Maternal and neonatal outcomes of abnormal placentation: a case-control study

Effect of abnormal placentation on fetal heart function and neonatal outcomes

OBJECTIVE

This study aimed to investigate the fetal modified (mod)-myocardial performance index (MPI) for fetal cardiac function in placenta percreta (PPC) pregnancies with placenta previa (PP) and assess neonatal outcomes.

MATERIALS AND METHODS

This study included 104 pregnant women: 52 with PPC and 52 as the control group. Mod-MPI measurements and neonatal outcomes were evaluated in all cases.

RESULTS

The PPC group had a significantly lower left ejection time (p = 0.044) and significantly higher mod-MPI (p = 0.001) than the control group. The optimal mod-MPI predictive cut-off value at the neonatal intensive care unit (NICU) admission in the PPC group was 0.53 with 53.8% specificity and 88.5% sensitivity (p = 0.019). The optimal mod-MPI predictive cut-off value at the 5th APGAR score below 7 in the PPC group was 0.55 with a specificity of 67.7% and a sensitivity of 76.2% (p = 0.016).

CONCLUSION

Fetal MPI was higher in pregnant women with PPC compared to the control group. Among the PPC cases, those with MPI above a certain predictive level showed more frequent NICU admissions and lower APGAR scores.

Prevalence of fetal anomalies, stillbirth, neonatal morbidity, or mortality in pregnancies complicated by placenta accreta spectrum disorders

INTRODUCTION

Placenta accreta spectrum disorders (PAS) lead to major complications in pregnancy. While the maternal morbidity associated with PAS is well known, there is less information regarding neonatal morbidity in this setting. The aim of this study is to describe the neonatal outcomes (fetal malformations, neonatal morbidity, twin births, stillbirth, and neonatal death), using an international multicenter database of PAS cases.

MATERIAL AND METHODS

This was a prospective, multicenter cohort study based on prospectively collected cases, using the international multicenter database of the International Society for PAS, carried out between January 2020 and June 2022 by 23 centers with experience in PAS care. All PAS cases were included, regardless of whether singleton or multiple pregnancies and were managed in each center according to their own protocols. Data were collected via chart review. Local Ethical Committee approval and Data Use Agreements were obtained according to local policies.

RESULTS

There were 315 pregnancies eligible for inclusion, with 12 twin pregnancies, comprising 329 fetuses/newborns; 2 cases were excluded due to inconsistency of data regarding fetal abnormalities. For the calculation of neonatal morbidity and mortality, all elective pregnancy terminations were excluded, hence 311 pregnancies with 323 newborns were analyzed. In our cohort, 3 neonates (0.93%) were stillborn; of the 320 newborns delivered, there were 10 cases (3.13%) of neonatal death. The prevalence of major congenital malformations was 4.64% (15/323 newborns), most commonly, cardiovascular, central nervous system, and gastrointestinal tract malformations. The overall prevalence of major neonatal morbidity in pregnancies complicated by PAS was 47/311 (15.1%). There were no stillbirths, neonatal deaths, or fetal malformations in reported twin gestations.

CONCLUSIONS

Although some outcomes may be too rare to detect within our cohort and data should be interpreted with caution, our observational data supports reassuring neonatal outcomes for women with PAS.

Determinants of low birth weight among newborns delivered in China: a prospective nested case-control study in a mother and infant cohort

This nested case-control study aimed to investigate the determinants of low birth weight among newborn babies delivered in Shenzhen, Guangdong, China. We recorded socio-demographic data, health status before pregnancy, pregnancy outcomes and complications in a Shenzhen mother and infant cohort. Among 8951 cases, 401 (4.48%) had low birth weight and 1.65% were full-term with LBW. Maternal body mass index, family income, history of pregnancy, hypertension before pregnancy, vaginal bleeding in 1^st trimester, pregnancy-related diabetes, hypertension, placenta previa, placental abruption, premature rupture of membrane, oligohydramnios, and placental types were significantly associated with low birth weight (P < 0.05). In this study, high-risk and mainly preventable factors were linked to low birth weight. Adequate antenatal care, proper maternal nutrition and implementation of proven strategies to prevent high-risk factors may be effective ways to reduce the incidence of low birth weight.

The Association between Placenta Accreta Spectrum Severity and Incidence of Small for Gestational Age Neonates

OBJECTIVE

The aim of the study is to evaluate whether pathologic severity of placenta accreta spectrum (PAS) is correlated with the incidence of small for gestational age (SGA) and neonatal birthweight.

STUDY DESIGN

This was a multicenter cohort study of viable, non-anomalous, singleton gestations delivered with histology-proven PAS. Data including maternal history, neonatal birthweight, and placental pathology were collected and deidentified. Pathology was defined as accreta, increta, or percreta. The primary outcome was rate of SGA defined by birth weight less than the 10th percentile. The secondary outcomes included incidence of large for gestational age (LGA) babies as defined by birth weight greater than the 90th percentile as well as incidence of SGA and LGA in preterm and term gestations. Statistical analysis was performed using Chi-square, Kruskal-Wallis, and log-binomial regression. Increta and percreta patients were each compared with accreta patients.

