Perinatal mortality associated with abruptio placenta in singletons and multiples

Diagnosis and Management of Pregnant Women With Placental Abruption and Neonatal Outcomes

Background

Placenta abruptio (PA) remains a serious materno-fetal complication. According to progress realized in maternal-fetal medicine, we aimed to evaluate the diagnosis and management of PA and neonatal outcomes.

Methods

We conducted a retrospective study that involved all the patients that were diagnosed with PA in a tertiary maternity hospital between 2006 and 2013. Data were analyzed to determine mean and standard deviation and statistically analyzed using the Chi-square test.

Results

In total, 201 patients were diagnosed with PA out of 35184 deliveries (0.56%). The mean age of patients was 30 years and most of them were multiparous (56.2%). Thirty-six out of 201 patients (17.9%) smoked tobacco or consumed alcohol during the pregnancy. Three patients came from their homes. Twenty-eight patients had preeclampsia and 105 presented with high blood pressure. Furthermore, 117 patients presented metrorrhagia (58.2%) and 39% of patients exhibited abdominal pain. We reported fetal heart rate abnormalities in 57% of the cases. Ultrasound examination revealed PA in only 48 patients (23.9%). One hundred eighty out of 201 patients (84.6%) underwent an emergency caesarean section. One hundred sixty-seven fetuses were born prematurely. Thirteen out of 201 fetuses died, and 98 newborns needed neonatal resuscitation. In total, 31 fetuses had an umbilical artery (UA) with pH ≤ 7 (31/188). The mean time for delivery was 18.7 min. However, UA pH did not differ when the delivery time was shorter (p = 0.09). Seventy-six percent of cases came from their homes. The mean UA pH was significantly lower for PA cases who came from their homes compared to hospitalized women (p = 0.0015). Histological examination of the placenta confirmed the diagnosis in 71 out of 148 cases (47.9%). The mean duration of hospital stay of the newborns was 17 days.

Conclusion

PA remains a serious materno-fetal emergency with a bad fetal prognosis for many newborns. Many fetuses either died or exhibited severe acidosis. Clinical signs and radiological images of PA are absent in many cases. There was more fetal acidosis for mothers who came from their homes at the time of delivery. We recommend that the delivery should not be delayed and a cesarean section must be the preferred mode of delivery. Pregnant women with vascular and metabolic diseases should be carefully monitored and informed on the risk of PA.

Maternal weight gain and pregnancy outcomes in twin gestations

BACKGROUND

Data on the optimal gestational weight gain in twin pregnancies are limited. As a result, the Institute of Medicine currently provides only provisional recommendations on gestational weight gain in this population.

OBJECTIVE

This study aimed to identify the optimal range of gestational weight gain in twin pregnancies and to estimate the association between inappropriate gestational weight gain and adverse pregnancy outcomes.

STUDY DESIGN

This was a retrospective cohort study of all women with twin pregnancies that were followed up in a single, tertiary center between 2000 and 2014. We used 2 approaches to identify the optimal range of gestational weight gain: a statistical approach (the interquartile range of gestational weight gain in low-risk pregnancies with normal outcomes) and an outcome-based approach (by identifying thresholds of gestational weight gain below or above which the rate of adverse outcomes increases). The primary outcome was preterm birth. Associations of gestational weight gain below or above the normal range with the study outcomes were estimated using logistic regression analysis and were expressed as adjusted odds ratio with 95% confidence intervals. These associations were stratified by prepregnancy body mass index group.

RESULTS

A total of 1274 women with twin pregnancies met the study criteria: 43 were classified as underweight, 777 were normal weight, 278 were overweight, and 176 were obese. Our estimates of the optimal gestational weight gain range were similar to those recommended by the Institute of Medicine except for the obese category, in which our optimal gestational weight gain range at 37 weeks (9.3-16.3 kg) was lower than in the provisional Institute of Medicine recommendations (11.3-19.1 kg). Nearly half of our cohort experienced inappropriate gestational weight gain: 30% (n=381) gained weight below and 17% (n=216) gained weight above current Institute of Medicine recommendations. In the normal weight group, gestational weight gain below recommendations was associated with an increased risk of preterm birth and birthweight at the <10th centile and with a reduction in the risk of hypertensive disorders, whereas gestational weight gain above recommendations was associated with an increased risk of hypertensive disorders and a reduction in the risk of birthweight at the <10th centile. Associations were less consistent in the overweight and obese groups.

CONCLUSION

These findings identify gestational weight gain as a potentially modifiable risk factor for preterm birth and other pregnancy complications in twin gestations. Further prospective studies are needed to determine whether interventions aimed at optimizing gestational weight gain can improve the outcomes of these high-risk pregnancies.

Placental Abruption after Fetoscopic Laser Surgery in Twin-Twin Transfusion Syndrome: The Role of the Solomon Technique

INTRODUCTION

Twin-twin transfusion syndrome (TTTS) is a complication in monochorionic twin pregnancies which is preferably treated with fetoscopic laser surgery. A few small studies suggested a possible association between the Solomon laser technique and placental abruption.

METHODS

The objective of this study is to compare the rate of and to explore potential risk factors for placental abruption in TTTS treated with fetoscopic laser surgery according to the Selective and Solomon laser technique. We conducted a large retrospective cohort study of consecutive TTTS-cases treated with fetoscopic laser surgery in Shanghai, China, and Leiden, The Netherlands treated with either the Selective laser technique (Selective group) or Solomon laser technique (Solomon group).

RESULTS

The rate of placental abruption in the Selective group versus the Solomon group was 1.7% (5/289) and 3.4% (15/441), respectively (p = 0.184). No risk factors for placental abruption were identified. Placental abruption was associated with lower gestational age at birth (p = 0.003) and severe cerebral injury (p = 0.003).

CONCLUSION

The prevalence of placental abruption in TTTS after fetoscopic laser surgery is low, although it appears higher than in the overall population. Placental abruption is associated with a lower gestational age at birth, which is associated with severe cerebral injury. The rate of placental abruption was not significantly increased with the use of the Solomon technique. Continued research of placental abruption in TTTS is necessary to determine why the rate is higher than in the overall population.

Antepartum Hemorrhage and Outcome of Very Low Birth Weight, Very Preterm Infants: A Population-Based Study

OBJECTIVE

We aimed to determine the independent effect of maternal antepartum hemorrhage (APH) on mortality and major neonatal morbidities among very low birth weight (VLBW), very preterm infants.

STUDY DESIGN

A population-based cohort study of VLBW singleton infants born at 24 to 31 weeks of gestation between 1995 and 2016 was performed. Infants born with the following pregnancy associated complications were excluded: maternal hypertensive disorders, prolonged rupture of membranes, amnionitis, maternal diabetes, and small for gestational age. APH included hemorrhage due to either placenta previa or placental abruption. Univariate and multivariable logistic regression analyses were performed to assess the effect of maternal APH on mortality and major neonatal morbidities.

