No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Placenta-Related Hemorrhage: Pathophysiology, Diagnostics, Management
Abstract
The placenta is the interface between mother and child, and has a decisive influence on the development of the unborn child and the health of the mother. All too often, no special attention is paid to the role of the placenta. However, it is placenta-related changes, variations in development or disease, and associated complications that represent some of the major causes of maternal and neonatal morbidity and mortality. Understanding etiology and pathophysiology, using proper diagnostic methods, and implementing targeted therapy can help reduce maternal mortality and improve neonatal outcome. The following chapter discusses the major topics of placenta-related hemorrhage such as the placenta accreta spectrum (PAS), placenta praevia, variations of umbilical cord insertion, premature placental abruption, and placental tumors.
ResearchGate has not been able to resolve any citations for this publication.
Abnormally invasive placenta (AIP) is used to describe a placenta that does not separate naturally after delivery and cannot be extirpated without causing abnormally high blood loss. Recently, the use of a standardized terminology for descriptors of AIP signs seen on ultrasound has been prosed but to date no such unified descriptors have been developed for magnetic resonance imaging (MRI). The purpose of this paper is to propose a unified terminology based on a consensus opinion from the members of the International Society for AIP (IS-AIP) that include obstetricians, gynecologists, radiologists, pathologists, anesthesiologists and basic science researchers. We assume that using these standardized MRI descriptors for AIP will be useful for clinical use, education, teaching and future research projects, thus assumably improving care of patients with this condition. In addition, using a uniform terminology for AIP should become the first step of a standardized MRI report.
Background:
Though the same types of complication were found in both elective cesarean section (ElCS) and emergence cesarean section (EmCS), the aim of this study is to compare the rates of maternal and fetal morbidity and mortality between ElCS and EmCS.
Methods:
Full-text articles involved in the maternal and fetal complications and outcomes of ElCS and EmCS were searched in multiple database. Review Manager 5.0 was adopted for meta-analysis, sensitivity analysis, and bias analysis. Funnel plots and Egger's tests were also applied with STATA 10.0 software to assess possible publication bias.
Results:
Totally nine articles were included in this study. Among these articles, seven, three, and four studies were involved in the maternal complication, fetal complication, and fetal outcomes, respectively. The combined analyses showed that both rates of maternal complication and fetal complication in EmCS were higher than those in ElCS. The rates of infection, fever, UTI (urinary tract infection), wound dehiscence, DIC (disseminated intravascular coagulation), and reoperation of postpartum women with EmCS were much higher than those with ElCS. Larger infant mortality rate of EmCS was also observed.
Conclusion:
Emergency cesarean sections showed significantly more maternal and fetal complications and mortality than elective cesarean sections in this study. Certain plans should be worked out by obstetric practitioners to avoid the post-operative complications.
Aim:
The aim of this study was to elucidate the feasibility and safety of vaginal delivery (VD) when placental abruption causes fetal demise.
Methods:
We conducted a retrospective study of women who were managed for placental abruption with intrauterine fetal death at Kyoto University Hospital during the period from 1995 to 2015.
Results:
Sixteen cases were identified during the study period. VD was attempted in 15 cases and was accomplished in 14 (93.3%) cases. The median gestational age was 36 (24-39) weeks, and there were eight primiparas. The median Bishop score on admission was 2.5 (1-9). Eight pregnancies were complicated with pregnancy-induced hypertension. The median duration of labor was 5 h and 18 min (30 min-12 h 43 min), and the median amount of hemorrhage was 2503 (445-6808) mL. Fresh frozen plasma (? 20 U) and red cell concentrate (? 10 U) were administered in 10 (71%) and 9 (64%) cases, respectively. Two cases required uterine artery embolization for post-partum hemorrhage, while there was no case of maternal death or hysterectomy. Patients with Bishop score > 3 (n = 6) experienced shorter-duration deliveries (P = 0.020) and had significantly larger blood loss volume (P = 0.020) compared to patients with Bishop score???3. The duration of labor was negatively correlated with the amount of blood loss (R(2) = -0.56, P = 0.039).
Conclusion:
After placental abruption with intrauterine fetal death, VD is feasible and safe regardless of gestational age, parity, cervical maturity, and duration of labor when intensive medical resources are available.
To determine circadian variation in the onset of placental abruption. Methods. A retrospective study involving 115
placental abruptions, divided into four subgroups based on initial symptoms comprising abdominal pain, vaginal bleeding, both abdominal pain and bleeding, or other symptoms. The time of the initial symptom was considered the disease onset.We analyzed the frequency of disease onset and adverse perinatal outcome including perinatal death relative to the daily four 6-hour intervals.
