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PubMed2001

Indications for caesarean section.

Caesarean section rates are rising. Caesarean section confers an increase in maternal mortality and morbidity as well as having considerable financial implications. Caesarean section is usually justified by the assumed benefit for the fetus. These benefits are often unquantified and based on scanty evidence. The changing trends in the rates of caesarean section for various indications may be explained partly by improved anaesthetic and neonatal techniques. Cultural changes and expectations in the general population and obstetricians' fear of litigation may have made the changing rate and indications for caesarean section seem more acceptable. There is little research evidence in this area. The evidence that caesarean section is the optimal mode of delivery for various major indications is critically examined. The obstetrician is under an obligation to share the evidence that caesarean section is the optimum mode of delivery with the pregnant woman and her birth attendants to allow the woman to make wise decisions about her management.

Abruptio Placentae↗
PubMed2001

Hypovolaemic shock.

Measured blood loss up to 1000 ml is well tolerated by healthy pregnant women. This is partly due to physiological increases in plasma volume and red cell mass during pregnancy. Nevertheless, hypovolaemic shock is a major cause of maternal mortality. Management requires teamwork, co-ordination, speed and adequate facilities to be life-saving. The first priority is rapid fluid replacement. Evidence from randomized trials has established that crystalloids are the fluids of choice over colloids and particularly albumen, which was associated with increased mortality. Rapid access to blood or blood products for transfusion is necessary, as well as laboratory back-up. Further management includes accurate assessment of the site of bleeding; control of the bleeding; diagnosis and management of the underlying condition; supportive therapy; and monitoring of the clinical, haematological and biochemical response to treatment. Bedside diagnostic ultrasound has several applications in the evaluation of obstetric hypovolaemic shock.

Abruptio Placentae↗
PubMed2003

Management of obstetric hemorrhage.

A reluctance to proceed with hysterectomy for obstetric hemorrhage may be a more likely cause of preventable death in obstetrics than a lack of surgical or medical skills. Every obstetric unit should have protocols available to deal with hemorrhage and, in addition, have specific guidelines for patients who object to blood transfusions for various reasons. Risk factors for hemorrhage should be identified antenatally, using all possible imaging modalities available, and utilizing multidisciplinary resources whenever possible. Novel strategies for prenatal diagnosis of abnormal placentation include advanced sonography and magnetic resonance imaging. Placement and utilization of arterial catheters for uterine artery embolization is becoming more widespread and new surgical technology such as the argon beam coagulator seems promising. When intra or postpartum hemorrhage is encountered, a familiar protocol for dealing with blood loss should be triggered. Timely hysterectomy should be performed for signs of refractory bleeding. Application of medical and surgical principles combined with recent technologic advances will help the obstetrician avoid disastrous outcomes for both mother and fetus.

Abruptio Placentae↗
PubMed2002

Reproductive risk factors, Doppler findings, and outcome of affected births in placental abruption: a population-based analysis.

Placental abruption complicates about 1% of all singleton pregnancies and the aim of this study is to assess the reproductive maternal risk factors associated with placental abruption, and the outcome of affected births. We analyze 170 women with singleton pregnancies complicated by placental abruption who gave birth at Kuopio University Hospital from March 1989 to December 1999. The general obstetric population ( n = 22,905) was selected as the reference group and logistic regression analysis was used to identify independent reproductive risk factors. Furthermore, Doppler ultrasonographic results and pregnancy outcome measures in the two groups were also recorded. The incidence of placental abruption was 0.57% in the referral area. Preeclampsia, grand multiparity, velamentous umbilical cord insertion, cigarette smoking, prior fetal demise, advanced maternal age (>35 years), and previous miscarriage were independent risk factors of placental abruption, with adjusted relative risks of 4.39, 3.60, 2.53, 2.46, 2.02, 1.62, and 1.55, respectively. Most cases of placental abruption occur before the onset of labor in low-risk pregnancies and are not predictable with regard to maternal reproductive risk factors. Current antepartum methods of detecting uteroplacental problems, including Doppler ultrasonography, are not effective in prenatal prediction of placental abruption. The outcome of affected births is still poor.

