“Antenatal Corticosteroids” – with Dr. Celia Muoser

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB/GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, Dr. Celia Muoser, welcome to the podcast. You’re maiden voyage into the podcast here. This is great.

Dr. Muoser: Thank you, thank you. Excited.

Dr. Fox: Have you podcasted elsewhere and just not here or you’ve never done it before?

Dr. Muoser: No, definitely not. First-ever podcast.

Dr. Fox: How’s it going so far?

Dr. Muoser: So far so good.

Dr. Fox: Well, you sound good. The headphones are on right. The microphone is set up. You’re doing a good job.

Dr. Muoser: Yes, professional.

Dr. Fox: Just as a little background, so you joined our practice a little less than a year ago. How’s that been?

Dr. Muoser: Oh, that’s been great. I think about six months now. So, definitely settling in. Everyone’s great. Really a good experience and great patients, too.

Dr. Fox: Yeah, all right. So, tell our listeners, what do they need to know about you? You know, where are you from? Where do you train? Give us the story.

Dr. Muoser: I’m from here. I feel like that’s what I always start with. Born in the city and grew up outside the city in Westchester, Dobbs Ferry, and then was in upstate New York for school, for college, short time in Boston for medical school at Tufts. And then I’ve been back in the city the last few years. So, sort of went straight through in school. So, I’m not young, but in theory, I’m the youngest you can be though it’s not young.

Dr. Fox: Yeah, I remember when I finished my training, it was something like 20 plus years of schooling. Whatever it is, it’s crazy. I mean, you’re well trained. And so you’re an OB/GYN and you’re a maternal fetal medicine specialist.

Dr. Muoser: Yes.

Dr. Fox: Right. So, here we are. You’re an MFM and doing your thing. It’s great.

Dr. Muoser: Yeah, and so then I did residency and fellowship at Montefiore in the Bronx. So, I’ve been in the city but now back in Manhattan.

Dr. Fox: Terrific. Well, we’re happy to have you. Our patients are happy that you’re here. Most importantly, I’m glad you’re podcasting.

Dr. Muoser: Most importantly.

Dr. Fox: You know, we all have our needs. So, we were trying to come up with something to talk about that was a little bit on the MFM side and something that’s important but something maybe we didn’t cover before in the podcast. And you had a really good idea to talk about antenatal corticosteroids or what we sort of refer to as steroids, basically. And so just for a general overview, very high level for listeners, what are we talking about here? Like, why steroids? We’re not weightlifters. We’re not baseball players. Like, what are we talking about?

Dr. Muoser: Great question. So, this is something that comes up pretty often for us, especially as MFMs. And the whole idea is a very short course of steroids that we give to patients, mostly not for you, actually for your baby. It’s something that can help your baby’s lungs to develop in the case that we’re thinking about an early delivery.

Dr. Fox: Yes. So, in terms of the high level, it’s something that… It’s a really interesting phenomenon that there are things that we give to the mother while she’s pregnant…

Dr. Muoser: That are not for her.

Dr. Fox: Right, not going to help her, right? I always say it’s not going to make you a better baseball player, not going to do anything to you. And we’ll talk about it… It doesn’t really have a lot of side effects even because it’s a very short course but we’re giving it to her if/when, right? We don’t always know. But if/when she’s about to have a preterm delivery, that premature baby does better if the mom got the steroids.

Dr. Muoser: Exactly.

Dr. Fox: Right. It’s not a crazy concept, right, that makes some sense. But it’s just a very interesting phenomenon that a lot of what we do, it’s like we’re giving the mother medication because when the baby, let’s say a week from now, is in the NICU, he or she is going to do better because of that. And it’s just really neat actually.

Dr. Muoser: It is. It’s like the second patient. We always have two patients, and we’re thinking about both of them. And so I think it’s kind of like the epitome of what we do, an OB/GYN and MFM.