Results. Abdominal pain displayed significant circadian variation regarding the period of onset with higher levels from 0:00 AMto 6:00 AM(65%) compared with 0:00 PMto 6:00 PM(24%, 𝑝 < 0.01). Vaginal bleeding did not display significant circadian variation (𝑝 = 0.45). Adverse perinatal outcome showed significant circadian variation with a higher occurrence of perinatal death from0:00 AM to 6:00 AM (35%) compared with 0:00 PM to 6:00 PM (0%, 𝑝 < 0.01). After adjustment using variables of abdominal pain and time period, both variables significantly affected perinatal death (odds ratio: 13.0 and 2.2, resp.).The risk of adverse perinatal outcome increased significantly when abdominal pain occurred, except for the period 0:00 PM to 6:00 PM (OR, 9.5). Conclusion. Placental abruption beginning with abdominal pain has circadian variation.
Objective:
The aim of this study is to determine whether there is a relationship between first trimester serum pregnancy-associated plasma protein A (PAPP-A) and free beta human chorionic gonadotropin (fβhCG) MoM values and placenta accreta in women who had placenta previa.
Study design:
A total of 88 patients with placenta previa who had first trimester aneuploidy screening test results were enrolled in the study. Nineteen of these patients were also diagnosed with placenta accreta. As probable markers of excessive placental invasion, serum PAPP-A and fβhCG MoM values were compared in two groups with and without placenta accreta.
Results:
Patients with placenta accreta had higher statistically significant serum PAPP-A (1.20 vs 0.865, respectively, p = 0.045) and fβhCG MoM (1.42 vs 0.93, respectively, p = 0.042) values than patients without accreta.
Conclusion:
Higher first trimester serum PAPP-A and fβhCG MoM values seem to be associated with placenta accreta in women with placenta previa. Further studies are needed to use these promising additional tools for early detection of placenta accreta.
Introduction:
Placental abruption complicates about 1% of singleton pregnancies and is an important cause of perinatal mortality and morbidity. Though sensitivity and reliability of ultrasound are poor for detecting or excluding placental abruption, because of the advances in ultrasound resolution, imaging and interpretation, sensitivity of ultrasound is better than what was reported previously.
Aim:
To determine the diagnostic performance of Ultrasonography (USG) for the detection of placental abruption and whether sonographic results correlate with maternal and foetal management and outcome.
Materials and methods:
Thirty patients with clinical diagnosis of placental abruption were studied in the Obstetrics and Gynaecology Department of Krishna Institute of Medical Sciences, over a period of 6 months. These patients underwent ultrasonography for confirmation. Obstetric and neonatal outcome and sonographic results were compared and reviewed. Sonographic sensitivity and specificity and positive and negative predictive values were calculated.
Results:
Incidence of abruption in present study was 1.56% (28 patients out of 1786 total deliveries). Sensitivity of ultrasonography in the diagnosis of abruption was 57% (CI 37.15%-75.57%) while its specificity was 100% (CI 15.81%-100%) with a positive predictive value of 100% (CI 79.42%-100%) and a 14% (CI 1.78% - 42.83%) negative predictive value. An 87.5% of patients(14 out of 16) with a positive USG finding of abruption had Intrauterine foetal Death (IUD)/still birth while 91.6% of patients (11 out of 12) with negative USG findings of abruption gave birth to babies who required NICU admission.
Conclusion:
Sonography is not sensitive for the detection of placental abruption but it is highly specific. Positive sonographic findings are associated with increased maternal morbidity, require more aggressive obstetric management and it is associated with worse perinatal outcome. In case of a negative USG finding, but a strong clinical suspicion of abruption if obstetric intervention is made in due time, foetal as well as maternal outcome are better. Foetal outcome also depends on gestational age. Preterm patients with positive USG and intrapartum findings of abruption have worse foetal outcome compared to full-term patients with abruption.
Background & objective:
Placental abruption, an ischemic placental disorder, complicates about 1 in 100 pregnancies, and is an important cause of maternal and perinatal morbidity and mortality worldwide. Metabolomics holds promise for improving the phenotyping, prediction and understanding of pathophysiologic mechanisms of complex clinical disorders including abruption. We sought to evaluate maternal early pregnancy pre-diagnostic serum metabolic profiles and abnormal vaginal bleeding as predictors of abruption later in pregnancy.