RESULTS

The initial cohort included 33,627 VLBW infants. Following exclusions, the final study population comprised 6,235 infants of whom 2,006 (32.2%) were born following APH and 4,229 (67.8%) without APH. In the APH versus no APH group, there were higher rates of extreme prematurity (24-27 weeks of gestation; 51.6% vs. 45.3%, p < 0.0001), mortality (20.2 vs. 18.5%, p = 0.011), bronchopulmonary dysplasia (BPD, 16.1 vs. 13.0%, p = 0.004) and death or adverse neurologic outcome (37.4 vs. 34.5%, p = 0.03). In the multivariable analyses, APH was associated with significantly increased odds ratio (OR) for BPD in the extremely preterm infants (OR: 1.31, 95% confidence interval: 1.05-1.65). The OR's for mortality, adverse neurological outcomes, and death or adverse neurological outcome were not significantly increased in the APH group.

CONCLUSION

Among singleton, very preterm VLBW infants, maternal APH was associated with increased odds for BPD only in extremely premature infants, but was not associated with excess mortality or adverse neonatal neurological outcomes.

KEY POINTS

· Outcome of very low birth weight infants born after antepartum hemorrhage (APH) was assessed.. · APH was not associated with higher infant mortality.. · APH was not associated with adverse neurological outcome.. · APH was associated with increased bronchopulmonary dysplasia in extremely preterm infants..

No. 394-Stillbirth Investigation

OBJECTIVES

To provide an investigation protocol to help health care providers determine the cause of a fetal death.

OPTIONS

Consideration has been given to protocols for the investigation of fetal death that are currently available in Canada and in other countries.

OUTCOMES

Identification of possible causes of stillbirth and their relationship to future pregnancies.

EVIDENCE

Articles related to the etiology of fetal death were identified in a search of PubMed (June 2006 to September 2018), the Cochrane Library, and investigation protocols from the American College of Obstetricians and Gynecologists, the International Stillbirth Alliance Collaborative for Improving Classification of Perinatal Deaths, the Royal College of Obstetricians and Gynaecologists, the Queensland clinical guidelines, and the Reproductive Care Program of Nova Scotia.

BENEFITS

To provide better advice for women regarding possible causes of fetal death and implications for future pregnancies.

VALIDATION

The evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee and the Clinical Practice Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada. The level of evidence and quality of the recommendation made was described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.

RECOMMENDATIONS

Maternal autonomy and high-risk pregnancy in Bangladesh: the mediating influences of childbearing practices and antenatal care

BACKGROUND

Maternal, infant and neonatal mortality rates are high in Bangladesh. Certain childbearing practices and poor utilisation of antenatal care services make Bangladeshi women more vulnerable to experience poor health during pregnancy and adverse pregnancy outcomes. Also, women in Bangladesh remain considerably subordinate to men in almost all aspects of their lives, from education and work opportunities to healthcare utilisation. This study investigates the severity of health complications during pregnancy in relation to women's autonomy, and how childbearing practices and utilisation of antenatal care mediate this relationship.

METHODS

Data from the most recent Bangladesh Demographic and Health Survey (BDHS) is used in this study. Multinomial regression models (MLRM) are employed to examine the relationship between the outcome variable - high risk pregnancy, and explanatory variables - women's autonomy, childbearing practices and use of antenatal care.

RESULTS

In Bangladesh, about 41.5% of women experienced high-risk pregnancies involving multiple health complications. Findings showed that women's autonomy in decision-making, freedom of movement and economic autonomy were significantly associated with high-risk pregnancies. However, women's autonomy in physical mobility in particular did so only through the mediating factors of maternal childbearing practices and antenatal care. Specifically, both early and delayed childbearing and shorter birth interval increased the likelihood of high-risk (multiple complications) pregnancies by about 30% and 31% respectively, high parity increased the risk by 23% and use of antenatal care decreased it by 46%.

CONCLUSIONS

The Women's decision-making autonomy, freedom of movement and economic autonomy had significant effects on high-risk pregnancies. However, the effects were mediated by both maternal childbearing practices and use of antenatal care in a limited way. Policies and programmes aimed at improving pregnancy outcomes need to focus on all three sets of factors: women's autonomy, childbearing practices and use of antenatal care.

Does caesarean delivery in the first pregnancy increase the risk for adverse outcome in the second? A registry-based cohort study on first and second singleton births in Norway

OBJECTIVE

To explore if newborns in the second pregnancy following a previous caesarean delivery (CD) have higher risk of perinatal mortality or cerebral palsy than newborns in pregnancies following a previous vaginal delivery (VD).

DESIGN

Cohort study with information from the Medical Birth Registry of Norway and the Cerebral Palsy Registry of Norway.

SETTING

Births in Norway.

PARTICIPANTS

294 598 women with their first and second singleton delivery during 1996-2015.

MAIN OUTCOME MEASURES

Stillbirth, perinatal mortality, neonatal mortality and cerebral palsy.

RESULTS

Among 294 598 included women, 42 962 (15%) had a CD in their first pregnancy while 251 636 (85%) had a VD. Compared with the second delivery of mothers with a previous VD, the adjusted OR (adjOR), for stillbirth in the second pregnancy following a previous CD was 1.45, 95% CI 1.22 to 1.73; for perinatal death the adjOR was 1.42 (1.22 to 1.73) and for neonatal death 1.13 (0.86 to 1.49). Among children who survived the neonatal period, the adjOR for cerebral palsy was 1.27 (0.99 to 1.64). Secondary outcomes, including small for gestational age, preterm and very preterm birth, uterine rupture and placental complications (eg, postpartum haemorrhage and pre-eclampsia) were more frequent in the subsequent pregnancy following a previous CD compared with a previous VD, in particular for uterine rupture adjOR 86.7 (48.2 to 156.1). Adjustment for potential confounders attenuated the ORs somewhat, but the excess risk in the second pregnancy persisted for all outcomes.

CONCLUSION

A previous CD was in this study associated with increased risk for stillbirth and perinatal death compared with a previous VD. Although less robust, we also found that a previous CD was associated with a slightly increased risk of cerebral palsy among children surviving the neonatal period. The aetiology behind these associations needs further investigation.

Alcohol Consumption During Pregnancy and Risk of Placental Abnormality: The Japan Environment and Children's Study

There have been no large nationwide birth cohort studies examining for the effects of maternal alcohol use during pregnancy on placental abnormality. This study searched for associations between alcohol consumption and the placental abnormalities of placenta previa, placental abruption, and placenta accreta using the fixed dataset of a large national birth cohort study commencing in 2011 that included 80,020 mothers with a singleton pregnancy. The presence of placental abnormalities and potential confounding factors were recorded, and multiple logistic regression analysis was employed to search for correlations between maternal alcohol consumption during pregnancy and placental abnormalities. The overall rate of prenatal drinking until the second/third trimester was 2.7% (2,112). The prevalence of placenta previa, placental abruption, and placenta accreta was 0.58% (467), 0.43% (342), and 0.20% (160), respectively. After controlling for potential confounding factors, maternal alcohol use during pregnancy was significantly associated with the development of placenta accreta (OR 3.10, 95%CI 1.69-5.44). In conclusion, this large nationwide survey revealed an association between maternal drinking during pregnancy and placenta accreta, which may lead to excessive bleeding during delivery.

