydrate, protein, and lipid metabolism, as well as
other aspects of homeostasis. They are also potent anti-
inammatory and immunosuppressive molecules. One
common side-effect of these drugs is their propensity to
cause hyperglycemia. These drugs are used in pregnancy
to accelerate lung maturity in the preterm fetus.
Antenatal corticosteroids were rst recommended for
use in the National Institutes of Health (NIH) Consensus
Development Conference statement 1995.[1] Use of
glucocorticoids, i.e., dexamethasone or betamethasone,
in antenatal mothers at risk of preterm delivery,
prevents respiratory distress and lowers the risk of
hyaline membrane disease in their preterm infants.
Glucocorticoids increase alveolar surfactant, improve
pulmonary compliance, and expand maximal lung
volume in the fetus. This occurs due to induction of
protein synthesis in surfactant-producing type II cells
in the fetal lung.[2]
Rationale of Antenatal Corticosteroid
Treatment (ACS) in Diabetes
The need for ACS in threatened preterm pregnancies is
being felt in modern obstetric medicine. In women with
diabetes, this need is even more pronounced. Antenatal
women with diabetes are at higher risk of experiencing
various obstetric and medical complications. Fetal
lung maturity is delayed in pregnancies where
euglycemia is not achieved. These facts imply that
ACS may be required to improve neonatal survival
in preterm pregnancies complicated by diabetes. ACS
therapy is absolutely contraindicated in systemic
maternal infections such as tuberculosis, and advised
with caution in chorio-amnionitis.[3] These medical
aspects have to be considered before prescribing ACS
in immuno-compromised states like uncontrolled
diabetes.
Use of antenatal corticosteroid prophylaxis for threatened
preterm labor has become more prevalent in recent
years. Gestational diabetes is not considered a relative
contraindication for ACS. In fact, women with gestational
Glycemic Management after Antenatal
Corticosteroid Therapy
Sanjay Kalra, Bharti Kalra1, Yashdeep Gupta2
Departments of Endocrinology, 1Obstetrics and Gynecology, Bharti Hospital, Karnal, Haryana, 2Medicine, Government
Medical College and Hospital, Chandigarh, India
Abstract
Antenatal corticosteroids (ACS) are recommended for use in antenatal mothers at risk of preterm delivery before 34 weeks. One common
side-effect of these drugs is their propensity to cause hyperglycemia. A PubMed search was made using terms ‘steroid,’ ‘dexamethasone,’
‘betamethasone’ with diabetes/glucose. Relevant articles were extracted. In addition, important cross-reference articles were reviewed. This
review, based upon this literature search, discusses the available evidence on effects on glycemic status as well as management strategies in
women with pre-existing diabetes, gestational diabetes mellitus, as well as normoglycemic women after ACS use in pregnancy.
Keywords: Antenatal corticosteroid therapy, Betamethasone, Diabetes, Dexamethasone, Gestational diabetes mellitus, Pregnancy
Address for correspondence: Dr. Sanjay Kalra, Department of Endocrinology, Bharti Hospital, Kunjpura Road, Karnal, Haryana -132 001, India.
E-mail: brideknl@gmail.com
Access this article online
Quick Response Code: Website:
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DOI:
10.4103/1947-2714.127744
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Kalra, et al.: Glycemic Management after ACS Therapy
North American Journal of Medical Sciences | February 2014 | Volume 6 | Issue 2 |
72
diabetes were more likely (odds ratio 1.21; 95%
condence interval 1.05-1.40) to receive ACS in a study
conducted in British Columbia, Canada.[4]
Points to Ponder
As the prevalence of gestational diabetes mellitus (GDM)
increases, queries arise as to the
1. Indications for ACS in pre-existing, overt or GDM
complicated by threatened preterm delivery
2. Effects of ACS on glycemia
in previously euglycemic antenatal women
in women with GDM
in women with pre-existing diabetes (T1DM and
T2DM)
3. Glycemia monitoring in
all women receiving ACS
patients with GDM receiving ACS
patients with pre-existing or overt diabetes
4. Glycemic management after ACS administration
Answers to these questions can be gleaned from
recommendations and guidelines proposed by the
National Institutes of Health (NIH), on use of ACS in
1995, and on repeated courses of ACS in 2000;[1,5] the Royal
College of Obstetricians and Gynecologists (RCOG) in
2010;[6] the Cochrane reviews on this topic,[7-9] as well
as the WAPM.[3] Recent studies on the subject, though
few in numbers, also provide valuable guidelines. Yet,
some questions still remain unanswered. This review
tries to explore the lacunae in our knowledge of ACS in
diabetes, and proposes solutions based on the concept
of logical empiricism.
