Magnesium Sulphate For Fetal Neuroprotection Research Articles

Factors that influence the choice for neonatal resuscitation in periviable deliveries

Background Periviable preterm birth, defined as delivery between 20+0/7 to 25+6/7 weeks, represents less than 1% of all births but contributes to up to 40% of all infant deaths. Scenarios with high risks of morbidity and mortality to the maternal-neonatal dyad may result in periviable preterm delivery. These situations require shared decision making between healthcare teams and families to decide whether maternal and neonatal patients are candidates for obstetric interventions and neonatal resuscitation at delivery, respectively, and to determine the optimal mode of delivery at the cusp of fetal viability. Objective The primary objective is to describe the influence of patient demographics (i.e. maternal race) and societal factors (i.e. maternal religion) on the decision between neonatal resuscitation and comfort care in periviable deliveries. Our secondary goals are: 1. to quantify the use of obstetric interventions (antenatal steroids for fetal lung maturity, magnesium sulfate for fetal neuroprotection, tocolytics and GBS prophylaxis) at the threshold of viability and 2. to establish whether planned neonatal resuscitation versus comfort care influenced the choice of cesarean versus vaginal delivery. Methods This project is a retrospective cohort study; electronic medical records were queried for data at Ascension St. Vincent Women's Hospital of mothers and neonates delivered at 22 0/7 to 24 6/7 from January 1, 2016 to July 31, 2020. Study patients were separated to compare outcomes between those that received neonatal resuscitation and those for whom comfort care was provided at 22, 23, and 24 weeks gestational age. Results were further stratified by obstetric interventions, mode of delivery, and maternal race and maternal religion with statistical analysis utilizing Fisher's Exact Test. Results Of the 111 patient charts originally identified, 73 patients met inclusion criteria. For those patients that opted for obstetric interventions, the most likely intervention was antenatal steroids (86%), followed by magnesium for fetal neuroprotection (63%) and tocolytics (63%), with the least likely intervention being Group Beta Streptococcus antibiotic prophylaxis (43%). The overall cesarean delivery rate was 53%. Cesarean delivery was selected with increasing gestational age: 9.1%, 52%, and 67% at 22, 23, and 24 weeks respectively. While there was no significant difference in those that opted for comfort care versus neonatal resuscitation at 22 weeks, the majority of patients at 23 and 24 weeks overwhelmingly opted for resuscitation; 5 infants (45%) were resuscitated at 22 weeks, 24 infants (96%) at 23 weeks, and 36 infants (97%) at 24 weeks. Planned neonatal resuscitation increased by gestational age. Patients opting for comfort care were more likely to deliver vaginally (87%) versus those that opted for resuscitation (41%), (Fisher's Exact Test, p=0.02), with the most common diagnoses documented for cesarean delivery being malpresentation followed by fetal distress. As for the influence of maternal race, African American patients opted for resuscitation 100% of the time, regardless of gestational age, in comparison to Caucasian (87%) and "other" (62%) counterparts. As for maternal religion, there was no significant difference between patients that self-identified as Christian, Roman Catholic, Unaffiliated or Other and their decision for neonatal resuscitation at 22 weeks. However, at 23 and 24 weeks, the only patients to opt in favor of comfort care were patients that were Unaffiliated with an organized religion. Overall, our infant survival rates were 7.6%, 44%, 63%, at 22, 23, and 24 weeks respectively, with an overall survival rate of 41%. Conclusion While the decision to resuscitate periviable preterm infants is multifactorial, demographic and societal factors influence the decision for planned resuscitation for this vulnerable patient population. Planned neonatal resuscitation rates were higher among patients identified as African American than other demographics included in this study. Patients not affiliated with an organized religion are less likely to opt for resuscitation at later gestational ages. Regardless ofplans for resuscitation, the majority of patients received obstetric interventions including antenatal steroids and cesarean delivery. These findings may be used by clinicians for shared decision making during future antenatal counseling sessions.

Management of preterm birth using protocols in a low resource setting.

Preterm birth is the leading cause of neonatal deaths and the second leading cause of death in children under five after pneumonia. The study aimed at improving the management of preterm birth through the development of protocols for standardization of care. The study was conducted in Mulago National Referral Labor ward in two phases. A total of 360 case files were reviewed and mothers whose files had missing data interviewed for clarity for both the baseline audit and the re-audit. Chi squares were used to compare results for the baseline and the re-audit. There was significant improvement in four parameters out of the six that were used to assess quality of care and these were 32% increase in administration of Dexamethasone for fetal lung maturity, 27% increase in administration of Magnesium Sulphate for fetal neuroprotection and 23% increase in anti-biotic administration. A 14% reduction noted in patients who received no intervention. However, there was no change in the administration of Tocolytic. The results of this study have shown that protocols standardize care and improve the quality of care in preterm delivery to optimize outcomes.

