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PubMed1995

The very low birthweight infant: maternal complications leading to preterm birth, placental lesions, and intrauterine growth.

The placental lesions of the very low birthweight (VLBW) infant were investigated in relation to clinical complications leading to preterm birth and evidence of growth impairment. The 249 singleton gestations yielding infants less than 1500 g were grouped according to the clinical complications leading to preterm birth as premature membrane rupture (116/249, 47%) preterm labor (55/249, 22%), pregnancy-induced hypertension (PIH, 54/249, 22%), and normotensive abruption (ABR, 24/249, 10%). Specifically excluded from this data set were cases with greater than 2 weeks discordance, fetal congenital anomalies, placenta previa, and maternal medical or gestational diseases such as chronic hypertension and diabetes mellitus, and intrauterine growth retardation (IUGR) as a primary indication for delivery. Placental weight and lesions including decidual vasculopathy and related villous lesions, chronic villitis/intervillositis, and decidual plasmacytosis were considered as variables in analyses in which raw birthweight was the dependent variable and gestational age a confounder. Of the 195 VLBW, 79 (41%) infants from normotensive mothers had lesions of decidual vasculopathy or chronic inflammation. In the VLBW infants from hypertensive mothers, growth restriction was related to markers of decidual vasculopathy. In the absence of maternal hypertension the growth restriction was independently associated with chronic villitis. Decidual vasculopathy (characteristic of PIH) and chronic intrauterine inflammation underlie the complications of many normotensive VLBW infants. The placental lesions in VLBW-IUGR depend on the presence or absence of maternal hypertension. In the absence of maternal hypertension, VLBW-IUGR is associated with chronic inflammation and is independent of decidual vasculopathy. In the presence of maternal hypertension, VLBW-IUGR is directly related to decidual vasculopathy.

Abruptio Placentae↗
PubMed2004

Maternal, neonatal, and placental features associated with diffuse chorioamniotic hemosiderosis, with special reference to neonatal morbidity and mortality.

OBJECTIVE: Our purpose was to examine the significance of diffuse chorioamniotic hemosiderosis (DCH) on neonatal morbidity and mortality. METHODS: Using data from a retrospective case-control study, we analyzed 46 singleton placentas with DCH from infants who were delivered and/or admitted to the neonatal intensive care unit of Kanagawa Children's Medical Center during 1987-2001 and 92 control placentas without DCH from infants of comparable gestational age, birth weight, and duration. RESULTS: Mean and standard deviation of gestational age and infants' birth weight at delivery from the DCH group were 27 +/- 3 weeks and 939 +/- 342 g, respectively. Macroscopically, the placentas with DCH were more likely to show old peripheral blood clots (46% in the DCH group vs 8% in control group), subchorionic hematoma (20% vs 1%), and circumvallation (13% vs 1%). Histologically, amniotic necrosis was significantly more frequent in the DCH group (63% vs 24%). Of the obstetric factors, incidence of recurrent episodes of vaginal bleeding (70% vs 11%), oligohydramnios (59% vs 8%), and chronic abruption-oligohydramnios sequence (57% vs 5%) were significantly higher in the DCH group. Of the neonatal factors, persistent pulmonary hypertension of the newborn (29% vs 8%) and dry lung and/or pulmonary hypoplasia (20% vs 4%) were more common. However, respiratory distress syndrome was rare (15% vs 45%) in the DCH group. Neonatal death including stillbirth was increased in the DCH group but was not significant (24% vs 15%). Of infants who survived beyond day 28, chronic lung disease (CLD) was more frequent in the DCH group (51% vs 22%). The association of DCH, especially accompanied by amniotic necrosis, with CLD was still evident using likelihood ratio test. CONCLUSION: DCH is closely associated with preterm delivery, pulmonary hypertension of the newborn, and dry lung syndrome and is a significant risk factor for CLD.

Abruptio Placentae↗
PubMed2003

Massive obstetric hemorrhage.