Issue 1: Indications for ACS in GDM
Complicated by reatened Preterm
Delivery
In general, the indications for ACS are driven by obstetric
and perinatal, rather than medical, factors. Indications
remain the same, irrespective of glycemic status. The
NIH Consensus Development Panel of 1995 firmly
conducted that it was reasonable to use ACS in diabetes,
though the experts could not nd sufcient data for the
use of ACS in pregnancy complicated by diabetes.[1]
World Association of Perinatal Medicine (WAPM)
clearly recommends ACS in antenatal women with
diabetes. It calls for “close monitoring and treatment by
an experienced obstetrical team” to guarantee diabetic
control” and “to avoid the possibility of severe transient
hyperglycemia.”[3]
A similar suggestion is made by the Fifth International
Workshop – Conference on Gestational Diabetes Mellitus
(2007). The recommendation acknowledges that the
frequency of preterm delivery is higher in women with
untreated GDM. It recommends following normal
indications for the use of ACS, albeit with “intensied
monitoring of maternal glucose levels” and “temporary
addition or increase of insulin doses.”[10]
However, the National Institute of Health and Clinical
Excellence (NICE) have published a clinical guideline
for diabetes in pregnancy that states that ‘diabetes
should not be considered a contra-indication to antenatal
corticosteroids.’[11]
The conventional antenatal corticosteroid regimes:
Betamethasone 12 mg IM q24h x 2 doses, or
dexamethasone 6 mg IM q12h x 4 doses, can be used
in diabetes. Unpublished data from our hospital
shows that three doses of betamethasone 8 mg, given
at 12 hourly intervals, lead to less hyperglycemia than
the conventional dosage regimes. Though the total
steroid dose remains the same, the lower boluses of
dexamethasone lead to lower glycemic peaks in patients
with GDM or pre-existing diabetes.
It must be remembered that strict maternal glycemic
control per se reduces the incidence of respiratory distress
syndrome in neonates of mothers with diabetes.
Suggestion
In consonance with all international guidelines, ideally,
all women with threatened preterm should receive ACS
as per routine obstetric practice, irrespective of diabetes
status.
The decision of prescribing ACS should be individualized,
based on the benet: risk rates in the particular clinical
situation. Lack of expertise in managing diabetes, for
example, may be a relative contraindication for ACS in
borderline patients. The availability of neonatal care will
also have a bearing upon obstetric decision making. In
doubtful cases, a team-based shared decision-making
approach, involving all members of the perinatal
care team- the endocrinologist, obstetrician, and
neonatologist, should be followed.
In extreme cases, where ACS may jeopardize maternal
health, e.g., in diabetic ketoacidosis or fulminant
infection, maternal health should take precedence over
fetal prophylaxis.