The relationship between maternal body mass index and pregnancy outcomes in twin compared with singleton pregnancies

OBJECIVE

Women with twins have an a priori increased risk for many of the complications associated with maternal obesity. Thus, the impact of maternal obesity in twins may differ from that reported in singletons. In addition, given the increased metabolic demands in twin pregnancies, the impact of maternal underweight may be greater in twin compared with singleton gestations. Our objective was to test the hypothesis that the relationship between maternal pre-pregnancy body mass index (BMI) and adverse pregnancy outcomes differ between twin and singleton gestations.

METHODS

This was a retrospective population-based study of all women who had a singleton or twin hospital birth in Ontario, Canada, between April 2012 and March 2016. Data were obtained from the Better Outcomes Registry & Network (BORN) Ontario. The relationship between maternal BMI category and pregnancy complications was assessed separately in twin and singleton gestations. The primary outcome was a composite variable that included any of the following complications: preeclampsia, gestational diabetes, or preterm birth before 32^0/7 weeks. Relative risk (aRR) and 95% confidence intervals (CI) for adverse outcomes for each BMI category as defined by WHO (using normal weight category as reference) were generated using modified Poisson regression, adjusting for maternal age, nulliparity, smoking, previous preterm birth, and fetal sex.

RESULTS

A total of 487,870 women with singleton (n = 480,010) and twin (n = 7860) pregnancies met the inclusion criteria. The risk of the composite primary outcome, preeclampsia, gestational diabetes, and cesarean delivery increased with high maternal BMI in both singleton and twin gestations, but these associations were weaker in twin compared with singleton gestations (association of BMI ≥ 40.0 kg/m² with primary outcome: aRR = 3.10, 95%-CI 2.96-3.24 in singletons compared with aRR = 1.74, 95%-CI 1.37-2.20 in twins). In singleton pregnancies the risk of preterm birth at < 32^0/7 weeks increased with maternal BMI, mainly due to an increased risk of provider-initiated preterm birth. In twin gestations, however, underweight (but not overweight or obesity) was associated with the greatest risk of preterm birth at < 32 weeks (aRR 1.67, 95%-CI 1.17-2.37), mainly due to an increased risk of spontaneous preterm birth (aRR 2.10, 95%-CI 1.44-3.08).

CONCLUSION

In healthy women with twin pregnancies, underweight is associated with the greatest risk for preterm birth, while the association of maternal obesity with adverse pregnancy outcomes is weaker than that observed in singletons.

North American Fetal Therapy Network: Timing of and indications for delivery following laser ablation for twin-twin transfusion syndrome

Background

Despite improvements in fetal survival for pregnancies affected by twin-twin transfusion syndrome since the introduction of laser photocoagulation, prematurity remains a major source of neonatal morbidity and mortality.

Objective

To investigate the indications and factors influencing the timing of delivery following laser treatment, we collected delivery information regarding twin-twin transfusion syndrome cases in a large multicenter cohort.

Study Design

Eleven North American Fetal Therapy Network (NAFTNet) centers conducted a retrospective review of twin-twin transfusion syndrome patients who underwent laser photocoagulation. Clinical, demographic and ultrasound variables including twin-twin transfusion syndrome stage, and gestational age at treatment and delivery were recorded. Primary and secondary maternal and fetal indications for delivery were identified. Univariate analysis was used to select candidate variables with significant correlation with latency and GA at delivery. Multivariable Cox regression with competing risk analysis was utilized to determine the independent associations.

Results

A total of 847 pregnancies were analyzed. After laser, the average latency to delivery was 10.11 ± 4.8 weeks and the mean gestational age at delivery was 30.7 ± 4.5 weeks. Primary maternal indications for delivery comprised 79% of cases. The leading indications included spontaneous labor (46.8%), premature rupture of membranes (17.1%), and placental abruption (8.4%). Primary fetal indications accounted for 21% of cases and the most frequent indications included donor non-reassuring status (20.5%), abnormal donor Dopplers (15.1%), and donor growth restriction (14.5%). The most common secondary indications for delivery were premature rupture of membranes, spontaneous labor and donor growth restriction. Multivariate modeling found gestational age at diagnosis, stage, history of prior amnioreduction, cerclage, interwin membrane disruption, procedure complications and chorioamniotic membrane separation as predictors for both gestational age at delivery and latency.

Conclusion

Premature delivery after laser therapy for twin-twin transfusion syndrome is primarily due to spontaneous labor, preterm premature rupture of membranes and non-reassuring status of the donor fetus. Placental abruption was found to be a frequent complication resulting in early delivery. Future research should be directed toward the goal of prolonging gestation after laser photocoagulation to further reduce morbidity and mortality associated with twin-twin transfusion syndrome.

Management of acute abdomen in pregnancy: current perspectives

Acute abdomen in pregnancy represents a unique diagnostic and therapeutic challenge. Acute abdominal pain in pregnancy can occur due to obstetric factors as well for reasons that are unrelated to pregnancy. The diagnostic approach of acute abdomen during pregnancy can be tricky owing to the altered clinical presentations brought about by the anatomical and physiological changes of gestation along with the reluctance to use certain radiological investigations for fear of harming the fetus. Delay in diagnosis and treatment can lead to adverse outcomes for both the mother and fetus. In this article, we attempt to review and discuss the various etiologies, the current concepts of diagnosis, and treatment, with a view to developing a strategy for timely diagnosis and management of pregnant women presenting with acute abdominal pain.

Estimating risk of severe neonatal morbidity in preterm births under 32 weeks of gestation

