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Melamud K, Wahab SA, Smereka PN, Dighe MK, Glanc P, Kamath A, Maheshwari E, Scoutt LM, Hindman NM. Imaging of Antepartum and Postpartum Hemorrhage. Radiographics 2024; 44:e230164. [PMID: 38547034 DOI: 10.1148/rg.230164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Severe obstetric hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Major hemorrhage in the antepartum period presents potential risks for both the mother and the fetus. Similarly, postpartum hemorrhage (PPH) accounts for up to a quarter of maternal deaths worldwide. Potential causes of severe antepartum hemorrhage that radiologists should be familiar with include placental abruption, placenta previa, placenta accreta spectrum disorders, and vasa previa. Common causes of PPH that the authors discuss include uterine atony, puerperal genital hematomas, uterine rupture and dehiscence, retained products of conception, and vascular anomalies. Bleeding complications unique to or most frequently encountered after cesarean delivery are also enumerated, including entities such as bladder flap hematomas, rectus sheath and subfascial hemorrhage, and infectious complications of endometritis and uterine dehiscence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Javitt and Madrazo in this issue.
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Affiliation(s)
- Kira Melamud
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Shaun A Wahab
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Paul N Smereka
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Manjiri K Dighe
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Phyllis Glanc
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Amita Kamath
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Ekta Maheshwari
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Leslie M Scoutt
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Nicole M Hindman
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
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Brandt JS, Ananth CV. Placental abruption at near-term and term gestations: pathophysiology, epidemiology, diagnosis, and management. Am J Obstet Gynecol 2023; 228:S1313-S1329. [PMID: 37164498 PMCID: PMC10176440 DOI: 10.1016/j.ajog.2022.06.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 05/12/2023]
Abstract
Placental abruption is the premature separation of the placenta from its uterine attachment before the delivery of a fetus. The clinical manifestations of abruption typically include vaginal bleeding and abdominal pain with a wide variety of abnormal fetal heart rate patterns. Clinical challenges arise when pregnant people with this condition present with profound vaginal bleeding, necessitating urgent delivery, especially when there is a concern for maternal and fetal compromise and coagulopathy. Abruption occurs in 0.6% to 1.2% of all pregnancies, with nearly half of abruption occurring at term gestations. An exposition of abruption at near-term (defined as the late preterm period from 34 0/7 to 36 6/7 weeks of gestation) and term (defined as ≥37 weeks of gestation) provides unique insights into its direct effects, as risks associated with preterm birth do not impact outcomes. Here, we explore the pathophysiology, epidemiology, and diagnosis of abruption. We discuss the interaction of chronic processes (decidual and uteroplacental vasculopathy) and acute processes (shearing forces applied to the abdomen) that underlie the pathophysiology. Risk factors for abruption and strengths of association are summarized. Sonographic findings of abruption and fetal heart rate tracings are presented. In addition, we propose a management algorithm for acute abruption that incorporates blood loss, vital signs, and urine output, among other factors. Lastly, we discuss blood component therapy, viscoelastic point-of-care testing, disseminated intravascular coagulopathy, and management of abruption complicated by fetal death. The review seeks to provide comprehensive, clinically focused guidance during a gestational age range when neonatal outcomes can often be favorable if rapid and evidence-based care is optimized.
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Affiliation(s)
- Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
| | - Cande V Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; Cardiovascular Institute of New Jersey and Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ
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Kawamura H, Takahashi N, Miyazaki Y, Tsuyoshi H, Orisaka M, Yoshida Y. Impact of maternal late hospital arrival on adverse outcome of offspring affected by placental abruption: A regional multicenter nested case-control study in Japan. J Obstet Gynaecol Res 2023; 49:1341-1347. [PMID: 36808792 DOI: 10.1111/jog.15579] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/28/2023] [Indexed: 02/20/2023]
Abstract
AIMS To elucidate the influence of the time-intervals between the onset and arrival (TIME 1), onset and delivery (TIME 2), and the decision to deliver and delivery (TIME 3) on severe adverse outcomes of offspring born to mothers complicated by placental abruption outside the hospital. METHODS This is a multicenter nested case-control study about placental abruption at Fukui Prefecture, a regional area in Japan, through 2013 to 2017. Multiple pregnancy, fetal or neonatal congenital abnormality, and unknown detailed information at onset of placental abruption were excluded. A composite of perinatal death and cerebral palsy or death at 18-36 months of corrected age was defined as the adverse outcome. The relationship between time-intervals and the adverse outcome was analyzed. RESULTS The 45 subjects for analysis were divided into two groups, including a group with and without adverse outcome (poor, n = 8; and good, n = 37). TIME 1 was longer in the poor group (150 vs. 45 min, p < 0.001). A subgroup analysis targeted to 29 cases with preterm birth at the third trimester indicates that TIME 1 and TIME 2 were longer in the poor group (185 vs. 55 min, p = 0.02; and 211 vs. 125 min, p = 0.03), while TIME 3 was shorter in the poor group (21 vs. 53 min, p = 0.01). CONCLUSIONS Long time-intervals between onset and arrival or onset and delivery may be correlated with perinatal death or cerebral palsy in surviving infants affected by placental abruption.
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Affiliation(s)
- Hiroshi Kawamura
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Nozomu Takahashi
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Yumiko Miyazaki
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Hideaki Tsuyoshi
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Makoto Orisaka
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Yoshio Yoshida
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
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4
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Parc E, Benin A, Lecarpentier E, Goffinet F, Lepercq J. Risk factors for hypoxic-ischemic encephalopathy or neonatal death in placental abruption. J Gynecol Obstet Hum Reprod 2023; 52:102498. [PMID: 36336280 DOI: 10.1016/j.jogoh.2022.102498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To identify risk factors for moderate or severe hypoxic-ischemic encephalopathy (HIE), or neonatal death in clinical placental abruption. MATERIAL AND METHODS A nested case-control study within a cohort of singleton pregnancies complicated by placental abruption with a live born infant at two academic reference centers in France, from 2006 to 2019. Cases were patients who gave birth to an infant with moderate or severe HIE or death within 28 days (HIE/death group), and controls were patients whose infant did not have any of these outcomes (no-HIE group). Independent risk factors were identified by logistic regression. Binary decision tree discriminant (CART) analysis was performed to define high-risk subgroups of HIE or death. RESULTS Among 152 patients, the infants of 44 (29%) had HIE or death. Out-of-hospital placental abruption and fetal bradycardia at admission were more frequent in cases than in controls: 39 (89%) vs 61 (56%), p < .01 and 24 (59%) vs 19 (18%), p < .01, respectively. In multivariate analysis, out-of-hospital placental abruption (aOR, 7.05; 95% CI, 1.94-25.66) and bradycardia at admission (aOR, 8.60; 95% CI, 2.51-29.42) were independently associated with an increased risk of HIE or death. The combination of out-of-hospital placental abruption and bradycardia was the highest risk situation associated with HIE or death (67%). The decision-to-delivery interval was 15 [12-20] minutes among cases. CONCLUSION Out-of-hospital placental abruption combined with bradycardia at admission was associated with a major risk of moderate or severe HIE or death. An optimal decision-to-delivery interval does not guarantee the absence of an adverse neonatal outcome.
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Affiliation(s)
- Enora Parc
- Department of Obstetrics and Gynecology of Port Royal, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
| | - Amelie Benin
- Department of Obstetrics and Gynecology of Port Royal, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
| | - Edouard Lecarpentier
- Department of Obstetrics Gynecology and Reproductive Medicine, University Paris Est Créteil, Centre Hospitalier Inter-Communal de Créteil, Créteil, France
| | - François Goffinet
- Department of Obstetrics and Gynecology of Port Royal, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France; Obstetrical, Perinatal and Pediatric Epidemiology (Epopé) Research Team, Center for Epidemiology and Statistics (CRESS), INSERM U1153, Paris, France
| | - Jacques Lepercq
- Department of Obstetrics and Gynecology of Port Royal, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France.