Methods:
Maternal serum was collected in early pregnancy (mean 16 weeks, range 15 to 22 weeks) from 51 abruption cases and 51 controls. Quantitative targeted metabolic profiles of serum were acquired using electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and the Absolute IDQ® p180 kit. Maternal sociodemographic characteristics and reproductive history were abstracted from medical records. Stepwise logistic regression models were developed to evaluate the extent to which metabolites aid in the prediction of abruption. We evaluated the predictive performance of the set of selected metabolites using a receiver operating characteristics (ROC) curve analysis and area under the curve (AUC).
Results:
Early pregnancy vaginal bleeding, dodecanoylcarnitine/dodecenoylcarnitine (C12 / C12:1), and phosphatidylcholine acyl-alkyl C 38:1 (PC ae C38:1) strongly predict abruption risk. The AUC for these metabolites alone was 0.68, for early pregnancy vaginal bleeding alone was 0.65, and combined the AUC improved to 0.75 with the addition of quantitative metabolite data (P = 0.003).
Conclusion:
Metabolomic profiles of early pregnancy maternal serum samples in addition to the clinical symptom, vaginal bleeding, may serve as important markers for the prediction of abruption. Larger studies are necessary to corroborate and validate these findings in other cohorts.
Objective:
Placental abruption has a profound impact on perinatal mortality, but implications for neurodevelopment during childhood remain unknown. We examined the association between abruption and neurodevelopment at 8 months and 4 and 7 years and evaluated the extent to which these associations were mediated through preterm delivery.
Design:
Secondary analysis of a multicenter prospective cohort study.
Setting:
Multicenter US National Collaborative Perinatal Project (1959-76).
Population:
Women that delivered singleton live births.
Methods:
Analyses of IQ scores were based on marginal structural models (MSM) to account for losses to follow-up. We also carried out a causal mediation analysis to evaluate if the association between abruption and cognitive deficits was mediated through preterm delivery, and performed a sensitivity analysis for unobserved confounding.
Main outcome measures:
We evaluated cognitive development based on the Bayley scale at 8 months (Mental and Motor Scores), and intelligent quotient (IQ) based on the Stanford-Binet scale at 4 years and the Wechsler Intelligence Scale for Children at 7 years.
Results:
The confounder and selection-bias adjusted risk ratio (RR) of abnormal 8-month Motor and Mental assessments were 2.35 (95%CI 1.39, 3.98) and 2.03 (95%CI 1.13, 3.64), respectively, in relation to abruption. The associations at 4 years were attenuated and resolved at 7 years. The proportion of children with abruption-associated neurological deficits mediated through preterm delivery ranged from 27 to 75%. Following adjustment for unobserved confounding the proportion mediated through preterm delivery was attenuated.
Conclusion:
The effect of abruption on neurodevelopmental outcomes appears restricted to an effect that is largely mediated through preterm delivery.
Tweetable abstract:
Increased risk of cognitive deficits in relation to abruption appears to be mediated through preterm delivery.
Placental abruption is one of the major life-threatening obstetric conditions. The fetomaternal outcome of a severe placental abruption depends largely on prompt maternal resuscitation and delivery. A case of severe preterm placental abruption with intrauterine fetal death. Following a failed induction of labor with a deteriorating maternal condition despite resuscitation, emergency cesarean delivery was offered with good maternal outcome. Cesarean delivery could avert further disease progression and possible maternal death in cases of severe preterm placental abruption where vaginal delivery is not imminent. However, further studies are necessary before this could be recommended for routine clinical practice.
Background:
The correlation between gestational hypertension-preeclampsia (GH-PE) and placenta previa (PP) is controversial. Specifically, it is unknown whether placenta previa has any effect on the various types of preeclampsia (PE), and the role PP with concurrent placenta accreta (PA) play in the occurrence of GH-PE are not well understood.
Objective:
The aim of this study was to identify the effects of PP on GH, mild and severe preeclampsia (MPE and SPE), and early- and late-onset preeclampsia (EPE and LPE). Another aim of the study was to determine if concurrent PA impacts the relationship between PP and GH-PE.
Methods:
A retrospective single-center study of 1,058 patients having singleton pregnancies with PP was performed, and 2,116 pregnant women were randomly included as controls. These cases were collected from a tertiary hospital and met the inclusion criteria for the study. Clinical information, including PP and the gestational age at the onset of GH-PE were collected. Binary and multiple logistic regression analyses were conducted after the confounding variables were controlled to assess the effects of PP on different types of GH-PE.