Dr. Fox: Yeah. And it’s in this… You know, I have this conversation a lot with people in terms of other things not related to steroids specifically but some of the screening tests we do in pregnancy, for example, like cervical lengths, right? So, there’s this whole debate about: should you do them? Should you not do them? And one of the main arguments against checking someone’s cervix in pregnancy is that, well, okay, you’re going to learn if someone is or is not at high risk for preterm birth. But what are you going to do to prevent the preterm birth? And what I say is I agree, our ability to prevent preterm birth is very, very limited. But if I know someone’s going to deliver preterm or higher risk to deliver preterm compared to somebody else, I can sometimes give her those treatments.

Dr. Muoser: We can prepare for them.

Dr. Fox: Yeah, we can prepare. And so I say it like… The analogy I usually give is like, if I check my weather app in the morning, it’s not because I can prevent it from raining.

Dr. Muoser: That’s a great analogy.

Dr. Fox: If I know it’s going to rain, I’ll bring an umbrella, right? And so, like, if I know someone’s going to deliver preterm or I think someone’s going to deliver preterm, I’m not going to prevent that. But the umbrella here is the steroids. It’s like, “Okay, this is a person… As opposed to the other 99 people, this is the one who needs the steroids and other things.” But we’re going to focus on steroids today. Yeah, that’s the analogy I use. You can use that.

Dr. Muoser: That’s perfect.

Dr. Fox: Yeah, weather. It’s always always good. Checking the weather. So, all right. So, let’s get to… So, that’s a great introduction to what we’re talking about. And sometimes you’ll hear them referred to as steroids just like that. Sometimes corticosteroids, sometimes antenatal corticosteroids. Antenatal just means giving them during pregnancy. But sometimes you’ll hear us referring to beta, right, which is the…

Dr. Muoser: Betamethasone.

Dr. Fox: Yeah, or BMZ, like “Bob” “Mary” “Zebra,” right, which is short for betamethasone. These all mean the same thing.

Dr. Muoser: Yes, yes.

Dr. Fox: Okay. So, question, how does giving steroids improve the outcomes for the baby?

Dr. Muoser: Great question.

Dr. Fox: Like, what’s going on here?

Dr. Muoser: Great question. So, the answer to that is really that we think that the steroids are acting on some of the cells and the linings of the lungs, the pneumocytes specifically. And it helps to improve…

Dr. Fox: The baby’s lungs.

Dr. Muoser: The baby’s lungs, not mom’s lungs. Baby’s lungs. And it helps to improve their maturity and helps them to have a better effect on gas exchange when the baby is born. So, reducing things like respiratory distress syndrome, reducing the amount of respiratory or ventilatory support the baby needs after delivery. So, that’s sort of the biggest category that we’re thinking about with steroids. So, there are other…

Dr. Fox: Right. I mean, and respiratory, like breathing issues, tends to be, for most premature babies, the biggest issue, right? Is the baby on a ventilator? Is the baby not on a ventilator? Does the baby need oxygen? How much oxygen? Because the lungs are one of the last organs to, sort of, catch up. So, that’s the main mechanism. So, let me ask this question. If they improve lung function for babies, why don’t we just give them to everybody when they’re pregnant? Why wouldn’t you just say, “Okay,” just like we take a prenatal vitamin or whatever it is? Why don’t you just give steroids to every pregnant mom at a certain point in pregnancy—24 weeks, 26 weeks, 28 weeks, whatever it is?

Dr. Muoser: That’s a good question.

Dr. Fox: Thank you.

Dr. Muoser: And the answer is that, well, we think a short course is safe. There are sort of some effects to being on steroids long-term, to getting multiple courses. And probably the majority of people don’t need them. That’s why we don’t need to give them to everyone. So, we really sort of want to risk stratify who will benefit from them.

Dr. Fox: Right. I think also one of the really… You may be too young for this—The Price Is Right game show?

Dr. Muoser: Yes.

Dr. Fox: Yeah. So, some of the… So, maybe our listeners are familiar. So, some of it is like the thing when you’re guessing the price but you can’t go over, right? So, with steroids, they do improve lung function for the premature newborn, but the benefit is highest if you give it within a week of delivery, maybe within two weeks, so like shorter. So, if I gave it to everybody at 24 weeks, it would really only help the ones who happen to coincidentally deliver in the next week or two, which is going to be the minuscule number of patients. But if someone delivers at 31 weeks, it may not be as beneficial, and you wish you could go back and give them a 30. So, we’re sort of like playing this high-stakes game, so to speak.