RESULTS

Among the cohort of 1,008 women from seven United States centers, 865 subjects were included in the analysis. The relative risk (RR) of SGA for increta and percreta did not differ from accreta after adjusting for confounders (adjusted RR = 0.63, 95% confidence interval [CI]: 0.36-1.10 for increta and aRR = 0.72, 95% CI: 0.45-1.16 for percreta). The results were stratified by placenta previa status, which did not affect results. There was no difference in incidence of LGA (p = 1.0) by PAS pathologic severity. The incidence of SGA for all PAS patients was 9.2% for those delivered preterm and 18.7% for those delivered at term (p = 0.004). The incidence of LGA for all PAS patients was 12.6% for those delivered preterm and 13.2% for those delivered at term (p = 0.8203).

CONCLUSION

There was no difference in incidence of SGA or LGA when comparing accreta to increta or percreta patients regardless of previa status. Although we cannot suggest causation, our results suggest that PAS, regardless of pathologic severity, is not associated with pathologic fetal growth in the preterm period.

KEY POINTS

· PAS severity is not associated with SGA in the preterm period.. · PAS severity is not associated with LGA.. · Placenta previa does not affect the incidence of SGA in women with PAS..

Effect of placenta previa on umbilical cord hematocrit value

OBJECTIVE

Placenta previa is one of the causes of neonatal anemia. This condition is mainly explained by antenatal hemorrhage and incision of the anteriorly located placenta during cesarean section. However, the mechanism of neonatal anemia in placenta previa has not been extensively studied or well elucidated. This study investigates whether placenta previa is associated with lower hematocrit levels in newborns with no antenatal hemorrhage and placental incision.

KEY FINDINGS

This prospective study investigated 47 patients with previa and 43 control patients who gave birth with a cesarean section at 34-38 weeks of gestation. Blood samples were obtained from the fetal end of the umbilical vein. The mean umbilical cord hematocrit value was 49.3% in the control patients and 46.7% in the patients with previa, and the difference was statistically significant (p = .029). No significant association was observed between hematocrit value and birth weight, gestational age, newborn gender, placenta position, or preoperative maternal hemoglobin level.

CONCLUSION

The study findings reveal that even if not complicated by antepartum or intrapartum hemorrhage, placenta previa may be associated with lower hematocrit values in newborns. Although in none of the cases, the umbilical cord hematocrit value was not as low as to be defined as anemia, this effect of previa on newborns should be considered because of the importance of iron status.

Complicated placenta accreta spectrum: identifying a high-risk cohort

OBJECTIVE

To assess differences in the perioperative complication rate between patients with placenta accreta spectrum (PAS) with and without complicating factors.

METHODS

This retrospective cohort study included subjects who underwent cesarean hysterectomy with histology-proven PAS between 23 0/7 and 42 0/7 weeks gestational age (GA) from 1 July 2008 to 11 April 2017. Perioperative outcomes were compared between those with uncomplicated PAS and "complicated PAS," defined as PAS subjects who experienced ≥2 bleeding episodes, preterm premature rupture of membranes (PPROM), or premature contractions requiring tocolysis.

RESULTS

Overall, 26 complicated PAS and 27 uncomplicated PAS cases were compared; no difference in the rate of perioperative complications was identified. An increased proportion of complicated PAS cases required blood product transfusion before delivery: 2 (40%), 3 (27.3%), and 2 patients (20%) for those with PPROM, preterm contractions, and ≥2 bleeding episodes respectively, compared to patients with uncomplicated PAS, having no transfusions (p = .001). Time of delivery was earlier for patients with complicated compared to uncomplicated PAS (median GA 30.9 [Q1 = 27.9; Q3 = 31.9] and 34.9 [Q1 = 32.1; Q3 = 35.7], p < .001). Median birthweights were lower (p < .0144) and maternal length of stay longer (p < .0012) for complicated PAS.

CONCLUSION

Patients with complicated PAS were not at higher risk for perioperative complications but were associated with earlier delivery, required more antenatal blood transfusions, and had a longer LOS.

First-trimester screening model for small-for-gestational-age using maternal clinical characteristics, serum screening markers, and placental volume: prospective cohort study

OBJECTIVE

To examine predictive value of first trimester placental volume, maternal clinical characteristics, and serum biomarkers in predicting small-for-gestational-age (SGA) singleton pregnancy.