Factors influencing appropriate use of interventions for management of women experiencing preterm birth: A mixed-methods systematic review and narrative synthesis.

Preterm birth-related complications are the leading cause of death in newborns and children under 5. Health outcomes of preterm newborns can be improved with appropriate use of antenatal corticosteroids (ACSs) to promote fetal lung maturity, tocolytics to delay birth, magnesium sulphate for fetal neuroprotection, and antibiotics for preterm prelabour rupture of membranes. However, there are wide disparities in the rate and consistency in the use of these interventions across settings, which may underlie the differential health outcomes among preterm newborns. We aimed to assess factors (barriers and facilitators) affecting the appropriate use of ACS, tocolytics, magnesium sulphate, and antibiotics to improve preterm birth management. We conducted a mixed-methods systematic review including primary qualitative, quantitative, and mixed-methods studies. We searched MEDLINE, EMBASE, CINAHL, Global Health, and grey literature from inception to 16 May 2022. Eligible studies explored perspectives of women, partners, or community members who experienced preterm birth or were at risk of preterm birth and/or received any of the 4 interventions, health workers providing maternity and newborn care, and other stakeholders involved in maternal care (e.g., facility managers, policymakers). We used an iterative narrative synthesis approach to analysis, assessed methodological limitations using the Mixed Methods Appraisal Tool, and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. Behaviour change models (Theoretical Domains Framework; Capability, Opportunity, and Motivation (COM-B)) were used to map barriers and facilitators affecting appropriate use of these interventions. We included 46 studies from 32 countries, describing factors affecting use of ACS (32/46 studies), tocolytics (13/46 studies), magnesium sulphate (9/46 studies), and antibiotics (5/46 studies). We identified a range of barriers influencing appropriate use of the 4 interventions globally, which include the following: inaccurate gestational age assessment, inconsistent guidelines, varied knowledge, perceived risks and benefits, perceived uncertainties and constraints in administration, confusion around prescribing and administering authority, and inadequate stock, human resources, and labour and newborn care. Women reported hesitancy in accepting interventions, as they typically learned about them during emergencies. Most included studies were from high-income countries (37/46 studies), which may affect the transferability of these findings to low- or middle-income settings. In this study, we identified critical factors affecting implementation of 4 interventions to improve preterm birth management globally. Policymakers and implementers can consider these barriers and facilitators when formulating policies and planning implementation or scale-up of these interventions. Study findings can inform clinical preterm birth guidelines and implementation to ensure that barriers are addressed, and enablers are reinforced to ensure these interventions are widely available and appropriately used globally.

Preeclampsia and Venous Thromboembolism: Pathophysiology and Potential Therapy.

Preeclampsia (PET) is a multisystem inflammatory disorder that represents a leading cause of feto-maternal morbidity and mortality, complicating 2–5% of all pregnancies. PET incurs an increased risk of venous thromboembolism, which is one of the leading causes of death in pregnancy and in the postpartum period. This prothrombotic phenotype is attributable to the maternal phase of PET, which is characterized by a systemic inflammatory response and coagulation activation. Research continues to be undertaken in terms of preventative measures, however, currently revolves around pharmacological low dose aspirin initiated in the first trimester of pregnancy for those with risk factors. Treatment involves antenatal corticosteroids for fetal lung development in preterm birth, parenteral magnesium sulfate for fetal neuroprotection and maternal seizure prophylaxis, and timely birth of the fetus and placenta being the only definitive treatment of PET. Patients with a venous thromboembolism (VTE) risk deemed to be >1–3% are treated with pharmacological thromboprophylaxis in the form of low molecular weight heparin. Completing each woman’s VTE risk assessment is crucial, particularly in the setting of PET, as there is also a proven associated competing hemorrhagic risk.

