Placental abruption: epidemiology, risk factors and consequences

Associations of maternal ambient temperature exposures during pregnancy with the placental weight, volume and PFR: A birth cohort study in Guangzhou, China

BACKGROUND

The placenta performs crucial functions to ensure normal fetal development. Experimental studies have indicated associations between exposure to elevated temperatures during pregnancy and reduction in placental weight and volume. However, epidemiological studies in humans are lacking.

OBJECTIVE

To estimate the associations between prenatal exposure to ambient temperature with placental weight, volume, and the placental weight to birth weight ratio (PFR).

METHODS

We conducted a prospective birth cohort study using the Prenatal Environment and Offspring Health Cohort (PEOH Cohort) beginning in 2016 in Guangzhou, China. Women in early pregnancy were recruited and followed up during their hospitalization for childbirth. An inverse distance-weighted method was employed to estimate the average temperature exposure of every 4 weeks as well as the trimester-specific average temperature exposure at the individual's residential address. A generalized linear model was applied to estimate the effects of temperature exposure during pregnancy on the placental weight, volume, and PFR.

RESULTS

A total of 4051 pregnant women were enrolled. Compared with the reference temperature of 20 °C, maternal exposure to 29 °C (95th centile) during late pregnancy was associated with an average of -6.03 g (95% confidence interval [CI]: -11.28 g, -0.78 g) in placental weight, -16.15 cm³ (95% CI: -26.24 cm³, -6.07 cm³) in placental volume, and 0.26 (95% CI: 0.07, 0.45) in PFR. The peak effects of high temperatures on placental weight, volume, and PFR were found from 29 to 32 weeks (β = -3.79 g, 95% CI: -8.39 g, 0.82 g), 37 to 40 weeks (β = -19.34 cm³, 95% CI: -30.99 cm³, -7.69 cm³), and 25 to 28 weeks (β = 0.35, 95% CI: 0.04, 0.66), respectively.

CONCLUSIONS

Maternal exposure to elevated temperatures was associated with a decrease in placental weight and volume and an increase in PFR. The associations were stronger when exposures occurred during late pregnancy.

The effect of antithrombotic therapy on the recurrence of placenta-mediated diseases in pregnancy

Objectives: To analyze the recurrence rate of placenta-mediated diseases (PMDs) such as preeclampsia (PE) and/or intrauterine growth restriction (IUGR), intrauterine fetal death (IUFD), and placental abruption (PA) in high-risk patients on antithrombotic therapy (AT) because of a previous obstetrical history for such complications.Methods: The study group (SG) included 150 patients to whom either 100 mg of aspirin or low-molecular weight heparin (LMWH) was administered due to a previous history of PMDs. The AT in the SG was started before 16 gestational weeks (g.w.). The patients in the first control group (CG-1) were 150 who also had a previous obstetrical history of PMDs, but did not receive antithrombotic therapy (AT) throughout their ongoing pregnancies. The second CG (CG-2) comprised 320 patients with a previous history of normally developing pregnancies and without AT throughout their ongoing pregnancies.Results: The total percentage of PE in pregnant patients from the SG was 25.3% (38/150 patients), with 22.2% (10/45) in the SG on AT only with LDA (SG-LDA group), 25% (17/68) in the SG on AT only with LMWHs (SG-LMWH group) and 29.7% (11/37) in the SG on combined AT with LDA and LMWHs (SG-LDA + LMWH group), as opposed to 18.67% (28/150) in CG-1 and 0.62% (2/320) in CG-2. The recurrent severe PE/total PE ratio in the SG was 44.7% (17/38), with 30% (3/10) in the SG-LDA group, 47% (8/17) in the SG-LMWH group and 54% (6/11) in the SG-LDA + LMWH group, against 75% (21/28) in CG-1. There were no cases with severe PE in CG-2. All cases with recurrent IUGR from the SG were equal to 13.3% (20/150), with 13.3% (6/45) in the SG-LDA group, 11.76% (8/68) in the SG-LMWH group and 16.2% (6/37) in the SG-LDA + LMWH group, as compared to 30% (45/150) in CG-1 and 5% (16/320) in CG-2. As a whole, the overall recurrence rate of PMDs in the SG was 38.67% (58/150), with 35.56% (16/45) in the SG-LDA group, 36.76% (25/68) in the SG-LMWH group and 45.9% (17/37) in the SG-LDA + LMWH group, as compared to 50.67% (76/150) in CG-1 and 5.94% (19/320) in CG-2.Conclusion: AT had a partial beneficial effect on the prophylaxis of recurrent PMDs. On the one hand, AT led to a significant reduction in the recurrent severe PE/total PE ratio, as well as in the total PMDs' recurrence rate in the SG as compared to the one in CG-1. On the other hand, the percentage of recurrent PMDs still remained significantly higher in the SG as compared to CG-2. Pregnant patients with previous PMDs still need close surveillance in subsequent pregnancies as they remain at a high risk for complications.

Risk Factors for Neonatal/Maternal Morbidity and Mortality in African American Women with Placental Abruption

Background and Objectives: Risk factors for neonatal/maternal morbidity and mortality in placental abruption have been incompletely studied in the current literature. Most of the research overlooked the African American population as mostly Caucasian populations are selected. We aimed to find which risk factor influence the neonatal and maternal outcome in cases of placental abruption occurring in African American pregnant women in an inner-city urban setting. Materials and Methods: We performed a retrospective cohort study at St. Joseph’s Regional Medical Center, NJ United States of America (USA), between 1986 and 1996. Inclusion criteria were African American race, singleton pregnancy with gestational age over 20 weeks and placental abruption. Maternal age, gravidity, parity, gestational age at delivery/occurrence of placental abruption and mode of delivery were collected. Risk factors for placental abruption such as placenta previa, hypertensive disorders of pregnancy, cigarette smoking, crack/cocaine and alcohol use, mechanical trauma, preterm premature rupture of membranes (PPROM), and premature rupture of membranes (PROM) were recorded. Poor neonatal outcome was considered when anyone of the following occurred: 1st and 5th minute Apgar score lower than 7, intrauterine fetal demise (IUFD), perinatal death, and neonatal arterial umbilical cord pH less than 7.15. Poor maternal outcome was considered if any of the following presented at delivery: hemorrhagic shock, disseminated intravascular coagulation (DIC), hysterectomy, postpartum hemorrhage (PPH), maternal intensive care unit (ICU) admission, and maternal death. Results: A population of 271 singleton African American pregnant women was included in the study. Lower gestational age at delivery and cesarean section were statistically significantly correlated with poor neonatal outcomes (p = 0.018; p < 0.001; p = 0.015) in the univariate analysis; only lower gestational age at delivery remained significant in the multivariate analysis (p = < 0.001). Crack/cocaine use was statistically significantly associated with poor maternal outcome (p = 0.033) in the univariate analysis, while in the multivariate analysis, hemolysis, elevated enzymes, low platelet (HELLP) syndrome, crack/cocaine use and previous cesarean section resulted significantly associated with poor maternal outcome (p = 0.029, p = 0.017, p = 0.015, p = 0.047). PROM was associated with better neonatal outcome in the univariate analysis, and preeclampsia was associated with a better maternal outcome in the multivariate analysis. Conclusions: Lower gestational age at delivery is the most important risk factor for poor neonatal outcome in African American women with placental abruption. Poor maternal outcome correlated with HELLP syndrome, crack/cocaine use and previous cesarean section. More research in this understudied population is needed to establish reliable risk factors and coordinate preventive interventions.

Maternal Exposure to Ambient Air Pollution and Pregnancy Complications in Victoria, Australia

The relationship between maternal exposure to ambient air pollution and pregnancy complications is not well characterized. We aimed to explore the relationship between maternal exposure to ambient nitrogen dioxide (NO₂) and fine particulate matter (PM_2.5) and hypertensive disorders of pregnancy, gestational diabetes mellitus (GDM) and placental abruption. Using administrative data, we defined a state-wide cohort of singleton pregnancies born between 1 March 2012 and 31 December 2015 in Victoria, Australia. Annual average NO₂ and PM_2.5 was assigned to maternal residence at the time of birth. 285,594 singleton pregnancies were included. An IQR increase in NO₂ (3.9 ppb) was associated with reduced likelihood of hypertensive disorders of pregnancy (RR 0.89; 95%CI 0.86, 0.91), GDM (RR 0.92; 95%CI 0.90, 0.94) and placental abruption (RR 0.81; 95%CI 0.69, 0.95). Mixed observations and smaller effect sizes were observed for IQR increases in PM_2.5 (1.3 µg/m³) and pregnancy complications; reduced likelihood of hypertensive disorders of pregnancy (RR 0.95; 95%CI 0.93, 0.97), increased likelihood of GDM (RR 1.02; 95%CI 1.00, 1.03) and no relationship for placental abruption. In this exploratory study using an annual metric of exposure, findings were largely inconsistent with a priori expectations and further research involving temporally resolved exposure estimates are required.

Histologic chorioamnionitis concomitant placental abruption and its effects on pregnancy outcome

INTRODUCTION

Two possible causative pathways have been suggested to participate in the development of placental abruption (PA), an acute inflammatory pathway and placental vascular derived, a chronic pathway. We aimed to study the impact of the inflammatory pathway on maternal and neonatal outcome.