Dr. Muoser: Yes, and we can’t keep giving.

Dr. Fox: Right, so you get one and we’ll talk maybe two chances at this. And so you definitely want to give it to everyone who is going to deliver preterm.

Dr. Muoser: As best as you can.

Dr. Fox: Right. But you want to get as close to delivery as possible without going over, without missing it. And so the strategy of giving it to everyone really isn’t… No one does that because it’s really not going to work. And so we do all these things to try to figure out, does someone need it or does someone not need it? And that’s why we have a job, to help work all this out to see who gets it, when should they get it, and all of that. But that’s the reason we don’t just give it to everybody, because that’s usually the first question people ask, “Well, it helps the baby, I’ll just give it to everybody.” So, it really won’t help the baby unless we time it right and give it to the right person. Like I said, maybe there are side effects if you give it to the whole population, but it’s more so I think timing it is safety. Okay, so when is the timing that we typically would give steroids? Like, I don’t mean in terms of prior to delivery, but what gestational age will we typically give them?

Dr. Muoser: So, that’s a really good question. And we can start to give them as early as we think a baby might have a chance to survive if they were born. So, it can be as early now, even as 22, 23, 24 weeks. We do know that probably the benefits are bigger and more significant for those babies that are born really, really early. So, we can give them from that point on, in theory, up now, basically until term. Definitely before 34 weeks, and there’s some new data for that last preterm period.

Dr. Fox: Yeah, it’s such an interesting story, because when I was training 150 years ago, the rule, the tenet was you give steroids between 24 weeks and 0 days and 33 weeks and 6 days, right, so 24 to 34 weeks. And then the only stretching you would do on that is if someone came in, let’s say, at 23 weeks and 6 days, you thought they were going to deliver the next day at 24 weeks, you would give them. Fine. And so that’s when the majority of studies were done. That’s sort of the data that we have, all this stuff about improving outcomes and lowering the chance of respiratory and neonatal death. Like, all these things is for 24 and 34 weeks. So, that was sort of, like, the rule, and you did not give them earlier. But the reason we didn’t give them earlier was, number one, we weren’t sure if it would work, because in order… It’s just a fascinating thing. In order for the steroids to affect the lungs and the pneumocytes, there have to be lungs and pneumocytes. And earlier, the lungs aren’t developed enough maybe to even respond to it.

Dr. Muoser: To even have any effect at all.

Dr. Fox: Yes, so we weren’t sure if it was going to work. And number two, the chance of the baby surviving under 24 weeks was so low, if not zero, that it was like, “Well, what’s the point? Like, what are we improving?” And so that was the rule. But over the course of…starting around the time I was training until now, number one, some babies under 24 weeks are going to survive, obviously more so at 23 weeks than 22 weeks, and less so at 23 weeks than 24 weeks. But, okay, some do survive. And we have started to accumulate more data on those babies, showing that if they survive, they’re better off having been exposed to steroids. So, we stretch it as early as…again, as early if we think the baby might survive and they’re going to try to save the baby, so to speak. Usually, everyone says, “Well, maybe they’ll get steroids because it’ll probably work.” But that’s, I mean, a relatively new phenomenon, new meaning past 10 to 15 years, as opposed to 50 years or whatever it is.

Dr. Muoser: You’re not that old.

Dr. Fox: Correct. Thank you. But I assume when you were trading, it was pretty routine to give them at 23 weeks. Yeah, and maybe 22 would have been the stretch probably when you were training is my guess.

Dr. Muoser: Yes. Yes, that’s correct. Also, when I was training, that’s when we started the late preterm steroids. That was in my residency.

Dr. Fox: Right, the other end. So, that’s like 30… right? Because for our listeners who know and are very educated on this, they’re like, “Wait a second. You only give them to 34 weeks, but preterm/premature is under 37 weeks. What about those 34, 35, and 36-week babies?” And so tell us about that. What happened with that end of the gestational age window, that we started to stretch it a little bit?