Results:
There were 155 patients with GH-PE in the two groups. The incidences of GH-PE in the PP group and the control group were 2.5% (26/1058) and 6.1% (129/2116), respectively (P = 0.000). Binary and multiple regression analyses were conducted after controlling for confounding variables. Compared to the control group, in the PP group, the risk of GH-PE was reduced significantly by 78% (AOR: 0.216; 95% CI: 0.135-0.345); the risks of GH and PE were reduced by 55% (AOR: 0.451; 95% CI: 0.233-0.873) and 86% (AOR: 0.141; 95% CI: 0.073-0.271), respectively; the risks of MPE and SPE were reduced by 73% (AOR: 0.269; 95% CI: 0.087-0828) and 88% (AOR: 0.123; 95% CI: 0.055-0.279), respectively; and the risks of EPE and LPE were reduced by 95% (AOR: 0.047; 95% CI: 0.012-0.190) and 67% (AOR: 0.330; 95% CI: 0.153-0.715), respectively. The incidence of concurrent PA in women with PP was 5.86%; PP with PA did not significantly further reduce the incidence of GH-PE compared with PP without PA (1.64% vs. 2.51%, P>0.05). Binary logistic regression analyses were conducted after controlling for confounding variables, compared with the non-PP + GH-PE group, and the AOR of FGR in the non-PP + non-GH-PE group was 0.206 (0.124-0.342). Compared with the PP + GH-PE group, the AOR of FGR in the PP + non-GH-PE group was 0.430 (0.123-1.500).
Conclusion:
PP is not only associated with a significant reduction in the incidence of GH-PE, but also is associated with a reduction in incidence of various types of PE. Concurrent PA and PP do not show association with a reduction in incidence of GH-PE.
Women with preeclamptic pregnancies have increased long-term cardiovascular disease (CVD) mortality. We explored this mortality risk among women with placental abruption, another placental pathology. We used linked Medical Birth Registry and Death Registry data to study CVD mortality among over two million women with a first singleton birth between 1967 and 2002 in Norway and 1973 and 2003 in Sweden. Women were followed through 2009 and 2010, respectively, to ascertain subsequent pregnancies and mortality. Cox regression analysis was used to estimate associations between placental abruption and cardiovascular mortality adjusting for maternal age, education, year of the pregnancy and country. There were 49,944 deaths after an average follow-up of 23 years, of which 5453 were due to CVD. Women with placental abruption in first pregnancy (n = 10,981) had an increased risk of CVD death (hazard ratio 1.8; 95 % confidence interval 1.3, 2.4). Results were essentially unchanged by excluding women with pregestational hypertension, preeclampsia or diabetes. Women with placental abruption in any pregnancy (n = 23,529) also had a 1.8-fold increased risk of CVD mortality (95 % confidence interval 1.5, 2.2) compared with women who never experienced the condition. Our findings provide evidence that placental abruption, like other placental complications of pregnancy, is associated with women’s increased risk of later CVD mortality.
To test an objective ultrasound marker for diagnosing the presence and severity of abnormally invasive placenta.
Women at risk of abnormally invasive placenta underwent a three-dimensional power Doppler ultrasound scan. The volumes were examined offline by a blinded observer. The largest area of confluent three-dimensional power Doppler signal (Area of Confluence [Acon], cm) at the uteroplacental interface was measured and compared in women subsequently diagnosed with abnormally invasive placenta and women in a control group who did not have abnormally invasive placenta. Receiver operating characteristic curves were plotted for prediction of abnormally invasive placenta and abnormally invasive placenta requiring cesarean hysterectomy.
Ninety-three women were recruited. Results were available for 89. Abnormally invasive placenta was clinically diagnosed in 42 women; 36 required hysterectomy and had abnormally invasive placenta confirmed histopathologically. Median and interquartile range for Acon was greater for abnormally invasive placenta (44.2 [31.4-61.7] cm) compared with women in the control group (4.5 cm [2.9-6.6], P<.001) and even greater in the 36 requiring hysterectomy (46.6 cm [37.2-72.6], P<.001). Acon rose with histopathologic diagnosis: focal accreta (32.2 cm [17.2-57.3]), accreta (59.6 cm [40.1-89.9]), and percreta (46.6 cm [37.5-71.5]; P<.001 analysis of variance for linear trend). Receiver operating characteristic analysis for prediction of abnormally invasive placenta revealed that with an Acon of 12.4 cm or greater, 100% sensitivity (95% confidence interval [CI] 91.6-100) could be obtained with 92% specificity (95% CI 79.6-97.6); area under the curve is 0.99 (95% CI 0.94-1.0). For prediction of abnormally invasive placenta requiring hysterectomy, 100% sensitivity (95% CI 90.3-100) can be obtained with an Acon of 17.4 cm or greater with 87% specificity (95% CI 74.7-94.5; area under the curve 0.98 [0.93-1.0]).