METHODS

The computerized medical files and placental reports of all pregnancies diagnosed with PA, between 11/2008-1/2019, at 24-42 weeks, were reviewed. Placental lesions were classified according to "Amsterdam" criteria into maternal and fetal vascular malperfusion lesions, acute inflammatory responses and chronic villitis. Composite neonatal morbidity included ≥1 of the following: seizures, intra-ventricular hemorrhage (IVH), hypoxic-ischemic encephalopathy, periventricular leukomalacia (PVL), blood transfusion, necrotizing enterocolitis (NEC), neonatal sepsis, respiratory distress syndrome, or neonatal death. Maternal and neonatal outcome were compared between PA with and without histologic chorioamnionitis (HC).

RESULTS

As compared to the PA without HC group (n = 267), the PA with HC group (n = 77) was characterized by lower gestational age (GA) at delivery (32.9 ± 5.5 vs. 35.6 ± 4.1 weeks, p < 0.001), higher rates of oligohydramnios (p < 0.001), bloody amniotic fluid at labor (p < 0.001), maternal postpartum fever (p < 0.001), longer maternal hospitalization (<0.001), and increased composite adverse neonatal morbidity (41.6% vs. 22.8%, p = 0.002). By multivariate analysis, GA and HC were found to be independently associated with adverse neonatal outcome, aOR 0.63 95% CI 0.43-0.78, p < 0.001, and aOR1.12, 95% CI 1.02-3.87, p = 0.04, respectively.

DISCUSSION

The involvement of the inflammatory causative pathway in the development of placental abruption, is associated with increased maternal and neonatal morbidity.

Combining Biomarkers to Predict Pregnancy Complications and Redefine Preeclampsia: The Angiogenic-Placental Syndrome

Placental dysfunction underlies a spectrum of perinatal pathologies, including preeclampsia and fetal growth restriction. Angiogenesis-related factors, including sFlt-1 (soluble fms-like tyrosine kinase 1) and PlGF (placental growth factor), play an important role in placental dysfunction; altered levels are detectable several weeks before onset of pregnancy complications. In vitro diagnostic tests for these biomarkers can improve early diagnosis and facilitate prediction of maternal and fetal outcomes. We assessed evidence for combining angiogenic biomarkers with other biomarkers or clinical parameters to predict maternal/fetal outcomes in pregnant women with placental dysfunction. Pooled information on placental perfusion (ultrasonography, mean arterial pressure), clinical characteristics, and biomarker levels (PlGF) can improve first-trimester prediction and preeclampsia diagnosis. Angiogenic factors (sFlt-1/PlGF ratio; PlGF alone) with or without clinical characteristics can facilitate second-/third-trimester prediction of early-onset and late-onset preeclampsia. A combination of increased sFlt-1/PlGF ratio and ultrasound can rule out early fetal growth restriction. The sFlt-1/PlGF ratio is also a reliable tool for discriminating between pregnancy-related hypertensive disorders, including superimposed preeclampsia and gestational hypertension. Analysis of angiogenic factors with or without uterine Doppler substantially improves sensitivity and specificity for predicting adverse outcomes and iatrogenic preterm delivery. We propose to extend the American College of Obstetricians and Gynecologists definition of preeclampsia in the future to include the combination of new-onset hypertension and new-onset of altered angiogenic factors (sFlt-1/PlGF ratio or PlGF alone). In summary, altered angiogenic biomarkers indicate placental dysfunction, and their implementation into clinical practice will help reduce the considerable burden of morbidity and mortality associated with adverse pregnancy outcomes as a consequence of angiogenic-placental syndrome.

Systematic review with meta-analysis: risk of adverse pregnancy-related outcomes in inflammatory bowel disease

BACKGROUND

The effect of inflammatory bowel disease (IBD) on pregnancy-related outcomes remains unknown.

AIM

To determine the risk of adverse maternal, placental and obstetric outcomes in IBD METHODS: We searched Medline, Embase and Cochrane library through May 2019 for studies reporting adverse maternal, placental and obstetric outcomes in patients with IBD. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for these outcomes in patients with IBD compared to healthy controls.

RESULTS

Fifty-three studies were included (7917 IBD pregnancies and 3253 healthy control pregnancies). Caesarean delivery was more common in patients with IBD compared to healthy controls (OR 1.79, 95% CI, 1.16-2.77). This remained significant for UC (OR 1.80, 95% CI, 1.21-2.90) but not CD (OR 1.48, 95% CI, 0.94-2.34). Similarly, gestational diabetes occurred more commonly in IBD (OR 2.96, 95% CI, 1.47-5.98). The incidences of placental diseases were 2.0% (95% CI, 0.9%-3.1%) for pre-eclampsia, 3.3% (95% CI, 0%-7.2%) for placental abruption, 0.5% (95% CI, 0.2%-0.9%) for placenta previa and 0.3% (95% CI, 0%-0.5%) for chorioamnionitis. Patients with IBD were more likely to experience preterm prelabour rupture of membranes (OR 12.10, 95% CI, 2.15-67.98), but not early pregnancy loss (OR 1.63, 95% CI 0.49-5.43). Anti-tumour necrosis factor therapy was not associated with chorioamnionitis (OR 1.12, 95% CI, 0.16-7.67), early pregnancy loss (OR 1.49, 95% CI, 0.83-2.64) or placenta previa (OR 1.58, 95% CI, 0.30-8.47).

CONCLUSIONS

Gestational diabetes and preterm prelabour rupture of membranes occurs more commonly in patients with IBD, although the incidence of placental diseases remains low.

Acute kidney injury associated with preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome

OBJECTIVE

To determine the prevalence of acute kidney injury (AKI), placental abruption and postpartum hemorrhage in patients with preeclampsia or HELLP syndrome.

STUDY DESIGN

A retrospective study of patients with preeclampsia or HELLP syndrome treated at the University of Mississippi Medical Center from January 2000 through December 2010.

MAIN OUTCOME MEASURES

Relationships among the obstetric complications of placental abruption, postpartum hemorrhage, and AKI (serum creatinine >107 µmol/L) of women with preeclampsia or HELLP syndrome. Additional analysis was undertaken to explore if there was a correlation between postpartum hemorrhage/placental abruption and the severity of HELLP syndrome according to the Mississippi classification system.

RESULTS

Data from 1276 women over 11 years were included in the analysis. 67 of 466 patients (14.4%) with HELLP syndrome and 38 of 810 preeclampsia patients (4.7%) met criteria for AKI. Women with either placental abruption or postpartum hemorrhage had statistically significant increased odds of also having AKI (p < 0.01). Women with HELLP and AKI were also more likely to experience either placental abruption or postpartum hemorrhage. Women with Class 1 HELLP with placental abruption or postpartum hemorrhage were also more likely to have AKI than women with preeclampsia.

CONCLUSION

HELLP syndrome, AKI and placental abruption or postpartum hemorrhage appear to be interrelated. AKI occurs more frequently in women with HELLP syndrome with or without associated postpartum hemorrhage and placental abruption.

Major obstetric haemorrhage in Metro East, Cape Town, South Africa: a population-based cohort study using the maternal near-miss approach

Background

Major obstetric haemorrhage is a leading cause of maternal mortality and accounts for one-third of maternal deaths in of Africa. This study aimed to assess the population-based incidence, causes, management and outcomes of major obstetric haemorrhage and risk factors associated with poor maternal outcome.

Methods

Women with major obstetric haemorrhage who met the WHO maternal near-miss criteria or died in the Metro East region, Cape Town, South Africa, were evaluated from November 2014–November 2015. Major obstetric haemorrhage was defined as haemorrhage in pregnancies of at least 20 weeks’ gestation or occurring up to 42 days after birth, and leading to hysterectomy, hypovolaemic shock or blood transfusion of ≥5 units of Packed Red Blood Cells. A logistic regression model was used to analyse associations with poor outcome, defined as major obstetric haemorrhage leading to massive transfusion of ≥8 units of packed red blood cells, hysterectomy or death.

Results

The incidence of major obstetric haemorrhage was 3/1000 births, and the incidence of massive transfusion was 4/10.000 births in the Metro East region (32.862 births occurred during the studied time period). Leading causes of haemorrhage were placental abruption 45/119 (37.8%), complications of caesarean section 29/119 (24.4%) and uterine atony 13/119 (10.9%). Therapeutic oxytocin was administered in 98/119 (82.4%) women and hysterectomy performed in 33/119 (27.7%). The median numbers of packed red blood cells and units of Fresh Frozen Plasma transfused were 6 (interquartile range 4–7) and 3 (interquartile range 2–4), ratio 1.7:1. Caesarean section was independently associated with poor maternal outcome: adjusted OR 4.01 [95% CI 1.58, 10.14].

Conclusions

Assessment of major obstetric haemorrhage using the Maternal Near Miss approach revealed that placental abruption and complications of caesarean section were the major causes of major obstetric haemorrhage. Caesarean section was associated with poor outcome.

Predicting peripartum blood transfusion: focusing on pre-pregnancy characteristics

Background

Obstetric hemorrhage is one of the most common causes of obstetrical morbidity and mortality, and transfusion is the most important management for hemorrhage. The aim of our study was to investigate the pre-pregnancy and pregnancy risk factors for peripartum transfusion.