Magnesium Sulfate for Fetal Neuroprotection in Women at Risk of Preterm Birth: Analysis of its Effect on Cerebral Palsy

Magnesium Sulfate for Fetal Neuroprotection in Women at Risk of Preterm Birth: Analysis of its Effect on Cerebral Palsy

The rising preterm birth rate in China: a cause for concern

The rising preterm birth rate in China: a cause for concern

Magnesium Sulphate for Fetal Neuroprotection at Imminent Risk for Preterm Delivery: A Systematic Review With Meta-analysis and Trial Sequential Analysis

(BJOG. 2020;127:1180–1188) Preterm birth is associated with higher risk of cerebral palsy (CP) and other complications. Magnesium sulfate (MgSO4) may decrease risk of CP when taken immediately before preterm birth. A recent trial investigated the neuroprotective functions of MgSO4. This updated systematic review, meta-analysis and trial sequential analysis (TSA) assessed the effects of MgSO4 administered before preterm birth to prevent CP in neonates.

Magnesium Sulphate for Fetal Neuroprotection at Imminent Risk for Preterm Delivery: A Systematic Review With Meta-analysis and Trial Sequential Analysis

(Abstracted from BJOG 2020;127:1180–1188) Preterm delivery puts infants at risk of developing cerebral palsy (CP). Conventional meta-analyses have shown that administering magnesium sulfate (MgSO4) at imminent preterm birth may help decrease this risk.

Neuroprotective magnesium sulfate administration increases maternal Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio and Systemic Immune-Inflammation Index.

We aimed to analyze the linear changes of Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR) and Systemic Immune-Inflammation Index (SII) levels in pregnant women who administrated magnesium sulfate for fetal neuroprotection. This retrospective study included 63 pregnant women who underwent neuroprotective magnesium sulfate administration during January 2015 and July 2020. Women with co-existing diseases or obstetric complications such as preeclampsia, gestational diabetes mellitus, suspicion of chorioamnionitis etc. excluded. The laboratory test results were obtained for each participant. Three results were compared; (1) Before magnesium sulfate-0th hour, (2) 6h and (3) 12h after starting loading dose. The mean NLR was 7.18 ± 5.14 in patients before treatment. The mean NLR increased to 10.09 ± 4.77 and 10.04 ± 4.35 at 6th and 12th hour of magnesium sulfate treatment. The mean PLR was also increased after starting neuroprotective magnesium sulfate (170.35 ± 89.09 at the beginning; 209.85 ± 88.77 at 6th hour and 209.24 ± 76.66 at 12th hour). The mean SII was found to be increased from 1783.33 ± 1367.29 to 2517.15 ± 1325.77 with magnesium sulfate treatment. However, no statistically significant difference was observed in terms of SII between 6 and 12th hours of treatment (p = 0.752). Maternal serum magnesium levels at 6th and 12th hour were found to be not correlated with NLR, PLR and SII. We demonstrated that values of NLR, PLR and SII at 6th hour were all increased after starting magnesium sulfate. Levels of these systemic inflammatory indices were similar at 6th and 12th hour of therapy.

Magnesium Sulfate for Fetal Neuroprotection: Pros and Cons

Magnesium Sulfate for Fetal Neuroprotection: Pros and Cons

Magnesium Sulfate for Fetal Neuroprotection: Pros and Cons

Magnesium Sulfate for Fetal Neuroprotection: Pros and Cons

Magnesium sulphate for fetal neuroprotection at imminent risk for preterm delivery: a systematic review with meta-analysis and trial sequential analysis.

Ordinary meta-analyses indicate that magnesium sulphate (MgSO4 ) treatment in women at imminent risk for preterm delivery decreases the offspring's risk of cerebral palsy (CP). However, repetitive testing of cumulative data calls for statistical caution, e.g. by trial sequential analysis (TSA), for which there are previously insufficient samples to draw a firm conclusion. Recently, a randomised controlled trial (RCT) provided additional data that potentially increased the sample size such that a new TSA might detect a statistically significant effect. To assess the possible fetal neuroprotective effect of MgSO4 for women at imminent risk for preterm delivery in an updated systematic review with meta-analysis and TSA. We searched MEDLINE, Embase, Cochrane and ClinicalTrials.gov on 8 October 2019. The search strategy clustered terms describing the MgSO4 intervention and preterm delivery. RCTs. Two reviewers extracted the data. Summary relative risks (RRs) and 95% confidence intervals (CIs) were calculated using fixed-effects models. A TSA was applied to the primary outcome, CP. The quality of the evidence was assessed usingGRADE. The protocol was registered in PROSPERO (registration: CRD42019151441). We identified six eligible trials (5917 women). MgSO4 intervention in women at imminent risk for preterm birth decreased the offspring's CP risk (meta-analysis RR 0.68, 95% CI 0.54-0.85; TSA RR 0.69, 95% CI 0.48-0.97). This systematic review with meta-analysis and TSA shows conclusively that MgSO4 , when given to women at imminent risk for preterm delivery, decreases the offspring's CP risk. Antenatal magnesium sulphate decreases the risk of cerebral palsy in children born preterm.