Issue 2: Eects of ACS on Glycemia
Long-term steroid therapy and GDM
The increased risk of GDM receiving long-term
glucocorticoid therapy is well-known,[12,13] but the effect
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Kalra, et al.: Glycemic Management after ACS Therapy
North American Journal of Medical Sciences | February 2014 | Volume 6 | Issue 2 | 73
of a few doses of corticosteroids on glucose metabolism
is less documented, especially in a cohort of persons
already at high risk of glucose intolerance. In general,
the glycemic effect of steroids begins about 12 hours after
the rst dose and lasts up to 5 days.[3]
ACS in women without pre-existing diabetes
In 10 healthy pregnant women volunteers, acting as
a control group, betamethasone in a dose of 12 mg
twice daily for one day was shown not to induce
hyperglycemia. However, this study by Ramirez-Torres
et al. monitored only fasting and post-prandial blood
glucose.[14]
In a retrospective study involving laboratory recorded
records of 3396 patients, Fisher et al. analyzed the
incidence of diagnosed GDM in patients receiving ACS.
Patients who received ACS for threatened preterm
delivery (n = 50) were more likely to have abnormal
one hour post-glucose challenge values (60% vs. 25%,
P < 0.001) and abnormal 3 hour glucose tolerance tests
(23.8% vs. 4.0%; P < 0.001%) than controls (n = 1985) who
were not exposed to ACS.[15]
In apparently healthy women, though fasting and post-
prandial glucose levels may remain normal after ACS,
50 g glucose challenge test may provide false-positive
reports (Gurbuz et al). Plasma glucose values measured
one hour after administration of 50 g glucose were higher
at 24 hours after ACS administration, as compared to
the tests done prior to ACS, (P < 0.001) in non-diabetic
women at risk of preterm labor. However, there was no
difference observed at 72 hours (P = 0.96) and 7 days
(P = 0.99) after ACS therapy. Screening results were
positive in 42.5%, 10%, and 5% of subjects, at 24 hours,
72 hours, and 7 days.[16]
In another study, using continuous glucose monitoring
(GDM), Refuerzo et al. identied a 16% to 33% increase
in glucose levels in pregnant women without diabetes,
at 20, 44, and 68 hours after receiving the rst dose of
ACS. A higher risk of 33% to 48% was noticed at the
same time periods in woman with diabetes. CGM is
thus able to identify short, but signicant, episodes of
hyperglycemia after ACS, which may be missed with
conventional monitoring.[17]
ACS in women with diabetes
In a retrospective study of 55 patients with diabetes
who received ACS, the impact on fasting and 2 hour
post-prandial glucose was measured. Fasting glucose
levels were elevated >95 mg% in over 90% of women on
day 2 and day 3 after ACS administration. At least one
post-prandial glucose value was elevated (>120 mg %)
in 81%-98% of women on days 1 through 3.[18]
Suggestion
There is no recommendation by any international
professional body to check blood glucose prior to
prescription of ACS. However, we strongly recommend
checking casual blood glucose before administering
corticosteroids to any person. This is indicated in view
of the high prevalence of GDM, and ts well with the
concept of targeted screening in high-risk persons. The
results also help inform decisions regarding the need
for further maternal surveillance, including ketonuria
and glycemia, the need for medical nutrition therapy,
and the possibility of insulin therapy. Most importantly,
this simple, economical investigation helps determine
the etiology and temporal prole of hyperglycemia, so
that dysglycemia detected later on in pregnancy or the
postpartum period is not attributed iatrogenic causes
(ACS) by the patient and her family.
Steroid use should warrant more aggressive screening for
GDM, above and beyond routine recommendations.[19]
Issue 3: Glycemia Monitoring in Peri-ACS
Period
Recommendations for screening for gestational diabetes
mellitus are a subject of great controversy. None of the
various recommendations specically suggest screening
methods for women receiving ACS.
As described earlier, 50 g glucose challenge test may
provide false-positive reports immediately after ACS.
Studies imply that screening tests for GDM should not be
performed for up to 1 week after ACS administration.[16]
Suggestion
Euglycemic women should undergo screening for GDM
as per routine obstetric practice. However, steroid use
should warrant more aggressive screening for GDM,
above and beyond routine recommendations. Blood
glucose estimation must be done prior to administration
of ACS. Regular frequent feto-maternal surveillance
must be carried out in the patient-ward for at least 5 days
after ACS administration.