Methods

Women who delivered a baby from 2010 to 2014 in Korea and participated in the Korean National Health Screening Program for Infants and Children were included. To analyze pre-pregnant risk factors for peripartum transfusion, an additional analysis was done for women who underwent a National Health Screening Examination within 1 year before pregnancy, including maternal waist circumference, body mass index, blood pressure, laboratory tests and history of smoking. Multivariable logistic regression analysis was used to estimate the risk factors for peripartum transfusion.

Results

Of the total 1,980,126 women who met the inclusion criteria, 36,868 (1.86%) were transfused at peripartum. In a multivariable regression model, the pregnancy risk factors for peripartum transfusion included maternal age above 35 years [odds ratio (OR): 1.41; 95% confidence interval (CI): 1.32–1.50], preterm birth (OR: 2.39; 95% CI: 2.15–2.65), and maternal hypertension (OR: 2.49; 95% CI: 2.24–2.77). Pre-pregnancy risk factors including fasting glucose level of more than 126 mg/dL (OR: 1.11; 95% CI: 1.02–1.20), current-smoker status (OR: 1.20; 95% CI: 1.06–1.37), and waist-circumference less than 80 cm (OR: 1.18; 95% CI: 1.06–1.30) were independently associated with peripartum blood transfusion.

Conclusions

Several pre-pregnancy and pregnancy risk factors were associated with peripartum blood transfusion. Some identified factors are modifiable before conception, and our study validated peripartum blood transfusion as a form of triage.

The impact of pre-pregnancy body mass index and gestational weight gain on placental abruption risk: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review was to evaluate the associations between pre-pregnancy body mass index and gestational weight gain and placental abruption.

METHODS

Relevant studies were identified from PubMed, EMBASE, Scopus and CINAHL. Unpublished findings from analyses of linked population-based data sets from Western Australia (2012-2015, n = 114,792) were also included. Studies evaluating pre-pregnancy body mass index and/or gestational weight gain and placental abruption were included. Two independent reviewers evaluated studies for inclusion and quality. Data including odds ratios (ORs) and 95% confidence intervals (CIs) were extracted and analysed by random effects meta-analysis.

RESULTS

21 studies were included, of which 15 were eligible for meta-analyses. The summary ORs for the association of being underweight, overweight and obese, and placental abruption, compared to normal weight women, were 1.4 (95% CI 1.1, 1.7), 0.8 (95% CI 0.8, 0.9) and 0.8 (95% CI 0.7, 0.9), respectively. These findings remained unchanged when each study was eliminated from the analysis and in subgroup analyses. Although data were scarce, women with gestational weight gain below the Institute of Medicine recommendations appeared to be at greater risk of abruption compared with women who had optimal weight gain.

CONCLUSIONS

Mothers that are underweight prior to or in early pregnancy are at a moderately increased risk of placental abruption.

Placental MRI: Developing Accurate Quantitative Measures of Oxygenation

The Human Placenta Project has focused attention on the need for noninvasive magnetic resonance imaging (MRI)-based techniques to diagnose and monitor placental function throughout pregnancy. The hope is that the management of placenta-related pathologies would be improved if physicians had more direct, real-time measures of placental health to guide clinical decision making. As oxygen alters signal intensity on MRI and oxygen transport is a key function of the placenta, many of the MRI methods under development are focused on quantifying oxygen transport or oxygen content of the placenta. For example, measurements from blood oxygen level-dependent imaging of the placenta during maternal hyperoxia correspond to outcomes in twin pregnancies, suggesting that some aspects of placental oxygen transport can be monitored by MRI. Additional methods are being developed to accurately quantify baseline placental oxygenation by MRI relaxometry. However, direct validation of placental MRI methods is challenging and therefore animal studies and ex vivo studies of human placentas are needed. Here we provide an overview of the current state of the art of oxygen transport and quantification with MRI. We suggest that as these techniques are being developed, increased focus be placed on ensuring they are robust and reliable across individuals and standardized to enable predictive diagnostic models to be generated from the data. The field is still several years away from establishing the clinical benefit of monitoring placental function in real time with MRI, but the promise of individual personalized diagnosis and monitoring of placental disease in real time continues to motivate this effort.

Management of disseminated intravascular coagulation associated with placental abruption and measures to improve outcomes

Placental abruption is a condition that should be carefully considered in perinatal management because it is associated with serious events in both the mother and neonate, such as intrauterine fetal death, cerebral palsy, obstetric critical bleeding, and uncontrollable bleeding. The concomitant presence of disseminated intravascular coagulation (DIC) more easily causes critical bleeding that may necessitate hysterectomy or multi-organ failure resulting in maternal death. Therefore, early management should be provided to prevent progression to serious conditions by performing both hemostatic procedures and DIC treatment. To take measures to improve the outcomes in both the mother and neonate, health guidance for pregnant women, early diagnosis, early treatment, development of the emergency care system, and provision of a system for transport to higher-level medical institutions should be implemented.

The relationship between prenatal psychological stress and placental abruption in Japan, The Japan Environment and Children's Study (JECS)

Background

Prenatal psychological stress may increase the risk of placental abruption (PA). This study aimed to clarify the effects of psychological distress during pregnancy and exposure to stressful life events in the year before or during pregnancy on the occurrence of PA in Japanese women.

Methods

Using a nationwide prospective birth cohort study, we obtained data from 103,099 women between January 2011 and March 2014. Information on exposure to 14 stressful life events and psychological distress (Kessler 6 scale) was collected using a self-administered questionnaire during pregnancy. Clinical diagnoses of PA were obtained from medical records. A total of 80,799 women with singleton births were analyzed using logistic regression models that adjusted for possible confounders.

Results

PA was diagnosed in 335 (0.4%) women. There was no significant difference in the Kessler 6 score during pregnancy between the PA group and non-PA group. Exposure to the death of a child in the year before or during pregnancy was significantly associated with PA in multigravid women (adjusted odds ratio [aOR] 3.57; 95% confidence interval [CI] 1.50–8.34). A spouse’s loss of employment was significantly associated with PA in parous women (aOR 3.25; 95% CI 1.40–7.56).

Conclusions

This study identified the possible effects of exposure to the death of a child on PA occurrence that adjusted for important confounding factors.

Analysis of 62 placental abruption cases: Risk factors and clinical outcomes

OBJECTIVE

This study aimed to explore the clinical characteristics and outcomes of placental abruption.

MATERIALS AND METHODS

A total of 62 placental abruption cases were collected from the Second Hospital of Jilin University between January 2007 and December 2012. A retrospective study was conducted to explore the risk factors for placental abruption, clinical characteristics, and maternal and fetal outcomes.

RESULTS

Risk factors for placental abruption mainly include preeclampsia (39%) and premature rupture of membrane (10%). Abdominal pain (68%) and bleeding (35%) comprise the classical symptoms of placental abruption but the clinical picture varies from asymptomatic, in which the diagnosis is made by inspection of the placenta at delivery, to massive abruption leading to fetal death and severe maternal morbidity. Emergency cesarean section was performed in 45 cases (73%) of placental abruption. Sixty-two placental abruption cases were divided into 2 groups according to whether uteroplacental apoplexy occurred. The incidence of preeclampsia and the duration (time between on-set of clinical symptom and placenta delivery) in the observational group were significantly higher than that of the control group, showing statistical significance (P < 0.01).

CONCLUSION

The diagnosis of placental abruption should consider risk factors, symptoms, physical signs, dynamic ultrasound monitoring, and cardiac care. Early diagnosis and treatment can improve maternal and infant prognosis.

Effect of interpregnancy interval after a first pregnancy complicated by placental abruption, on adverse maternal and fetal outcomes in a second pregnancy

Background: For women who suffer from abruption in the first pregnancy, the extent to which birth spacing has an impact on maternal and fetal outcomes in a second pregnancy remains unclear.Objectives: To examine the effect of interpregnancy interval (IPI) after a first pregnancy complicated by placental abruption, on adverse maternal and fetal outcomes in a subsequent pregnancy.Study design: This was a population-based retrospective cohort study using maternally-linked Missouri birth registry from 1989 to 2005 (n = 2069). Exposure of interest was IPI and outcomes were placental abruption, preeclampsia, preterm birth, small for gestational age, cesarean delivery, and neonatal plus fetal deaths (neofetal death) in a second pregnancy. Logistic regressions were used to assess the association between IPI and the outcomes.Results: Compared with women with an IPI of 1-2 years, those with short IPI (<1 year) were more likely to experience preterm birth (aOR 3.01, 95% CI 1.71-5.28) and neonatal death (aOR 3.52, 95% CI 1.24-10.02) in their subsequent pregnancy. No significant associations between IPI and recurrent placental abruption or preeclampsia were detected.Conclusions: Women who become pregnant in less than a year's time of an initial placental abruption are at increased risk for preterm birth and neofetal death in a subsequent pregnancy. Other ischemic placental disease conditions are also shown to have serious health implications for a woman's next pregnancy.