Antenatal Corticosteroids and Magnesium Sulfate for Improved Preterm Neonatal Outcomes: A Review of Guidelines.

In cases of anticipated preterm delivery, corticosteroids for fetal lung maturation and magnesium sulfate for fetal neuroprotection may improve neonatal outcomes. The aim of this study was to summarize and compare published guidelines from 4 leading medical societies on the administration of antenatal corticosteroids and magnesium sulfate. A descriptive review of major national guidelines on corticosteroids and magnesium sulfate was conducted: National Institute for Health and Care Excellence on "Preterm labour and birth," World Health Organization on "WHO recommendations on interventions to improve preterm birth outcomes," American College of Obstetricians and Gynecologists on "Antenatal corticosteroid therapy for fetal maturation" and "Magnesium sulfate use in obstetrics," and Society of Obstetricians and Gynecologists of Canada on "Antenatal corticosteroid therapy for improving neonatal outcomes" and "Magnesium sulphate for fetal neuroprotection." A variation in the appropriate timing of administration exists, whereas repeated courses are not routinely recommended for corticosteroids or magnesium sulfate. In addition, the recommendations are the same for singleton and multiple gestations, and no specific recommendation exists according to maternal body mass index. Finally, a variation in guidelines regarding the administration of corticosteroids before cesarean delivery exists. The adoption of an international consensus on corticosteroids and magnesium sulfate may increase their endorsement by health care professionals, leading to more favorable neonatal outcomes after preterm delivery.

Early-onset Neonatal Sepsis in a Premature Infant

A male infant was born at 31 weeks of gestation by spontaneous vaginal delivery. He was the second child of a 25-year-old mother who had regular prenatal care and presented with preterm labor and spontaneous rupture of membranes. The mother reported having flu-like symptoms with low-grade fever and myalgia over the preceding week, for which she had no evaluation or treatment. She received 2 doses of intramuscular dexamethasone to enhance fetal lung maturity and magnesium sulfate for fetal neuroprotection. The baby was delivered 24 hours later through green-tinged amniotic fluid with Apgar scores of 7 and 9 at 1 and 5 minutes, respectively. Growth parameters at birth were at the 50th–75th percentiles with a weight of 1920 grams, length of 42 cm, and occipitofrontal circumference of 29 cm. The respiratory rate of the baby was 70 breaths per minute and oxygen saturation was 90%–95% while receiving fractionated oxygen of 30% via continuous positive airway pressure. He had mild subcostal retractions and intermittent grunting, but the remainder of his physical examination was normal. Chest radiograph showed mild symmetric ground-glass opacification in both lung fields, consistent with respiratory distress syndrome (RDS). Complete blood count revealed a white blood cell count of 21,900/mm3 (with differential of 53% neutrophils, 34% lymphocytes, 11% monocytes, 1% eosinophils, and 1% basophils), hemoglobin (Hb) of 11.1 gm/dL, and platelet count of 324,000/mm3. Reticulocyte count was 5%, total bilirubin was 5 mg/dL and direct comb’s test was negative. A blood culture was obtained, and the patient was empirically treated with ampicillin (100 mg/kg/dose every 12 hours) and piperacillin/tazobactam (100 mg/kg/dose every 12 hours). Twelve hours later, the baby developed increased work of breathing, increasing FiO2 requirement and worsening respiratory acidosis. A repeat chest radiograph showed worsening RDS. Accordingly, the baby was intubated and given surfactant and then was extubated and restarted on continuous positive airway pressure. His respiratory status improved, and with no growth from blood culture after 48 hours of incubation, antibiotics were discontinued. A subsequent result confirmed the diagnosis.

Survey on use of antenatal magnesium sulphate for fetal neuroprotection prior to preterm birth in Australia and New Zealand - Ongoing barriers and enablers.