The marker Acon provides a quantitative means for diagnosing abnormally invasive placenta and assessing severity. If further validated, subjectivity could be eliminated from the diagnosis of abnormally invasive placenta.
II.
Although rare, placental abruption is implicated in disproportionately high rates of perinatal morbidity and mortality. Understanding geographic and temporal variations may provide insights into possible amenable factors of abruption. We examined abruption frequencies by maternal age, delivery year, and maternal birth cohorts over three decades across seven countries.
Women that delivered in the US (n = 863,879; 1979-10), Canada (4 provinces, n = 5,407,463; 1982-11), Sweden (n = 3,266,742; 1978-10), Denmark (n = 1,773,895; 1978-08), Norway (n = 1,780,271, 1978-09), Finland (n = 1,411,867; 1987-10), and Spain (n = 6,151,508; 1999-12) were analyzed. Abruption diagnosis was based on ICD coding. Rates were modeled using Poisson regression within the framework of an age-period-cohort analysis, and multi-level models to examine the contribution of smoking in four countries.
Abruption rates varied across the seven countries (3-10 per 1000), Maternal age showed a consistent J-shaped pattern with increased rates at the extremes of the age distribution. In comparison to births in 2000, births after 2000 in European countries had lower abruption rates; in the US there was an increase in rate up to 2000 and a plateau thereafter. No birth cohort effects were evident. Changes in smoking prevalence partially explained the period effect in the US (P = 0.01) and Sweden (P<0.01).
There is a strong maternal age effect on abruption. While the abruption rate has plateaued since 2000 in the US, all other countries show declining rates. These findings suggest considerable variation in abruption frequencies across countries; differences in the distribution of risk factors, especially smoking, may help guide policy to reduce abruption rates.
Chorangiomas are rather frequent neoplasms encountered on placental examination but in rare cases they present some worrisome histological features that could alarm the pathologist and be misinterpreted as a malignant neoplasm, even if their biological behavior is favorable. We describe an unusual chorangioma with high cellularity and abundant mitosis that, after careful examination and postpartum follow-up, showed benign clinical course for mother and child confirming previous reported cases. This type of tumor is known in the literature as atypical cellular chorangioma and its identification is important in order to exclude potentially dangerous overtreatment.
© The Author(s) 2015.
Placenta previa has been associated with adverse birth outcomes, but its association with congenital malformations is inconclusive. We examined the association between placenta previa and major congenital malformations among singleton births in Finland.
We performed a retrospective population register-based study on all singletons born at or after 22+0 weeks of gestation in Finland during 2000 to 2010. We linked three national health registers: the Finnish Medical Birth Register, the Hospital Discharge Register, and the Register of Congenital Malformations, and examined several demographic and clinical characteristics among women with and without placenta previa, in association with major congenital malformations. We estimated adjusted odds ratios and 95% confidence intervals using multivariable logistic regression models.
The prevalence of placenta previa was estimated as 2.65 per 1000 singleton births in Finland (95% confidence interval, 2.53-2.79). Overall, 6.2% of women with placenta previa delivered a singleton infant with a major congenital malformation, compared with 3.8% of unaffected women (p ≤ 0.001). Placenta previa was positively associated with almost 1.6-fold increased risk of major congenital malformations in the offspring, after controlling for maternal age, parity, fetal sex, smoking, socio-economic status, chorionic villus biopsy, In vitro fertilization, pre-existing diabetes, depression, preeclampsia, and prior caesarean section (adjusted odds ratio = 1.55; 95% confidence interval, 1.27-1.90).
Using a large population-based study, we found that placenta previa was weakly, but significantly associated with an increased risk of major congenital malformations in singleton births. Future studies should examine the association between placenta previa and individual types of congenital malformations, specifically in high-risk pregnancies. Birth Defects Research (Part A), 2015. © 2015 Wiley Periodicals, Inc.
© 2015 Wiley Periodicals, Inc.