The impact of the abruption severity and the onset-to-delivery time on the maternal and neonatal outcomes of placental abruption

Objective: We examined the impact of the abruption severity and the onset-to-delivery time on the maternal and neonatal outcomes of cases of clinically diagnosed placental abruption (PA).Material and methods: We investigated 84 patients who were diagnosed with PA at our hospital from January 2009 to September 2017. We classified the patients with PA into three groups based on the extent of the abruption: (1) mild abruption, <20%; (2) moderate abruption, 20-49%; (3) severe abruption, ≥50%, which was defined by the attending obstetricians at the time of delivery. The neonatal outcome was measured by the umbilical artery pH and the maternal outcome was measured by the obstetric disseminated intravascular coagulation score (DIC score).Results: The rate of hypertensive disorders of pregnancy in the moderate abruption group was significantly lower than that in other groups (p = .010). The umbilical artery pH was below 7.00 in 29 cases. The umbilical artery pH of the severe abruption group (6.92) was the lowest and was significantly lower in comparison to other groups (mild group [7.24], p < .001; moderate group [7.11], p < .05). There was a significant correlation between the onset-to-delivery time and the umbilical artery pH in the moderate group (R = -0.43). The maternal DIC scores in the three groups did not differ to a statistically significant extent.Conclusions: The severity of placental separation is significantly correlated with poor neonatal outcomes and there was a significant negative correlation between the onset-to-delivery time and the umbilical artery pH in moderate abruption.

Contributory factors and potentially avoidable neonatal encephalopathy associated with acute peripartum events: An observational study

BACKGROUND

In 25% of affected babies, neonatal encephalopathy results from acute peripartum events, but rigorous review of these cases for quality improvement is seldom reported. New Zealand has maintained a national database of all babies diagnosed with Sarnat moderate and severe neonatal encephalopathy since 2010 under the Perinatal and Maternal Mortality Review Committee.

AIMS

To determine the rate of contributory factors, potentially avoidable mortality or morbidity, and to identify key areas for improvements to maternity and neonatal care among cases of neonatal encephalopathy following an acute peripartum event.

MATERIALS AND METHODS

Sarnat moderate and severe cases identified from the national collection of neonatal encephalopathy with a history of an acute peripartum event were reviewed using a standardised independent multidisciplinary methodology and a tool for assessing contributory factors and potential avoidability, with the addition of a human factors lens.

RESULTS

Forty-seven cases from 2013 to 2015 were reviewed. The most common acute peripartum events were placental abruption (12) and shoulder dystocia (11). Contributory factors were identified in 89%, and the severity of outcome was potentially avoidable in 66%. Key modifiable areas included dynamic risk assessment, preparedness for obstetric and neonatal emergencies, best practice for maternal and fetal surveillance in labour, and documentation.

CONCLUSIONS

There is significant potential to improve quality and safety in acute peripartum care to reduce the risk of neonatal encephalopathy. Human factors were not well captured by the clinical notes or review tool. Attention to human factors by improved methodology can enhance review of neonatal encephalopathy.

Bloody amniotic fluid during labor - Prevalence, and association with placental abruption, neonatal morbidity, and adverse pregnancy outcomes

OBJECTIVE

To study the association between bloody amniotic fluid (BAF) during labor and adverse pregnancy outcomes.

STUDY DESIGN

In the last 10 years we have implemented an institutional protocol that mandates obstetricians/midwives to report their subjective impression of the color of amniotic fluid (clear, meconium stained, bloody) during labor. The medical records, and neonatal charts of all singleton deliveries ≥ 37^0/7 weeks between 2008-2018 were reviewed. The cohort was divided into two groups: clear AF (Clear group) and BAF (BAF group). Cases with meconium stained AF were excluded. The primary outcome was a composite of the following complications: umbilical Ph ≤ 7.1, seizures, hypoxic-ischemic encephalopathy, intra-ventricular hemorrhage, periventricular leukomalacia, hypoglycemia, hypothermia, mechanical ventilation, meconium aspiration syndrome, RDS, NEC, phototherapy, sepsis, or transfusion.

RESULTS

Overall, 21,300 deliveries were reviewed, 20,983 (98.5%) in the Clear group and 317 (1.5%) in the BAF group. The rate of the primary outcome did not differ between the BAF (2.2%) and the Clear (2.1%) groups. The rate of placental abruption (both clinically and hystopathologically) did not differ between the groups (3.2% vs. 1.9% and 1.6% vs. 0.6%, respectively). BAF was associated with higher rates of labor induction (p = 0.002), assisted vaginal deliveries (p = 0.04), cesarean deliveries (p = 0.03), and lower birth weights (p = 0.03).

CONCLUSION

BAF observed in labor was not associated with composite adverse neonatal outcome, nor with placental abruption. BAF was associated with higher rates of labor induction, assisted vaginal deliveries, cesarean deliveries, and lower birth weights. These findings may assist obstetricians and neonatologists in the interpretation of BAF observed in labor.

Reproductive outcomes after surgical treatment of asherman syndrome: A systematic review

In this systematic review, we analysed the reproductive outcomes of hysteroscopic adhesiolysis in women with Asherman syndrome (AS). We searched PubMed, Web of Science and Cochrane Library (from database inception to April 2018) and selected studies that quantitatively described the reproductive outcomes. We assessed study quality and pooled rate data for each outcome. There were 54 studies (4640 women) of varying quality. The pooled rate of pregnancy was 50.7% (95% CI [confidence interval]: 49.1 to 52.3) in 53 studies, early pregnancy loss was 17.7% (95% CI: 15.9 to 19.6) in 31 studies, ectopic pregnancy (EP) was 4.2% (95% CI: 2.8 to 6.3) in 9 studies, mid-trimester loss (MTL) was 11.5% (95% CI: 7.6 to 17.8) in 7 studies, cervical incompetence was 12.5% (95% CI: 3.3 to 33.5) in 2 studies and placenta accreta syndrome was 10.1% (95% CI: 8.6 to 11.8) in 23 studies. The pregnancy rate in women with severe adhesion was significantly lower than that in women with mild adhesion (P = 0.021). These results can be used to counsel women with AS before surgical treatment and for planning antenatal care after conception.

Subsequent risk of cancer among women with a history of placental abruption

BACKGROUND

Placentation is characterized by extensive cell proliferation and neovascularization, which is similar to the processes observed in the development of cancer. Nonetheless, little is known about the relation between abnormal placentation, such as placental abruption, and cancer.

MATERIAL AND METHODS

Data on women with placental abruption in a singleton pregnancy between 1971 and 2005 (n = 7804) were collected from the Finnish Hospital Discharge Registry and the Finnish Medical Birth Registry. The cohort was then linked with the Finnish Cancer Registry records until the end of 2013. Standardized incidence ratios (SIRs) were calculated for different cancers by dividing the observed numbers of cancers by those expected. The expected numbers were based on national cancer incidence rates.

RESULTS

During follow-up, 597 cancers were found among women with a history of placental abruption. The overall risk of cancer was not increased (SIR 0.95, 95% CI 0.88-1.02). However, the history of placental abruption was associated with an increased risk of lung cancer (SIR 1.51, 95% CI 1.05-2.10) and thyroid cancer (SIR 1.47, 95% CI 1.04-2.02). A decreased risk was found for breast cancer (SIR 0.85, 95% CI 0.75-0.96). The risk of rectal cancer was also decreased, although these numbers were small (SIR 0.49, 95% CI 0.20-1.01).

CONCLUSIONS

Overall, the risk of lung cancer was increased, and the risk of breast cancer decreased, in women with a history of placental abruption. These observations can be explained to some extent by risk factors or risk markers for placental abruption. The increased risk of thyroid cancer may be explained by surveillance bias.

Thyroid function test reference ranges in the first trimester of gestation and pregnancy outcomes: Protocol and preliminary results for cohort population-based study Isfahan, Iran

Background:

This paper presents the protocol and primary findings of pregnancy cohort population-based study in Isfahan, Iran.

Materials and Methods:

In this cohort, 418 pregnant and 438 nonpregnant women were enrolled. In the first phase, serum concentrations of thyroid-stimulating hormone (TSH), free thyroxine (FT4), free triiodothyronine (FT3), thyroid peroxidase antibody, and urinary iodine concentration (UIC) were measured. Furthermore, the thyroid ultrasound was also performed. According to the results of thyroid function tests in the first phase, local reference range for TSH, FT4, and FT3 in pregnant and nonpregnant women are determined. The 2.5^th and 97.5^th percentiles are determined as limits of the reference ranges. In the second phase, all pregnant women underwent prenatal care visits in each trimester and they followed for 7 days after delivery and the pregnancy outcomes data are reported.

Results:

The mean ± standard deviation for TSH, FT4, FT3, and UIC in the first trimester of gestation was 1.84 ± 1.32 mIU/L, 1.01 ± 0.15 ng/dL, 4.50 ± 0.64 pmol/L, and 172.0 ± 90.29 μg/L, respectively. In nonpregnant women, these values for TSH, FT4, FT3, and UIC were 2.58 ± 1.77 mIU/L, 1.10 ± 0.21 ng/dL, 4.49 ± 0.57 pmol/L, and 190.0 ± 109.6 μg/L, respectively.