Dr. Muoser: And so essentially, we do think that the benefit probably becomes sort of less in magnitude the closer we get to term, because we do think the lungs are more developed, and most babies probably won’t need it. But there was a sort of landmark study or trial that came out when I was in my residency looking at sort of late preterm steroids, right? And they did find there probably was some benefit in the late preterm period. So, that’s in the 34th, 35th, 36th weeks. And they found that there was probably some decrease in need for respiratory support for babies who got it within that time period. And there wasn’t sort of an increased risk of things like infections for the baby, sepsis. So, offering that to patients and discussing that option with them became more a part of practice.

Dr. Fox: Yeah, definitely. And I would say, again, when I was training, it was like sacrilege to give them after 34. You were like beaten over the head if you gave them after 34 weeks, “It doesn’t work, this or that.” And someone said, “Well, I mean, why would it work at 33 and a half weeks, and then not work at all at 34 weeks?” It would make sense it maybe works a little bit less, right? It doesn’t work as well. But like, you know, whenever there’s a very hard line cutoff in medicine, it’s often…

Dr. Muoser: It’s arbitrary.

Dr. Fox: Yeah, it’s like, “Why then?”

Dr. Muoser: Or, it’s how we studied it in the past.

Dr. Fox: Yeah. And the way the data shook out in that study is, as you would expect, the greatest effect was for babies at 34 weeks, followed by 35 weeks, and then 36 weeks. There was much less effect, which makes complete sense to anybody who just thinks about it. Like, of course. And also it’s hard to prove anything because almost all babies born at 34 and 35 weeks are going to be fine. And so how much more fine can you make them? If a baby’s going to be perfectly healthy, how much better can you do it?

So, I’d say look at things like going to the NICU, time in the NICU, which is important, but it’s not long-term, like serious issues. It’s like, you know, if I could shorten the NICU stay from four days to two days, like that’s valuable, obviously, but it’s not quite the same outcome as, you know, your child will or won’t have long-term lung issues, right? Those are very different conversations.

And so at the 34, 35, and 36, it’s more these sort of, like, smaller types of outcomes that we’re talking about, which is why there is more discussion. It’s not as black and white that someone must have them or must not have them. There’s some discussion and there’s definitely much more variation in practice out there around the world, around the country, between doctors of what to do during that gestational age. I don’t know if you ever had this when you were training, but there’s also a question about maybe people who have C-sections who are, like, 37 weeks even, maybe they’ll benefit from steroids. And some studies show yes. Why would how the baby’s being delivered—C-section versus vaginal—affect how steroids would impact them?

Dr. Muoser: So, the babies actually get some benefit from that transition period when they’re having a vaginal delivery,s and having a vaginal delivery actually decreases your risk of having, you know, sort of difficulties of breathing, right? A delivery even for term babies.

Dr. Fox: Right, just because they’re getting squeezed.

Dr. Muoser: Yep.

Dr. Fox: It’s good to get squeezed. So, like C-section, we sort of like pull them out of a pool of water.

Dr. Muoser: Just shocking. Just, “You’re here.”

Dr. Fox: Yeah, they don’t have as much time to, like, you know, get the water out of their lungs and this. So, I would say most…

Dr. Muoser: But most do well that are born.

Dr. Fox: Yeah, all those babies generally do fine. And I would say that most places around the country and around the world would not be giving steroids after 37 weeks. But some places—and we’ve done this also from time to time—will give them at just, like, 37 weeks if it’s a C-section plan, things like that. But the data on that is much more mixed, whether it is or isn’t helpful. But some people might hear about that in a certain sense.

Now, if the mom… Let’s say a decision is made to give her steroids, like, “All right, we think you’re at high risk for delivering, either because you’re in preterm labor, your water is broken, or we think you’re going to deliver because your blood pressure is high,” or whatever it is, you know, what happens logistically? What are we talking about? How do the steroids get given to the mother?