Placental abruption, early separation of the placenta, is associated with preterm birth and perinatal mortality, but associations with other neonatal morbidities remains under-studied. We examined the association between abruption and newborn outcomes. We analyzed n = 223,341 singleton deliveries from the Consortium on Safe Labor Study, a retrospective, multi-site, observational study (2002-2008) of electronic medical records in the U.S. Adjusted relative risks (RR), incident ratio ratios and 99% confidence intervals (CI) were estimated. Direct effects attributable to abruption were examined by conditioning on intermediates (preterm birth and small for gestational age) with sensitivity analyses. Incidence of abruption was 1.6% (n = 3,619). Abruption was associated with an elevated risk of newborn resuscitation (RR = 1.5, 99% CI: 1.5, 1.6), apnea (RR = 5.8, 99% CI: 5.1, 6.5), asphyxia (RR = 8.5, 99% CI: 5.7, 11.3), respiratory distress syndrome (RR = 6.5, 99% CI: 5.9, 7.1), neonatal intensive care unit admission (RR = 3.4, 99% CI: 3.2, 3.6), longer intensive care length of stay (Incident rate ratio = 2.0, 99% CI: 1.9, 2.2), stillbirth (RR = 6.3, 99% CI: 4.7, 7.9), and neonatal mortality (RR = 7.6, 99% CI: 5.2, 10.1). In sensitivity analyses, there was a direct effect of abruption associated with increased neonatal risks. These findings expand our knowledge of the association between abruption and perinatal and neonatal outcomes.
To evaluate the relative risk of placental abruption in monochorionic (MC) twin pregnancies complicated with twin-to-twin transfusion syndrome (TTTS) and treated with endoscopic laser coagulation of placental vessels (ELCPV). A retrospective analysis from January 2004 and December 2015 of 373 TTTS pregnancies, treated with selective ELCPV until January 2012 (287 cases), after which the Solomon technique was introduced (86 cases), compared with 243 normal MC pregnancies. A significant improvement in perinatal survival was observed after the introduction of the Solomon technique when compared to the selective procedure (77% vs 54%, p < 0.001). The rate of placental abruption was 1% (3/243) in normal MC pregnancies, 6% (21/373) in TTTS group, increased with Solomon technique (12/86, 14%, vs 9/287, 3%, p < 0.001). MC twin pregnancies treated with laser coagulation of placental vascular anastomoses could be at increased risk of placental abruption, especially when the Solomon technique is used.
Background
Congenital leukemia is a rare condition and most commonly found in infants with Down syndrome. The occurrence in newborns without a genetically predisposing syndrome is extremely infrequent.
Highlights
We describe a case of peripartal fetal death at 30 weeks and 4 days of gestation. Emergency cesarean section was performed after a previously uncomplicated pregnancy because of pathologic fetal heart rate tracing and suspected intracranial hemorrhage on ultrasound imaging. Resuscitation of the newborn was unsuccessful and stopped after 30 min, when ultrasound of the fetus confirmed very severe intracranial and intraabdominal bleeding. Autopsy was performed after informed consent and demonstrated evidence of acute lymphoblastic leukemia in the bone marrow, associated with wide spread visceral involvement.
Conclusion
Perinatal fetal demise due to congenital leukemia is exceedingly rare and can occur unexpectedly in the third term after a normal pregnancy. We here report the clinical and pathologic findings, discuss the pathogenesis of fetal leukemia and its clinical manifestations along with a thorough review of the relevant literature.
Background:
Cardiovascular (CVD) complications stemming from vascular dysfunction have been widely explored in the setting of preeclampsia. However, the impact of abruption, a strong indicator of microvascular disturbance, on the risk of CVD mortality and morbidity remains poorly characterised.
Methods:
We designed a cohort analysis of 828 289 women who delivered singletons in Denmark between 1978 and 2010. We linked the National Patient Registry and the Registry of Causes of Death to the Danish Birth Registry to ascertain CVD events. We estimated CVD risks in relation to abruption from Cox proportional hazards regression following adjustments for confounders.
Results:
With 13 231 562 person-years of follow-up of women with at least one delivery, 11 829 pregnancies were complicated by abruption. The median (interquartile range) follow-up in the non-abruption and abruption groups was 16 (8, 24) and 18 (10, 25) years, respectively. CVD mortality rates in women with and without abruption were 0.9 and 0.3 per 10 000 person-years, respectively (adjusted hazard ratio (HR) 2.7, 95% confidence interval (CI) 1.5, 5.0). The corresponding CVD morbidity complication rates were 16.7 and 10.0 per 10 000 person-years, respectively (HR 1.5, 95% CI 1.4, 1.8). The increased risks were evident for ischaemic heart disease, acute myocardial infarction, hypertensive heart disease, non-rheumatic valvular disease, and congestive heart failure.
Conclusions:
This study shows increased hazards of CVD morbidity and mortality in relation to abruption. A better understanding of the pathogenesis of distorted placental microvasculature is needed as this appears to be a harbinger of CVD later in life.
Objective:
We hypothesized that the origins of abruption may extend to the stages of placental implantation; however, there are no reliable markers to predict its development. Based on this hypothesis, we sought to evaluate whether first-trimester and second-trimester serum analytes predict placental abruption.