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Oltean I, Rajaram A, Tang K, MacPherson J, Hondonga T, Rishi A, Toltesi R, Gowans R, Jahangirnia A, Nasr Y, Lawrence SL, El Demellawy D. The Association of Placental Abruption and Pediatric Neurological Outcome: A Systematic Review and Meta-Analysis. J Clin Med 2022; 12:jcm12010205. [PMID: 36615006 PMCID: PMC9821447 DOI: 10.3390/jcm12010205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/17/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
Placental histopathology provides insights, or "snapshots", into relevant antenatal factors that could elevate the risk of perinatal brain injury. We present a systematic review and meta-analysis comparing frequencies of adverse neurological outcomes in infants born to women with placental abruption versus without abruption. Records were sourced from MEDLINE, Embase, and the CENTRAL Trials Registry from 1946 to December 2019. Studies followed the PRISMA guidelines and compared frequencies of neurodevelopmental morbidities in infants born to pregnant women with placental abruption (exposure) versus women without placental abruption (comparator). The primary endpoint was cerebral palsy. Periventricular and intraventricular (both severe and any grades of IVH) and any histopathological neuronal damage were the secondary endpoints. Study methodologic quality was assessed by the Ottawa-Newcastle scale. Estimated odds ratios (OR) and hazards ratio (HR) were derived according to study design. Data were meta-analyzed using a random effects model expressed as pooled effect sizes and 95% confidence intervals. We included eight observational studies in the review, including 1245 infants born to women with placental abruption. Results of the random effects meta-analysis show that the odds of infants born to pregnant women with placental abruption who experience cerebral palsy is higher than in infants born to pregnant women without placental abruption (OR 5.71 95% CI (1.17, 27.91); I2 = 84.0%). There is no statistical difference in the odds of infants born to pregnant women with placental abruption who experience severe IVH (grade 3+) (OR 1.20 95% CI (0.46, 3.11); I2 = 35.8%) and any grade of IVH (OR 1.20 95% CI (0.62, 2.32); I2 = 32.3%) vs. women without placental abruption. There is no statistically significant difference in the odds of infants born to pregnant women with placental abruption who experience PVL vs. pregnant women without placental abruption (OR 6.51 95% CI (0.94, 45.16); I2 = 0.0%). Despite our meta-analysis suggesting increased odds of cerebral palsy in infants born to pregnant women with placental abruption versus without abruption, this finding should be interpreted cautiously, given high heterogeneity and overall poor quality of the included studies.
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Affiliation(s)
- Irina Oltean
- Department of Surgery & Pathology, Children’s Hospital of Eastern Ontario, Ottawa, ON K1H 8L1, Canada; (I.O.); (K.T.)
| | - Ajay Rajaram
- Department of Pathology, McGill University, Montreal, QC H4A 3J1, Canada;
| | - Ken Tang
- Department of Surgery & Pathology, Children’s Hospital of Eastern Ontario, Ottawa, ON K1H 8L1, Canada; (I.O.); (K.T.)
| | - James MacPherson
- Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada; (J.M.); (Y.N.)
| | | | - Aanchal Rishi
- Schulich School of Medicine & Dentistry, Western University, London, ON N6A 5C1, Canada;
| | - Regan Toltesi
- Faculty of Science, Engineering and Architecture, Laurentian University, Sudbury, ON P3E 2C6, Canada;
| | - Rachel Gowans
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON K1N 6N5, Canada;
| | - Ashkan Jahangirnia
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada; (A.J.); (S.L.L.)
| | - Youssef Nasr
- Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada; (J.M.); (Y.N.)
| | - Sarah L. Lawrence
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada; (A.J.); (S.L.L.)
- Division of Neonatology, Children’s Hospital of Eastern Ontario, Ottawa, ON K1H 8L1, Canada
| | - Dina El Demellawy
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada; (A.J.); (S.L.L.)
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Eastern Ontario, Ottawa, ON K1H 8L1, Canada
- Correspondence: ; Tel.: +1-613-737-7600
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Shi Z, Luo K, Jani S, February M, Fernandes N, Venkatesh N, Sharif N, Tan S. Mimicking partial to total placental insufficiency in a rabbit model of cerebral palsy. J Neurosci Res 2022; 100:2138-2153. [PMID: 34173261 PMCID: PMC8709884 DOI: 10.1002/jnr.24901] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 01/07/2023]
Abstract
All placental abruptions begin as partial abruptions, which sometimes manifest as fetal bradycardia. The progression from partial to total abruption was mimicked by a new rabbit model of placental insufficiency, and we compared it, with sufficient statistical power, with the previous model mimicking total placental abruption. The previous model uses total uterine ischemia at E22 or E25 (70% or 79% term, respectively), in pregnant New Zealand white rabbits for 40 min (Full H-I). The new model, Partial+Full H-I, added a 30-min partial ischemia before the 40-min total ischemia. Fetuses were delivered either at E31.5 (full term) vaginally for neurobehavior testing, or by C-section at E25 for ex vivo brain cell viability evaluation. The onset of fetal bradycardia was within the first 2 min of either H-I protocol. There was no difference between Full H-I (n = 442 for E22, 312 for E25) and Partial+Full H-I (n = 154 and 80) groups in death or severely affected kits at E22 (76% vs. 79%) or at E25 (66% vs. 64%), or normal kits at E22 or E25, or any of the individual newborn neurobehavioral tests at any age. No sex differences were found. Partial+Full H-I (n = 6) showed less cell viability than Full H-I (n = 8) at 72-hr ex vivo in the brain regions studied. Partial+Full H-I insult produced similar cerebral palsy phenotype as our previous Full H-I model in a sufficiently powered study and may be more suitable for testing of potential neuroprotectants.
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Affiliation(s)
- Zhongjie Shi
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI
| | - Kehuan Luo
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI
| | - Sanket Jani
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI
| | - Melissa February
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI
| | - Nithi Fernandes
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI
| | | | | | - Sidhartha Tan
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI
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Crimmins S, Baumer S, Theodoru A, Driscoll CH. Impact of Obstetric Communication on Decision-to-Delivery Time. Am J Perinatol 2022; 39:1389-1395. [PMID: 35613929 DOI: 10.1055/s-0042-1748843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE In obstetric emergencies, care coordination is critical in achieving a "decision-to-delivery" time of 30 minutes. Reliable communication is essential to optimize coordinated care of mother and baby. Clinical mobility (CM) platforms have been shown to improve communication during medical emergencies; however, their impact on improving decision-to-delivery times has not been shown. This study aimed to determine the impact of a new CM platform on decision-to-delivery time. STUDY DESIGN A multidisciplinary team designed a CM platform that employs a wall-mounted panel paired with mobile technology to alert all relevant clinical staff. This new platform uses in-room preprogrammed messages that alert predetermined responders matching the emergency. For example, the "STAT section" button summons doctors (obstetrics, anesthesiology, and neonatology), obstetric nurses, and newborn resuscitation staff via smartphones. Impact of this platform was assessed with process and outcome data: cord artery pH, 5-minute Apgar's score; and decision for cesarean section to time of: skin incision, uterine incision, and delivery. This pre- and postimplementation study (October-September 2018 vs. January-December 2019) centered on the opening of our new Obstetric Care Unit. Data were analyzed with Chi-square and Mann-Whitney U-test. RESULTS Emergent cesarean delivery was performed in 172 women pre- and 124 postimplementation of the new CM platform. In postimplementation, we observed a 7.4-minute reduction in time from decision-to-delivery (26 pre- vs. 18.6 minutes postimplementation, p = 0.001). Delivery within 30 minutes improved by 15.2% (p = 0.018). Times to skin and uterine incision were also significantly reduced. The two groups had similar neonatal outcomes: birth weight, Apgar's score at 5 minutes, and cord artery pH did not differ, but the study was underpowered to compare these outcomes. CONCLUSION This new CM platform significantly reduced decision-to-delivery time, in turn improving compliance with the "30-minute rule." All relevant personnel were contacted specifically, while avoiding overhead paging and other unnecessary messages. KEY POINTS · Obstetric communication via a clinical mobility platform shortens the delivery to delivery interval. · Obstetric communication systems via an information technology (IT)-system results in a higher frequency of deliveries within 30 minutes.. · Communication systems may be a useful tools to synchronously call multiple services to respond..
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Affiliation(s)
- Sarah Crimmins
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sarah Baumer
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrea Theodoru
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Colleen H Driscoll
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
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8
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Kundu R, Srinivasan S. Parturient with Acute Abdomen. Indian J Crit Care Med 2022; 25:S223-S229. [PMID: 35615606 PMCID: PMC9108781 DOI: 10.5005/jp-journals-10071-24013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Management of a parturient with an acute abdomen presents unique challenges. We aim to review the common obstetric and nonobstetric causes for acute abdomen in pregnancy, approach to diagnosis, the role of imaging, and management including the scope and timing of operative intervention.
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Affiliation(s)
- Riddhi Kundu
- Department of Critical Care Medicine, Manipal Hospital, New Delhi, India
| | - Shrikanth Srinivasan
- Department of Critical Care Medicine, Manipal Hospital, New Delhi, India
- Shrikanth Srinivasan, Department of Critical Care Medicine, Manipal Hospital, New Delhi, India, Phone: +91 9560300723, e-mail:
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9
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Alouini S, Valery A, Lemaire B, Evrard ML, Belin O. Diagnosis and Management of Pregnant Women With Placental Abruption and Neonatal Outcomes. Cureus 2022; 14:e21120. [PMID: 35028248 PMCID: PMC8751657 DOI: 10.7759/cureus.21120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 11/15/2022] Open
Abstract
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.