Massive obstetric haemorrhage is a major cause of maternal death and morbidity; abruption of the placenta, placenta praevia and postpartum haemorrhage being the main causes of haemorrhages. A delay in the correction of hypovolaemia, diagnosis and treatment of defective coagulation and/or surgical control of bleeding are the avoidable factors in most maternal deaths caused by haemorrhage. The main goal is to maintain effective circulating intravascular volume by prompt and adequate replacement of blood, crystalloids or fresh-frozen plasma through more than one intravenous line (it might be necessary to pump blood under pressure) with constant monitoring of the pulse rate and the arterial blood pressure. The rapid correction of hypovolaemia with crystalloids and red cells is the first priority, followed by blood component therapy. Oxytocin and prostaglandin will correct uterine atony, and appropriate surgical intervention is required for traumatic bleeding. Ligation of the uterine arteries, ovarian arteries and hypogastric arteries will usually control uterine bleeding and arterial embolization is also effective. Hysterectomy should also be considered in severe cases. All gynecologists should be able to perform without delay the operative maneuvers which are necessary to control the bleeding, including hypogastric artery ligation, or even emergency hysterectomy. This topic may have received little attention because it is perceived as being associated with maternal morbidity rather than mortality in developed countries; it is only recently that the extent and importance of postnatal maternal morbidity has been recognized.

Abruptio Placentae↗
PubMed2006

Maternal-fetal conditions necessitating a medical intervention resulting in preterm birth.

OBJECTIVE: The objective of the study was to evaluate the extent to which maternal and fetal conditions necessitate medically indicated preterm birth. STUDY DESIGN: A population-based, retrospective, cohort study of women who delivered a singleton live birth at 20 weeks or longer in Missouri, 1989 to 1997 was performed (n = 684,711). Maternal-fetal conditions that necessitated iatrogenic preterm birth included preeclampsia, small-for-gestational-age birth, fetal distress, placental abruption, placenta previa, unexplained vaginal bleeding, pregestational and gestational diabetes, renal disease, Rh sensitization, and congenital malformations. We examined the association between each of the aforementioned conditions and risk of medically indicated preterm birth at less than 35 weeks. Medically indicated preterm birth was defined as a labor induction or a prelabor cesarean in the absence of premature rupture of membranes at preterm gestations. Adjusted relative risk with 95% confidence interval for preterm birth was derived from multivariable logistic regression models, and population attributable fractions were calculated. RESULTS: The preterm birth rate (less than 35 weeks) was 4.6% (n = 31,238), with 23.5% (n = 7,347) of such births being medically indicated. Preeclampsia, fetal distress, small-for-gestational-age, and placental abruption were the most common indications for a medical intervention resulting in preterm birth, with at least 1 of these conditions present in 53.2% of medically indicated preterm births and in 17.7% of term births (relative risk 4.9, 95% confidence interval 4.7, 5.2). CONCLUSION: Preeclampsia, fetal distress, small-for-gestational-age, and placental abruption, conditions that are associated with ischemic placental disease, are implicated in well over half of all medically indicated preterm births. Although the etiology of preterm birth is heterogeneous, it is reasonable that ischemic placental disease may serve as an important pathway to preterm birth.

Abruptio Placentae↗
PubMed1991

Placental pathologic findings in preterm birth.

Microscopic features of placentas from 539 consecutive preterm deliveries and 214 term deliveries were compared. The presence of either umbilical or chorionic vasculitis was identified in 38% of the cases at 22 to 28 weeks' gestation, in 32% of the cases at 29 to 32 weeks' gestation, in 13% of the cases at 33 to 36 weeks' gestation, and in 10% of the cases at term (p less than 0.0001). Decidual vascular abnormality was present in 70% of the cases at 22 to 28 weeks' gestation, in 35% of the cases at 29 to 32 weeks, in 29% of the cases at 33 to 36 weeks, and in 15% of the cases at term (p less than 0.0001). Chronic villitis was significantly more frequent in preterm deliveries without umbilical vasculitis than in those cases with umbilical vasculitis (17% vs 8%, p less than 0.05). Our data indicate that the placental lesions of umbilical-chorionic vasculitis, decidual vascular abnormality, and chronic villitis are related to preterm birth. Umbilical-chorionic vasculitis reflects acute ascending bacterial infection. Decidual vascular abnormality has been associated with maternal autoimmune or alloimmune disorders. Chronic villitis may indicate either congenital viral infection or maternal-fetal immunopathologic conditions. Both decidual vascular abnormality and chronic villitis may reflect the activation of inflammatory mechanisms capable of leading to preterm delivery.

Abruptio Placentae↗
PubMed2006

Previous cesarean delivery and risks of placenta previa and placental abruption.

