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PubMed2003

Gestational vascular complications.

Severe pregnancy complications, primarily severe pre-eclampsia, placental abruption, intrauterine growth restriction (IUGR) and intrauterine fetal death (IUFD) occur in about 1-5% of gestations. This rate is even higher in special medical situations. These pregnancy complications have been shown to increase maternal and fetal morbidity and mortality considerably. Severe pregnancy complications have also been shown to be associated with deficient uteroplacental circulation and are linked with intervillous and spiral vessel thrombosis. Moreover, it has been suggested that these complications could have their basis in a deficient trophoblast invasion in the uterine spiral arteries at a stage much earlier than the clinical manifestations become evident. In the last few years, evidence has accumulated to suggest that severe pregnancy complications could have a common thrombogenic basis associated with inherited and acquired thrombophilia. In this chapter we present a comprehensive update of the aetiology, pathophysiology, clinical manifestations, diagnosis and treatment of these severe pregnancy complications.

Abruptio Placentae↗
PubMed2003

Placental abruption is associated with decreased maternal plasma levels of soluble HLA-G.

During pregnancy the fetus represents a semi-allograft. Both membrane-bound and soluble forms of the nonclassic human leukocyte antigen (HLA)-G protect the fetus from maternal immune attack. To assess the relevance of soluble HLA-G (sHLA-G) levels in the maternal circulation for the occurrence of characteristic pregnancy disorders, we analyzed sHLA-G plasma levels of women with normal and pathological pregnancies. Compared to normal pregnancy, significantly increased sHLA-G levels were detected in women delivered preterm because of intrauterine activation (uncontrollable labor, rupture of fetal membranes, cervical insufficiency) and women with Hemolysis, Elevated Liver enzymes, Low Platelet count (HELLP) syndrome. Contrary to these disorders, the sHLA-G levels in women with placental abruption were more than three times lower than in normal pregnancy (p < .0001). Nonparametric discriminant analysis showed that women with sHLA-G levels below 9.95 ng/mL had a relative risk of 7.12 for the development of placental abruption during further course of pregnancy. These results suggest that the occurrence of pregnancy-associated diseases is strongly influenced by maternal sHLA-G plasma levels.

Abruptio Placentae↗
PubMed2000

A hypothesis to explain the occurence of inner myometrial laceration causing massive postpartum hemorrhage.

BACKGROUND: Inner myometrial lacerations were found in three patients who developed uncontrollable postpartum massive bleeding despite the usual treatment for uterine atony. Because all the patients suffered from hemorrhage shock and their medical status deteriorated, their uteri were surgically removed to stop bleeding. After removal, one of them died. Postpartum hemorrhage was caused by inner myometrial laceration. We hypothesized a cause of inner myometrial laceration, using the three resected uteri, an assumed model of the uterine body, and 34 women. METHODS: The subjects were 37 women, of whom three were patients with inner myometrial laceration, 23 were women without inner myometrial laceration who underwent cesarean section, and 11 were women in the first stage of labor. The three resected uteri were examined both macroscopically and microscopically. We measured the thickness of the wall of the uterine muscle at the widest point of the uterine corpus and the thickness of the myometrial wall at a transverse section of the uterine cervix, as well as the radius of the inner lumen at the widest point of the uterus in 23 women during cesarean section. We also measured the thickness of the myometrial wall at the widest point of the uterine corpus in 11 women at the end of the first stage of labor during ultrasonic examination. The data were then used to estimate the stress on the uterine muscle. RESULTS: The stress on the uterine cervix was stronger than that on the uterine corpus during labor. When the stress on the uterine muscle is stronger than a specific value, inner myometrial lacerations develop on the right and/or left side of the uterine cervix. These lacerations may involve large vessels. CONCLUSIONS: We have discovered another cause of postpartum hemorrhage which we have named inner myometrial laceration. These lacerations appeared to result from a strong stress on the uterine cervix caused by an abnormal rise in intrauterine pressure during labor.

Abruptio Placentae↗
PubMed2001

Women with a history of placental abruption: when in a subsequent pregnancy should special surveillance for a recurrent placental abruption be initiated?

BACKGROUND: It is common to admit to hospital or start intensive ambulatory antenatal care of pregnant women with a previous placental abruption using the gestational age of the previous placental abruption as a starting point. In some instances, close surveillance may be commenced much earlier. There is no consensus when in a subsequent pregnancy such measures should be initiated. OBJECTIVE: The analyses aimed at the prevention of complicated (preterm, small for gestational age, or perinatal death) recurrent placental abruptions, assessing at which time in a subsequent pregnancy special surveillance should start in order to anticipate and prevent a recurrence. DESIGN: A cohort study based on the Medical Birth Registry of Norway. Calculation of gestational age specific risks of placental abruption in a second pregnancy and estimation of when to initiate surveillance in order to reduce an increased risk of recurrent placental abruption to the initial level of initial abruption in the second pregnancy. RESULTS: In women with a complicated (preterm, small for gestational age, or perinatal death) first delivery, the risks of an initial and recurrent complicated placental abruption in the second pregnancy were 7/1000 and 33/1000, respectively (relative risk 4.9). To reduce the recurrence risk in a second pregnancy to 7/1000, special surveillance six weeks prior to the gestational age of the initial abruption would be necessary. In women with an uncomplicated first delivery, the risks in the second pregnancy of an initial and recurrent complicated abruption were 3 and 19/1000, respectively (relative risk 7.1). To reduce the recurrence risk to 3/1000, surveillance at least 12 weeks prior would be necessary. CONCLUSION: The increased recurrence rate would necessitate increased awareness in terms of special surveillance in the second pregnancy. In pregnancies at risk of a recurrent placental abruption, monitoring up to three months before the gestational age of the initial abruption is necessary.