Conclusion:

The results of the present study could contribute to establish a local thyroid function tests reference ranges in the first trimester of pregnancy. It could possibly be effective on making a local reference value to prevent of thyroid disease misdiagnosis during pregnancy and adverse pregnancy outcomes.

Placental abruption and long-term cardiovascular morbidity of the offspring

OBJECTIVE

While placental abruption is often associated with short-term adverse pregnancy outcomes, we sought to assess whether placental abruption increases the risk for long-term cardiovascular morbidity of the offspring.

METHODS

To study the long-term cardiovascular hospitalizations of offspring of patients with and without placental abruption, cardiovascular morbidity was assessed up to the age of 18 years according to a predefined set of ICD-9 codes associated with hospitalization of the offspring. Our data consist of deliveries which occurred between the years 1991 and 2014 in a tertiary medical center. Pregnancies following fertility treatments, multifetal pregnancies, and pregnancies with offspring with congenital anomalies, lack of prenatal care, and perinatal mortality were excluded from the study. We used Kaplan-Meier curve to compare cumulative morbidity incidence and Cox proportional hazards model to control for confounder.

RESULTS

During the study period, we examined 217,910 deliveries, out of which 0.46% (n = 1003) were effected by placental abruption. Compared to normal birth children, children born to mothers with placental abruption did not show a significantly higher cumulative incidence of long-term cardiovascular morbidity (1.0% vs. 0.6%; p = 0.127). Placental abruption was not noted as an independent risk factor for long-term cardiovascular morbidity of offspring in the Cox regression analysis, which adjusted for confounders.

CONCLUSION

Our study does not support the association between placental abruption and risk for long-term cardiovascular morbidity of the offspring.

Decoding stillbirths using the Relevant Condition at Death classification: Study from the developing world

Objective:

To determine the stillbirth rate in 2017 at Christian Medical College, a tertiary care perinatal center in South India, and to identify causes for the various stillbirths that occurred using the Relevant Condition at Death (ReCoDe) classification.

Material and Methods:

Medical records of the women with stillbirths between January 1^st, to December 31^st, 2017, were retrieved and analyzed using the SPSS software (IBM, version 23). The study was approved by the institutional review board (minute no: 11273, retro dated: 28/3/2018).

Results:

Of the total 14696 deliveries between January 1^st, 2017, to December 31^st, 2017, there were 247 stillbirths, a rate of 16.8 per 1000 births. Maternal factors: 156 (64.2%) women were booked and the rest were un-booked. Hypertensive disorders of pregnancy were detected in 27.5% (n=67). A greater number of un-booked women had gestational hypertension as compared with booked women (41% vs 24%, p=0.005). Fetal characteristics: still births secondary to lethal congenital anomalies were seen in 18.2% (n=45). Lethal congenital anomalies were diagnosed 10 times more in the booked patients than un-booked ones (24.7% vs 2.3%, p=0.001). Obstetric factors: one or two previous miscarriages were seen in 29.5% cases. Seventeen women (6.9%) had a prior stillbirth. ReCoDe Classification: we were able to successfully classify 84.2% of the stillbirths, leaving 15.78% unclassified. Fetal growth restriction secondary to uteroplacental insufficiency was found in 25.9% cases. Of the placental causes, abruption accounted for 10.9% of cases. Medical co-morbidities were seen in 46.5% pregnancies.

Conclusion:

The ReCoDe method of classifying stillbirths is useful in the developing world. It helped to elucidate the cause for stillbirths in 84.2% of cases. The majority of cases in our set were due to fetal growth restriction, hypertensive disorders of pregnancy, and uteroplacental insufficiency. Stillbirths can be prevented by a comprehensive antenatal care system, early recognition, and close monitoring of high-risk pregnancies.

Preeclampsia predicts higher incidence of bronchopulmonary dysplasia

INTRODUCTION

It is not known whether very preterm infants born to preeclamptic women have worse outcomes than those delivered preterm for other causes.

OBJECTIVE

We assessed the association between preeclampsia (PE) and the neonatal morbidity and mortality of very preterm infants.

METHODS

Over 2015 and 2016, 11 collaborating Portuguese level III NICUs prospectively enrolled a cohort of mothers with or without PE who delivered liveborn premature infants between 24 and 30 completed weeks of gestation. Data on neonatal morbidities were collected and their association to PE was assessed.

RESULTS

The final cohort consisted of 410 mothers who delivered 494 preterm infants. Infants from PE mothers weighed less than those of non-PE mothers (819 ± 207 g vs. 989 ± 256 g, p < 0.0001). Incidences of respiratory distress syndrome, patent ductus arteriosus, early and nosocomial sepsis, necrotizing enterocolitis, pneumonia, meningitis, retinopathy of prematurity, intraventricular hemorrhage, periventricular infarction, periventricular leukomalacia, and mortality did not differ significantly between infants of PE or non-PE mothers. Incidence of bronchopulmonary dysplasia (BPD-defined as oxygen dependency at 36 weeks) was higher in PE infants compared with non-PE infants by both univariate and multivariate logistic regression (p = 0.007).

CONCLUSION

We conclude that, when controlling for gestational age, maternal PE results in higher incidence of only BPD among preterm Portuguese infants.

Placental abruption and hemorrhage-review of imaging appearance

Placental and periplacental bleeding are common etiologies for antepartum bleeding. Placental abruption complicates approximately 1% of pregnancies and is associated with increased maternal, fetal, and neonatal morbidity and mortality. This article reviews the normal placental appearance on ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) and then discusses the different morphological appearance of placental and periplacental hematomas along with their mimics. Hematomas are classified based on the location as retroplacental, marginal subchorionic, preplacental (subamniotic), or intraplacental. Placenta-related bleeding is a common finding during first trimester ultrasound and its detection can help triage the pregnant females into low- and high-risk groups. This article reviews placenta related bleeding in the setting of trauma. Trauma can complicate pregnancy with potential severe maternal and fetal outcomes. CT is usually performed as part of the trauma workup and it can be challenging for placental evaluation. MRI can characterize the age of the hematomas and can differentiate hematomas from tumors.

Obstetric emergencies as antecedents to neonatal hypoxic ischemic encephalopathy, does parity matter?

INTRODUCTION

Our aim was to investigate the risk of moderate to severe hypoxic ischemic encephalopathy (HIE) by obstetric emergencies, with focus on the distribution of obstetric emergencies by parity, taking the history of a previous cesarean into account.

MATERIAL AND METHODS

Population-based cohort study of 692 428 live births at ≥ 36 weeks of gestation in Sweden, 2009-2015. Data were retrieved by linking the Swedish Medical Birth Register with the Swedish Neonatal Quality Register. Therapeutic hypothermia served as surrogate for moderate to severe HIE. Logistic regression analysis was used to estimate associations between HIE and placental abruption, eclampsia, cord prolapse, uterine rupture, and shoulder dystocia, presented as adjusted odds ratios (aORs) with 95% CI.

RESULTS

An obstetric emergency occurred in 133/464 (29%) of all HIE cases, more commonly in the parous (overall 37%; 48% with and 31% without a previous cesarean) than in the nulliparous (21%). Among nulliparas, shoulder dystocia was the most common obstetric emergency with the strongest association with HIE (aOR 48.2; 95% CI 28.2-82.6). In parous women without a previous cesarean, shoulder dystocia was most common, but placental abruption had the strongest association with HIE. Among parous women with a previous cesarean, uterine rupture was the most prevalent obstetric emergency with the strongest association with HIE (aOR 45.6; 95% CI 24.5-84.6).

CONCLUSIONS

Obstetric emergencies are common among cases of moderate to severe HIE. The strong association with shoulder dystocia in nullipara, and with uterine rupture in women with previous cesarean deliveries, implies an opportunity for reducing the incidence of HIE.

The association between cervical inflammation and histologic evidence of HPV in PAP smears and adverse pregnancy outcome in low risk population

OBJECTIVE

Recent studies suggest an association between Human Papilloma Virus (HPV) infection, cervical inflammation and obstetric complications (i.e. spontaneous preterm parturition and cervical insufficiency). It has been proposed that viral inflammation of the placenta causes changes in the mother's immune reaction to bacterial pathogens, which leads to enhanced inflammatory reaction and preterm delivery. Therefore, the aim of this population-based study was to determine the association between abnormal cervical cytology prior to pregnancy and obstetric outcomes.

STUDY DESIGN

A Retrospective population-based cohort study was designed, including all women who had a Pap smear up to two years prior to delivery or during first trimester of pregnancy (n = 15,357). Women were divided into the following groups, according to Pap smear results: group 1 - Normal PAP smear (n = 11,261); group 2 - Pap smear with evidence of an inflammatory process (n = 3895); and group 3 - Pap smear with evidence of HPV infection (n = 201). Obstetrical outcomes, gestational age at delivery, and pregnancy complications were compared among the groups.

RESULTS

The rate of HPV infection in our study population was 1.3%. The rate of preterm delivery (group 1 - 8.5%, group 2 - 8.5%, group 3 - 7%, p = 0.7), preterm PROM (group 1 - 1.7%, group 2-1.6%, group 3 - 2%, p = 0.66) and cervical insufficiency (group 1 - 0.5%, group 2 - 0.7%, group 3 - 1.5%, p = 0.11) did not differ significantly among the study groups. There was no statistical difference in the rate of premature rapture of membranes, newborn small-for-gestational-age, preeclampsia or placental abruption. Women with abnormal cervical cytology, either due to inflammation or HPV infection, had similar obstetric outcome in comparison to those with a normal cervical cytology.