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10
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May RL, Clayton MA, Richardson AL, Kinsella SM, Khalil A, Lucas DN. Defining the decision-to-delivery interval at caesarean section: narrative literature review and proposal for standardisation. Anaesthesia 2021; 77:96-104. [PMID: 34494667 DOI: 10.1111/anae.15570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2021] [Indexed: 12/01/2022]
Abstract
The decision-to-delivery interval is a widely used term at non-elective caesarean section. While the definition may appear self-evident, there is no universally agreed consensus about when this period begins and ends. We reviewed the literature for original research utilising the terms 'decision-to-delivery', 'decision-to-incision' or 'incision-to-delivery' and examined definitions used for decision, delivery, incision, as well as any additional time intervals that were assessed. Our analysis demonstrated an inconsistent non-standardised approach to defining these intervals, which might have clinical practice and medicolegal ramifications. We propose that the decision-to-delivery interval should be defined as follows: the interval between the time at which the senior obstetrician makes the decision that a caesarean section is required and the time at which the fetus (or first fetus in the case of multiples) is delivered. The decision time should ideally be recorded contemporaneously in the medical notes or partogram.
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Affiliation(s)
- R L May
- Imperial School of Anaesthesia, London, UK
| | | | - A L Richardson
- Department of Anaesthesia, London North West University Healthcare NHS Trust, London, UK
| | - S M Kinsella
- Department of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - A Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - D N Lucas
- Department of Anaesthesia, London North West University Healthcare NHS Trust, London, UK
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11
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Kinsella SM. A 20-minute decision-delivery interval at emergency caesarean section using general anaesthesia: a clinically-relevant target. Anaesthesia 2021; 76:1021-1025. [PMID: 33586177 DOI: 10.1111/anae.15427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 11/30/2022]
Affiliation(s)
- S M Kinsella
- Department of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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12
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Moors X, Biesheuvel TH, Cornette J, Van Vledder MG, Veen A, de Quelerij M, Weelink E, Duvekot JJ. Analysis of prehospital perimortem caesarean deliveries performed by Helicopter Emergency Medical Services in the Netherlands and recommendations for the future. Resuscitation 2020; 155:112-118. [PMID: 32745580 DOI: 10.1016/j.resuscitation.2020.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/08/2020] [Accepted: 07/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prehospital perimortem caesarean delivery (PCD) is a rarely performed procedure. In this study, we aimed to examine all PCDs performed by the four Helicopter Emergency Medical Services in the Netherlands; to describe the procedures, outcomes, complications, and compliance with the recommended guidelines; and to formulate recommendations. METHODS We performed a population-based retrospective cohort study of all consecutive maternal out-of-hospital cardiac arrests that underwent PCD in the prehospital setting between May 1995 and December 2019. Registered data included patient demographics, operator background, advanced life support interventions, and timelines. Resuscitation performance was evaluated according to the 2015 European Resuscitation Guidelines. RESULTS Seven patients underwent a prehospital PCD. Three mothers died on the scene, while four were transported to a hospital but died in the hospital. Seven neonates were born by PCD. One neonate died on the scene and six were transported to a hospital. Three neonates were eventually discharged from the hospital. Among the three surviving neonates, the periods from dispatch to start of PCD were 13, 14, and 21 min. CONCLUSIONS There was a low incidence of maternal perimortem caesarean deliveries in The Netherlands. Only some neonates survived after PCD. It is recommended that PCD be performed as quickly as possible. Due to the delay, the mother has a far lower chance of survival than the neonate. In fatal cases, autopsy is strongly recommended.
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Affiliation(s)
- Xrj Moors
- Department of Anaesthesiology, Erasmus MC, University Medical Center Rotterdam-Sophia Children's Hospital, Rotterdam, The Netherlands; HEMS, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - T H Biesheuvel
- Department of Surgery and HEMS, VU University Medical Center, Amsterdam, The Netherlands
| | - J Cornette
- Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M G Van Vledder
- HEMS, Erasmus University Medical Center, Rotterdam, The Netherlands; Trauma Research Unit, Department of Surgery ErasmusMC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A Veen
- HEMS, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M de Quelerij
- Department of Anaesthesiology, Franciscus Hospital Rotterdam, The Netherlands
| | - Eem Weelink
- Department of Anaesthesiology and HEMS, University Medical Center Groningen, University of Groningen, The Netherlands
| | - J J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam, The Netherlands
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13
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Baxter P. Markers of perinatal hypoxia-ischaemia and neurological injury: assessing the impact of insult duration. Dev Med Child Neurol 2020; 62:563-568. [PMID: 31872436 DOI: 10.1111/dmcn.14421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2019] [Indexed: 12/30/2022]
Abstract
Hypoxic-ischaemic insults occurring during or after birth can cause both acute and long-term neurological impairment. The duration of the insult is a critical factor, but most published reports of duration have important limitations. After the onset of a persistent bradycardia in 125 term born infants, abnormal outcomes occurred in two by 10 minutes, in 12 out of 47 (26%) delivered between 11 and 20 minutes, and in 55 out of 65 (85%) delivered after 20 minutes. Series with unspecified gestation or including infants born preterm give comparable results in over 500 additional cases. Before 20 minutes there was little correlation with severity, while after 20 minutes most were severely impaired. Limited neuroimaging data suggest that damage restricted to the basal ganglia and thalamus may begin to occur after 10 minutes, associated Rolandic damage after 15 minutes, and other cortical involvement after 20 minutes. Associated white matter damage can occur after any duration. There were little data for other patterns of damage. WHAT THIS PAPER ADDS: Some term born infants can withstand 20 minutes of fetal bradycardia without acute or chronic damage. Durations in humans are not the same as in animal models.
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Affiliation(s)
- Peter Baxter
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
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14
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Le Mitouard M, Gaucher L, Huissoud C, Gaucherand P, Rudigoz RC, Dupont C, Cortet M. Decision-delivery intervals: Impact of a colour code protocol for emergency caesareans. Eur J Obstet Gynecol Reprod Biol 2019; 246:29-34. [PMID: 31927407 DOI: 10.1016/j.ejogrb.2019.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/16/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Assess the impact of implementation by simple distribution of a "colour code" protocol for emergency caesareans on the course over time of the "decision-delivery interval" (DDI) and neonatal outcome. DESIGN Observational study in 26 maternity units of the AURORE perinatal network, conducted between October 1, 2017, and April 30, 2018. Each maternity ward́ was supposed to prospectively include 20 consecutive cases of caesareans performed either as an emergency, that is, as a code orange, or an extreme emergency, that is, code red. We compared the DDIs observed in 2017 to those in 2007 according to the degree of emergency, the maternity unit level of care, and their adherence to the protocol. Neonatal outcome in 2007 and 2017, assessed from laboratory and clinical indicators, was also compared, overall and according to the degree of emergency. RESULTS The DDI was significantly lower in 2017 (n = 478) than in 2007 (n = 447), regardless of the degree of emergency and the level of care (p < 0.0001). In 2017, all code red caesareans were performed in less than 15 min in level 3 maternity units compared with 73 % (p = 0.039) in 2007. Fewer than 20 % of the caesareans in the 2007 study period were performed in less than 15 min in level 1 and 2 maternity units. Today, this is the case for 83 % of these caesareans in level 2 units (p < 0.001) and 36 % in level 1 (p = 0.01). In 2017, code orange caesareans were performed in less than 30 min in 96 % of cases in level 3 units, 67 % in level 2, and 33 % in level 1, compared respectively with 67 % (p = 0.015), 25 % (p < 0.0001) and 16 % (p = 0.0003) in 2007. We did not observe any difference in the neonatal outcome between 2007 and 2017 or as a function of the DDI expected based on the caesarean colour code. CONCLUSION The implementation of the colour code protocols was associated with an improved DDI and better adherence to the recommendations in all 26 maternity units in this perinatal network.
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Affiliation(s)
- Marine Le Mitouard
- Hospices civils de Lyon, Service de Gynécologie-Obstétrique, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France.
| | - Laurent Gaucher
- Hospices civils de Lyon, Service de Gynécologie-Obstétrique, Hôpital Femme Mère Enfant, 59 boulevard Pinel, 69500, Bron-Lyon, France; Health Services and Performance Research - HESPER EA 7425, F-69008, Lyon, France
| | - Cyril Huissoud
- Hospices civils de Lyon, Service de Gynécologie-Obstétrique, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France; Université Claude-Bernard Lyon 1, 43, boulevard du 11-Novembre-1918, 69100, Villeurbanne, France
| | - Pascal Gaucherand
- Hospices civils de Lyon, Service de Gynécologie-Obstétrique, Hôpital Femme Mère Enfant, 59 boulevard Pinel, 69500, Bron-Lyon, France
| | - René-Charles Rudigoz
- Hospices civils de Lyon, Service de Gynécologie-Obstétrique, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France
| | - Corinne Dupont
- Hospices civils de Lyon, Service de Gynécologie-Obstétrique, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France; Health Services and Performance Research - HESPER EA 7425, F-69008, Lyon, France
| | - Marion Cortet
- Hospices civils de Lyon, Service de Gynécologie-Obstétrique, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, 69004, Lyon, France; UMR CNRS 5558, laboratoire de biométrie et biologie évolutive, équipe biostatistiques santé, « adresse Lacassagne », 69008, Lyon, France
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15
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Abstract
Cesarean section (CS) is a common surgical procedure worldwide. The anesthesiologist is responsible, together with obstetrician and neonatologist, for safe perioperative management. A continuum of risk exists for urgent CS. The decision-to-delivery interval is an important audit tool, to ensure international standards are upheld and good outcomes for mother and neonate are achieved. Urgent CS may be performed under either GA or RA, with benefits and risks attributable to each. Specific clinical scenarios require an individualized approach to anesthesia, including hemorrhage, hypertensive disorders, cardiac disease, the difficult airway and fetal compromise. Ongoing training is integral to the provision of safe anesthesia.