Abruptio Placentae↗
PubMedDate not supplied

Traumatic aortic rupture during pregnancy.

A 29-year-old woman, in her third trimester of pregnancy, underwent emergency Caesarian section for placental abruption following a road traffic accident. Following transfer, an abrupt change in the diameter of the aorta was noted on CT scan. Aortography confirmed aortic rupture distal to the left subclavian artery and Dacron graft replacement of this segment was carried out, utilizing a left atrial to descending aorta partial bypass through a centrifugal pump. The mother is alive and well at 4 months follow-up.

Abruptio Placentae↗
PubMed2003

Cardiac failure caused by severe pre-eclampsia with placental abruption, and its treatment with anti-hypertensive drugs.

Pre-eclampsia is the abnormality of blood circulation in late pregnancy, often caused by renal failure, hemolysis, elevated liver enzyme, low platelet syndrome, and eclampsia. We present a case of severe pre-eclampsia with placental abruption in a 24-year-old woman, pregnant for the first time. The patient was diagnosed with congestive heart failure, which came as a result of pre-eclampsia. Anti-hypertensive drugs were used for its treatment.

Abruptio Placentae↗
PubMed1998

Perinatal events and the risk of intraparenchymal echodensity in very-low-birthweight neonates.

A case-control study was performed to identify perinatal events associated with intraparenchymal echodensity on cranial ultrasonography--an important antecedent of cerebral palsy in very-low-birthweight infants. Forty-eight infants with birthweight < 1500 g and intraparenchymal echodensity on cranial ultrasound examination and 90 controls with normal cranial ultrasounds were identified within a cohort of 1791 consecutive very-low-birthweight infants born at a regional obstetric referral centre. Data about potential risk factors were obtained from medical records of cases and controls. Among prenatal factors, chorioamnionitis (odds ratio[OR]: 3.2; 95% confidence interval: 1.3, 8.1) and placental abruption (OR 2.6 [1.0, 6.6]) were associated most strongly with an increased risk of intraparenchymal echodensity and pre-eclampsia (OR 0.3 [0.1, 0.8]) was associated most strongly with a decreased risk. When controlling for gestational age, multiple gestation was also associated with an increased risk (OR 2.7 [1.0, 7.5]). Neonatal factors independently associated with an increased risk included low systolic blood pressure (< 33 mmHg in the first 12 h of life; odds ratio 8.0 [2.0, 31.3]), receipt of a fluid bolus in the first 12 h of life (OR 19.7 [4.6, 84.3]), need for cardiopulmonary resuscitation in the first 72 h (OR 6.9 [1.5, 31.3]) and pneumothorax in the first 72 h of life (OR 27.0 [4.3, 167.2]). When analyses were restricted to infants who were not given a fluid bolus, the associations with chorioamnionitis and placental abruption were attenuated. When excluding infants who had a pneumothorax, the associations with placental abruption and multiple gestation were attenuated. Restriction of infants with systolic blood pressure < 33 mmHg resulted in attenuation of associations with pre-eclampsia and multiple gestation. These analyses suggest the possibility that potentially modifiable postnatal events may be involved as intervening factors linking chorioamnionitis, placental abruption and multiple gestation with subsequent intraparenchymal echodensity.

Abruptio Placentae↗
PubMed1999

A history of placental dysfunction and risk of placental abruption.

In a population-based historic cohort study, we assessed the possible association of fetal growth retardation, preterm birth and pregnancy-induced hypertension in the immediately preceding pregnancy with placental abruption in the current pregnancy, which would suggest a shared aetiological factor. We also assessed whether chronic hypertension, diabetes mellitus and a history of Caesarean section are associated with placental abruption. Preterm birth and small-for-gestational-age (SGA) in the immediately preceding delivery were associated with an increased risk of placental abruption with unadjusted odds ratios (ORs) of 2.1 [95% CI = 1.9, 2.4] and 1.6 [95% CI = 1.5, 1.8] respectively. Women with a history of an SGA preterm birth in the immediately preceding delivery and an appropriate-for-gestational-age infant in the current had an adjusted OR of 3.2 [95% CI = 2.3, 4.5]. The adjusted odds ratio of placental abruption in women who had pregnancy-induced hypertension in the previous pregnancy, but not in the current, was 1.4 [95% CI = 1.2, 1.7]. Women who delivered a preterm or SGA infant in the previous delivery and had chronic hypertension or diabetes mellitus in the current had adjusted ORs of 2.3-5.7 and 2.5-6.0 respectively. Caesarean section in the previous delivery increased the risk of placental abruption by 40%. These results suggest that pregnancy-induced hypertension, intrauterine growth retardation, preterm delivery and placental abruption share an aetiological factor or represent different clinical expressions of recurring placental dysfunction. Chronic hypertension and diabetes mellitus may cause or aggravate such dysfunction thus causing placental abruption. A history of Caesarean section is associated with an increased risk of placental abruption.