Clinical practice guidelines recommend the use of antenatal magnesium sulphate for fetal neuroprotection before preterm birth at <30weeks' gestation. This survey assessed the use of antenatal magnesium sulphate for fetal neuroprotection to determine if use has changed since the previous survey in 2012, and to evaluate enablers and barriers to use. A questionnaire was sent to clinical leaders at 29 hospitals with a neonatal intensive care unit in Australia and New Zealand asking at what gestational ages magnesium sulphate was given, if use was audited and any enablers and barriers to use. Responses were received for 24 (83%) hospitals. The use of magnesium sulphate for fetal neuroprotection was reported as 89% (IQR 80-90%), an increase from 80% (IQR 53-90%) from the earlier survey. The majority of health professionals were reported as using magnesium sulphate at <30weeks' gestation. The top enablers for use of magnesium sulphate were availability of pamphlets, posters, case record stickers and PowerPoint presentations. The main reasons as to why eligible women did not receive magnesium sulphate were imminent birth, the hospital being short staffed and the patient declined. The use of antenatal magnesium sulphate has been or is being audited in 11 (46%) of the hospitals. Clinical leaders at institutions in Australia and New Zealand report that uptake in the use of magnesium sulphate for fetal neuroprotection has continued to increase since the earlier, bi-national survey in 2012. Barriers to the use of magnesium sulphate identified have institutional and consumer implications.

Magnesium sulfate use for fetal neuroprotection.

The aim of this review is to describe the proposed mechanisms of action of magnesium sulfate for fetal neuroprotection, different dosing regimens of the drug that have shown benefit, and to review recent pharmacokinetic studies of the drug to better inform clinicians regarding expected benefits and remaining research questions. Retrospective secondary analysis of the beneficial effects of antenatal magnesium sulfate trial database and prospective pharmacokinetic/pharmacodynamic modeling indicate magnesium sulfate administration for duration longer than 18 h, given within 12 h of delivery, and maintaining a maternal serum level of 4.1 mg/dl may maximize the neuroprotective benefits of the drug. Magnesium sulfate in some dosage given before very preterm pregnancy delivery is beneficial for fetal neuroprotection. The exact dose, duration, and timing of administration to maximize this benefit may be more precisely studied using pharmacokinetic/pharmacodynamic modeling techniques before conducting larger randomized trials.

No. 376-Magnesium Sulphate for Fetal Neuroprotection.

The objective is to provide guidelines for the use of antenatal magnesium sulphate for fetal neuroprotection of the preterm infant. Antenatal magnesium sulphate administration should be considered for fetal neuroprotection when women present at ≤33 + 6 weeks with imminent preterm birth, defined as a high likelihood of birth because of active labour with cervical dilatation ≥4 cm, with or without preterm pre-labour rupture of membranes, and/or planned preterm birth for fetal or maternal indications. There are no other known fetal neuroprotective agents. The outcomes measured are the incidence of cerebral palsy (CP) and neonatal death. Published literature was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library in December 2017, using appropriate controlled vocabulary and key words (magnesium sulphate, cerebral palsy, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Antenatal magnesium sulphate for fetal neuroprotection reduces the risk of "death or CP" (relative risk [RR] 0.85; 95% confidence interval [CI] 0.74-0.98; 4 trials, 4446 infants), "death or moderate-severe CP" (RR 0.85; 95% CI 0.73-0.99; 3 trials, 4250 infants), "any CP" (RR 0.71; 95% CI 0.55-0.91; 4, trials, 4446 infants), "moderate-to-severe CP" (RR 0.60; 95% CI 0.43-0.84; 3 trials, 4250 infants), and "substantial gross motor dysfunction" (inability to walk without assistance) (RR 0.60; 95% CI 0.43-0.83; 3 trials, 4287 women) at 2 years of age. Results were consistent between trials and across the meta-analyses. There is no anticipated significant increase in health care-related costs because women eligible to receive antenatal magnesium sulphate will be judged to have imminent preterm birth. Australian National Clinical Practice Guidelines were published in March 2010 by the Antenatal Magnesium Sulphate for Neuroprotection Guideline Development Panel. Antenatal magnesium sulphate was recommended for fetal neuroprotection in the same dosage as recommended in these guidelines. However, magnesium sulphate was recommended only at <30 weeks gestation, based on 2 considerations. First, no single gestational age subgroup was considered to show a clear benefit. Second, in the face of uncertainty, the committee felt it was prudent to limit the impact of their clinical practice guidelines on resource allocation. In March 2010, the American College of Obstetricians and Gynecologists issued a Committee Opinion on magnesium sulphate for fetal neuroprotection. It stated that "the available evidence suggests that magnesium sulfate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants." No official opinion was given on a gestational age cut-off, but it was recommended that physicians develop specific guidelines around the issues of inclusion criteria, dosage, concurrent tocolysis, and monitoring in accordance with 1 of the larger trials. Similarly, the World Health Organization also strongly recommends use of magnesium sulphate for fetal neuroprotection in its 2015 recommendations on interventions to improve preterm birth outcomes but cites further researching on dosing regimen and re-treatment. Canadian Institutes of Health Research (CIHR). RECOMMENDATIONS.