Dr. Muoser: Good question. So, it’s an intramuscular injection. The most commonly used injection is the betamethasone. That’s the most common formulation of steroids that we use. And it’s two doses that are given 24 hours apart. So, we say 48 hours after the first dose, 24 hours after the second dose. You’re what we call steroid complete. You’ve completed the whole course. It’s only those two doses.

Dr. Fox: Right. So, two injections.

Dr. Muoser: Two injections. There’s another form, dexamethasone that is also sometimes used that’s actually for injections. The injections are 12 hours apart.

Dr. Fox: Right. Either way, it’s 48 hours.

Dr. Muoser: It’s 48 hours.

Dr. Fox: And option A, with betamethasone, you get an injection at hour zero, an injection at hour 24. You’re done getting your injections, but we say 48 hours because it has to take effect in your body. And with dexamethasone, it would be given at 0, 12, 24, and 36. And for whatever reason, certain steroids will work. They’ll go through the placenta, get to the baby. Like, the type of steroids people take, like if they have an asthma attack or it’s like prednisone pills and those…

Dr. Muoser: Exactly, so that’s not beneficial.

Dr. Fox: Yeah, different. Yeah. So, someone who takes oral steroids for some reason or another, we tell them that’s not going to work for the baby generally. So, it’s really just almost everybody uses one of these two. And like you said, betamethasone is a workhorse. So, let’s say mom is going to get steroids. Just in case, are there any downsides to her getting these steroids? Like, people think all steroids have side effects and this or that. Like, does she have any of those?

Dr. Muoser: So, steroids in this sense are actually pretty safe. They don’t have, you know, like a very large immunosuppressive effect, things like gaining weight, things like… You know, people worry about things like that. The one thing that, you know, we come across often in pregnancy is sometimes they can’t increase your sugars. We have a lot of patients who have diabetes. We need to follow that. That can also impact the baby as well. So, you know, that’s kind of the most important thing that we’re paying attention to for mom.

Dr. Fox: Yeah, I would say that more than 9 out of 10 report nothing. You know, like, “My arm hurts, I got a shot,” like that type of thing. Okay, fine. Yeah, yeah.

Dr. Muoser: Yes. Yeah, you can feel it.

Dr. Fox: Yeah, it’s like a flu shot like, “Oh, yeah, not pleasant.” And then some people have told me that maybe during those few days, they have a harder time sleeping. Now, is that because of the steroids or because they’re now in a stressful situation where we’re giving steroids? Hard to tease that out. But it could be the steroids, and that’s a possibility. And then yes, those who have diabetes, their sugars can go up. It doesn’t cause people to have diabetes.

Dr. Muoser: Yes. No, it does not.

Dr. Fox: But if someone has it and they’re like, “Hey, my sugars have been normal and now they’re high for a week,” the steroids absolutely can do that. And then long term, it doesn’t affect the mother at all, because it’s just a much shorter course, right? When someone gets steroids, like someone says, “I was put on steroids,” usually it’s one, two, three weeks of steroids, not two days. And so two days of steroids won’t give the same side effects. So, someone is getting steroids and they deliver prematurely under 34 weeks. And, you know, we’re not happy to deliver prematurely, but we feel like, “Good job, we got the steroids on board.”

Dr. Muoser: We chose correctly.

Dr. Fox: Yeah, we did a good job. So, let’s say someone doesn’t deliver, right? Someone comes in, let’s say… I’ll give you a scenario. They come in at 28 weeks. They have contractions. Their cervix is dilated. We think they’re in preterm labor. You know, we do A, B, and C. We say, “You know what? We’re going to give you a course of steroids.” So, she gets steroids. This is Monday. She gets steroids on Monday. She gets steroids on Tuesday. And she’s still pregnant, right?

Dr. Muoser: A very common scenario.

Dr. Fox: She doesn’t deliver. The labor stopped on its own, or we gave her something to stop it and it worked, or whatever it is. And now it’s a week later. So, I’m going to ask you a few questions about that scenario. So, the first question is, does that mean we made a bad decision?

Dr. Muoser: The answer is no, we didn’t make a bad decision.

Dr. Fox: We never make bad decisions. Never.