Frequency and nature of monitoring required will vary
with the nature of diabetes. The need for monitoring in
various types of diabetes is listed in descending order,
as follows: Pre-existing type 1 diabetes mellitus, pre-
existing type 2 diabetes mellitus, gestational diabetes
mellitus on insulin, and gestational diabetes mellitus on
medical nutrition therapy.
Ideal frequency of monitoring in antenatal women
with diabetes is a 7 point prole, including 3 pre- meal
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Kalra, et al.: Glycemic Management after ACS Therapy
North American Journal of Medical Sciences | February 2014 | Volume 6 | Issue 2 |
74
estimations, 3 post-meal estimations, and a 3 am value.
This is concordant with recommendation for routine
management of gestational diabetes mellitus.[10] Urine
ketone estimation and continuous glucose monitoring
may be considered in select patient populations.
Issue 4: Glycemic Management in Women
with Diabetes aer ACS Administration
The challenges in management of glycemia after ACS
are well documented. No simple, one-size-fits-all
solution is available for this clinical challenge. An
individualized approach is necessary, because of the
wide inter-individual and intra-individual variability
noted in degree and duration of hyperglycemia after
steroid injections.
The NICE guideline recommends that diabetic women
receiving steroids should have additional insulin
according to an agreed protocol.[11] The national
Indian guidelines on indoor management of diabetes
recommend a 20% increase in the dose of insulin in
persons with diabetes who receive steroid therapy.[20]
In the study by Ramirez-Torres,[14] patients with GDM,
treated by diet alone, required insulin de novo in 40%
cases, which those already on insulin needed an increase
of 39% to 112% in the daily insulin dose. An increased
requirement of 26% to 64% was documented in women
with pre-existing type 2 diabetes mellitus on insulin
therapy. The greatest changes occurred on the 2nd, 3rd, and
4th day after ACS therapy. This nding highlights the need
for regular glycemic monitoring during this period, and a
proactive increase in insulin doses, if clinically indicated.
In another retrospective study of 55 patients with
diabetes who received ACS, insulin had to be started
in 11 of 19 women earlier controlled on diet, and in
3 of 6 patients earlier controlled with glyburide.[18]
Kaushal et al. published a nurse-driven protocol to
manage diabetes and prevent hyperglycemia after
the use of intramuscular dexamethasone in antenatal
women. They continued subcutaneous insulin and diet
and added intravenous insulin infusion from the rst
dexamethasone dose until 12 h after the second. Titration
was based on hourly blood glucose measurements, using
any of four-graded sliding scales, selected according
to the patient’s current subcutaneous insulin dose and
modified as per blood glucose values. The median
amount of supplementary intravenous insulin required
was 74 U (range 32-88 U).[21]
A proactive approach to insulin dose modication may
help control glycemia after ACS and avoid deleterious
effects to both mother and fetus. An increase in dose
of 16% to 40% has been recommended by various
authors.[18,22]
Suggestion
Medical nutrition therapy should be reinforced in all
patients receiving ACS, irrespective of prior glycemic
status. High calorie foods should be avoided for up to 5
days after ACS administration.
Insulin therapy may be required for a short period,
after ACS therapy, in women who were previously well
controlled on medical nutrition therapy. Both the patient
and the health care provider should be prepared for such
a possibility.
In patients already on insulin, an increase in dosage
or a change in insulin regime may be mandated. If
glycemic control is not achieved by increasing the dose
of insulin by 20-30%, it may be advisable to increase
the number of injections per day. This can be done by
adding rapid acting insulin by substituting pre-mixed
insulin with rapid acting insulin or by changing basal
insulin to pre-mixed or basal bolus regime [Table 1]. In
rare cases, intravenous insulin may be needed to achieve
glycemic control. Indications for intravenous insulin
include ketoacidosis, highly uncontrolled glycemia
not responding to subcutaneous insulin, and fetal or
maternal distress deemed due to hyperglycemia.