CONCLUSION

This population-based retrospective cohort study indicates no association between positive HPV testing with Pap smear and obstetric complications such as preterm delivery, cervical insufficiency, placental abruption, PROM, Preterm PROM, neonatal SGA and preeclampsia, in a population with low prevalence HPV infection.

Maternal carriers of the ANXA5 M2 haplotype are exposed to a greater risk for placenta-mediated pregnancy complications

PURPOSE

Annexin A5 (ANXA5) is a protein abundantly expressed in normal placenta where it contributes to the healthy outcome of a pregnancy. Lower ANXA5 levels have been observed in M2/ANXA5 haplotype carrying chorion. Consequently, this study aimed to assess the potential association of M2 maternal carrier status with the risk of recurrent pregnancy loss (RPL), the timing of miscarriages, and other obstetric complications, for the first time in a population from Latin America.

METHODS

This study was designed as a prospective recruitment of RPL patients with post hoc analysis. The distribution of the M2/ANXA5 haplotype was compared between a group of 229 Argentine women with RPL and 100 parous controls, and was further analyzed in subgroups of patients stratified according to the timing of miscarriages and in relation to other obstetric complications.

RESULTS

No significant differences were found in the distribution of M2 haplotype among either RPL patients or the subgroups with embryonic, early fetal, or late fetal losses compared to parous controls. Notwithstanding, maternal M2/ANXA5 was found to be independently associated with a higher risk of suffering intrauterine growth restriction (IUGR) and/or preeclampsia (PE). Simultaneously, the presence of inherited and/or acquired thrombophilia also proved to be an independent risk factor for these.

CONCLUSIONS

The association found between the maternal carriage of the M2/ANXA5 haplotype and an elevated risk of IUGR and/or PE supports the hypothesis that carrier status of this haplotype and the consequently reduced placental ANXA5 expression might be responsible, at least partially, for the onset of these gestational vascular complications.

Relationship Between Pregnancy Complications and Psychiatric Disorders: A Population-Based Study With a Matched Control Group

OBJECTIVES

This study sought to identify whether pregnancy complications differ between women with and without a psychiatric disorder diagnosis prior to pregnancy.

METHODS

Women who gave birth between 2007 and 2009 in Pennsylvania and were enrolled in Medicaid from one year prior to their pregnancy until their delivery were included (N=9,930); those with psychiatric disorders were compared with a matched control group (N=4,965 for each). Logistic regression analysis estimated the odds of having a pregnancy complication among those with a psychiatric diagnosis prior to pregnancy, adjusting for demographic characteristics and chronic general medical conditions.

RESULTS

Compared with the control group, women with a psychiatric disorder prior to pregnancy had greater odds of having at least one pregnancy complication (odds ratio=1.48, 95% confidence interval=1.37-1.61). Compared with the control group, their odds of antepartum hemorrhage were 1.50 times higher, their odds of preterm labor were 1.45 times higher, and their odds of preterm birth were 1.61 times higher.

CONCLUSIONS

Women with psychiatric disorders prior to pregnancy were more likely to experience pregnancy complications, including pregnancy hemorrhage, preterm labor, and preterm birth, after the analysis controlled for age, race-ethnicity, and chronic illness status before and during pregnancy. The finding of an association between psychiatric disorders and a higher complication risk suggests the importance of population-based preconception interventions for women with psychiatric disorders and prenatal monitoring to reduce the risk of pregnancy complications in this group.

Air Pollutant Exposure Within a Few Days of Delivery and Placental Abruption in Japan

BACKGROUND

Placental abruption is an emergency obstetric complication. Although the etiology of abruption is not fully understood, acute stimuli, such as ischemia and/or inflammation, are associated with rupture of the decidual artery, resulting in placental separation. Ischemia and inflammation are acute biologic effects of air pollution. Using a case-crossover design, we tested the hypothesis that a short-term increase in exposure to air pollutants is a potential trigger of placental abruption.

METHODS

We received data for western Japan (Kyushu-Okinawa Districts) from the Japan Perinatal Registry Network database. From 2005 to 2010, 821 singleton pregnant women with placental abruption were identified. We assigned daily concentrations of air pollutants, including nitrogen dioxide (NO2), suspended particulate matter, ozone, and sulfur dioxide (SO2), from the nearest monitoring station to the respective delivery hospital of each woman. Because information on the onset day of abruption was not obtained, we assumed the case day to be 1 day before the day of delivery.

RESULTS

Exposure to NO2 at 2 days' lag was associated with placental abruption (temperature adjusted odds ratio per 10 ppb increase = 1.4; 95% confidence interval = 1.1, 1.8). The association patterns were similar, when we restricted to participants who delivered by emergency cesarean (1.4, 1.1, 1.9), or who delivered after 35 weeks of gestation (1.4, 1.0, 2.0). There was no association with suspended particulate matter, ozone, or SO2.

CONCLUSIONS

We observed an association between NO2 exposure at 2 days before the day of delivery and placental abruption in pregnant Japanese women.

Heat and pregnancy-related emergencies: Risk of placental abruption during hot weather

INTRODUCTION

Outdoor heat increases the risk of preterm birth and stillbirth, but the association with placental abruption has not been studied. Placental abruption is a medical emergency associated with major morbidity and mortality in pregnancy. We determined the relationship between ambient temperature and risk of placental abruption in warm seasons.

MATERIAL AND METHODS

We performed a case-crossover analysis of 17,172 women whose pregnancies were complicated by placental abruption in Quebec, Canada from May to October 1989-2012. The main exposure measure was the maximum temperature reached during the week before abruption. We computed odds ratios (OR) and 95% confidence intervals (CI) for the association of temperature with placental abruption, adjusted for humidity and public holidays. We assessed whether associations were stronger preterm or at term, or varied with maternal age, parity, comorbidity and socioeconomic status.

RESULTS

Compared with 15°C, a maximum weekly temperature of 30°C was associated with 1.07 times the odds of abruption (95% CI 0.99-1.16). When the timing of abruption was examined, the associations were significantly stronger at term (OR 1.12, 95% CI 1.02-1.24) than preterm (OR 0.96, 95% CI 0.83-1.10). Relationships were more prominent at term for women who were younger than 35years old, nulliparous or socioeconomically disadvantaged, but did not vary with comorbidity. Associations were stronger within 1 and 5days of abruption. Temperature was not associated with preterm abruption regardless of maternal characteristics.

CONCLUSIONS

Elevated temperatures in warm seasons may increase the risk of abruption in women whose pregnancies are near or at term. Pregnant women may be more sensitive to heat and should consider preventive measures such as air conditioning and hydration during hot weather.

Peripartum events associated with severe neurologic morbidity and mortality among acidemic neonates

PURPOSE

To identify peripartum events that may predict the development of short-term neurologic morbidity and mortality among acidemic neonates.

METHODS

Retrospective case-control study conducted at a single-teaching hospital on data from January 2010 to December 2015. The study cohort group included all acidemic neonates (cord artery pH ≤ 7.1) born at ≥ 34 weeks. Primary outcome was a composite including any of the following: neonatal encephalopathy, convulsions, intra-ventricular hemorrhage, or neonatal death. The study cohort was divided to the cases group, i.e., acidemic neonates who had any component of the primary outcome, and a control group, i.e., acidemic neonates who did not experience any component of the primary outcome.

RESULTS

Of all 24,311 neonates born ≥ 34 weeks during the study period, 568 (2.3%) had a cord artery pH ≤ 7.1 and composed the cohort study group. Twenty-one (3.7%) neonates composed the cases group. Multivariate logistic regression analysis revealed that cases were significantly more likely to have experienced placental abruption (OR 18.78; 95% CI 5.57-63.26), born ≤ 2500 g (OR 13.58; 95% CI 3.70-49.90), have meconium (OR 3.80; 95% CI 1.20-11.98) and cord entanglement (OR 5.99; 95% CI 1.79-20.06). The probability for developing the composite outcome rose from 3.7% with isolated acidemia to 97% among neonates who had all these peripartum events combined with intrapartum fetal heart rate tracing category 2 or 3.

CONCLUSION

Neonatal acidemia carries a favorable outcome in the vast majority of cases. In association with particular antenatal and intrapartum events, the short-term outcome may be unfavorable.

Cause-specific stillbirth and exposure to chemical constituents and sources of fine particulate matter

The stillbirth rate in the United States is relatively high, but limited evidence is available linking stillbirth with fine particulate matter (PM_2.5), its chemical constituents and sources. In this study, we explored associations between cause-specific stillbirth and prenatal exposures to those pollutants with using live birth and stillbirth records from eight California locations during 2002-2009. ICD-10 codes were used to identify cause of stillbirth from stillbirth records. PM_2.5 total mass and chemical constituents were collected from ambient monitors and PM_2.5 sources were quantified using Positive Matrix Factorization. Conditional logistic regression was applied using a nested case-control study design (N = 32,262). We found that different causes of stillbirth were associated with different PM_2.5 sources and/or chemical constituents. For stillbirths due to fetal growth, the odds ratio (OR) per interquartile range increase in gestational age-adjusted exposure to PM_2.5 total mass was 1.23 (95% confidence interval (CI): 1.06, 1.44). Similar associations were found with resuspended soil (OR=1.25, 95% CI: 1.10, 1.42), and secondary ammonium sulfate (OR=1.45, 95% CI: 1.18, 1.78). No associations were found between any pollutants and stillbirths caused by maternal complications. This study highlighted the importance of investigating cause-specific stillbirth and the differential toxicity levels of specific PM_2.5 sources and chemical constituents.