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Affiliation(s)
- Nicole L Fernandes
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, D23 Groote Schuur Hospital, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Robert A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, D23 Groote Schuur Hospital, Anzio Road, Observatory, Cape Town 7925, South Africa.
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16
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Chahal HS, Gelaye B, Mostofsky E, Salazar MS, Sanchez SE, Ananth CV, Williams MA. Relation of outbursts of anger and the acute risk of placental abruption: A case-crossover study. Paediatr Perinat Epidemiol 2019; 33:405-411. [PMID: 31642555 PMCID: PMC6823109 DOI: 10.1111/ppe.12591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 08/09/2019] [Accepted: 08/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Roughly, a fourth of all placental abruption cases have an acute aetiologic underpinning, but the causes of acute abruption are poorly understood. Studies indicate that symptoms of stress, depression, and anxiety during pregnancy may be associated with a higher risk of abruption. OBJECTIVE We examined the rate of abruption in the 2 hours immediately following outbursts of anger. METHODS In a multicentre case-crossover study, we interviewed 663 women diagnosed with placental abruption admitted to one of the seven Peruvian hospitals between January 2013 and August 2015. We asked women about outbursts of anger before symptom onset and compared this with their usual frequency of anger during the week before abruption. RESULTS The rate of abruption was 2.83-fold (95% confidence interval [CI] 1.85, 4.33) higher in the 2 hours following an outburst of anger compared with other times. The rate ratio (RR) was lower for women who completed technical school or university (RR 1.38, 95% CI 0.52, 3.69) compared to women with secondary school education or less (RR 3.73, 95% CI 2.32, 5.99, P-homogeneity = .07). There was no evidence that the association between anger episodes and abruption varied by hypertensive disorders of pregnancy (ie preeclampsia/ eclampsia) or antepartum depressive symptoms. CONCLUSION There was a higher rate of abruption in the 2 hours following outbursts of anger compared with other times, providing potential clues to the aetiologic mechanisms of abruption of acute onset.
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Affiliation(s)
- Harpreet S. Chahal
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts,Mississauga Academy of Medicine, University of Toronto Mississauga, Mississauga, Canada
| | - Bizu Gelaye
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Mostofsky
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts,Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Manuel S. Salazar
- Universidad Nacional Mayor de San Marcos, Departamento de Gineco Obstetricia, Lima, Peru
| | - Sixto E. Sanchez
- Universidad de San Martin de Porres, Facultad de Medicina, Lima, Peru,Asociación Civil Proyectos en Salud, Lima, Peru
| | - Cande V. Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ,Environmental and Occupational Health Sciences Institute (EOHSI), Rutgers Robert Wood Johnson Medical School, Piscataway, NJ
| | - Michelle A. Williams
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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17
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Analysis of 62 placental abruption cases: Risk factors and clinical outcomes. Taiwan J Obstet Gynecol 2019; 58:223-226. [PMID: 30910143 DOI: 10.1016/j.tjog.2019.01.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2019] [Indexed: 11/20/2022] Open
Abstract
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.
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18
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Chahal HS, Gelaye B, Mostofsky E, Sanchez SE, Mittleman MA, Maclure M, Pacora P, Torres JA, Romero R, Ananth CV, Williams MA. Physical Exertion Immediately Prior to Placental Abruption: A Case-Crossover Study. Am J Epidemiol 2018; 187:2073-2079. [PMID: 29992226 PMCID: PMC6194205 DOI: 10.1093/aje/kwy138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 04/13/2018] [Accepted: 04/17/2018] [Indexed: 12/14/2022] Open
Abstract
While there is consistent evidence that episodes of physical exertion are associated with an immediately higher risk of acute ischemic vascular events, the risk of placental abruption immediately following episodes of physical exertion has not been studied. In a multicenter case-crossover study, we interviewed 663 women with placental abruption at 7 Peruvian hospitals between January 2013 and August 2015. We asked women about physical exertion in the hour before symptom onset and compared this with their frequency of physical exertion over the prior week. Compared with times with light or no exertion, the risk of placental abruption was 7.8 (95% confidence interval (CI): 5.5, 11.0) times greater in the hour following moderate or heavy physical exertion. The instantaneous incidence rate ratio of placental abruption within an hour of moderate or heavy physical exertion was lower for women who habitually engaged in moderate or heavy physical activity more than 3 times per week in the year before pregnancy (rate ratio (RR) = 3.0, 95% CI: 1.6, 5.9) compared with more sedentary women (RR = 17.3, 95% CI: 11.3, 26.7; P for homogeneity < 0.001), and the rate ratio was higher among women with preeclampsia/eclampsia (RR = 13.6, 95% CI: 7.0, 26.2) than among women without (RR = 6.7, 95% CI: 4.4, 10.0; P for homogeneity = 0.07).
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Affiliation(s)
- Harpreet S Chahal
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Mississauga Academy of Medicine, University of Toronto Mississauga, Mississauga, Canada
| | - Bizu Gelaye
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Elizabeth Mostofsky
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sixto E Sanchez
- Universidad Peruana de Ciencias Aplicadas, Lima, Peru
- Asociación Civil Proyectos en Salud , Lima, Peru
| | - Murray A Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Percy Pacora
- Department of Obstetrics and Gynecology, San Marcos University, Hospital Madre-Nino San Bartolome, Lima, Peru
| | - Jose A Torres
- Department of Obstetrics and Gynecology, San Marcos University, Hospital Madre-Nino San Bartolome, Lima, Peru
- Department of Obstetrics and Gynecology, San Marcos University, Hospital Nacional Hipólito Unanue, Lima, Peru
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- Department of Obstetrics and Gynecology, University of Michigan Health System, University of Michigan, Ann Arbor, Michigan
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Michelle A Williams
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Cesari E, Ghirardello S, Brembilla G, Svelato A, Ragusa A. Clinical features of a fatal shoulder dystocia: The hypovolemic shock hypothesis. Med Hypotheses 2018; 118:139-141. [PMID: 30037602 DOI: 10.1016/j.mehy.2018.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
Shoulder dystocia is a rare but severe obstetric complication associated with an increased risk of brachial plexus palsies, fractures of the clavicle and humerus, hypoxic-ischemic encephalopathy and, rarely, neonatal death. Here we describe a fatal case of shoulder dystocia in a term newborn, although labor was uneventful, fetal heart rate tracing was normal until the delivery of the head and the head-to-body delivery interval (HBDI) occurred within 5 min. Full resuscitation was performed for 35 min without success. Hemoglobin concentration evaluated on the umbilical cord still attached to the placenta was within normal range, while neonatal venous hemoglobin concentration blood gases at 9 min of life showed severe metabolic acidosis and anemia. As previously described by others, our case supports the hypothesis of a hypovolemic shock as the cause of neonatal death, probably due to acute placental retention of fetal blood. The death of the newborn following shoulder dystocia is an event that still presents numerous gaps in knowledge. Further research should focus on.