Regular glycemic monitoring is necessary with
intensive insulin therapy and is the basis of insulin dose
adjustment. Hyperglycemia and hypokalemia both,
which are side-effects of aggressive insulin therapy, are
linked with intrauterine death and must be avoided.
Feto-maternal surveillance should continue along with
routine obstetric care.
The national Indian guidelines, which recommend a
20% increase in dose, seem a reasonable suggestion. A
small subset of patients, however, may require more
aggressive up titration.
Summary
ACS has proven benefits for neonatal survival in
antenatal women with threatened preterm labor, many
of whom may have co-existing diabetes. All women
with threatened preterm should receive ACS as per
routine obstetric practice irrespective of diabetes status.
Exceptions will include medical conditions that may
worsen with steroid therapy.
Blood glucose estimation must be done prior to
administration of ACS. Regular frequent fetomaternal
surveillance must be estimated on indoor basis for at
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Kalra, et al.: Glycemic Management after ACS Therapy
North American Journal of Medical Sciences | February 2014 | Volume 6 | Issue 2 | 75
least 5 days after ACS administration. Frequency and
nature of monitoring required will vary with the nature
of diabetes.
Medical nutrition therapy should be reinforced in all
patients receiving ACS irrespective of prior glycemic
status. Supplementary insulin should be added, using
a proactive approach, to minimize the negative impact
of hyperglycemia upon mother and fetus. However,
individualization of therapy is needed to ensure optimal
management.
There is a great need for further research in this
important, yet relatively neglected, eld of obstetric
diabetology.
References
1. Effect of Corticosteroids for Fetal Maturation on Perinatal
Outcomes. NIH Consens Statement 1994;12:1-24.
2. Ballard PL, Ballard RA. Scientific basis and therapeutic
regimens for use of antenatal glucocorticoids. Am J Obstet
Gynecol 1995;173:254-62.
3. Miracle X, Di Renzo GC, Stark A, Fanaroff A, Carbonell-
Estrany X, Saling E; Coordinators Of World Associatin of
Perinatal Medicine Prematurity Working Group. Guideline
for the use of antenatal corticosteroids for fetal maturation.
J Perinat Med 2008;36:191-6.
4. Kazem M, Hutcheon JA, Joseph KS. A population-based study
of antenatal corticosteroid prophylaxis for preterm birth.
J Obstet Gynaecol Can 2012;34:842-8.
5. Antenatal corticosteroids revisited: Repeat courses. NIH
Consens Statement 2000;17:1-18.
6. Roberts D, Dalziel SR. Antenatal corticosteroids for
accelerating fetal lung maturation for women at risk of
preterm birth. Cochrane Database Syst Rev 2006;3:CD004454.
7. Crowther CA, Harding JE. Repeat doses of prenatal
corticosteroids for women at risk of preterm birth for
preventing neonatal respiratory disease. Cochrane Database
Syst Rev 2007;3:CD003935.
8. Brownfoot FC, Crowther CA, Middleton P. Different
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9. Royal College of Obstetricians and Gynaecologists (RCOG).
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mortality. London (UK): Royal College of Obstetricians and
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National%20Guidelines/RCOG%20No7.pdf).
10. Metzger BE, Buchanan TA, Coustan DR, de Leiva
A, Dunger DB, Hadden DR, et al. Summary and
recommendations of the Fifth International Workshop-
Conference on Gestational Diabetes Mellitus.
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11. National Institute for Health and Clinical
Excellence. Diabetes in pregnancy: Management of
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postnatal period. London: NICE, 2008. (Accessed August
4, 2013, at http://www.nice.org.uk/nicemedia/pdf/
CG63NICEGuidelineReissue.pdf).
12. Ha Y, Lee KH, Jung S, Lee SW, Lee SK, Park YB. Glucocorticoid-
induced diabetes mellitus in patients with systemic lupus
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Lupus 2011;20:1027-34.