Background: A large recent study analyzed the relationship between multiple factors and neonatal outcome and in preterm births. Study variables included the reason for admission, indication for delivery, optimal steroid use, gestational age, and other potential prognostic factors. Using stepwise multivariable analysis, the only two variables independently associated with serious neonatal morbidity were gestational age and the presence of suspected intrauterine growth restriction as a reason for admission. This finding was surprising given the beneficial effects of antenatal steroids and hazards associated with some causes of preterm birth. Multivariable logistic regression techniques have limitations. Without testing for multiple interactions, linear regression will identify only individual factors with the strongest independent relationship to the outcome for the entire study group. There may not be a single "best set" of risk factors or one set that applies equally well to all subgroups. In contrast, machine learning techniques find the most predictive groupings of factors based on their frequency and strength of association, with no attempt to identify independence and no assumptions about linear relationships.Objective: To determine if machine learning techniques would identify specific clusters of conditions with different probability estimates for severe neonatal morbidity and to compare these findings to those based on the original multivariable analysis.Materials and methods: This was a secondary analysis of data collected in a multicenter, prospective study on all admissions to the neonatal intensive care unit between 2013 and 2015 in 10 hospitals. We included all patients with a singleton, stillborn, or live newborns, with a gestational age between 23 0/7 and 31 6/7 week. The composite endpoint, severe neonatal morbidity, defined by the presence of any of five outcomes: death, grade 3 or 4 intraventricular hemorrhage (IVH), and ≥28 days on ventilator, periventricular leukomalacia (PVL), or stage III necrotizing enterocolitis (NEC), was present in 238 of the 1039 study patients. We studied five explanatory variables: maternal age, parity, gestational age, admission reason, and status with respect to antenatal steroid administration. We concentrated on Classification and Regression Trees because the resulting structure defines clusters of risk factors that often bear resemblance to clinical reasoning. Model performance was measured using area under the receiver-operator characteristic curves (AUC) based on 10 repetitions of 10-fold cross-validation.Results: A hybrid technique using a combination of logistic regression and Classification and Regression Trees had a mean cross-validated AUC of 0.853. A selected point on its receiver-operator characteristic (ROC) curve corresponding to a sensitivity of 81% was associated with a specificity of 76%. Rather than a single curve representing the general relationship between gestational age and severe morbidity, this technique found seven clusters with distinct curves. Abnormal fetal testing as a reason for admission with or without growth restriction and incomplete steroid administration would place a 20-year-old patient on the highest risk curve.Conclusions: Using a relatively small database and a few simple factors known before birth it is possible to produce a more tailored estimate of the risk for severe neonatal morbidity on which clinicians can superimpose their medical judgment, experience, and intuition.

Maternal, fetal and neonatal consequences associated with the use of crack cocaine during the gestational period: a systematic review and meta-analysis

OBJECTIVE

Crack cocaine consumption is one of the main public health challenges with a growing number of children intoxicated by crack cocaine during the gestational period. The primary goal is to evaluate the accumulating findings and to provide an updated perspective on this field of research.

METHODS

Meta-analyses were performed using the random effects model, odds ratio (OR) for categorical variables and mean difference for continuous variables. Statistical heterogeneity was assessed using the I-squared statistic and risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. Ten studies met eligibility criteria and were used for data extraction.

RESULTS

The crack cocaine use during pregnancy was associated with significantly higher odds of preterm delivery [odds ratio (OR), 2.22; 95% confidence interval (CI), 1.59-3.10], placental displacement (OR, 2.03; 95% CI 1.66-2.48), reduced head circumference (- 1.65 cm; 95% CI - 3.12 to - 0.19), small for gestational age (SGA) (OR, 4.00; 95% CI 1.74-9.18) and low birth weight (LBW) (OR, 2.80; 95% CI 2.39-3.27).

CONCLUSION

This analysis provides clear evidence that crack cocaine contributes to adverse perinatal outcomes. The exposure of maternal or prenatal crack cocaine is pointedly linked to LBW, preterm delivery, placental displacement and smaller head circumference.

Meta-analysis on the effect of aspirin use for prevention of preeclampsia on placental abruption and antepartum hemorrhage

OBJECTIVE DATA

Impaired placentation in the first 16 weeks of pregnancy is associated with increased risk of subsequent development of preeclampsia, birth of small-for-gestational-age neonates, and placental abruption. Previous studies reported that prophylactic use of aspirin reduces the risk of preeclampsia and small-for-gestational-age neonates with no significant effect on placental abruption. However, meta-analyses of randomized controlled trials that examined the effect of aspirin in relation to gestational age at onset of therapy and dosage of the drug reported that significant reduction in the risk of preeclampsia and small-for-gestational-age neonates is achieved only if the onset of treatment is at ≤16 weeks of gestation and the daily dosage of the drug is ≥100 mg.

STUDY

We aimed to estimate the effect of aspirin on the risk of placental abruption or antepartum hemorrhage in relation to gestational age at onset of therapy and the dosage of the drug.

STUDY APPRAISAL AND SYNTHESIS METHODS

To perform a systematic review and meta-analysis of randomized controlled trials that evaluated the prophylactic effect of aspirin during pregnancy, we used PubMed, Cinhal, Embase, Web of Science and Cochrane library from 1985 to September 2017. Relative risks of placental abruption or antepartum hemorrhage with their 95% confidence intervals were calculated with the use of random effect models. Analyses were stratified according to daily dose of aspirin (<100 and ≥100 mg) and the gestational age at the onset of therapy (≤16 and >16 weeks of gestation) and compared with the use of subgroup difference analysis.

RESULTS

The entry criteria were fulfilled by 20 studies on a combined total of 12,585 participants. Aspirin at a dose of <100 mg per day had no impact on the risk of placental abruption or antepartum hemorrhage, irrespective of whether it was initiated at ≤16 weeks of gestation (relative risk, 1.11; 95% confidence interval, 0.52-2.36) or at >16 weeks of gestation (relative risk, 1.32; 95% confidence interval, 0.73-2.39). At ≥100 mg per day, aspirin was not associated with a significant change on the risk of placental abruption or antepartum hemorrhage, whether the treatment was initiated at ≤16 weeks of gestation (relative risk, 0.62, 95% confidence interval, 0.31-1.26), or at >16 weeks of gestation (relative risk, 2.08; 95% confidence interval, 0.86-5.06), but the difference between the subgroups was significant (P=.04).

CONCLUSION

Aspirin at a daily dose of ≥100 mg for prevention of preeclampsia that is initiated at ≤16 weeks of gestation, rather than >16 weeks, may decrease the risk of placental abruption or antepartum hemorrhage.

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.

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.

A multicenter prospective study of neonatal outcomes at less than 32 weeks associated with indications for maternal admission and delivery

BACKGROUND

Counseling for patients with impending premature delivery traditionally has been based primarily on the projected gestational age at delivery. There are limited data regarding how the indications for the preterm birth affect the neonatal outcome and whether this issue should be taken into account in decisions regarding management and patient counseling.

OBJECTIVE

We performed a prospective study of pregnancies resulting in premature delivery at less than 32 weeks to determine the influence of both the indications for admission and their associated indications for delivery on neonatal mortality and complications of prematurity.

STUDY DESIGN

This is a multicenter, prospective study in 10 hospitals where all data from the neonatal intensive care unit routinely was imported to a deidentified data warehouse. Maternal data were collected prospectively at or near the time of delivery. Eligible subjects included singleton deliveries in these hospitals between 23 0/7 and 31 6/7 weeks. The primary hypothesis of the study was to determine whether there was a difference in the primary outcome, which was defined as neonatal composite morbidity, between those neonates delivered after admission for premature labor vs premature rupture of membranes, because these were expected to be the 2 most frequent diagnoses leading to premature birth. The sample size was calculated based on a 10% difference in outcomes for these 2 entities. We based this hypothesis on the knowledge that premature rupture of membranes has a greater incidence of intra-amniotic infection and inflammation than premature labor and that outcomes for premature neonates are worse when delivery is associated with intra-amniotic infection. Additional outcomes were analyzed for all other indications for admission and delivery. Composite morbidity was defined as ≥1 of the following: respiratory distress syndrome (oxygen requirement, clinical diagnosis, and consistent chest radiograph), bronchopulmonary dysplasia (requirement for oxygen support at 28 days of life), severe intraventricular hemorrhage (grades 3 or 4), periventricular leukomalacia, blood culture-proven sepsis present within 72 hours of birth, necrotizing enterocolitis, or neonatal death before discharge from the hospital. A secondary composite of serious neonatal morbidity also was defined prospectively.

