The use of progesterone during pregnancy to prevent preterm birth.

One of the most significant problems facing maternal and children health worldwide is preterm birth (PTB). Although strategies to increase the survival of premature infants have significantly improved in the past few decades, they have yet to be successful. Nine years ago, the use of progesterone in pregnancy was approved by the United States Food and Drug Administration (FDA) for PTB prevention. This paper reviews the recent evidence supporting the use of progesterone in pregnancy for PTB prevention and provides guidelines for its use in daily clinical practice. The guidelines address multiple current controversial areas regarding the prevention of PTB to aid physicians with their clinical decision-making practice, including the use in multifetal gestation, different formulations, safety in pregnancy, dose and route of administration.Saudi Med J 2020; Vol. 41 (4): 333-340doi: 10.15537/smj.2020.4.25036How to cite this article:Alsulmi ES, Alfaraj M, Faden Y, Al Qahtani N. The use of progesterone during pregnancy to prevent preterm birth. Saudi Med J 2020; Vol. 41: 333-340. doi: 10.15537/smj.2020.4.25036.

Congenital diaphragmatic hernia: Observed/expected lung-to-head ratio as a predictor of long-term morbidity.

AIM: The aim of this study was to investigate the association of observed/expected (O/E) lung-to-head ratio (LHR) with long-term morbidity for isolated fetal congenital diaphragmatic hernia (CDH) patients in a single institution. METHODS: We performed a retrospective study of prenatally diagnosed CDH from 18 to 38weeks of gestation (01/2002-04/2010). Two cohorts of O/E LHR were defined (22.6-45%, 45.1-78.3%) based upon previous studies. Survivors with at least 1-year follow-up of prospectively collected long-term morbidity assessments were included. RESULTS: O/E LHR was available in 43 survivors (median 40%, range 22.8-78.3%). Follow-up data were available in 41 survivors (M:F=24:17, left CDH=39/41). Median follow-up was 6.5years (1-11years). Height/weight trajectories were similar between the two cohorts, with the majority below the 50th centile. There were no differences between the two cohorts by age 3years for Bayley scales (developmental domains) and/or REEL-3 (language development). In addition, V/Q scans in the two cohorts demonstrated similar degrees of mismatch (mean delta V/Q=35.4 versus 31.3). CONCLUSIONS: In fetuses with isolated CDH, a reduction in O/E LHR does not predict a worse outcome in long-term follow-up. There is no association between a lower O/E LHR and a reduction in REEL-3 or Bayley score nor V/Q mismatch.

Expectant management compared with elective delivery at 37 weeks for gastroschisis.

OBJECTIVE: To estimate obstetric and neonatal outcomes after induction of labor at 37 weeks of gestation compared with expectant management in pregnancies complicated by fetal gastroschisis. METHODS: The management of 296 pregnancies involving fetal gastroschisis (1980-2011) was reviewed from a single perinatal center. Ultrasound surveillance and nonstress testing were performed every 2 weeks from 30 weeks of gestation, weekly from 34 weeks of gestation, and twice weekly after 35 weeks of gestation until delivery. Labor was induced if fetal well-being testing was abnormal and, since 1994, labor was routinely induced at 37 weeks of gestation. RESULTS: Of 153 pregnancies reaching 37 weeks of gestation, labor was induced in 77 (26%) and 76 (25.7%) were allowed to labor spontaneously. There were no significant differences in mean maternal age (22 years in both), parity (56% compared with 66% nulliparous), presence of other fetal anomalies (12% compared with 9%), cesarean delivery rate (20% in both), 5-minute Apgar score less than 7 (10% compared with 12%), meconium at birth (36% compared with 49%), or respiratory distress syndrome (16% compared with 7%) between the induced and expectantly managed groups. However, neonatal sepsis (25% compared with 42%; P=.02) and a composite outcome of neonatal death and bowel damage (necrosis, atresia, perforation, adhesion; 8% compared with 21%; P=.02) were more common in expectantly managed pregnancies. Moreover, time to oral feeds (-3.4 days), time on total parenteral nutrition (-6.2 days), and hospital stay (-6.7 days) were reduced when labor was induced. CONCLUSION: In fetuses with gastroschisis, induction of labor at 37 weeks of gestation was associated with reduced risks of sepsis, bowel damage, and neonatal death compared with pregnancies managed expectantly beyond 37 weeks of gestation. LEVEL OF EVIDENCE: II.

Congenital diaphragmatic hernia: lung-to-head ratio and lung volume for prediction of outcome.

OBJECTIVE: The purpose of this study was to evaluate observed/expected (O/E) lung-to-head ratio (LHR) by ultrasound (US) and total fetal lung volume (TFLV) by magnetic resonance imaging as neonatal outcome predictors in isolated fetal congenital diaphragmatic hernia (CDH). STUDY DESIGN: We conducted a retrospective study of 72 fetuses with isolated CDH, in whom O/E LHR and TFLV were evaluated as survival predictors. RESULTS: O/E LHR on US and O/E TFLV by magnetic resonance imaging were significantly lower in newborn infants with isolated CDH who died compared with survivors (30.3 ± 8.3 vs 44.2 ± 14.2; P < .0001 for O/E LHR; 21.9 ± 6.3 vs 41.5 ± 17.6; P = .001 for O/E TFLV). Area under receiver-operator characteristics curve for survival for O/E LHR was 0.80 (95% confidence interval, 0.70-0.90). On multivariate analysis, O/E LHR predicted survival, whereas hernia side and first neonatal pH did not. For each unit increase in O/E LHR, mortality odds decreased by 11% (95% confidence interval, 4-17%). CONCLUSION: In fetuses with isolated CDH, O/E LHR (US) independently predicts survival and may predict severity, allowing management to be optimized.