13. Yildirim Y, Tinar S, Oner RS, Kaya B, Toz E. Gestational
diabetes mellitus in patients receiving long-term corticosteroid
therapy during pregnancy. J Perinat Med 2006;34:280-4.
14. Ramírez-Torres MA, Pérez-Monter SE, Espino y Sosa S,
Ibargüengoitia-Ochoa F. Effect of betamethasone in blood
glucose levels in pregnant diabetic women at risk of preterm
birth. Ginecol Obstet Mex 2011;79:565-71.
15. Fisher JE, Smit h RS, Lagrandeur R, Lorenz RP. Gestational diabetes
mellitus in women receiving beta-adrenergics and corticosteroids
for threatened preterm delivery. Obstet Gynecol 1997;90:880-3.
16. Gurbuz A, Karateke A, Ozturk G, Kabaca C. Is 1-hour
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administration of antenatal betamethasone? Am J
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17. Refuerzo JS, Garg A, Rech B, Ramin SM, Vidaeff A, Blackwell
SC. Continuous glucose monitoring in diabetic women
following antenatal corticosteroid therapy: A pilot study. Am
J Perinatol 2012;29:335-8.
Table 1: Strategies for glycemic control aer antenatal corticosteroid (ACS) therapy
Therapy Suggested therapy after ACS
Glycemic status Current Regimen
of patient Well controlled glycemia Poorly controlled glycemia
Medical nutrition therapy (MNT) Strict MNT Rapid acting insulin
Basal Insulin Dose optimization of basal insulin Intensify basal insulin to either pre-mixed insulin
or basal bolus regime
Pre-mixed insulin Dose optimization of pre-mixed insulin
Addition of rapid acting insulin to pre-mixed
insulin: either a Mix — Rapid — Mix or a
Rapid- Rapid-Mix regime can be followed
with three meals.
Intensify pre-mixed insulin to basal bolus regime
Addition of rapid acting insulin to pre-mixed
insulin, either a
Mix- Rapid — Mix or a
Rapid- Rapid-Mix regime can be followed.
Intravenous insulin
Basal bolus insulin Dose optimization
Addition of correction doses of rapid acting
insulin
Addition of subcutaneous correction doses
Intravenous Insulin
MNT = Medical nutrition therapy
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Kalra, et al.: Glycemic Management after ACS Therapy
North American Journal of Medical Sciences | February 2014 | Volume 6 | Issue 2 |
76
18. Kreiner A, Gil K, Lavin J. The effect of antenatal corticosteroids
on maternal serum glucose in women with diabetes. Open J
Obstet Gynecol 2012;2:112-5.
19. Kitzmiller JL, Block JM, Brown FM, Catalano PM, Conway
DL, Coustan DR, et al. Managing preexisting diabetes
for pregnancy: Summary of evidence and consensus
recommendations for care. Diabetes Care 2008;31:1060-79.
20. Bajwa SS, Baruah MP, Kalra S, Kapoor MC. Guidelines on
Inpatient Management of Hyperglycemia. In: Muruganathan
A, editor. Medicine Update. Vol. 23. Association of Physicians
of India; 2013. p. 164-9.
21. Kaushal K, Gibson JM, Railton A, Hounsome B, New JP,
Young RJ. A protocol for improved glycaemic control
following corticosteroid therapy in diabetic pregnancies.
Diabet Med 2003;20:73-5.
22. Mathiesen ER, Christensen AB, Hellmuth E, Hornnes P, Stage
E, Damm P. Insulin dose during glucocorticoid treatment
for fetal lung maturation in diabetic pregnancy: Test of an
algorithm [correction of analgoritm]. Acta Obstet Gynecol
Scand 2002;81:835-9
How to cite this article: Kalra S, Kalra B, Gupta Y. Glycemic management
after antenatal corticosteroid therapy. North Am J Med Sci 2014;6:71-6.
Source of Support: Nil. Conict of Interest: None declared.
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