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Affiliation(s)
- E Cesari
- Gynecologic and Obstetric Department, Children Hospital V. Buzzi, Via Castelvetro 32, Milan, Italy.
| | - S Ghirardello
- Neonatal Intensive Care Unit Department of Clinical Science and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - G Brembilla
- Gynecologic and Obstetric Department, Children Hospital V. Buzzi, Via Castelvetro 32, Milan, Italy
| | - A Svelato
- Gynecologic and Obstetric Department, Nuovo Ospedale delle Apuane, Via Enrico Mattei 21, Massa Carrara, Italy
| | - A Ragusa
- Gynecologic and Obstetric Department, Nuovo Ospedale delle Apuane, Via Enrico Mattei 21, Massa Carrara, Italy
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20
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Warren M, Kamania J, Dennis A. Immediate birth – an analysis of women and their babies undergoing time critical birth in a tertiary referral obstetric hospital. Int J Obstet Anesth 2018; 33:46-52. [DOI: 10.1016/j.ijoa.2017.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/02/2017] [Accepted: 06/11/2017] [Indexed: 11/28/2022]
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21
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Rasmussen S, Ebbing C, Linde LE, Baghestan E. Placental abruption in parents who were born small: registry-based cohort study. BJOG 2017; 125:667-674. [DOI: 10.1111/1471-0528.14837] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 11/28/2022]
Affiliation(s)
- S Rasmussen
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - C Ebbing
- Department of Obstetrics and Gynecology; Haukeland University Hospital; Bergen Norway
| | - LE Linde
- Department of Obstetrics and Gynecology; Haukeland University Hospital; Bergen Norway
| | - E Baghestan
- Department of Obstetrics and Gynecology; Haukeland University Hospital; Bergen Norway
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22
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Chen AL, Goldfarb IT, Scourtas AO, Roberts DJ. The histologic evolution of revealed, acute abruptions. Hum Pathol 2017; 67:187-197. [PMID: 28823573 DOI: 10.1016/j.humpath.2017.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/27/2017] [Accepted: 08/05/2017] [Indexed: 10/19/2022]
Abstract
There is considerable interest in using pathology to confirm acute abruptions. It has been suggested that pathologic findings can help to determine the timing of abruptions. Because of the dearth of evidence in the literature supporting this claim and its medicolegal implications, we undertook this study to explore further the possibility of timing abruptions by histopathology. We sought to correlate bleeding interval (duration from maternal presentation with vaginal bleeding [revealed abruption] to placental delivery) with placental histopathologic findings. We performed a retrospective review of clinical data and placental pathology from all cases of clinically diagnosed, acute, revealed abruptions at a single, large institution in New England between 2000 and 2015. Cases were identified based on clinical diagnoses, bleeding intervals were calculated from clinical notes, and histologic evaluations were performed by 2 pathologists blinded to the bleeding intervals. A total of 177 cases were analyzed. Of these, 103 (58%) had histologic findings corroborating the clinical diagnosis of abruption. The most frequent finding was maternal surface indentation (51 cases) followed by intravillous hemorrhage (50 cases). The former was also the earliest finding, with a minimum bleeding interval of 4 minutes. In multivariate modeling, plasma cell deciduitis was significantly associated with a longer bleeding interval (median 63 hours). If there were 2 pathologic findings, there was a trend toward a longer bleeding interval. There was modest sensitivity for the pathologic diagnosis of acute revealed abruption. Although there was not a clear, stepwise progression of histologic lesions; the presence of 2 or more findings tended to be seen with longer bleeding intervals. Our results suggest that histologic findings cannot be used to time acute revealed abruptions reliably, and any interpretation of such should be made with caution.
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Affiliation(s)
- Athena L Chen
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114
| | - Ilona T Goldfarb
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Massachusetts General Hospital, Boston, MA 02114
| | | | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114.
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Computed tomographic imaging interpretation improves fetal outcomes after maternal trauma. J Trauma Acute Care Surg 2017; 81:1131-1135. [PMID: 27533904 DOI: 10.1097/ta.0000000000001210] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Computed tomography (CT) has been validated to identify and classify placental abruption following blunt trauma. The purpose of this study was to demonstrate improvement in fetal survival when delivery occurs by protocol at the first sign of class III fetal heart rate tracing in pregnant trauma patients with a viable fetus on arrival and CT evidence of placental perfusion 50% or less secondary to placental abruption. METHODS This is a retrospective review of pregnant trauma patients at 26 weeks' gestation or greater who underwent abdominopelvic CT as part of their initial evaluation. Charts were reviewed for CT interpretation of placental pathology with classification of placental abruption based upon enhancement (Grade 1, >50% perfusion; Grade 2, 25%-50% perfusion; Grade 3, <25% perfusion), as well as need for delivery and fetal outcomes. RESULTS Forty-one patients met inclusion criteria. Computed tomography revealed evidence of placental abruption in six patients (15%): Grade 1, one patient, Grade 2, one patient, and Grade 3, four patients. Gestational ages ranged from 26 to 39 weeks. All patients with placental abruption of Grade 2 or greater developed concerning fetal heart tracings and underwent delivery emergently at first sign. Abruption was confirmed intraoperatively in all cases. Each birth was viable, and Apgar scores at 10 minutes were greater than 7 in 80% of infants, all of whom were ultimately discharged home. The remaining infant was transferred to an outside facility. CONCLUSIONS Delivery at first sign of nonreassuring fetal heart rate tracings in pregnant trauma patients (third trimester) with placental abruption of Grade 2 or greater can lead to improved fetal outcome. LEVEL OF EVIDENCE Therapeutic/care management study, level III.
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Dunn CN, Zhang Q, Sia JT, Assam PN, Tagore S, Sng BL. Evaluation of timings and outcomes in category-one caesarean sections: A retrospective cohort study. Indian J Anaesth 2016; 60:546-51. [PMID: 27601736 PMCID: PMC4989804 DOI: 10.4103/0019-5049.187782] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background and Aims: A decision-to-delivery interval (DDI) of 30 min for category-one caesarean section (CS) deliveries is the standard of practice recommended by clinical guidelines. Our institution established a protocol for category-one (‘crash’) CS to expedite deliveries. The aim of this study is to evaluate DDI, factors that affect DDI and the mode of anaesthesia for category-one CS. Methods: This retrospective cohort study evaluated 390 women who underwent category-one CS in a tertiary obstetric centre. We analysed the factors associated with DDI, mode of anaesthesia and perinatal outcomes. Summary statistics were performed for the outcomes. The association factors were considered significant at P < 0.05. Results: The mean (standard deviation) DDI was 9.4 (3.2) min with all deliveries achieved within 30 min. The longest factor in the DDI was time taken to transfer patients. A shorter DDI was not significantly associated with improved perinatal outcomes. The majority (88.9%) of women had general anaesthesia (GA) for category-one CS. Of those who had an epidural catheter already in situ (34.4%), 25.6% had successful epidural extension. GA was associated with shorter DDI, but worse perinatal outcomes than regional anaesthesia (RA). Conclusions: Our ‘crash’ CS protocol achieved 100% of deliveries within 30 min. The majority (88.9%) of the patients had GA for category-one CS. GA was found to be associated with shorter anaesthesia and operation times, but poorer perinatal outcomes compared to RA.
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Affiliation(s)
- Clare Newton Dunn
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Qianpian Zhang
- Sing Health Anaesthesiology Residency Programme, Singapore Health Services, Singapore
| | - Josh Tjunrong Sia
- International Bacclaureate Diploma Programme, Anglo-Chinese School (Independent), Singapore
| | - Pryseley Nkouibert Assam
- Centre for Quantitative Medicine, Duke NUS Graduate Medical School, Singapore; Department of Biostatistics, Singapore Clinical Research Institute, Singapore
| | - Shephali Tagore
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Ban Leong Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore; Anaesthesiology Program, Duke-NUS Graduate Medical School, Singapore
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Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, Quinn AC. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2016; 70:1286-306. [PMID: 26449292 PMCID: PMC4606761 DOI: 10.1111/anae.13260] [Citation(s) in RCA: 287] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2015] [Indexed: 12/16/2022]
Abstract
The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training.
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Affiliation(s)
- M C Mushambi
- Department of Anaesthesia, Leicester Royal Infirmary, Leicester, UK
| | - S M Kinsella
- Department of Anaesthesia, St Michael's Hospital, Bristol, UK
| | - M Popat
- Nuffield Department of Anaesthesia, Oxford University Hospital NHS Trust, Oxford, UK
| | - H Swales
- Department of Anaesthesia, University Hospitals Southampton Foundation Trust, Southampton, UK
| | - K K Ramaswamy
- Department of Anaesthesia, Northampton General Hospital, Northampton, UK
| | - A L Winton
- Department of Anaesthesia, St Michael's Hospital, Bristol, UK
| | - A C Quinn
- Department of Anaesthesia, James Cook University Hospital, Middlesborough, UK.,Leeds University, Leeds, UK
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Kinsella S, Winton A, Mushambi M, Ramaswamy K, Swales H, Quinn A, Popat M. Failed tracheal intubation during obstetric general anaesthesia: a literature review. Int J Obstet Anesth 2015; 24:356-74. [DOI: 10.1016/j.ijoa.2015.06.008] [Citation(s) in RCA: 219] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 06/23/2015] [Accepted: 06/24/2015] [Indexed: 11/27/2022]
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Boisramé T, Sananès N, Fritz G, Boudier E, Aissi G, Favre R, Langer B. Placental abruption: risk factors, management and maternal–fetal prognosis. Cohort study over 10 years. Eur J Obstet Gynecol Reprod Biol 2014; 179:100-4. [DOI: 10.1016/j.ejogrb.2014.05.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 05/19/2014] [Accepted: 05/22/2014] [Indexed: 10/25/2022]
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Ananth CV, Friedman AM. Ischemic placental disease and risks of perinatal mortality and morbidity and neurodevelopmental outcomes. Semin Perinatol 2014; 38:151-8. [PMID: 24836827 DOI: 10.1053/j.semperi.2014.03.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Preeclampsia, intrauterine growth restriction, and placental abruption are serious obstetrical complications that constitute the syndrome of ischemic placental disease and account for a disproportionate degree of perinatal morbidity and mortality. We review the risks of stillbirth and neonatal and infant mortality in relation to ischemic placental disease, focusing on population-based studies. We also review the risks of neonatal morbidity and neurodevelopmental outcomes in relation to ischemic placental disease. A synthesis of the findings of the relevant studies relating ischemic placental disease to adverse perinatal outcomes underscores two important observations. First, despite the low prevalence of each of the three obstetrical complications, all are associated with increased risks of adverse perinatal and infant outcomes, as well as neurodevelopmental deficits. Second, the burden of increased perinatal risks appears strongest during the preterm period. Efforts to reduce the risks of ischemic placental disease remain critically important and developing effective clinical interventions will be a target worthy for consideration.