RESULTS

The study included 1089 mother/baby pairs. Composite morbidity between those with premature labor (77.2%) and premature rupture of membranes (73.2%) was not significantly different (P = .29). A few neonatal complications were associated with indications for admission and delivery, but on logistic regression adjusting for gestational age and other confounders, suspected intrauterine growth restriction was the only indication for admission or delivery associated with an increase in serious morbidity (odds ratio 4.5, [2.1 to 9.8], P < .003). Other factors not related to the indications for admission including cesarean delivery, and low 5-minute Apgar were associated with an increase in morbidity.

CONCLUSION

Studies of many single factors related to the indications for preterm delivery have been shown to be associated with adverse neonatal outcome. In this study evaluating all of the most frequent indications, however, we found only suspected intrauterine growth restriction as an indication for admission and delivery was found to be so. Thus, it seems that in almost all situations counseling patients can be based primarily on gestational age along with other factors including estimated fetal weight, sex, race, plurality, and completion of a course of antenatal corticosteroids.

Interventions to prevent stillbirth

Stillbirth is one of the most distressing complications of pregnancy and still occurs far too frequently. The rate of stillbirth has been decreasing worldwide but room for improvement remains even in high-income countries. Risk factors for stillbirth have been identified in an effort to detect those women at increased risk. However, risk factors are non-specific and do not identify most stillbirths. Strategies employed to screen the general population such as assessment of fetal activity, fetal growth screening and biomarkers have also been used to identify increased risk for stillbirth. As with clinical risk factors, these methods are non-specific. Interventions to prevent stillbirth include antenatal testing of high-risk women, ultrasonographic assessments of fetal growth and Doppler velocimetry as well as iatrogenic preterm or term delivery. Additional research into the role of these interventions and better identification of those at high risk for stillbirth will help to achieve further stillbirth reduction.

Identification and Management of Obstetric Hemorrhage

Obstetric hemorrhage remains the leading cause of maternal death and severe morbidity worldwide. Although uterine atony is the most common cause of peripartum bleeding, abnormal placentation, coagulation disorders, and genital tract trauma contribute to adverse maternal outcomes. Given the inability to reliably predict patients at high risk for obstetric hemorrhage, all parturients should be considered susceptible, and extreme vigilance must be exercised in the assessment of blood loss and hemodynamic stability during the peripartum period. Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are critical to the successful management of peripartum bleeding.

Does apoptotic activity have a role in the development of the placental abruption?

OBJECTIVE

The purpose of the present study is to analyses the role of apoptotic activity in placental abruption (PA) development by evaluating the level of plasma M30-M65.

METHODS

The study group included 46 pregnant women who underwent caesarean sections (CS) because of PA, and the control group included 48 pregnant women who underwent CS because of obstetric causes. Venous blood samples were received from all expectants before starting the CS for the purpose of evaluating the M30-M65 levels, which are indicators of apoptotic activity in maternal plasma.

RESULTS

The plasma M30-M65 levels were determined to be statistically significantly higher in with PA group. The sensitivity and specificity of the test were determined to be 71.7% and 64.6%, respectively in identifying the expectants with PA when the cut-off value was taken as 163.50 U/L for the plasma M30 value. The sensitivity and specificity of the test were determined to be 76.1% and 66.7%, respectively in identifying the PA when the cut-off value was taken as 295.50 U/L for the M65 value.

CONCLUSIONS

The increase of apoptotic activity induced by thrombin resulting from decidual bleeding may have a role in the development of PA.

Gestational age specific stillbirth risk among Indigenous and non-Indigenous women in Queensland, Australia: a population based study

Background

In Australia, significant disparity persists in stillbirth rates between Aboriginal and Torres Strait Islander (Indigenous Australian) and non-Indigenous women. Diabetes, hypertension, antepartum haemorrhage and small-for-gestational age (SGA) have been identified as important contributors to higher rates among Indigenous women. The objective of this study was to examine gestational age specific risk of stillbirth associated with these conditions among Indigenous and non-Indigenous women.

Methods

Retrospective population-based study of all singleton births of at least 20 weeks gestation or at least 400 grams birthweight in Queensland between July 2005 and December 2011 using data from the Queensland Perinatal Data Collection, which is a routinely-maintained database that collects data on all births in Queensland. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95 % confidence intervals, adjusting for maternal demographic and pregnancy factors.

Results

Of 360987 births analysed, 20273 (5.6 %) were to Indigenous women and 340714 (94.4 %) were to non-Indigenous women. Stillbirth rates were 7.9 (95 % CI 6.8–9.2) and 4.1 (95 % CI 3.9–4.3) per 1000 births, respectively. For both Indigenous and non-Indigenous women across most gestational age groups, antepartum haemorrhage, SGA, pre-existing diabetes and pre-existing hypertension were associated with increased risk of stillbirth. There were mixed results for pre-eclampsia and eclampsia and a consistently raised risk of stillbirth was not seen for gestational diabetes.

Conclusion

This study highlights gestational age specific stillbirth risk for Indigenous and non-Indigenous women; and disparity in risk at term gestations. Improving access to and utilisation of appropriate and responsive healthcare may help to address disparities in stillbirth risk for Indigenous women.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0943-7) contains supplementary material, which is available to authorized users.

Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes

BACKGROUND

Regular antenatal care for women with a multiple pregnancy is accepted practice, and while most women have an increase in the number of antenatal visits, there is no consensus as to what constitutes optimal care. 'Specialised' antenatal clinics have been advocated as a way of improving outcomes for women and their infants.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of 'specialised' antenatal clinics compared with 'standard' antenatal care for women with a multiple pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials with reported data that compared outcomes in mothers and babies with a multiple pregnancy who received antenatal care specifically designed for women with a multiple pregnancy (as defined by the trial authors) with outcomes in controls who received 'standard' antenatal care (as defined by the trial authors).

DATA COLLECTION AND ANALYSIS

Two of the review authors independently assessed trials for inclusion and trial quality. Both review authors extracted data. Data were checked for accuracy. We graded the quality of the evidence using GRADEpro software.

MAIN RESULTS

Findings were based on the results of a single study with some design limitations.Data were available from one study involving 162 women with a multiple pregnancy. For the only reported primary outcome, perinatal mortality, we are uncertain whether specialised antenatal clinics makes any difference compared to standard care (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.26 to 4.03; 324 infants, very low quality evidence). Women receiving specialised antenatal care were significantly more likely to birth by caesarean section (RR 1.38; 95% CI 1.06 to 1.81; 162 women, moderate quality evidence). Data were not reported in the study on the following primary outcomes: small-for-gestational age, very preterm birth or maternal death. There were no differences identified between specialised antenatal care and standard care for other secondary outcomes examined: postnatal depression (RR 0.48; 95% CI 0.19 to 1.20; 133 women, very low quality evidence), breastfeeding (RR 0.63; 95% CI 0.24 to 1.68; 123 women, very low quality evidence), stillbirth (RR 0.68; 0.12 to 4.04) or neonatal death (RR 2.05; 95% CI 0.19 to 22.39) (324 infants).