Abruptio Placentae↗
PubMed2002

Prenatal and intrapartum events and sudden infant death syndrome.

The purpose of this study was to evaluate specific pregnancy and labour and delivery events that may increase the risk of sudden infant death syndrome (SIDS). A matched case-control study was conducted in five counties in southern California, using California death certificate records. The sample consisted of 239 Caucasian, African-American, Hispanic and Asian mothers of SIDS infants and 239 mothers of control infants matched on sex, race, birth hospital and date of birth. Mothers participated in a detailed telephone interview and provided access to obstetric and paediatric records. More case than control mothers reported a family history of anaemia (OR=2.12, P < 0.001). Placental abruptions were strongly associated with SIDS (unadjusted OR=7.94, [95% CI 1.34,47.12]). There was an increased risk of SIDS death associated with maternal anaemia during pregnancy (OR=2.51, [95% CI 1.25,5.03]), while simultaneously adjusting for maternal smoking during pregnancy, maternal years of education and age, parity, infant birthweight, gestational age, medical conditions at birth, infant sleep position and post-natal smoking. Interactions of anaemia and prenatal smoking as well as anaemia and post-natal smoking were not statistically significant. There were no other statistically significant differences between case and control mothers for pregnancy conditions, labour and delivery events (e.g. caesarean sections, anaesthesia, forceps) or newborn complications (e.g. nuchal cord, meconium aspiration). Anaemia and placental abruptions were significantly associated with an increased risk of SIDS; both are circumstances in which a fetus may become hypoxic, thereby compromising the subsequent growth, development and ultimate survival of the infant.

Abruptio Placentae↗
PubMed2000

Oral hypoglycaemic agents in 118 diabetic pregnancies.

AIMS: To assess maternal and neonatal complications in pregnancies of diabetic women treated with oral hypoglycaemic agents during pregnancy. METHODS: A cohort study including all consecutively registered, orally treated pregnant diabetic patients set in a diabetic obstetrical service at a university hospital: 50 women treated with metformin, 68 women treated with sulphonylurea during pregnancy and a reference group of 42 diabetic women treated with insulin during pregnancy. RESULTS: The prevalence of pre-eclampsia was significantly increased in the group of women treated with metformin compared to women treated with sulphonylurea or insulin (32 vs. 7 vs. 10%, P < 0.001). No difference in neonatal morbidity was observed between the orally treated and insulin-treated group; no cases of severe hypoglycaemia or jaundice were seen in the orally treated groups. However, in the group of women treated with metformin in the third trimester, the perinatal mortality was significantly increased compared to women not treated with metformin (11.6 vs. 1.3%, P < 0.02). CONCLUSION: Treatment with metformin during pregnancy was associated with increased prevalence of pre-eclampsia and a high perinatal mortality.

Abruptio Placentae↗
PubMed1996

Doppler ultrasound of the uterine arteries: the importance of bilateral notching in the prediction of pre-eclampsia, placental abruption or delivery of a small-for-gestational-age baby.

The use of Doppler studies of the uterine arteries in the prediction of pre-eclampsia and intrauterine growth retardation has had mixed success. The introduction of color Doppler imaging and the use of the "notch' to define an abnormal waveform have helped to improve the predictive value of uterine artery Doppler screening. The aim of this study was to evaluate the use of uterine artery Doppler in a group of women of mixed race and parity. This study was a prospective, cross-sectional analysis of 1326 unselected women who were screened with continuous wave uterine Doppler at 19-21 weeks, as part of a fetal anomaly/dating scan. A total of 214 women with abnormal uterine artery waveforms (notching) were referred for assessment at 24 weeks; 191 attended and had color Doppler imaging/pulsed Doppler studies of both uterine arteries. Data from 185 pregnancies were suitable for analysis. There were abnormal uterine Doppler findings (uni- or bilateral notching) in 110 patients at 24 weeks; 48 had bilateral notching. The sensitivity of notching for the prediction of proteinuric pregnancy-induced hypertension (PPIH) was similar in primiparas (76.9%), multiparas (77.7%), African-Caribbean women (82.6%) and Caucasian women (71.4%). The sensitivity of bilateral notching for the prediction of PPIH requiring delivery before 34 weeks was 81.2%, and 57.6% for babies small for gestational age (SGA), with positive predictive values of 27% (PPIH), 31.2% (SGA) and 37.5% (any complication). Patients with persistent bilateral notching are particularly at risk of developing PPIH or delivering an SGA baby before 34 weeks' gestation; they warrant increased surveillance, and may be a group that could benefit from prophylactic therapies.

Abruptio Placentae↗