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Affiliation(s)
- Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
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Weiner E, Bar J, Fainstein N, Ben-Haroush A, Sadan O, Golan A, Kovo M. The effect of a program to shorten the decision-to-delivery interval for emergent cesarean section on maternal and neonatal outcome. Am J Obstet Gynecol 2014; 210:224.e1-6. [PMID: 24565432 DOI: 10.1016/j.ajog.2014.01.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 12/21/2013] [Accepted: 01/07/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study the effect of a departmental program designed to shorten the decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for nonreassuring fetal heart rate (NRFHR) on maternal and neonatal outcome. STUDY DESIGN A protocol for managing ECS that included documenting precise time-intervals, identification of delaying obstacles and debriefing of each case, was implemented from March 2011. All women who delivered by ECS for NRFHR, as the only indication were included. Detailed information regarding DDI, maternal intraoperative and postoperative complications, and neonatal early outcomes were compared before (period-P1) (-27 months) and after (period 2) (+27 months) program implementation. RESULTS During 54 months of study, 593 ECS DDI were included. Mean DDI decreased at period 2 (12.3 ± 3.8 min, n = 301) compared with period 1 (21.7 ± 9.1 min, n = 292), P < .001. Rate of cord pH ≤7.1 and 5 min Apgar score ≤7 decreased at period 2 compared with period 1, P = .016 and P = .031, respectively. Worse composite neonatal outcome decreased at period 2 compared with period 1, 15.6% vs 32.2%, respectively, P ≥ .001. Composite maternal outcome did not differ between the groups. Worse neonatal outcome was dependent on time period (period 1), odds ratio, 2.12; 95% confidence interval, 1.27-3.55; P = .004 and on gestational age at delivery, odds ratio, 0.68; 95% confidence interval, 0.62-0.76; P < .001. CONCLUSION Introduction of a management protocol to shorten DDI in ECS for NRFHR was associated with improved early neonatal outcome without change in maternal complications.
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Affiliation(s)
- Eran Weiner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel
| | - Jacob Bar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel
| | - Nataly Fainstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel
| | - Avi Ben-Haroush
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Rabin Medical Center, Petah-Tikva, Israel
| | - Oscar Sadan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel
| | - Abraham Golan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel
| | - Michal Kovo
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel
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Gabbay-Benziv R, Ashwal E, Lahav-Ezra H, Rabinerson D, Wiznitzer A, Ben-Haroush A, Yogev Y. Decision-to-delivery interval in suspected placental abruption – association with pregnancy outcome. J Matern Fetal Neonatal Med 2014; 27:1680-3. [DOI: 10.3109/14767058.2013.871703] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Boisramé T, Sananès N, Fritz G, Boudier E, Viville B, Aissi G, Favre R, Langer B. [Abruptio placentae. Diagnosis, management and maternal-fetal prognosis: a retrospective study of 100 cases]. ACTA ACUST UNITED AC 2013; 42:78-83. [PMID: 24309032 DOI: 10.1016/j.gyobfe.2013.06.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 06/12/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To update knowledge on placental abruption because there are few recent series published although the perinatal care has progressed. PATIENTS AND METHODS A retrospective observational study has been conducted on 100 consecutive cases of abruptio placentae, occurring from January 2008 to June 2011, in the two maternity units of the University Hospital of Strasbourg (France). RESULTS One hundred and five births among which five twin pregnancies were included. Clinical context was evident in 91% of cases, but the classic clinical triad was present in only 4% of cases. Clots were found at immediate placenta examination in 77% of cases. Pathological diagnosis was directly in accordance with clinical diagnosis in half the cases. Mean date of childbirth was 33 weeks of amenorrhea and 6 days. Sixty-seven patients gave birth prematurely. Among them, 50 patients delivered before 34 weeks. Sixty caesareans were performed in emergency before labor, including 47 with general anesthesia. Twelve patients had post-partum haemorrhage and ten coagulation disorders. There was no maternal death. Perinatal mortality was 19% with 13 fetal deaths in utero (12.4%), four children born in an apparent death state with resuscitation failure (3.8%) and three neonatal deaths (2.8%). DISCUSSION AND CONCLUSION Placental abruption is a serious and unpredictable situation. Joint medical care of obstetricians and intensivists is often required. Perinatal mortality mainly occurs in utero.
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Affiliation(s)
- T Boisramé
- Département de gynécologie-obstétrique des hôpitaux universitaires de Strasbourg, hôpital de Hautepierre, avenue Molière, 67098 Strasbourg, France.
| | - N Sananès
- Département de gynécologie-obstétrique des hôpitaux universitaires de Strasbourg, hôpital de Hautepierre, avenue Molière, 67098 Strasbourg, France
| | - G Fritz
- Département de gynécologie-obstétrique des hôpitaux universitaires de Strasbourg, hôpital de Hautepierre, avenue Molière, 67098 Strasbourg, France
| | - E Boudier
- Département de gynécologie-obstétrique des hôpitaux universitaires de Strasbourg, hôpital de Hautepierre, avenue Molière, 67098 Strasbourg, France
| | - B Viville
- Département de gynécologie-obstétrique des hôpitaux universitaires de Strasbourg, hôpital de Hautepierre, avenue Molière, 67098 Strasbourg, France
| | - G Aissi
- Département de gynécologie-obstétrique des hôpitaux universitaires de Strasbourg, centre médicochirurgical obstétrique (CMCO), 19, rue Louis-Pasteur, BP 120, 67303 Schiltigheim cedex, France
| | - R Favre
- Département de gynécologie-obstétrique des hôpitaux universitaires de Strasbourg, centre médicochirurgical obstétrique (CMCO), 19, rue Louis-Pasteur, BP 120, 67303 Schiltigheim cedex, France
| | - B Langer
- Département de gynécologie-obstétrique des hôpitaux universitaires de Strasbourg, hôpital de Hautepierre, avenue Molière, 67098 Strasbourg, France
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Morikawa M, Yamada T, Cho K, Yamada T, Sato S, Minakami H. Prospective risk of abruptio placentae. J Obstet Gynaecol Res 2013; 40:369-74. [PMID: 24245905 DOI: 10.1111/jog.12175] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/03/2013] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study was to better characterize the nature of abruptio placentae (AP) with regard to the timing of onset. MATERIAL AND METHODS Prevalence and prospective risk of AP according to gestational week (GW) were determined among 293,899 women who gave birth to singleton infants at and after GW 30. The prospective risk of AP at gestational week N was defined as the number of all women who experienced an AP at ≥GW N divided by the number of all women who gave birth at ≥GW N. RESULTS AP developed in 2649 (0.90%) women. The prevalence of AP (6.7% among women who gave birth at GW 30-33) sharply decreased with advancing GW at delivery to 0.9% for GW 37 and 0.1% for ≥GW 42. The highest prospective risk of AP, 9 per 1000 women at GW 30, decreased linearly with advancing gestation to 1 per 1000 women at ≥GW 42. AP accounted for 4.7% (1591/33,725) of all preterm births at GW <37, while prevalence of AP was 0.41% (1058/260,174) among term births. Preterm AP accounted for 60.1% (1591/2649) of all AP. CONCLUSION Our figures indicate that AP is more common in preterm births than in term birth and may be helpful for better understanding the epidemiology of this condition.