AUTHORS' CONCLUSIONS

There is currently limited information available from randomised controlled trials to assess the role of 'specialised' antenatal clinics for women with a multiple pregnancy compared with 'standard' antenatal care in improving maternal and infant health outcomes. The value of 'specialised' multiple pregnancy clinics in improving health outcomes for women and their infants requires evaluation in appropriately powered and designed randomised controlled trials.

Frequency, risk factors and feto-maternal outcomes of abruptio placentae in Northern Tanzania: a registry-based retrospective cohort study

Background

Abruptio placentae remains a major cause of maternal and perinatal morbidity and mortality in developing countries. Little is known about the burden of abruptio placentae in Tanzania. This study aimed to determine frequency, risk factors for abruptio placentae and subsequent feto-maternal outcomes in women with abruptio placentae.

Methods

We designed a retrospective cohort study using maternally-linked data from Kilimanjaro Christian Medical Centre (KCMC) medical birth registry. Data on all women who delivered live infants and stillbirths at 28 or more weeks of gestation at KCMC hospital from July 2000 to December 2010 (n = 39,993) were analysed. Multivariate logistic models were used to calculate odds ratios (OR) and 95 % confidence intervals (CIs) for risk factors, and feto-maternal outcomes associated with abruptio placentae.

Results

The frequency of abruptio placentae was 0.3 % (112/39,993). Risk factors for abruptio placentae were chronic hypertension (OR 4.1; 95 % CI 1.3–12.8), preeclampsia/eclampsia (OR 2.1; 95 % CI 1.1–4.1), previous caesarean delivery (OR 1.3; 95 % CI 1.2–4.2), previous abruptio placentae (OR 2.3; 95 % CI 1.8–3.4), fewer antenatal care visits (OR 1.3; 95 % 1.1–2.4) and high parity (OR 1.4; 95 % CI 1.2–8.6). Maternal complications associated with abruptio placentae were antepartum haemorrhage (OR 11.5; 95 % CI 6.3–21.2), postpartum haemorrhage (OR 17.9; 95 % 8.8–36.4),), caesarean delivery (OR 5.6; 95 % CI 3.6–8.8), need for blood transfusions (OR 9.6; 95 % CI 6.5–14.1), altered liver function (OR 5.3; 95 % CI 1.3–21.6) and maternal death (OR 1.6; 95 % CI 1.5–1.8). In addition, women with abruptio placentae had prolonged duration of hospital stay (more than 4 days) and were more likely to have been referred during labour. Adverse fetal outcomes associated with abruptio placentae include low birth weight (OR 5.9; 95 % CI 3.9–8.7), perinatal death (OR 17.6; 95 % CI 11.3–27.3) and low Apgar score (below 7) at 1 and 5 min.

Conclusions

Frequency of abruptio placentae is comparable with local and international studies. Chronic hypertension, preeclampsia, prior caesarean section delivery, prior abruptio placentae, poor attendance to antenatal care and high parity were independently associated with abruptio placentae. Abruptio placentae was associated with adverse maternal and foetal outcomes. Clinicians should identify risk factors for abruptio placentae during prenatal care when managing pregnant women to prevent adverse maternal and foetal outcomes.

The effect of placental abruption on the outcome of extremely premature infants

OBJECTIVE

To determine the effect of placental abruption on the outcome of infants born between 22 and 26 weeks of gestation.

METHODS

A retrospective study involving 32 cases of placental abruption. Controls were matched to cases according to gestational age and birth weight. Medical records were reviewed to confirm maternal background and neonatal outcome. We compared characteristics of maternal background and neonatal outcome between the two groups.

RESULTS

There were no significant differences in the incidence of pregnancy-induced hypertension, low maternal fibrinogen (<200 mg/dl), premature rupture of membrane, intrauterine infection, ischemic changes of the placenta, or funisitis between the groups. Non-reassuring fetal heart rate patterns (NRFHRs) during intrapartum were frequently seen in the placental abruption group compared to controls (75% versus 51%, p = 0.02). However, no differences were found for the incidence of low umbilical artery pH (<7.1), cerebral palsy, or neonatal death. The incidence of chronic lung disease (CLD, 66% versus 43%, p = 0.04) and hemosiderin deposition on the placenta (16% versus 0%, p < 0.01) was higher in abruptions compared to controls.

CONCLUSION

Placental abruption has a risk for the development of NRFHRs and CLD in infants born between 22 and 26 weeks of gestation, but shows no effect on neonatal mortality.

Maternal pre-gravid body mass index and obstetric outcomes in twin gestations

OBJECTIVE

The aim of this study is to evaluate the impact of maternal pre-gravid and/or first trimester overweight and obesity, and the adverse obstetrics outcome in twin pregnancies.

STUDY DESIGN

This is a retrospective study of women who delivered viable twins after 23 weeks of gestation with available prepregnancy body mass index (BMI) and/or were at their earliest visit during the first trimester of pregnancy in the period 2007-2011. The patients were divided into four subgroups according to their BMI (underweight, normal weight, overweight and obese) according to the WHO classification and their outcomes were compared. Obstetrical outcomes of interest including gestational diabetes, gestational hypertension, preterm birth, antepartum hemorrhage, intrahepatic cholestasis of pregnancy, method of delivery and neonatal intensive care unit (NICU) admission were all studied and compared.

RESULT

Electronic records of 1228 pregnant subjects who delivered twins were abstracted. Five hundred and four patients with twin gestations with available BMI were identified (underweight BMI<18.5% (n=22), normal weight BMI 18.5-24.9% (n=260), overweight 25-29.9% (n=114) and obese ⩾30% (n=108)). Obstetric complications occurred more often in the overweight and obese groups as compared with the normal weight group. There was an increased risk of gestational diabetes in overweight and obese women (odds ratio (OR), 3.3; 95% confidence interval (CI) 1.52-7.3; P=0.001) and (OR, 3.2; 95% CI, 1.41-7.1; P=0.002), respectively. There was an increased risk of gestational hypertension in the obese group compared with the normal weight group (OR, 2.29; 95% CI, 1.1-4.7; P=0.02) but not in the overweight group (OR, 1.71; 95% CI, 0.8-3.6; P=0.1). In addition, an increased risk of very preterm delivery (<32 weeks) in the overweight group and obese groups was seen when compared with the normal weight group (OR, 2.2; 95% CI, 1.18-4.20; P=0.014 and OR, 2; 95% CI, 1.024-3.91; P=0.04, respectively). Increased rate of cesarean section in the obese group was seen when compared with the normal weight group (OR, 2; 95% CI, 1.2-3.4; P=0.006). Risks of antepartum hemorrhage, intrahepatic cholestasis and NICU admission were similar between the groups.