Dr. Muoser: Yeah, the answer is we made the best decision with the information we had at the time. And, you know, especially if you’re on the earlier side, you know, the baby would get the most benefit really in the first 48 hours to 7 days after we give it. So, if we think you’re going to have an earlier delivery, it is important to give it. But the answer is, you know, we still do have one opportunity.

Dr. Fox: Right. Talk about that. So, don’t jump ahead. I know you’re predicting my question. My second question is… You’re answering the third now. I’m going to go to the second. My second question is we gave steroids and she didn’t deliver preterm. Did I just do something harmful, right? Is it like, “Oh, I can’t believe it, we didn’t deliver. We just did something bad.”

Dr. Muoser: No, the answer to that is no.

Dr. Fox: Right. So, good. So, as far as we know, everything that’s been… This has been looked at a lot, giving a course of steroids and then the babies deliver…

Dr. Muoser: Full term.

Dr. Fox: …many weeks later full term. They’re fine. So, it does not impact that negatively.

Dr. Muoser: Yes.

Dr. Fox: So, the third question, which is you’re going to answer, which is the great one is, okay, did I just miss my window to get steroids and I’m 28 weeks? What if I deliver at 31 weeks? If I just like, oh, are we like, are we hosed? And so that’s the question.

Dr. Muoser: And so that’s the hardest thing I think we deal with. We do… So, there’s been a lot of studies in the past sort of looking at the idea of giving people multiple courses of steroids, even serial courses of steroids, because we do think the biggest benefit is in the first week, you know, definitely within the first two weeks. And so what happens if we give more courses after that? And there probably are some downsides to giving serial courses of steroids, sort of say, if you start at 28 weeks and then giving them all the way through.

Dr. Fox: Yeah, every week or something.

Dr. Muoser: And one of the biggest things that the studies found is an increased risk of growth restriction, the babies being on the smaller side. So, the recommendation for all the studies that we have gotten is that you do have an opportunity to give one course of what we call rescue steroids. So, another 48-hour course of steroids, at least a week, usually two weeks or more after the first.

Dr. Fox: Yeah. So, when I was a fellow, a lot of these studies were coming out because they were… Again, it was pretty solid that we knew that steroids were beneficial. And then people were like, well…

Dr. Muoser: Let’s keep giving.

Dr. Fox: Right, if the max benefit is within a week or two, why don’t we just keep giving them every week or two, right? If they seem to be safe, just keep doing them every week or two. That way you’re automatically guaranteed, no matter when she delivers, that you’ll deliver within a week or two. And the logic is there. And so when they studied it, there was some benefit because, yes, babies in that strategy were all born, you know, within a week or two of steroids, and the other strategy, maybe they were, maybe they weren’t. But there was a downside, it seems. So, no one does that really, the weekly or every-other-week. Whether the downside is horrible, we don’t know. But it was significant enough to be like, “You know what? It’s not worth it.”

But no one ever found a downside to just two total courses of steroids. And again, since it’s two injections, that would mean four injections. We call a course, that 24-48 hours’ worth. So, yeah. And that’s the sort of like, what I’m saying before, it’s like The Price is Right. It’s almost like The Price is Right, but you get to rebuy. You get to buy in again.

Dr. Muoser: Yeah, you get one more chance.

Dr. Fox: And, yeah, so you have an opportunity. So, in that scenario that we talked about before, someone comes in at 28 weeks. We think they’re in preterm labor. They are in preterm labor. We give them the steroids, and they don’t deliver. And then let’s say it’s two or three weeks later, and now they come back and their water is broken or they’re 8 centimeters dilated and we know they’re going to deliver the next day or two or whatever, you can give another course of steroids, and it has a beneficial effect similar to the first time. So, because of that, it becomes then an even more interesting, sort of, exercise in timing. And so the way I sort of do it—and I’m not asking you to do differently—is for, like, the first course of steroids, I’m much more liberal in giving it.

Dr. Muoser: Yeah, my threshold is lower. A hundred percent.

Dr. Fox: Yeah, because I’m like, all right, the first one is always the earlier one. I’m like, “This is a time where we really can’t get it wrong. We do not want to go over on this one.” So, I’m much more comfortable giving them potentially unnecessarily than I am missing an opportunity.