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Affiliation(s)
- Mamoru Morikawa
- Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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McLaurin R, Geraghty S. Placenta praevia, placental abruption and amphetamine use in pregnancy: A case study. Women Birth 2013; 26:138-42. [DOI: 10.1016/j.wombi.2012.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 09/25/2012] [Accepted: 11/12/2012] [Indexed: 11/26/2022]
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Leung TY, Lao TT. Timing of caesarean section according to urgency. Best Pract Res Clin Obstet Gynaecol 2013; 27:251-67. [DOI: 10.1016/j.bpobgyn.2012.09.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 09/26/2012] [Indexed: 10/27/2022]
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Korda V, Zimmermann R. Five-year impact of a new departmental protocol on emergency cesarean target times. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojog.2013.31a028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Clinical features of abruptio placentae as a prominent cause of cerebral palsy. Early Hum Dev 2012; 88:861-4. [PMID: 22805996 DOI: 10.1016/j.earlhumdev.2012.06.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 06/20/2012] [Accepted: 06/26/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although abruptio placentae causes hypoxia in the infant and thus leading to cerebral palsy (CP), its incidence and clinical features at a nationwide level have not been demonstrated. AIMS To determine the proportion of abruptio placentae among antenatal and intrapartum causative factors leading to cerebral palsy (CP) and clinical features of such abruptio placentae. STUDY DESIGN A review was conducted in 107 infants with CP in whom CP was determined to be due to antenatal and or intrapartum hypoxic conditions by the Japan Council for Quality Health Care until April 2012. RESULTS Abruptio placenta was responsible for 28 (26%) of the 107 CP infants, and was the single leading causative factor of CP. Of these 28 women, 22 (79%) exhibited non-reassuring fetal status on admission to obstetric facilities at 36.2 ± 2.6 weeks of gestation and had neonates with umbilical cord arterial blood pH (base excess) of 6.728 ± 0.164 (-25 ± 5.4 mmol/L). In these 22 women, strong abdominal pain and/or profuse vaginal bleeding occurred 159 ± 99 min prior to admission to an obstetric facility, and the interval until delivery after admission was 47 ± 31 min. Hypertension or isolated proteinuria preceded clinical events in one (4.5%) and five (23%) of these 22 women, respectively. CONCLUSIONS Abruptio placentae was responsible for CP in one quarter of all cases determined to be due to antenatal and/or intrapartum hypoxic conditions in Japan. New strategies to shorten the interval until admission to an obstetric facility after onset of symptoms are urgently needed.
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Homer CSE, Catling-Paull C. Safe timing for an urgent Caesarean section: what is the evidence to guide policy? AUST HEALTH REV 2012; 36:277-81. [PMID: 22935117 DOI: 10.1071/ah11059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 10/12/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine, from the evidence, what is the optimum decision to delivery (DDI) intervals in emergency Caesarean sections (CS). The aim of the study was to help guide policy in maternity services and identify issues relating to DDI and safe practice in maternity care. METHOD A systematic review of the literature was undertaken. Assessment of the quality of eligible papers was undertaken using the Critical Appraisal Skills Program (CASP) rating. RESULTS There is no strong evidence that a DDI of 30 min or less is associated with improved outcomes for babies or mothers. Some evidence suggests that a DDI of greater than 30 min but less than 75 min confers benefit, but these findings were confounded by the indications for the emergency CS. CONCLUSION Urgent CS should occur as soon as possible, but there is insufficient evidence to support a definite time frame, such as 30 min. A consistency of approach and nomenclature in describing the urgency of CS is necessary, which would enable criteria for further audit regarding DDI. Staff training should be addressed to improve transfer systems for CS. Antenatal risk assessment and congruence with role delineation and service delivery capacity is important.
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Affiliation(s)
- Caroline S E Homer
- Centre for Midwifery, Child and Family Health, Faculty of Nursing, Midwifery and Health, University of Technology Sydney, PO Box 123, Broadway, NSW 2007, Australia.
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Takano Y, Furukawa S, Ohashi M, Michikata K, Sameshima H, Ikenoue T. Fetal heart rate patterns related to neonatal brain damage and neonatal death in placental abruption. J Obstet Gynaecol Res 2012; 39:61-6. [DOI: 10.1111/j.1447-0756.2012.01945.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Markhus VH, Rasmussen S, Lie SA, Irgens LM. Placental abruption and premature rupture of membranes. Acta Obstet Gynecol Scand 2011; 90:1024-9. [PMID: 21692757 DOI: 10.1111/j.1600-0412.2011.01224.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess whether premature rupture of membranes (PROM) is associated with placental abruption. DESIGN Population-based study. SETTING Data were extracted from the Medical Birth Registry of Norway. POPULATION All women with PROM (18,889 cases), including 3,077 cases of preterm premature rupture of membranes (p-PROM), among a total of 355 416 singleton births in Norway during 1999-2005 with gestational age 17-44 weeks. METHODS Logistic regression was used to assess whether placental abruption was associated with PROM in preterm and term births. MAIN OUTCOME MEASURES Placental abruption. RESULTS The occurrence of placental abruption in p-PROM was higher than in the total study population, 11.0 per 1,000 (34 of 3 077) vs. 4.2 per 1 000 (1 495 of 355 416; adjusted odds ratio 2.6, 95% confidence interval 1.8-3.7). Restricting the analyses to preterm births, the occurrence of placental abruption was less in p-PROM (11.0 per 1,000) than in births without p-PROM (36.1 per 1 000; adjusted odds ratio 0.3, 95% confidence interval 0.2-0.4). In term births, no statistically significant association was observed. CONCLUSIONS The findings suggest that in p-PROM the risk of placental abruption is not higher than in other preterm births; rather the opposite. However, comparing the risks in p-PROM and the total gestational age range, the present study confirmed results reported in previous studies of a higher risk of placental abruption in p-PROM than in the total birth population.
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Enrique Oyarzún E, Juan Pedro Kusanovic P. Urgencias en obstetricia. REVISTA MÉDICA CLÍNICA LAS CONDES 2011. [DOI: 10.1016/s0716-8640(11)70432-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Sanchez SE, Williams MA, Pacora PN, Ananth CV, Qiu C, Aurora SK, Sorensen TK. Risk of placental abruption in relation to migraines and headaches. BMC WOMENS HEALTH 2010; 10:30. [PMID: 20977769 PMCID: PMC2984417 DOI: 10.1186/1472-6874-10-30] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 10/26/2010] [Indexed: 11/17/2022]
Abstract
Background Migraine, a common chronic-intermittent disorder of idiopathic origin characterized by severe debilitating headaches and autonomic nervous system dysfunction, and placental abruption, the premature separation of the placenta, share many common pathophysiological characteristics. Moreover, endothelial dysfunction, platelet activation, hypercoagulation, and inflammation are common to both disorders. We assessed risk of placental abruption in relation to maternal history of migraine before and during pregnancy in Peruvian women. Methods Cases were 375 women with pregnancies complicated by placental abruption, and controls were 368 women without an abruption. During in-person interviews conducted following delivery, women were asked if they had physician-diagnosed migraine, and they were asked questions that allowed headaches and migraine to be classified according to criteria established by the International Headache Society. Logistic regression procedures were used to calculate odds ratios (aOR) and 95% confidence intervals (CI) adjusted for confounders. Results Overall, a lifetime history of any headaches or migraine was associated with an increased odds of placental abruption (aOR = 1.60; 95% CI 1.16-2.20). A lifetime history of migraine was associated with a 2.14-fold increased odds of placental abruption (aOR = 2.14; 95% CI 1.22-3.75). The odds of placental abruption was 2.11 (95% CI 1.00-4.45) for migraineurs without aura; and 1.59 (95% 0.70-3.62) for migraineurs with aura. A lifetime history of tension-type headache was also increased with placental abruption (aOR = 1.61; 95% CI 1.01-2.57). Conclusions This study adds placental abruption to a growing list of pregnancy complications associated with maternal headache/migraine disorders. Nevertheless, prospective cohort studies are needed to more rigorously evaluate the extent to which migraines and/or its treatments are associated with the occurrence of placental abruption.
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Affiliation(s)
- Sixto E Sanchez
- Department of Obstetrics and Gynecology, Hospital Nacional dos de Mayo, & Universidad San Martin de Porres, Lima, Peru
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Bohec C, Collet M. [Abruptio placentae]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2010; 29:e115-9. [PMID: 20488648 DOI: 10.1016/j.annfar.2010.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Retroplacental haematoma (RPH) is a complication affecting 0.25 to 0.4% of all pregnancies and 4% of severe PEs. It is of acute onset, usually unpredictable and its symptoms are not specific: Isolated metrorrhagia, foetal distress, uterine hypertonicity. Clinical, biological and sonographic features suggesting a RPH can be early or late. Haemoconcentration and the forming of notches on Doppler examination of the uterus can appear weeks before the event, whereas raised D-Dimers and foetal tachycardia are identified within days of the event. Although Caesarian section reduces the perinatal death rate by 20 to 50% in a setting of RPH with a live foetus, vaginal delivery is indicated in cases of RPH with fetal demise, following the control of haemorrhagic shock, clotting disorders and uterine hypotonicity.