CONCLUSION

In addition to the known obstetrics complications associated with twin gestations, the pregnancy outcomes in twins are further adversely influenced by increased maternal prepregnancy BMI.

Circulating endothelial progenitor cells and placental abruption in women with preeclampsia

OBJECTIVE

Abnormalities in circulating angiogenic factors and endothelial progenitor cells (EPCs) have been reported in patients with preeclampsia and placental abruption. The objective of this study was to determine whether the number of EPCs is altered in patients with placental abruption.

DESIGN

A case control study.

SETTING

Hiroshima University Hospital in Japan.

SAMPLE

Pregnant Japanese women with preeclampsia (n=27) and those without any complications (n=15).

METHOD

The EPC (CD45(low)CD34(+)CD133(+) cells) counts were examined using flow cytometry in peripheral blood collected from 27 women with preeclampsia and 15 normal pregnant women. Among the 27 women with preeclampsia, five subsequently developed placental abruption. All subjects were divided into three groups: normal pregnancy (NP, n=15), preeclampsia without placenta abruption (PE, n=22) and preeclampsia with placental abruption (PA, n=5).

MAIN OUTCOME MEASURES

The EPC counts were measured in pregnant women with preeclampsia who subsequently developed placental abruption.

RESULTS

The EPC count in the PE group significantly decreased in comparison to that observed in the NP group (620cells/ml versus 1918 cells/ml, P<0.01). In the PA group, the EPC count was found to markedly decrease in comparison to that observed in the PE group (221cells/ml, P<0.05).

CONCLUSIONS

The number of EPCs was found to significantly decrease in preeclamptic women who subsequently developed placental abruption.

Intrapartum hemorrhage

Intrapartum hemorrhage is a serious and sometimes life-threatening event. Several etiologies are known and include placental abruption, uterine atony, placenta accreta, and genital tract lacerations. Prompt recognition of blood loss, identification of the source of the hemorrhage, volume resuscitation, including red blood cells and blood products when required, will result in excellent maternal outcomes.

Fetal and neonatal deaths among cases of maternal near miss

OBJECTIVE

To determine the prevalence of fetal and neonatal deaths among patients with maternal near miss and the factors associated with this fatal outcome.

METHODS

The authors conducted a descriptive, cross-sectional, analyzing medical records of patients admitted to the ICU of a tertiary obstetric Recife (Brazil), between January 2007 and December 2010, who had at least one criterion of near miss defined by WHO. Statistical analysis was performed with Epi-Info 3.3.2, using chi-square and Fisher's exact test, considering a significance level of 5%. For multivariate analysis was constructed as a hierarchical model with the response variable fetal and neonatal deaths.

RESULTS

We included 246 cases of maternal near miss. Among women in the study, hypertensive disorders occurred in 62.7% to 41.2% in HELLP syndrome and the laboratory criteria for near miss in 59.6%. There were 48 (19.5%) stillbirths and 19 (7.7%) neonatal deaths. After analyzing the variables that remained statistically associated with fetal and neonatal deaths were: severe preeclampsia, placental abruption, endometritis, cesarean delivery, prematurity and the laboratory criteria for maternal near miss.

CONCLUSION

The high incidence of fetal and neonatal deaths among patients with maternal near miss. Among these women there is an overlap of factors contributing to this fatal outcome, in our study, those who had severe preeclampsia, placental abruption, endometritis, premature birth or laboratory criteria positively associated with deaths.

Decreasing incidence of placental abruption in Finland during 1980-2005

OBJECTIVE

To study the incidence trends of placental abruption.

DESIGN

Register-based retrospective study.

SETTING

The Finnish Medical Birth Register and Hospital Discharge Register.

POPULATION

A total of 6231 placental abruption cases among 1 576 051 deliveries.

METHODS

Data on demographic and pregnancy and delivery associated outcomes were collected. Data on overall incidence and maternal age were available 1980-2005. Data on other variables were available 1987-2005.

MAIN OUTCOME MEASURE

Placental abruption

RESULTS

The overall incidence of placental abruption was 395/100 000 (0.4%). The incidence decreased 31%, from 487/100 000 in 1980 to 337/100 000 in 2005 (p < 0.001). The incidence was lowest among women aged 20-24 years (305/100 000) and highest among women aged ≥45 years (1309/100 000). During 1987-2005 the incidence was lowest among women with one or two deliveries (353/100 000) and highest in nulliparous women (382/100 000) and in women with three or more deliveries (595/100 000). The incidence was nearly double (577/100 000) among smoking compared with non-smoking women (341/100 000). The incidence was highest between gestational weeks 26 and 29. Among newborns weighing <1500 g the incidence was higher (5734/100 000) than among those weighing ≥2500 g (251/100 000). The incidence was higher in multiple (903/100 000) than in singleton pregnancies (374/100 000).

CONCLUSION

The incidence of placental abruption decreased during 1980-2005. The incidence was highest among women aged 45 years or more, multiparous and smoking women, in multiple pregnancies and in women with low birthweight newborns.

Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality

Rates of cesarean delivery have substantially increased worldwide during the past 30 years. Indeed, almost one-third of deliveries in the United States are cesareans. Most cesareans are safe, and major complications are uncommon. However, there is a "concealed" downside to cesarean deliveries. There are rare but life-threatening morbidities that may occur, which are often overlooked because most cesareans go well. In addition, subsequent pregnancies are fraught with an increased risk of both maternal and fetal complications. The worst of these are associated with placental problems such as previa, abruption, and accreta. The risk dramatically worsens in patients with multiple repeat cesarean deliveries. This article will summarize and highlight the implications of the rising cesarean rate on maternal and fetal morbidity and mortality.

Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes

BACKGROUND

Regular antenatal care for women with a multiple pregnancy is accepted practice, and while most women have an increase in the number of antenatal visits, there is no consensus as to what constitutes optimal care. 'Specialised' antenatal clinics have been advocated as a way of improving outcomes for women and their infants.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of 'specialised' antenatal clinics compared with 'standard' antenatal care for women with a multiple pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 April 2012).

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials with reported data that compared outcomes in mothers and babies with a multiple pregnancy who received antenatal care specifically designed for women with a multiple pregnancy (as defined by the trial authors) with outcomes in controls who received 'standard' antenatal care (as defined by the trial authors).

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed trials for inclusion and trial quality. Both review authors extracted data. Data were checked for accuracy.

MAIN RESULTS

There were data available from one study included in the review involving 162 women with a multiple pregnancy. For the only reported primary outcome, perinatal mortality, there were no statistically significant differences identified between specialised antenatal care and standard care (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.26 to 4.03). Women receiving specialised antenatal care were significantly more likely to birth by caesarean section (RR 1.38; 95% CI 1.06 to 1.81). Data was not reported in the study on the following primary outcomes: small-for-gestational age, very preterm birth or maternal death. There were no statistically significant differences identified between specialised antenatal care and standard care for other secondary outcomes examined: postnatal depression (RR 0.48; 95% CI 0.19 to 1.20), breastfeeding (RR 0.63; 95% CI 0.24 to 1.68), still birth (RR 0.68; 0.12 to 4.04) or neonatal death (RR 2.05; 95% CI 0.19 to 22.39).