Neonatal Outcomes Associated With Placental Abruption

Placental abruption (early separation of the placenta) is associated with preterm birth and perinatal mortality, but associations with other neonatal morbidities remain understudied. We examined the association between abruption and newborn outcomes. We analyzed 223,341 singleton deliveries from the Consortium on Safe Labor study, a retrospective, multisite, observational study (2002-2008) of electronic medical records in the United States. Adjusted relative risks, incidence rate ratios, and 99% confidence intervals were estimated. Direct effects attributable to abruption were examined by conditioning on intermediates (preterm birth and small for gestational age) with sensitivity analyses. Incidence of abruption was 1.6% (n = 3,619). Abruption was associated with an elevated risk of newborn resuscitation (relative risk (RR) = 1.5, 99% confidence interval (CI): 1.5, 1.6), apnea (RR = 5.8, 99% CI: 5.1, 6.5), asphyxia (RR = 8.5, 99% CI: 5.7, 11.3), respiratory distress syndrome (RR = 6.5, 99% CI: 5.9, 7.1), neonatal intensive care unit admission (RR = 3.4, 99% CI: 3.2, 3.6), longer intensive care length of stay (incidence rate ratio = 2.0, 99% CI: 1.9, 2.2), stillbirth (RR = 6.3, 99% CI: 4.7, 7.9), and neonatal mortality (RR = 7.6, 99% CI: 5.2, 10.1). In sensitivity analyses, there was a direct effect of abruption associated with increased neonatal risks. These findings expand our knowledge of the association between abruption and perinatal and neonatal outcomes.

Obstetric risk factors for depression during the postpartum period in South Korea: a nationwide study

OBJECTIVE

Postpartum depression is related to many adverse effects in both mothers and their children; therefore, proper screening and early interventions are needed. This study aims to identify the risk factors of postpartum depression. Our primary focus is on obstetric risk factors.

METHODS

This study is a cross-sectional study which we extracted the data of women who gave birth between January 1st, 2010 and December 31st, 2012 from the Health Insurance Review and Assessment service (HIRA) database. We analyzed the data using multivariable logistic regression models.

RESULTS

A total of 17,483 (1.4%) women suffered from depression during the postpartum period. Younger (<20years) and advanced maternal age (≥35years), primiparity, previous depression, peripartum hysterectomy, uterine artery embolization, preterm delivery, placental abruption, cesarean delivery, induced labor, and preeclampsia were found to increase the likelihood of having depression after delivery.

CONCLUSIONS

Our findings suggest that there are several risk factors that lead women to postpartum depression. Therefore, early detection and well-management of the symptoms and risk factors for postpartum depression along with social support can help both physical and psychological conditions of women after childbirth.

Adverse Pregnancy Outcomes in Asthmatic Women: A Population-Based Family Design Study

BACKGROUND

Asthma is associated with several adverse pregnancy and perinatal outcomes. Familial factors may confound these associations.

OBJECTIVE

To examine the role of measured and unmeasured confounding by conducting a study that compared differentially exposed cousins and siblings from the same families.

METHODS

We retrieved data on adverse pregnancy outcomes, prescribed drugs, and physician-diagnosed asthma from nationwide registers for all women in Sweden with singleton births between 2001 and 2013. Logistic and linear regression estimated the association between maternal asthma and several outcomes in the whole population and within differently exposed pregnant relatives.

RESULTS

In total, 1,075,153 eligible pregnancies were included and 10.1% of the study population had asthma. We identified 475,200 cousin and 341,205 sister pregnancies. Women with asthma had increased risks for preeclampsia (adjusted odds ratio [aOR], 1.17; 95% CI, 1.13-1.21), emergency cesarean section (aOR, 1.24; 95% CI, 1.22-1.27), and having a child small for gestational age (aOR, 1.18; 95% CI, 1.12-1.23). In the conditional regression analyses, after adjustment for familial factors, the associations remained: preeclampsia in cousins (aOR, 1.16; 95% CI, 1.07-1.25) and siblings (aOR, 1.23; 95% CI, 1.08-1.38), emergency cesarean section in cousins (aOR, 1.28) and siblings (aOR, 1.21), and small for gestational age in cousins (aOR, 1.17) and siblings (aOR, 1.13).

CONCLUSIONS

Factors shared by siblings and cousins do not seem to explain the observed association between maternal asthma and adverse pregnancy outcomes. This implies that targeting the asthma disease will continue to be important in reducing risks for adverse outcomes in pregnancy.

Risk of stillbirth, preterm delivery, and fetal growth restriction following exposure in a previous birth: systematic review and meta-analysis

BACKGROUND

Little is known about the risk of non-recurrent adverse birth outcomes.

OBJECTIVES

To evaluate the risk of stillbirth, preterm birth (PTB), and small for gestational age (SGA) as a proxy for fetal growth restriction (FGR) following exposure to one or more of these factors in a previous birth.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Maternity and Infant Care, and Global Health from inception to 30 November 2016.

SELECTION CRITERIA

Studies were included if they investigated the association between stillbirth, PTB, or SGA (as a proxy for FGR) in two subsequent births.

DATA COLLECTION AND ANALYSIS

Meta-analysis and pooled association presented as odds ratios (ORs) and adjusted odds ratios (aORs).

MAIN RESULTS

Of the 3399 studies identified, 17 met the inclusion criteria. A PTB or SGA (as a proxy for FGR) infant increased the risk of subsequent stillbirth ((pooled OR 1.70; 95% confidence interval, 95% CI, 1.34-2.16) and (pooled OR 1.98; 95% CI 1.70-2.31), respectively). A combination of exposures, such as a preterm SGA (as a proxy for FGR) birth, doubled the risk of subsequent stillbirth (pooled OR 4.47; 95% CI 2.58-7.76). The risk of stillbirth also varied with prematurity, increasing three-fold following PTB <34 weeks of gestation (pooled OR 2.98; 95% CI 2.05-4.34) and six-fold following preterm SGA (as a proxy for FGR) <34 weeks of gestation (pooled OR 6.00; 95% CI 3.43-10.49). A previous stillbirth increased the risk of PTB (pooled OR 2.82; 95% CI 2.31-3.45), and subsequent SGA (as a proxy for FGR) (pooled OR 1.39; 95% CI 1.10-1.76).

CONCLUSION

The risk of stillbirth, PTB, or SGA (as a proxy for FGR) was moderately elevated in women who previously experienced a single exposure, but increased between two- and three-fold when two prior adverse outcomes were combined. Clinical guidelines should consider the inter-relationship of stillbirth, PTB, and SGA, and that each condition is an independent risk factor for the other conditions.

TWEETABLE ABSTRACT

Risk of adverse birth outcomes in next pregnancy increases with the combined number of previous adverse events.

PLAIN LANGUAGE SUMMARY

Why and how was the study carried out? Each year, around 2.6 million babies are stillborn, 15 million are born preterm (<37 weeks of gestation), and 32 million are born small for gestational age (less than tenth percentile for weight, smaller than usually expected for the relevant pregnancy stage). Being born preterm or small for gestational age can increase the chance of long-term health problems. The effect of having a stillbirth, preterm birth, or small-for-gestational-age infant in a previous pregnancy on future pregnancy health has not been summarised. We identified 3399 studies of outcomes of previous pregnancies, and 17 were summarised by our study. What were the main findings? The outcome of the previous pregnancy influenced the risk of poor outcomes in the next pregnancy. Babies born to mothers who had a previous preterm birth or small-for-gestational-age birth were more likely to be stillborn. The smaller and the more preterm the previous baby, the higher the risk of stillbirth in the following pregnancy. The risk of stillbirth in the following pregnancy was doubled if the previous baby was born both preterm and small for gestational age. Babies born to mothers who had a previous stillbirth were more likely to be preterm or small for gestational age. What are the limitations of the work? We included a small number of studies, as there are not enough studies in this area (adverse birth outcomes followed by adverse cross outcomes in the next pregnancy). We found very few studies that compared the risk of small for gestational age after preterm birth or stillbirth. Definitions of stillbirth, preterm birth categories, and small for gestational age differed across studies. We did not know the cause of stillbirth for most studies. What are the implications for patients? Women who have a history of poor pregnancy outcomes are at greater risk of poor outcomes in following pregnancies. Health providers should be aware of this risk when treating patients with a history of poor pregnancy outcomes.

Maternal and neonatal outcomes among pregnant women with fibromyalgia: a population-based study of 12 million births

PURPOSE

Fibromyalgia (FM) is a rheumatologic disorder marked by chronic, widespread pain and associated comorbid conditions. The purpose of our study was to evaluate the effect of FM on maternal and neonatal outcomes.