Abruptio Placentae↗
PubMed2004

The effect of placental abruption on the short-term outcome of premature infants.

The purpose of this study was to analyze the effect of abruption on the outcome of preterm infants. Live-born infants of 23 to 32 weeks gestation born at Beaumont Hospital between 1995 and 1999 who suffered abruption constitute the study group. Controls were matched to cases by sex, gestational age, and birth weight. Medical records were retrospectively reviewed for confirmation of abruption, determination of abruption grade, and subsequent neonatal outcome. Univariate analysis of the grade 2 abruption group revealed statistically significant differences in time from diagnosis to delivery (p = 0.04), Apgar scores at 5 minutes (p = 0.04), and acidotic cord blood (p = 0.04) between cases and controls. However, no differences in short-term outcome were appreciated. In addition, no differences in mortality or morbidity were noted between grade 1 abruption case and control infants. We conclude that abruption is not an independent risk factor for poor outcome among infants born between 23 and 32 weeks gestation, but instead induces the preterm delivery that is the main determinant of outcome.

Abruptio Placentae↗
PubMed1997

Doppler velocimetry and nonstress test for predicting outcome of pregnancies with decreased fetal movements.

Because fetal motor activity reflects the fetal condition in utero, maternal counting of fetal movements has been suggested as a useful method for monitoring fetal well-being, based on empirical evidence that a decrease in or absence of fetal movements often presages fetal death. The aim of this study was to compare the predictive capacity of umbilical artery (UA) Doppler velocimetry with that of nonstress test (NST) cardiotocography in 599 women with low-risk pregnancies, reporting decreased fetal movements. In 19 cases the fetus was dead on maternal admission. Umbilical artery Doppler velocimetry and NST were performed in the remaining 580. In 541 the NST and UA velocimetry findings were reassuring, and the women were discharged. There was one perinatal death in this group, due to extreme prematurity and placental abruption 1 week later. Thirty-nine women who gave birth on the day of admission or next day were especially given closer attention. Umbilical artery velocimetry was abnormal in only one fetus. In 6 cases, the NST trace on admission indicated fetal distress, and emergency cesarean section was performed, resulting in 3 infant deaths and 3 infants with sequelae. The umbilical cord pH was normal in 3, suggesting an earlier temporary intrauterine hypoxic event. Overall perinatal mortality was thus 23 (3.8%). Decreased fetal movement perception by mothers should therefore be taken seriously, even though an irreversible insult to the fetus might already have occurred.

Abruptio Placentae↗
PubMed1993

Placental abruption following placement of disposable intrauterine pressure transducer system.

There have been few reported complications of intrauterine pressure monitoring. We present four cases of placental abruption following insertion of a disposable intrauterine pressure transducer system (INTRAN). All four patients had placental abruptions, which were evident soon after insertion of the disposable intrauterine pressure transducer system (all of our cases had predisposing factors or signs of placental abruption at presentation). Whether there was a preexisting placental abruption, which was caused, revealed, or worsened by insertion of the disposable intrauterine pressure transducer system is unclear. We encourage careful patient selection with gentle insertion of the system opposite the placental site.

Abruptio Placentae↗
PubMed1992

Expectant management after sonographic diagnosis of placental abruption.

Forty cases of placental abruption were diagnosed by sonography after 20 weeks' gestation and managed expectantly. Tocolytics were used in 18 patients and were successful in delaying delivery for 34 +/- 24 days in 10. One-third of the patients delivered at term, after delays of 12.3 +/- 5.7 weeks. The majority of the patients who delivered before term (63%) had at least one other risk factor for preterm delivery, such as twins, ruptured membranes, or cervical dilation at presentation. Preterm delivery was not correlated with any of several clinical indicators of the severity of the abruption. Although the perinatal mortality rate was 22%, all perinatal deaths except one were attributable to extreme prematurity. It concluded that mild placental abruption is often a self-limited event and can safely be managed expectantly. Most of the perinatal morbidity and mortality is associated with premature delivery and, thus, in the absence of fetal distress or maternal compromise, delivery may often be delayed until fetal maturity is attained.

Abruptio Placentae↗