OBJECTIVE: To examine the association between cesarean delivery and previa and abruption in subsequent pregnancies. METHODS: A retrospective cohort study of first 2 (n = 156,475) and first 3 (n = 31,102) consecutive singleton pregnancies using the 1989-1997 Missouri longitudinally linked data were performed. Relative risk (RR) was used to quantify the associations between cesarean delivery and risks of previa and abruption in subsequent pregnancies, after adjusting for several confounders. RESULTS: Rates of previa and abruption were 4.4 (n = 694) and 7.9 (n = 1,243) per 1,000 births, respectively. The pregnancy after a cesarean delivery was associated with increased risk of previa (0.63%) compared with a vaginal delivery (0.38%, RR 1.5, 95% confidence interval [CI] 1.3-1.8). Cesarean delivery in the first and second births conferred a two-fold increased risk of previa in the third pregnancy (RR 2.0, 95% CI 1.3-3.0) compared with first two vaginal deliveries. Women with a cesarean first birth were more likely to have an abruption in the second pregnancy (0.95%) compared with women who had a vaginal first birth (0.74%, RR 1.3, 95% CI 1.2-1.5). Two consecutive cesarean deliveries were associated with a 30% increased risk of abruption in the third pregnancy (RR 1.3, 95% CI 1.0-1.8). A second pregnancy within a year after a cesarean delivery was associated with increased risks of previa (RR 1.7, 95% CI 0.9-3.1) and abruption (RR 1.5, 95% CI 1.1-2.3). CONCLUSION: A cesarean first birth is associated with increased risks of previa and abruption in the second pregnancy. There is a dose-response pattern in the risk of previa, with increasing number of prior cesarean deliveries. A short interpregnancy interval is associated with increased risks of previa and abruption. LEVEL OF EVIDENCE: II-2.

Abruptio Placentae↗
PubMed2001

Clotting disorders and placental abruption: homocysteine--a new risk factor.

Placental abruption is due to the rupture of the uterine spiral artery. The placenta separates totally or partially from the uterine wall during pregnancy. This serious syndrome has a great risk for the mother (shock and disseminated intravascular coagulation) and her child (mortality or morbidity). To the known risk factors like hypertension, the use of cocaine and smoking, homocysteine is recognized as an independent risk factor for vascular disease and endothelial dysfunction. In contrast to normal pregnancy where the spiral artery endothelium is replaced by trophoblast, the endothelium persists in case of placental abruption. In 165 women with placental vasculopathy and 139 matched controls hyperhomocysteinemia resulted in an odds ratio of 4.7 (95% CI: 1.6-14.0). The C677T mutation gave a risk of 2.5 (95% CI: 1.0-6.0). Even up to 2 or 3 years post-partum evidence could be found of endothelial dysfunction. The combination of hyperhomocysteinemia and thrombotic factors like APC resistance, Protein-C, Protein-S, antithrombin and factor V Leiden increases the risk of placental abruption 3-7 times. The common denominator of the effect of homocysteine on blood vessels could be sited in the process of proliferation of cells that need proper methyl groups for proper function (DNA synthesis and expression). These methyl groups are delivered by D-adenosylmethionine formed from methionine after remethylation of homocysteine. The coagulation factors and plasma homocysteine values can be modulated by vitamins, folic acid and folates in particular. To prove the clinical value of folate supplementation placebo-randomized trials are urgently needed: for placebo to be started after the period of neural tube closure.

Abruptio Placentae↗
PubMed2005

Metabolic syndrome and the risk of placental dysfunction.

BACKGROUND: Placental dysfunction (PD), which may manifest partly as the hypertensive disorders of pregnancy and abruption or infarction of the placenta, occurs more commonly in women with obesity, chronic hypertension, diabetes mellitus, and dyslipidemia-each a major feature of the metabolic syndrome. However, the relationship between the metabolic syndrome and the future risk of PD or fetal demise is unknown. METHODS: We completed a retrospective cohort study of 1.03 million women who had a first documented delivery in the province of Ontario between 1990 and 2002. Using linked administrative databases, we categorized women as having zero, one, two, or three to four features of the metabolic syndrome up to 24 months before their index delivery hospitalization. Women were considered to have placental dysfunction if they had a diagnosis of preeclampsia, gestational hypertension, placental abruption, or placental infarction during their first hospitalization for delivery in the period of study. RESULTS: At the time of delivery, 75 380 women (7.3%) were diagnosed as having PD. There was a progressive increase in the risk of PD in women with one (adjusted odds ratio [OR] 3.1; 95% confidence interval [CI] 3.0-3.1), two (OR 5.5; 95% CI 5.2-5.8), or three to four (OR 7.7; 95% CI 6.7-8.9) features of the metabolic syndrome, compared with none. A similar gradient effect was seen for the combined outcome of PD with poor fetal growth, or of PD with concomitant fetal death. CONCLUSIONS: Women who exhibit features of the metabolic syndrome before pregnancy have a higher graded risk of PD and fetal demise. Studies are needed to determine whether modifying a woman's metabolic profile before pregnancy, through modest caloric restriction and increased physical activity, can lower her future risk of PD.