Methods:
We performed a secondary analysis of data of 35,307 women (250 abruption cases) enrolled in the First and Second Trimester Evaluation of Risk cohort (1999-2003), a multicenter, prospective cohort study. Percentiles (based on multiples of the median) of first-trimester (pregnancy-associated plasma protein A and total and free β-hCG) and second-trimester (maternal serum alpha-fetoprotein, unconjugated estriol, and inhibin-A) serum analytes were examined in relation to abruption. Associations are based on risk ratio (RR) and 95% confidence interval (CI).
Results:
Women with an abnormally low pregnancy-associated plasma protein A (fifth percentile or less) were at increased risk of abruption compared with those without abruption (9.6% compared with 5.3%; RR 1.9, 95% CI, 1.2-2.8). Maternal serum alpha-fetoprotein 95th percentile or greater was more common among abruption (9.6%) than nonabruption (5.1%) pregnancies (RR 1.9, 95% CI 1.3-3.0). Inhibin-A fifth percentile or less (8.0% compared with 5.1%; RR 1.8, 95% CI 1.1-2.9), and 95th percentile or greater (9.6% compared with 5.0%; RR 2.0, 95% CI 1.3-3.1) were associated with abruption. Women with all three abnormal pregnancy-associated plasma protein A, maternal serum alpha-fetoprotein, and inhibin-A analytes were at 8.8-fold (95% CI 2.3-34.3) risk of abruption. No associations were seen with other analytes.
Conclusion:
These data provide support for our hypothesis that the origins of placental abruption may extend to the early stages of pregnancy.
Objective:
Placenta previa is associated with maternal hemorrhage, but most literature focuses on morbidity in the setting of placenta accreta. We aim to characterize maternal morbidity associated with previa and to define risk factors for hemorrhage.
Methods:
This is a secondary cohort analysis of the NICHD Maternal-Fetal Medicine Units Network Cesarean Section Registry. This analysis included all women undergoing primary Cesarean delivery without placenta accreta. 496 women with previa were compared to 24,201 women without previa. Primary outcome was composite maternal hemorrhagic morbidity. Non-hemorrhagic morbidities and risk factors for hemorrhage were also evaluated.
Results:
Maternal hemorrhagic morbidity was more common in women with previa (19 vs 7%, aRR 2.6, 95% CI 1.9-3.5). Atony requiring uterotonics (aRR 3.1, 95% CI 2.0-4.9), red blood cell transfusion (aRR 3.8, 95% CI 2.5-5.7), and hysterectomy (aRR 5.1, 95% CI 1.5-17.3) were also more common with previa. For women with previa, factors associated with maternal hemorrhage were pre-delivery anemia, thrombocytopenia, diabetes, magnesium use, and general anesthesia.
Conclusion:
Placenta previa is an independent risk factor for maternal hemorrhagic morbidity. Some risk factors are modifiable, but many are intrinsic to the clinical scenario.
Background:
The term cesarean scar pregnancy refers to placental implantation within the scar of a previous cesarean delivery. The rising numbers of cesarean deliveries in the last decades have led to an increased incidence of cesarean scar pregnancy. Complications of cesarean scar pregnancy include morbidly adherent placenta, uterine rupture, severe hemorrhage, and preterm labor. It is suspected that cesarean scar pregnancies that are implanted within a dehiscent scar ("niche") behave differently compared with those implanted on top of a well-healed scar. To date there are no studies that have compared pregnancy outcomes between cesarean scar pregnancies implanted either "on the scar" or "in the niche."
Objectives:
The purpose of this study was to determine the pregnancy outcome of cesarean scar pregnancy implanted either "on the scar" or "in the niche."
Study design:
This was a retrospective 2-center study of 17 patients with cesarean scar pregnancy that was diagnosed from 5-9 weeks gestation (median, 8 weeks). All cesarean scar pregnancies were categorized as either implanted or "on the scar" (group A) or "in the niche" (group B), based on their first-trimester transvaginal ultrasound examination. Clinical outcomes based on gestational age at delivery, mode of delivery, blood loss at delivery, neonate weight and placental histopathologic condition were compared between the groups with the use of the Mann-Whitney U test. Myometrial thickness overlying the placenta was compared among all the patients who required hysterectomy and those who did not with the use of the Mann-Whitney U test. Myometrial thickness was also correlated with gestational age at delivery with the use of Spearman's correlation.