Antenatal magnesium sulfate for fetal neuroprotection: a critical appraisal and systematic review of clinical practice guidelines.

Background Magnesium sulfate is an accepted intervention for fetal neuroprotection. There are some perceived differences in the international recommendations on the use magnesium sulfate for fetal neuroprotection in preterm labor. Content This systematic review analyses the available clinical guidelines for the use of magnesium sulfate for fetal neuroprotection and compares the recommendations, and assesses the quality of guidelines. This provides the consensus, differences and explores the areas for future collaborative research. We searched databases of PUBMED, EMBASE, COCHRANE, Web of Science, LILACS; and included the national and the international clinical practice guidelines. We included seven guidelines out of 227 search results. We evaluated the methodological quality of guidelines using the Appraisal of Guidelines Research and Evaluation (AGREE II) tool and systematically extracted guideline characters, recommendation and supporting evidence base. Summary Five guidelines were of high quality and two were of moderate quality. One guideline achieved more than an 80% score in all the domains of AGREE II tool. All guidelines recommend use of magnesium sulfate for fetal neuroprotection. However, there are differences in other recommendations such as upper gestational age, dose, duration, repeating treatment and use of additional tocolytics. Outlook Future guidelines should include recommendations on all aspects of magnesium sulfate therapy for fetal neuroprotection. Future research and international collaboration should focus on areas where there are no international consensual recommendations.

Congenital Diaphragmatic Hernia: Antenatal Diagnosis and Successful Repair In Preterm Neonate Case Report

Most of the congenital diaphragmatic hernias (CDH) observed in the left hemi diaphragm. The pathogenesis of CDH is not completely understood; but abnormal development of the diaphragm at 6-10 weeks' supposed to be the cause in most of the cases. Although CDH usually occurs sporadically, environmental exposures have been implicated. Improvement of the antenatal imaging techniques has allowed early diagnosis and evaluation of the associated anomalies. In antenatally diagnosed CDH cases, multidisciplinary team management and delivery at tertiary centers with proper facilities may be provided to optimize the outcome. A 39-year-old woman, with the history of one previous cesarean section, was admitted to the hospital at 25 weeks’ gestation, because of placenta previa and her antenatal ultrasound showed fetal CDH with polyhydramnios. During hospitalization, she was monitored for hemoglobin levels, consumptive coagulopathy, and fetal well-being. Betamethasone was given to accelerate the fetal lung maturity, and magnesium sulphate for fetal neuro-protection. Due to an attack of heavy antepartum hemorrhage, delivery occurred at the gestational age of 28 weeks + 6 days. The delivered female newborn was admitted to the neonatal intensive care unit (NICU) because of respiratory distress and prematurity, and received surfactant, dobutamine and intravenous antibiotics. Chest examination of the studied neonate showed diminished air entry on the left side, and chest X-ray showed stomach shadow in the left hemi thorax. After exclusion of congenital heart diseases and intracranial hemorrhage, the baby was successfully operated on the postpartum 7th day, and discharged from the NICU 60 days after the operation. Two months after discharge from the NICU, examination of the studied neonate was successfully operated on the postpartum 7th day showed normal growth parameters and appropriate motor and sensory development for her age. Antenatal diagnosis of CDH allows multidisciplinary team management and delivery at tertiary center with the proper facilities to optimize the outcome.

Preterm premature rupture of membranes

Preterm premature rupture of membranes occurs in around 3% of pregnancies, and several aspects related to its management are still controversial. The objective of this update is to provide a detailed review of strategies aimed at reducing morbidity and mortality associated with this maternal condition. We will discuss the available evidence regarding the maternal use of antibiotics, the use of corticosteroids according to gestational age, the use of magnesium sulphate for fetal neuroprotection, the use of tocolytic agents, and the best moment for and route of delivery. This review also covers the effects of prolonged preterm premature rupture of membranes, infant morbidity and mortality in the short and long term, the harmful effects of antibiotics after delivery, including the effects on neurodevelopment and the presence of longterm chronic diseases.