Abruptio Placentae↗
PubMed1996

Placental abruption and its association with hypertension and prolonged rupture of membranes: a methodologic review and meta-analysis.

OBJECTIVE: To conduct a meta-analysis of published studies on placental abruption to examine its incidence, recurrence, and association with hypertensive disorders (chronic hypertension and preeclampsia) and prolonged rupture of membranes (PROM) in pregnancy. DATA SOURCES: We reviewed studies on placental abruption published since 1950, based on a comprehensive literature search using MEDLINE, and by identifying studies cited in the references of published reports. METHODS OF STUDY SELECTION: We identified 54 studies, excluding case reports on placental abruption and studies relating to placenta previa and vaginal bleeding of unknown origin. We also restricted the search to articles published in English. TABULATION, INTEGRATION, AND RESULTS: Studies chosen for the meta-analysis were categorized based on their study design (case-control or cohort), where they were conducted (United States or other countries), source of the data (vital records versus other sources), and magnitude of risk (risk of abruption greater or less than 1.0%). We used both fixed- and random-effects analysis to identify sources of heterogeneity in results among studies. There were striking differences in the incidence of placental abruption between cohort (0.69%) and case-control (0.35%) studies. United States-based studies found a somewhat higher incidence both for cohort (0.81%) and case-control (0.37%) studies compared with studies conducted outside the U.S. (0.60% and 0.26%, respectively). Abruption was more than ten times more common in pregnancies preceded by a pregnancy with abruption. Chronically hypertensive patients were more than three times as likely to develop placental abruption (odds ratio [OR] 3.13, 95% confidence interval [CI] 2.04-4.80) as normotensive patients. The OR for placental abruption was 1.73 (95% CI 1.47-2.04) for patients with preeclampsia. Similarly, women with pregnancies complicated by PROM were more than three times as likely to develop placental abruption (OR 3.05, 95% CI 2.16-4.32). United States-based studies, case-control studies, and studies with an incidence of abruption greater than 1% demonstrated stronger associations between abruption and hypertension and PROM. CONCLUSION: Risk of abruption is strongly associated with chronic hypertension, PROM, and especially abruption in a prior pregnancy, and somewhat more modestly with preeclampsia. The criteria for the diagnosis of placental abruption, hypertensive disorders, and PROM may have introduced variability among the results of these studies. More standardized definitions of these pregnancy complications would improve the comparability of the study results.

Abruptio Placentae↗
PubMed1999

Placental abruption and adverse perinatal outcomes.

CONTEXT: Pregnancies complicated by abruption result in increased frequency of perinatal death and decreased fetal size and gestational duration, yet the extent of placental separation and its effect on these adverse outcomes is unknown. OBJECTIVE: To assess the contribution of placental abruption and extent of placental separation to stillbirth, preterm delivery, and fetal growth restriction. DESIGN: Hospital-based, retrospective cohort study. SETTING: Mount Sinai Hospital, New York City, NY. PARTICIPANTS: A total of 53,371 pregnancies occurring in 40,789 women who were delivered of singleton births between 1986 and 1996. MAIN OUTCOME MEASURES: Risks and relative risks for stillbirth (>20 weeks), preterm delivery (<37 weeks), and fetal growth restriction (birth weight below 10th percentile for gestational age) in relation to abruption. RESULTS: The incidence of abruption was 1 % (n = 530). Abruption was associated with an 8.9-fold (95% confidence interval [CI], 6.0-13.0) adjusted relative risk (aRR) of stillbirth. Preterm birth proportions among women with and without abruption were 39.6% and 9.1 %, respectively, yielding an aRR of 3.9 (95% CI, 3.5-4.4). In the abruption group, 14.3% of neonates were growth restricted, compared with 8.1 % among all other births (aRR, 2.0; 95% CI, 1.5-2.4). Extent of placental separation had a profound effect on stillbirth (aRR for 75% separation, 31.5; 95% CI, 17.0-58.4), although evident only among those with at least 50% separation. However, the risk of preterm delivery was substantially increased even for mild abruptions (aRR for 25% separation, 5.5; 95% CI, 4.2-7.3). CONCLUSIONS: In this cohort, placental abruption had a profound impact on stillbirth, preterm delivery, and fetal growth restriction. The risk of stillbirth was dramatically increased for severe placental separation, but preterm delivery was common even among women with lesser degrees of placental separation.