METHODS

Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1999 to 2013, we conducted a population-based retrospective cohort study consisting of women who delivered during that period. Logistic regression was used to compare maternal and neonatal outcomes among pregnancies in women with and without FM.

RESULTS

Of 12 584 918 births during the 15-year study period, 7758 (0.06%) were to women with FM with rates increasing over the study period. Women with FM were more commonly older in age, overweight or obese, and users of alcohol, tobacco, and illicit drugs. They were more likely to experience anxiety, depression, and bipolar disorder. Women with FM were at greater risk of gestational diabetes, preterm premature rupture of membranes, and placental abruption. Women with FM more commonly had cesarean deliveries (odds ratios (OR): 1.11, 95% CI: 1.05-1.16) and births complicated by venous thromboembolism (OR: 2.34, 95% CI: 1.91-2.86). Infants of women with FM were more likely to be premature (OR: 1.35, 95% CI: 1.25-1.46) and have intrauterine growth restriction (OR: 1.48, 95% CI: 1.30-1.68).

CONCLUSIONS

The prevalence of FM in pregnancy is rising in the US. FM is a high-risk pregnancy condition associated with adverse maternal and newborn outcomes.

Maternal serum homocysteine and uterine artery Doppler as predictors of preeclampsia and poor placentation

PURPOSE

The aim of this study was to evaluate the role of maternal serum total Homocysteine (tHcy) and uterine artery (Ut-A) Doppler as predictors of preeclampsia (PE), intrauterine growth restriction (IUGR), and other complications related to poor placentation.

PATIENTS AND METHODS

A prospective cohort study was conducted on 500 women with spontaneous pregnancies. tHcy was measured at 15-19 weeks, and then, Ut-A Doppler was performed at 18-22 weeks of pregnancy.

RESULTS

453 pregnant women completed the follow-up of the study. The tHcy and Ut-A resistance index were significantly higher in women who developed PE, IUGR, and other complications when compared to controls (tHcy: 7.033 ± 2.744, 6.321 ± 3.645, and 6.602 ± 2.469 vs 4.701 ± 2.082 μmol/L, respectively, p value <0.001 and Ut-A resistance index: 0.587 ± 0.072, 0.587 ± 0.053, and 0.597 ± 0.069 vs 0.524 ± 0.025, respectively, p value <0.001). The use of both tHcy assessment and Ut-A Doppler improved the sensitivity of prediction of PE relative to the use of each one alone (85.2 relative to 73.33 and 60%, respectively).

CONCLUSION

The use of elevated homocysteine and uterine artery Doppler screening are valuable in prediction of preeclampsia, IUGR, and poor placentation disorders. CLINCALTRIAL.

GOV ID

NCT02854501.

Mortality and causes of death among women with a history of placental abruption

INTRODUCTION

Women with a history of placental abruption have an increased later morbidity, but not much is known of the later mortality.

MATERIAL AND METHODS

Data on women with placental abruption (index cohort) between 1969 and 2005 (n = 7805) were collected from the Finnish Hospital Discharge Register and the Finnish Medical Birth Register. A matched reference cohort consisted of women without placental abruption (n = 23 523). The causes of death were retrieved from the Cause-of-Death Register. Cause-specific mortality was compared by hazard ratios (HR). Standardized mortality ratios were calculated to compare both cohorts with the general female population. The main outcome measure was subsequent mortality.

RESULTS

By the end of 2013 there were 395 deaths in the index cohort and 863 deaths in the reference cohort. The overall mortality was increased in the index cohort compared with the reference cohort [HR 1.39, 95% confidence interval (CI) 1.24-1.57]. The index cohort had an increased risk of death from respiratory tract malignancies (HR 1.72, 95% CI 1.05-2.82), alcohol-related causes (HR 1.84, 95% CI 1.25-2.72), and external causes (HR 1.63, 95% CI 1.19-2.22), especially suicide (HR 1.71, 95% CI 1.07-2.74). The mortality from cardiovascular diseases did not differ. The standardized mortality ratio was increased in the index cohort compared with the general Finnish female population (HR 1.13, 95% CI 1.02-1.24), especially for respiratory tract malignancies (HR 1.79, 95% CI 1.16-2.64). The index cohort women tended to die younger than referent women (p < 0.001).

CONCLUSIONS

Overall mortality among women with a history of placental abruption is increased. These women tend to die younger than referent women do.

Maternal, Labor, Delivery, and Perinatal Outcomes Associated with Placental Abruption: A Systematic Review

Objective Risk factors for placental abruption have changed, but there has not been an updated systematic review investigating outcomes. Methods We searched PubMed, EMBASE, Web of Science, SCOPUS, and CINAHL for publications from January 1, 2005 through December 31, 2016. We reviewed English-language publications reporting estimated incidence and/or risk factors for maternal, labor, delivery, and perinatal outcomes associated with abruption. We excluded case studies, conference abstracts, and studies that lacked a referent/comparison group or did not clearly characterize placental abruption. Results A total of 123 studies were included. Abruption was associated with elevated risk of cesarean delivery, postpartum hemorrhage and transfusion, preterm birth, intrauterine growth restriction or low birth weight, perinatal mortality, and cerebral palsy. Additional maternal outcomes included relaparotomy, hysterectomy, sepsis, amniotic fluid embolism, venous thromboembolism, acute kidney injury, and maternal intensive care unit admission. Additional perinatal outcomes included acidosis, encephalopathy, severe respiratory disorders, necrotizing enterocolitis, acute kidney injury, need for resuscitation, chronic lung disease, infant death, and epilepsy. Conclusion Few studies examined outcomes beyond the initial birth period, but there is evidence that both mother and child are at risk of additional adverse outcomes. There was also considerable variation in, or absence of, the reporting of abruption definitions.

Low expression of soluble human leukocyte antigen G in early gestation and subsequent placenta-mediated complications of pregnancy

AIM

Abnormal placentation is a common pathogenic mechanism of many placenta-mediated complications of late pregnancy, including pre-eclampsia, fetal growth restriction, stillbirth, and placental abruption. During successful placentation, the trophoblast (which is a semi-allograft) is not rejected by decidual immune cells because of maternal immune tolerance, mainly induced by human leukocyte antigen G (HLA-G). Deficient HLA-G expression seems to be associated with the development of complications of pregnancy. The aim of this study was to determine whether low soluble HLA-G (sHLA-G) levels in maternal blood at the beginning of pregnancy may be associated with subsequent placenta-mediated complications.

METHODS

For this retrospective case-control study, 117 cases of placenta-mediated complications of pregnancy and 234 controls with uneventful pregnancy were selected. Plasma sHLA-G levels were measured at 11-13 weeks' gestation by the enzyme-linked immunosorbent assay method in blood samples previously obtained at first-trimester prenatal screening for chromosomal fetal abnormalities.

RESULTS

Women who subsequently developed placenta-mediated complications had significantly lower sHLA-G levels at the beginning of pregnancy (median, 43.08 IU/mL) than controls (median, 49.10 IU/mL; P = 0.008). An sHLA-G level lower than 43.50 IU/mL at the end of the first trimester was associated with a twofold increased risk of developing a pregnancy complication (odds ratio, 1.82; 95% confidence interval, 1.22-2.73). The strongest association, although only moderately strong, was observed with severe pre-eclampsia (odds ratio, 2.66; 95% confidence interval, 1.08-6.56).

CONCLUSION

Placenta-mediated complications of pregnancy may be associated with low sHLA-G levels in the first trimester, suggesting a potential role of sHLA-G in the early stages of placentation.

Cardiovascular Disease in Relation to Placental Abruption: A Population-Based Cohort Study from Denmark

BACKGROUND

Cardiovascular (CVD) complications stemming from vascular dysfunction have been widely explored in the setting of preeclampsia. However, the impact of abruption, a strong indicator of microvascular disturbance, on the risk of CVD mortality and morbidity remains poorly characterised.

METHODS

We designed a cohort analysis of 828 289 women who delivered singletons in Denmark between 1978 and 2010. We linked the National Patient Registry and the Registry of Causes of Death to the Danish Birth Registry to ascertain CVD events. We estimated CVD risks in relation to abruption from Cox proportional hazards regression following adjustments for confounders.

RESULTS

With 13 231 562 person-years of follow-up of women with at least one delivery, 11 829 pregnancies were complicated by abruption. The median (interquartile range) follow-up in the non-abruption and abruption groups was 16 (8, 24) and 18 (10, 25) years, respectively. CVD mortality rates in women with and without abruption were 0.9 and 0.3 per 10 000 person-years, respectively (adjusted hazard ratio (HR) 2.7, 95% confidence interval (CI) 1.5, 5.0). The corresponding CVD morbidity complication rates were 16.7 and 10.0 per 10 000 person-years, respectively (HR 1.5, 95% CI 1.4, 1.8). The increased risks were evident for ischaemic heart disease, acute myocardial infarction, hypertensive heart disease, non-rheumatic valvular disease, and congestive heart failure.

CONCLUSIONS

This study shows increased hazards of CVD morbidity and mortality in relation to abruption. A better understanding of the pathogenesis of distorted placental microvasculature is needed as this appears to be a harbinger of CVD later in life.