METHODS

We conducted a prospective study to determine whether SGA is associated with maternal clinical factors. Between November 2016 to May 2018, 351 women were enrolled. We included pregnant women who underwent an integrated test for aneuploidy screening. Placental volume, maternal clinical characteristics, and maternal serum pregnancy-associated plasma protein A (PAPP-A) levels in the first trimester (at 10⁺⁰-13⁺⁶weeks) and maternal serum biomarkers after 15⁺⁰-22⁺⁶weeks were measured. We measured the width, height, and thickness of the placenta and calculated the placental volume using an established mathematical formula; then, we analyzed the association between SGA at delivery, estimated placental volume (EPV), maternal clinical characteristics, and maternal serum biomarkers by multiple logistic regression analysis.

RESULTS

In this study, 12.3% (43/351) neonates were delivered before 37 weeks of gestation, and the birth weight of 23.6% (83/351) was below the 10th percentile according to gestational age. On multivariate logistic regression, the MSAFP multiples of the median (MoM) showed the strongest association with SGA in singleton pregnancy (p < .01), and the PAPP-A MoM showed a weaker association in the multiple logistic regression than in the univariate regression (p = .0073 and .0068, respectively). Our prediction model using maternal age, maternal smoking, PAPP-A, and EPV achieved an area under the curve of 0.668 in singleton pregnancy.

CONCLUSION

During the first trimester, maternal clinical characteristics, serum biomarkers, and EPV may be used for predicting the risk of SGA in singleton pregnancy.

Neonatal outcome after conservative-reconstructive surgery for placenta accreta spectrum disorders

AIM

To report the neonatal outcome after conservative-reconstructive surgery for placenta accreta spectrum (PAS) disorders.

MATERIALS AND METHODS

Inclusion criteria were women undergoing conservative-reconstructive surgery for PAS. The outcomes explored were: 5 min Apgar score, birth weight, and need for ventilatory support (RS1 supplementary oxygen, RS2 nasal positive pressure ventilation, or RS3 mechanical ventilatory assistance). Descriptive statistics (means and standard deviations for quantitative and percentage and interquartile range for quantitative variables) were sued to report the data.

RESULTS

84% of women with PAS type 1 were delivered between 35 and 37 weeks of gestation. There was only one case of small for gestational age (SGA) newborn 81% of the newborns required admission to the NICU and 11% respiratory support of those pregnancies complicated by PAS type 2, 59% were delivered between 35 and 36.6 weeks. Neonatal birth weight was consistent with gestational age at birth for all the included cases, and there was no SGA newborn in this group. 84% of the newborns required admission to the NICU, while 21% respiratory support. All women with PAS type 3 were delivered between 30 and 33 weeks of gestation. Although all newborns were admitted to NICU and 73% required ventilatory support, there was no SGA case. Pregnancies complicated by PAS type 4 completed their pregnancy between weeks 35 and 37. There was no case affected by SGA; although all newborns were admitted to NICU, none required ventilatory support.

CONCLUSIONS

Conservative surgery in pregnancies complicated by PAS does not seem to increase the risk of adverse neonatal outcomes. Early gestational age at birth and invasion in the inferior third of the lower uterine segment is associated with an increased incidence of neonatal complications, likely due to the earlier gestational age at delivery for these pregnancies.

Outcomes of 42 pregnancies in 14 women with cartilage-hair hypoplasia: a retrospective cohort study

BACKGROUND

Cartilage-hair hypoplasia (CHH) is a rare skeletal dysplasia characterized by disproportionate short stature, immunodeficiency, anemia and risk of malignancies. All these features can affect pregnancy and predispose to maternal and fetal complications. This study aimed to evaluate obstetric history and maternal and fetal outcomes in women with CHH.

METHODS

Among 47 Finnish women with CHH, we identified 14 women with ICD codes related to pregnancies, childbirth and puerperium in the National Hospital Discharge Registry and obtained detailed data on gynecologic and obstetric history with a questionnaire. Offspring birth length and weight were collected and compared with population-based normal values.

RESULTS

There were altogether 42 pregnancies in 14 women (median height 124 cm, range 105-139 cm; 4'1'', range 3'5''-4'7''). Twenty-six pregnancies (62%), including one twin pregnancy, led to a delivery. Miscarriages, induced abortions and ectopic pregnancies complicated 9, 5, and 2 pregnancies, respectively. Severe pregnancy-related complications were rare. All women with CHH delivered by cesarean section, mostly due to evident cephalo-pelvic disproportion, and in 25/26 cases at full-term. In the majority, the birth length (median 48 cm, range 45.5-50 cm; 1'7'', range 1'6''-1'8'') and weight (3010 g, range 2100-3320 g; 6.6 lb, range 4.6-7.3 lb) of the offspring in full-term singleton pregnancies was normal.

CONCLUSIONS

Despite CHH mothers' significant short stature and other potential CHH-related effects on pregnancy outcome, most pregnancies lead to a term cesarean section delivery. Since fetal growth was generally unaffected, cephalo-pelvic disproportion was evident and planned cesarean section should be contemplated in term pregnancies.