Abruptio Placentae↗
PubMed2000

A comparison of several procedures to estimate the confidence interval for attributable risk in case-control studies.

The estimation of a confidence interval for attributable risk from the logistic model based on data from case-control studies is a problem for which an accepted solution is lacking. Two methods, one based on the delta method and one bootstrap on the population base, have been described but their accuracy has not been compared. We present two other methods, one based on a jack-knife approach and the other using a bootstrap on two samples (cases and controls). The four methods are compared in a simulation study. The four methods are also applied to a case-control study on risk factors for preterm delivery; the confidence intervals are obtained assuming normality and by logarithmic transformation. When attributable risk is not smooth (for example, when exposure prevalence is low) both the jack-knife and the delta method tend to fail. If attributable risk is close to zero or one, normality cannot be assumed and log-transformed confidence intervals must be used. Finally, the extension to matched studies is analysed using a case-control study on risk factors of cutaneous malignant melanoma. In this situation, the population-based bootstrap is not available.

Abruptio Placentae↗
PubMedDate not supplied

Preterm labor, placental abruption, and premature rupture of membranes in relation to maternal violence or verbal abuse.

OBJECTIVE: The prevalence of preterm labor (PTL) in prenatal populations has been estimated to be from 6.9 to 10.0%. It has been suggested that violence during pregnancy may be associated with an increase in antenatal complications. The hypothesis is that physical violence and verbal abuse in pregnancy lead to increased risk of PTL. METHODS: A cohort of 636 women attending the Adult Obstetrical Clinic for their first prenatal visit, between December 1989 and September 1990, were approached; 567 women enlisted as study participants. Study participants were interviewed 3 times during the course of their prenatal care, and 401 participants successfully completed their third prenatal interviews. Violence data were obtained during the third interview. Obstetrical and neonatal outcome data were obtained by abstracting the maternal and neonatal medical records. RESULTS: When stratified by levels of violence, women who experienced moderate or severe violence had incidences of PTL of 15.4 and 17.2%, respectively. Chi-square test for homogeneity revealed a significant difference among these groups. CONCLUSIONS: In our cohort of women, serious acts of verbal abuse and physical violence occurred with significant frequency. PTL was strongly correlated with increasing acts of violence with 4.1 times greater risk of PTL in women who experienced severe violence as compared to those who experienced no maternal abuse.

Abruptio Placentae↗
PubMed2003

Interventions for treating placental abruption.

BACKGROUND: Placental abruption is an important cause of maternal and fetal mortality and morbidity. OBJECTIVES: To assess the effectiveness and safety of any intervention for the care of women and/or their babies following a diagnosis of placental abruption. SEARCH STRATEGY: Comprehensive electronic search of the Cochrane Pregnancy and Childbirth trials register. Date of last search: October 2002. SELECTION CRITERIA: Randomised and 'quasi-randomised' trials that report clinically meaningful outcomes and present results on an intention to treat basis. DATA COLLECTION AND ANALYSIS: If eligible trials were to be identified, data will be extracted, unblinded, by the reviewer from all studies. MAIN RESULTS: No studies that met the inclusion criteria were identified. REVIEWER'S CONCLUSIONS: The clinical management of placental abruption has to rely on knowledge other than that obtained through randomised clinical trials.

Abruptio Placentae↗
PubMed2005

Uterine artery Doppler at 11-14 weeks of gestation to screen for hypertensive disorders and associated complications in an unselected population.

