Thrombophilia and Adverse Maternal-Perinatal Outcome

Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature

BACKGROUND

The safety of spinal manipulation during pregnancy and the postpartum periods has been a matter of debate among manual therapists. Spinal manipulative therapy during these periods is a commonly performed intervention as musculoskeletal pain is common in these patients. To date there has not been an evaluation of the literature on this topic exclusively.

METHODS

A literature search was conducted on PubMed, CINAHL and the Index to Chiropractic Literature along with reference searching for articles published in English and French in the peer-reviewed literature that documented adverse effects of spinal manipulation during either pregnancy or postpartum. Case reports, case series, and any other clinical study designs were deemed acceptable for inclusion, as were systematic reviews. The appropriate Scottish Intercollegiate Guidelines Network (SIGN) tools were used to rate included articles for quality when applicable.

RESULTS

Five articles identifying adverse events in seven subjects following spinal manipulation were included in this review, along with two systematic reviews. The articles were published between 1978 and 2009. Two articles describing adverse effects from spinal manipulation on two postpartum patients were included, while the remaining three articles on five patients with adverse effects following spinal manipulation were on pregnant patients. Injury severity ranged from minor injury such as increasing pain after treatment that resolved within a few days to more severe injuries including fracture, stroke, and epidural hematoma. SIGN scores of the prospective observational cohort study and systematic reviews indicated acceptable quality.

CONCLUSIONS

There are only a few reported cases of adverse events following spinal manipulation during pregnancy and the postpartum period identified in the literature. While improved reporting of such events is required in the future, it may be that such injuries are relatively rare.

Avascular villi, increased syncytial knots, and hypervascular villi are associated with pregnancies complicated by factor V Leiden mutation

There is controversy about whether pathologic abnormalities are associated with pregnancies complicated by factor V Leiden (FVL) mutation. The purpose of this study was to evaluate 105 placentas delivered to mothers heterozygous for FVL mutation to determine if there are pathologic changes suggestive of hypoxia or thrombosis, which correlate with mutation status. We examined placentas obtained as part of a prospective study of 5188 pregnancies analyzed for the presence of FVL mutation in either the mother or the infant. One hundred five placentas from mothers heterozygous for the mutation were compared with 225 controls matched for maternal age, race, and geographic site. Of the 330 pregnancies, 50 infants were FVL mutation heterozygotes. Maternal FVL heterozygote status was associated with more frequent increased numbers of syncytial knots (13% vs 4%); the difference remained significant after controlling for hypertension, preeclampsia, small-for-gestational-age infants, and delivery prior to 35 weeks of gestation (odds ratio 3.6, 95% confidence interval 1.5-8.7, P  =  0.004). Maternal FVL heterozygotes had more hypervascular villi (10% vs 3%), with significance retained controlling for delivery route (odds ratio 3.4, 95% confidence ratio 1.2-9.4, P  =  0.018). Placentas from infants heterozygous for FVL mutation had more avascular villi than controls (odds ratio 2.9, 95% confidence interval 1.5-5.6, P  =  0.001). Fetal or maternal FVL heterozygosity was not associated with infarcts, small-for-gestational-age placentas, or fetal thrombotic vasculopathy. This analysis demonstrates that pathologic findings associated with placental hypoxia, specifically focal avascular villi, increased numbers of syncytial knots, and hypervascular villi, also correlate with FVL heterozygosity in infants or mothers.

Recurrence of fetal growth restriction in singleton and twin gestations

OBJECTIVE

Patterns of recurrence of restricted fetal growth provide important insights to understand the relative contributions of genetic versus environmental influences. Although there is evidence of increased tendency of small for gestational age (SGA) births to recur, whether similar patterns of recurrence in twins among women that delivered a prior singleton SGA birth remains poorly studied.

METHODS

We used Missouri's maternally-linked data (1978-1997), and restricted the analysis to women that delivered their first two consecutive live births. SGA (birthweight <10th and <5th centile for gestational age) recurrence was examined in two distinct analyses: women that delivered their first two singleton live births (n = 305,654) and those that delivered their first singleton live birth followed by twin live births (n = 8594). Sib-sib pairwise odds ratio (pOR) were estimated from bivariate logistic regression with robust variance estimation after adjustments for confounders.

RESULTS

Risks of SGA were 24.3% and 6.1% in the second singleton birth among women with and without a previous singleton SGA, respectively (pOR 3.9, 95% CI 3.7-4.0). The corresponding risks among twins with and without a previous singleton SGA birth were 16.9% and 6.7%, respectively (pOR 2.3, 95% CI 1.8-2.8). In the singleton-singleton cohort, the highest recurrence risk for SGA occurred around the same gestational age window as the first singleton SGA birth. These associations were stronger for more severe forms of SGA (<5th centile).

CONCLUSIONS

The likelihood of SGA to recur within sibships is strong, with varying magnitude of risks between singleton-singleton and singleton-twin births.

The intrauterine growth-restricted fetus and placenta evaluation

Evaluation of the placenta is extremely important in attempting to understand the pathophysiology of intrauterine growth restriction. Only with careful gross and microscopic evaluation, along with clinical pathologic correlation can the underlying cause(s) and recurrence risks be understood.

Fetal growth restriction and subsequent pregnancy risks

Fetal growth restriction can result from a variety of intrinsic or extrinsic insults, resulting from maternal, fetal, and placental factors. Determining the underlying cause of poor fetal growth can be difficult but is essential for assessing potential risks for future pregnancies. Importantly, recurrence risks greatly depend on these underlying conditions. Understanding these risks can allow more appropriate patient counseling and may influence management strategies to optimize future pregnancies.