AUTHORS' CONCLUSIONS

There is currently limited information available from randomised controlled trials to assess the role of 'specialised' antenatal clinics for women with a multiple pregnancy compared with 'standard' antenatal care in improving maternal and infant health outcomes. The value of 'specialised' multiple pregnancy clinics in improving health outcomes for women and their infants requires evaluation in appropriately powered and designed randomised controlled trials.

Risk of Infant Mortality Among Twins in Relation to Placental Abruption: Contributions of Preterm Birth and Restricted Fetal Growth

While preterm birth and restricted fetal growth are strongly associated with infant mortality, the extent to which these associations are modified by placental abruption remains unknown. A retrospective cohort study was carried out to examine the risk of infant mortality among twins in relation to abruption, and explore the independent contributions of preterm birth and restricted fetal growth to these associations. The study was restricted to women who had delivered twins at 22 weeks' gestation or more and fetuses weighing 500 grams or more in the United States (1989–2000). Risks of preterm birth (less than 37 weeks' gestation), fetal growth restriction and infant mortality, in relation to placental abruption, were evaluated. All analyses were adjusted for potential sociodemographic confounding factors. The association between restricted twin fetal growth and abruption was the strongest among the most severely growth-restricted babies (i.e., less than 1 centile), with the strength of association diminishing with increasing birthweight centiles. The risk of preterm birth among pregnancies with and without abruption were 80.1% and 51.9%, respectively (relative risk [RR] 1.5, 95% confidence interval [CI] 1.4–1.6). The risk of small-for-gestational-age (SGA; birthweight of less than the 10th centile for gestational age) among abruption and nonabruption births was 11.7% and 9.2%, respectively (RR 1.3, 95% CI 1.2–1.4). Compared with twins of the appropriate growth delivered at term, the relative risks for infant mortality in the presence of abruption were 9.9 (95% CI 5.4–18.2) for term-SGA, 25.0 (95% CI 22.3–28.1) for preterm-non-SGA, and 36.2 (95% CI 28.4–46.1) for preterm-SGA births. The association between infant mortality and abruption among twins appears largely mediated through preterm birth, and to a lesser extent, through SGA. The association between fetal growth and abruption is strongest among the severely growth-restricted babies, suggesting that the origins of placental abruption may develop in early pregnancy.

Perinatal morbidity and risk of hypoxic-ischemic encephalopathy associated with intrapartum sentinel events

OBJECTIVE

To examine perinatal morbidity and rate of hypoxic-ischemic encephalopathy in infants exposed to intrapartum sentinel events.

STUDY DESIGN

Retrospective cohort study from 2000-2005. Perinatal mortality, perinatal morbidity and rate of hypoxic-ischemic encephalopathy were compared in 3 groups of infants exposed to different risk factors for perinatal asphyxia (sentinel events, nonreassuring fetal status, elective cesarean section).

RESULTS

Five hundred eighty-six infants were studied. Perinatal mortality was 6% in the sentinel event group and 0.3% in the nonreassuring fetal status group (relative risk, 2.4; 95% confidence interval, 1.95-2.94). Perinatal morbidity was 2-6 times more frequent in infants exposed to sentinel events; the incidence of hypoxic-ischemic encephalopathy was 10%, compared with 2.5% in the nonreassuring fetal status group (relative risk, 1.93; 95% confidence interval, 1.49-2.52). No infant in the elective cesarean section group died, had perinatal morbidity, or developed encephalopathy.

CONCLUSION

Intrapartum sentinel events are associated with a high incidence of perinatal morbidity and hypoxic-ischemic encephalopathy.

Alcohol consumption during pregnancy and risk of placental abruption and placenta previa

The purpose of this study was to examine the association between prenatal alcohol consumption and the occurrence of placental abruption and placenta previa in a population-based sample. We used linked birth data files to conduct a retrospective cohort study of singleton deliveries in the state of Missouri during the period 1989 through 2005 (n = 1,221,310). The main outcomes of interest were placenta previa, placental abruption and a composite outcome defined as the occurrence of either or both lesions. Multivariate logistic regression was used to generate adjusted odd ratios, with non-drinking mothers as the referent category. Women who consumed alcohol during pregnancy had a 33% greater likelihood for placental abruption during pregnancy (adjusted odds ratio (OR), 95% confidence interval (CI) = 1.33 [1.16-1.54]). No association was observed between prenatal alcohol use and the risk of placenta previa. Alcohol consumption in pregnancy was positively related to the occurrence of either or both placental conditions (adjusted OR [95% CI] = 1.29 [1.14-1.45]). Mothers who consumed alcohol during pregnancy were at elevated risk of experiencing placental abruption, but not placenta previa. Our findings underscore the need for screening and behavioral counseling interventions to combat alcohol use by pregnant women and women of childbearing age.

Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis

BACKGROUND

Stillbirth rates in high-income countries have shown little or no improvement over the past two decades. Prevention strategies that target risk factors could be important in rate reduction. This systematic review and meta-analysis was done to identify priority areas for stillbirth prevention relevant to those countries.

METHODS

Population-based studies addressing risk factors for stillbirth were identified through database searches. The factors most frequently reported were identified and selected according to whether they could potentially be reduced through lifestyle or medical intervention. The numbers attributable to modifiable risk factors were calculated from data relating to the five high-income countries with the highest numbers of stillbirths and where all the data required for analysis were available. Odds ratios were calculated for selected risk factors, from which population-attributable risk (PAR) values were calculated.

FINDINGS

Of 6963 studies initially identified, 96 population-based studies were included. Maternal overweight and obesity (body-mass index >25 kg/m(2)) was the highest ranking modifiable risk factor, with PARs of 8-18% across the five countries and contributing to around 8000 stillbirths (≥22 weeks' gestation) annually across all high-income countries. Advanced maternal age (>35 years) and maternal smoking yielded PARs of 7-11% and 4-7%, respectively, and each year contribute to more than 4200 and 2800 stillbirths, respectively, across all high-income countries. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths. Primiparity contributes to around 15% of stillbirths. Of the pregnancy disorders, small size for gestational age and abruption are the highest PARs (23% and 15%, respectively), which highlights the notable role of placental pathology in stillbirth. Pre-existing diabetes and hypertension remain important contributors to stillbirth in such countries.

INTERPRETATION

The raising of awareness and implementation of effective interventions for modifiable risk factors, such as overweight, obesity, maternal age, and smoking, are priorities for stillbirth prevention in high-income countries.

FUNDING

The Stillbirth Foundation Australia, the Department of Health and Ageing, Canberra, Australia, and the Mater Foundation, Brisbane, Australia.