OBJECTIVES: To establish reference values for the first-trimester uterine artery (UtA) pulsatility index (PI) and to investigate the role of UtA Doppler in the early prediction of hypertensive disorders and their associated complications in an unselected Mediterranean population. METHODS: A prospective study including 1091 consecutive singleton pregnancies undergoing routine early ultrasound screening at 11-14 weeks of gestation was performed. The left and right UtA were examined by color and pulsed Doppler transvaginally. The mean PI and the presence of bilateral protodiastolic notching were cross-sectionally recorded. Reference ranges were calculated and the pregnancies were followed for occurrence of pre-eclampsia, gestational hypertension, intrauterine growth restriction, placental abruption and stillbirth. The sensitivity and predictive values of a mean UtA-PI>95th percentile and the presence of bilateral notching in the prediction of these pregnancy complications were calculated. RESULTS: A total of 999 women were finally included. Both the mean UtA-PI and the prevalence of bilateral notches showed a significant linear decrease between 11 and 14 weeks' gestation. Sixty-seven (6.7%) pregnancies developed at least one of the formerly described complications, including 22 (2.2%) cases of pre-eclampsia and 37 (3.7%) cases with intrauterine growth restriction. Compared with women with a normal outcome, complicated pregnancies showed a significantly higher mean PI (2.04 vs. 1.75; P<0.05, t-test) and a higher prevalence of bilateral notching (58% vs. 41%; P<0.05, Chi-square test). Using the 95th percentile in mean UtA-PI as a cut-off, 23.9% (95% CI, 13.7-34.1) of complicated pregnancies and 30.8% (95% CI, 5.68-55.85) of severe cases were identified. CONCLUSIONS: Our results suggest that pregnancies with an increased risk of developing hypertensive disorders and related complications already have an abnormally increased UtA-PI in early pregnancy. However, the use of a single uterine Doppler measurement for screening purposes in unselected early pregnancy populations has limited clinical value. The use of UtA-PI combined with other screening tests needs to be determined by further investigation.

Abruptio Placentae↗
PubMed2007

Screening for pre-eclampsia and fetal growth restriction by uterine artery Doppler and PAPP-A at 11-14 weeks' gestation.

OBJECTIVE: To assess the role of maternal demographic characteristics, uterine artery Doppler velocimetry, maternal serum pregnancy-associated plasma protein-A (PAPP-A) and their combination in screening for pre-eclampsia and small-for-gestational age (SGA) fetuses at 11-14 weeks. METHODS: This was a prospective study of 878 consecutive women presenting for a routine prenatal ultrasound examination at 11-14 weeks. Pulsed wave Doppler was then used to obtain uterine artery flow velocity waveforms and the mean pulsatility index (PI) of the uterine arteries was calculated. Maternal serum samples for PAPP-A were assayed. Along with maternal history, these measurements were compared in their ability to predict adverse outcome, defined as pre-eclampsia and/or SGA and/or placental abruption. RESULTS: Mean uterine artery PI > or = 95(th) centile and PAPP-A < or = 10(th) centile each predicted 23% of the women that developed pre-eclampsia and 43% of cases of placental abruption. For SGA < or = 5(th) centile, mean uterine artery PI > or = 95(th) centile predicted 23% of cases and PAPP-A < or = 10(th) centile predicted 34%. Independent predictors for subsequent development of pre-eclampsia were increased mean uterine artery PI > or = 95(th) centile (OR, 2.76; 95% CI, 1.11-6.81) and maternal history of pre-eclampsia/hypertension (OR, 50.54; 95% CI, 10.52-242.73). The predicting factors for SGA < or = 5(th) centile were increased mean uterine artery PI > or = 95(th) centile (OR, 2.0; 95% CI, 1.07-3.74) and low PAPP-A (OR, 0.43; 95% CI, 0.20-0.93). Increased uterine artery PI was the only independent factor in the prediction of placental abruption (OR, 8.49; 95% CI, 2.78-25.94). The combination of uterine artery PI and maternal history of pre-eclampsia/hypertension was better than was using uterine artery Doppler alone in predicting pre-eclampsia. Similarly, for the prediction of SGA < or = 5(th) centile, combining uterine artery Doppler and maternal serum PAPP-A was better than was uterine artery Doppler alone. In both cases, the difference approached statistical significance. CONCLUSIONS: The combination of maternal history with abnormal uterine artery Doppler and low PAPP-A level at 11-14 weeks achieves better results than does either test alone in the prediction of pre-eclampsia and SGA.

Abruptio Placentae↗