Dr. Muoser: The stakes would be higher.

Dr. Fox: Yeah, 24, 25, 26, 27 weeks, whatever, it’s like, if there’s any significant chance that you’re going to deliver early, let’s just give them. And then if you do deliver the next two weeks, which isn’t great, but if you did, you got covered. And if you don’t, number one, yay, you didn’t deliver in the next two weeks, right, because we thought you would. And number two, all right. Now it’s a little bit later. You’re 28, you’re 29, you’re 30 weeks. If something comes up, we could be a little bit more discriminatory about saying, “All right, let’s really only give them if we really need to. We’re pretty high confident that you’re going to deliver in the next week or two.” And then once you get to, like, 32 weeks again, your threshold might drop because you’re like, “All right, if you do deliver, fine. You’re already 34 plus weeks. And it probably doesn’t make a big difference.” And so it’s sort of like with each passing week or two, your threshold is going to go up or down based on the circumstances. That’s what I do. That’s how I think about it.

Dr. Muoser: That’s exactly what I do. I tell people earlier on my threshold is much lower to give it to you because it would have such a higher sort of impact on benefit if baby was born. And then that second time around, you’re thinking, “Okay, is it real this time? Is it not? We have one more opportunity.” And like you mentioned, we typically don’t give the second course or the rest of the course once we get to 34 weeks.

Dr. Fox: Yeah, because it probably doesn’t help much. It’s so interesting because like from time to time, we deliver someone who’s under 28 weeks or whatever it is, you know, for whatever reason. And the pediatrician/neonatologist, NICU doctors, when they come in and we’re telling them, “Hey…”

Dr. Muoser: First question.

Dr. Fox: Yeah, the first question, they’re always going to say…

Dr. Muoser: Did they get beta?

Dr. Fox: Yeah, “Did they get steroids?”

Dr. Muoser: When did they get it? When did they get it?

Dr. Fox: Because they who take care of the babies, the differences are so pronounced. They see it. They’re like, “This baby is 27 weeks who got steroids is doing so much better than this baby is over 27 weeks who didn’t get steroids.” And again, it doesn’t mean that someone is wrong. Sometimes people deliver too quickly to get steroids. Sometimes it was not expected or anticipated. So, there’s not always an opportunity to give it. But they see that and it’s like, “Did you get it? When? If yes, when? Good. All right. Fine.” And again, if not, they’re like, “Oh, you sure we have to deliver?” because they really, really… And the proof is in the pudding, so to speak, the ones who take care of the babies, that’s the thing they care about the most. And so we take that very seriously, obviously. And so it ends up being a large part of our conversation. When we meet as MFMs, almost every day we’re talking about the decision to give steroids. Do we give them? Do we wait?

Dr. Muoser: And we talk about this all the time. It’s always like group consensus. Like, is it time? Is it not time? What do people think? And trying to predict this.

Dr. Fox: Yeah, because again, it is a very interesting phenomenon. And we didn’t cover this today, and we’re not, but there are other things sort of in the same category, you know, that we sometimes give, like magnesium is one of them. And so, you know, sometimes it’s a similar concept, that for different outcomes, magnesium can be helpful. At certain times, antibiotics. And these are the things that we do. But again, the concept is to improve outcomes for the baby by treating the mother prior to birth, which is again I still think it’s just really cool.

Dr. Muoser: Yeah, yeah. And we’re doing the best with the clinical knowledge that we have, the scenario. But new scenarios come up every time. So, like you said, sometimes we don’t get it right. Yeah, we do the best that we can.

Dr. Fox: Yeah, good stuff. Dr. Muoser, Celia, thank you for coming on the podcast. How did it go?

Dr. Muoser: Thank you for having me.

Dr. Fox: You’re a natural.

Dr. Muoser: Good.

Dr. Fox: You’ll be hosting soon.

Dr. Muoser: Easier than I thought.

Dr. Fox: Great. Thanks a lot.

Dr. Muoser: All right. Thanks.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.