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Affiliation(s)
- C Bohec
- Service de gynécologie-obstétrique, CHU de la Cavale-Blanche, 5, boulevard Tanguy-Prigent, 29609 Brest cedex, France
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Kinsella SM, Girgirah K, Scrutton MJL. Rapid sequence spinal anaesthesia for category-1 urgency caesarean section: a case series. Anaesthesia 2010; 65:664-9. [DOI: 10.1111/j.1365-2044.2010.06368.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Abruptio placentae is an important cause of vaginal bleeding in the latter half of pregnancy. The key factor in the pathophysiology is hemorrhage at the decidual-placental interface. Small episodes may escape clinical detection, but severe grades impact significantly on fetal and maternal morbidity and mortality, with the most frequent complications being fetal death, severe maternal shock, disseminated intravascular coagulopathy, and renal failure. Important risk factors for the development of abruptio placentae are previous abruption, hypertensive diseases, abdominal trauma, growth restriction, and smoking. The diagnosis is essentially made on the clinical picture that includes vaginal bleeding (usually dark blood), abdominal pain, and uterine contractions. The essence of management is restoration of circulating volume followed by delivery of the fetus and placenta, most often by cesarean section when the diagnosis is clear and the fetus alive and viable. Aggressive resuscitation and expeditious vaginal delivery are the goals when the fetus is dead.
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Affiliation(s)
- David R Hall
- Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg Hospital, Tygerberg, South Africa.
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Usui R, Matsubara S, Ohkuchi A, Kuwata T, Watanabe T, Izumi A, Suzuki M. Fetal heart rate pattern reflecting the severity of placental abruption. Arch Gynecol Obstet 2007; 277:249-53. [PMID: 17896112 DOI: 10.1007/s00404-007-0471-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Accepted: 09/10/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To identify fetal heart rate (FHR) patterns reflecting the severity of placental abruption, and to determine the incidence of normal FHR pattern in cases of placental abruption. MATERIALS AND METHODS We analyzed FHR tracings from 40 pregnant Japanese women with placental abruption. We analyzed which FHR patterns appeared more frequently in cases of low 5-min Apgar score, low cord arterial pH, and large separation. RESULTS Eight out of 40 cases showed a normal FHR pattern, while 32 cases did not show a normal FHR pattern. Undetectable variability and bradycardia appeared more frequently in cases with 5-min Apgar < 7, with cord blood pH < 7.1, and with larger placental separation than in cases without these features. The normal FHR pattern was associated with 5-min Apgar > or = 7, cord blood pH > or = 7.1, and separation of <25%. CONCLUSION Fetal heart rate pattern reflected the severity of placental abruption. Undetectable variability and bradycardia occurred significantly more frequently in cases of severe placental abruption, and thus may reflect the severity of placental abruption.
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Affiliation(s)
- Rie Usui
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, Japan
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Joseph KS. Theory of obstetrics: an epidemiologic framework for justifying medically indicated early delivery. BMC Pregnancy Childbirth 2007; 7:4. [PMID: 17391525 PMCID: PMC1851971 DOI: 10.1186/1471-2393-7-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Accepted: 03/28/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Modern obstetrics is faced with a serious paradox. Obstetric practice is becoming increasingly interventionist based on empirical evidence but without a theoretical basis for such intervention. Whereas obstetric models of perinatal death show that mortality declines exponentially with increasing gestational duration, temporal increases in medically indicated labour induction and cesarean delivery have resulted in rising rates of preterm birth and declining rates of postterm birth. Other problems include a disconnection between patterns of gestational age-specific growth restriction (constant across gestation) and gestational age-specific perinatal mortality (exponential decline with increasing duration) and the paradox of intersecting perinatal mortality curves (low birth weight infants of smokers have lower neonatal mortality rates than the low birth weight infants of non-smokers). DISCUSSION The fetuses at risk approach is a causal model that brings coherence to the various perinatal phenomena. Under this formulation, pregnancy complications (such as preeclampsia), labour induction/cesarean delivery, birth, revealed small-for-gestational age and death show coherent patterns of incidence. The fetuses at risk formulation also provides a theoretical justification for medically indicated early delivery, the cornerstone of modern obstetrics. It permits a conceptualization of the number needed to treat (e.g., as low as 2 for emergency cesarean delivery in preventing perinatal death given placental abruption and fetal bradycardia) and a calculation of the marginal number needed to treat (i.e., the number of additional medically indicated labour inductions/cesarean deliveries required to prevent one perinatal death). Data from the United States showed that between 1995-96 and 1999-2000 rates of labour induction/cesarean delivery increased by 45.1 per 1,000 and perinatal mortality decreased by 0.31 per 1,000 total births among singleton pregnancies at > or = 28 weeks of gestation. The marginal number needed to treat was 145 (45.1/0.31), showing that 145 excess labour inductions/cesarean deliveries in 1999-2000 (relative to 1995-96) were responsible for preventing 1 perinatal death among singleton pregnancies at > or = 28 weeks gestation. SUMMARY The fetuses at risk approach, with its focus on incidence measures, provides a coherent view of perinatal phenomena. It also provides a theoretical justification for medically indicated early delivery and reconciles the contemporary divide between obstetric theory and obstetric practice.
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Affiliation(s)
- K S Joseph
- Perinatal Epidemiology Research Unit, Department of Obstetrics & Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.
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Abstract
Placental abruption complicates about 1% of pregnancies and is a leading cause of vaginal bleeding in the latter half of pregnancy. It is also an important cause of perinatal mortality and morbidity. The maternal effect of abruption depends primarily on its severity, whereas its effect on the fetus is determined both by its severity and the gestational age at which it occurs. Risk factors for abruption include prior abruption, smoking, trauma, cocaine use, multifetal gestation, hypertension, preeclampsia, thrombophilias, advanced maternal age, preterm premature rupture of the membranes, intrauterine infections, and hydramnios. Abruption involving more than 50% of the placenta is frequently associated with fetal death. The diagnosis of abruption is a clinical one, and ultrasonography and the Kleihauer-Betke test are of limited value. The management of abruption should be individualized on a case-by-case basis depending on the severity of the abruption and the gestational age at which it occurs. In cases where fetal demise has occurred, vaginal delivery is preferable. Disseminated intravascular coagulopathy should be managed aggressively. When abruption occurs at or near term and maternal and fetal status are reassuring, conservative management with the goal of vaginal delivery may be reasonable. However, in the presence of fetal or maternal compromise, prompt delivery by cesarean is often indicated. Similarly, abruption at extremely preterm gestations may be managed conservatively in selected stable cases, with close monitoring and rapid delivery should deterioration occur. Most cases of placental abruption cannot be predicted or prevented. However, in some cases, maternal and infant outcomes can be optimized through attention to the risks and benefits of conservative management, ongoing evaluation of fetal and maternal well-being, and through expeditious delivery where appropriate.
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Affiliation(s)
- Yinka Oyelese
- Divisions of Maternal-Fetal Medicine and Epidemiology and Biostatistics, Department of Obstetrics, Gynecology and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08901, USA.
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Wolfe EL, Davis T, Guydish J, Delucchi KL. Mortality risk associated with perinatal drug and alcohol use in California. J Perinatol 2005; 25:93-100. [PMID: 15496968 PMCID: PMC3349286 DOI: 10.1038/sj.jp.7211214] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To analyze the relationship between perinatal drug/alcohol use and maternal, fetal, neonatal, and postneonatal mortality. STUDY DESIGN Linked California discharge, birth and death certificate data from 1991-1998 were used to identify drug/alcohol-diagnosed births. Mortality relative risk (RR) ratios were calculated and logistic models were generated for mortality outcomes. RESULTS Among 4,536,701 birth records, 1.20% contained drug/alcohol discharge diagnostic codes (n=54,290). The unadjusted RRs for maternal (RR=2.7), fetal (RR=1.3), neonatal (RR=2.4), and postneonatal (RR=4.3) mortality were increased for drug/alcohol-diagnosed births. After controlling for potential confounding, the odds of maternal death for cocaine use (OR=2.15) remained significant as did amphetamine (OR=1.77), cocaine (OR=1.43), polydrug (OR=2.01) and other drug/alcohol use (OR=1.79) for postneonatal mortality. CONCLUSIONS The association of cocaine use with maternal mortality and any drug/alcohol use with postneonatal mortality supports screening and identifying women using illicit drugs and alcohol during pregnancy. Increased collaboration with drug treatment programs and closer follow-up for drug-using women and their children may improve mortality outcomes.
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Affiliation(s)
- Ellen L Wolfe
- Family Health Care Nursing (E.L.W.), University of California, San Francisco, San Francisco General Hospital, San Francisco, CA 94110, USA.
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Russell IF. Epidural top-ups for category I/II emergency caesarean section should be given only in the operating theatre. Int J Obstet Anesth 2004; 13:259-65. [PMID: 15477058 DOI: 10.1016/j.ijoa.2004.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Ian F Russell
- Consultant Anaesthetist, Hull Royal Infirmary, Hull HU3 2JZ, UK.
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