Results:
Group A consisted of 6 patients; group B consisted of 11 patients. Gestational age at delivery was lower in group B (median, 34 weeks; range, 20-36 weeks) than in group A (median, 38 weeks; range, 37-39 weeks; P=.001). In group A, 5 patients were delivered via cesarean delivery (with normal placenta), and 1 patient underwent a cesarean-hysterectomy for placenta accreta. In group B, 10 patients had a cesarean-hysterectomy for placenta increta/percreta, and 1 patient underwent gravid-hysterectomy for vaginal bleeding at 20 weeks gestation. Blood loss was increased, but not significantly higher in group B (median, 1200 mL; range, 600-4000 mL) than in group A (median, 700 mL; range, 600-1400 mL; P=.117). Myometrium was statistically significantly thinner in the patients group that require hysterectomy (median, 1 mm; range, 0-2 mm) than in the group that did not (median, 5 mm; range, 4-9 mm; P=.001). Myometrial thickness showed a positive correlation with the gestational age (r=0.820; P<.0005).
Conclusion:
Patients with cesarean scar pregnancy implanted "on the scar" had a substantially better outcome compared with patients in whom the cesarean scar pregnancy implanted "in the niche." Myometrial thickness <2 mm in the first-trimester ultrasound examination is associated with morbidly adherent placenta at delivery.
Objective:
To describe outcomes for a large cohort of women with prenatally diagnosed vasa previa, determine the percentage in patients without risk factors, and compare delivery timing and indications for singletons and twins.
Methods:
This was a retrospective case series of women with prenatally diagnosed vasa previa delivered at a single tertiary center over 12 years. Potential participants were identified using hospital records and perinatal databases. Patients were included if vasa previa was confirmed at delivery and by pathologic examination. Maternal and newborn data were gathered from medical records.
Results:
There were 77 singleton and 19 twin pregnancies with a prenatal diagnosis of vasa previa. There was one neonatal death from congenital heart disease. Perinatal management of recommended elective hospitalizations with corticosteroid administration and elective early delivery resulted in average gestational age for delivery in singletons at 34.7±1.6 weeks and 32.8±2.2 weeks for twins. Among the 77 singletons, delivery was elective in 48, as a result of contractions or labor in 21, bleeding in four, nonreassuring tracing in two, asymptomatic cervical shortening in one, and preeclampsia in one. Among 19 twins, delivery was elective in six and for contractions or labor in 13. Sixty-eight percent of twins compared with 37% of singletons had nonelective delivery (P<.05). Delivery occurred by 32 weeks of gestation in 6.4% of singletons and 26% of twins (P<.05) and by 34 weeks of gestation in 11% of singletons and 58% of twins (P<.001). Six neonates (5.2%) had major anomalies, all prenatally detected. Respiratory distress syndrome occurred in 57.1% of singletons and 65.7% of twins. Nineteen singletons (24.7%) had no risk factors for vasa previa.
Conclusion:
Planned preterm delivery for women with prenatally diagnosed vasa previa resulted in elective delivery for singletons in 62% and for twins 32%. Gestational age at birth on average was 34.7 weeks for singletons and 32.8 weeks of gestation for twins. Major anomalies were frequent as was respiratory distress syndrome. Elective delivery between 34 and 35 weeks of gestation for singletons is reasonable. As a result of the high rate of nonelective delivery in twins, delivery at 32-34 weeks of gestation may be risk-beneficial. The high rate of singletons without risk factors for vasa previa reinforces the recommendation to screen routinely for cord insertion site.
Malignant melanoma is the most common malignancy during pregnancy, and is diagnosed during childbearing age in approximately one-third of women diagnosed with melanoma. The impact of hormonal changes during pregnancy and from iatrogenic hormones on melanoma is controversial. Women undergo immunologic changes during pregnancy that may decrease tumor surveillance. In addition, hormone receptors are found on some melanomas. In spite of these observations, the preponderance of evidence does not support a poorer prognosis for pregnancy-associated melanomas. There is also a lack of evidence that oral contraceptives or hormone replacement therapy worsens melanoma prognosis.
BACKGROUND: Ante partum haemorrhage remains to be a major cause of morbidity and mortality.30% of this haemorrhage is attributed to placental abruption. Along with other adverse maternal outcomes, it increases the risk of Caesarean sections in patients, which is a public health concern. This study was conducted to find out whether any significant association exists between placental abruption and C-section in our set up.
Objective: To evaluate whether changes in the cerebroplacental Doppler and birth weight (BW) suggestive of chronic fetal hypoxemia, precede the development of late-onset placental abruption (PA) after 32 weeks.
Methods: In a multicenter retrospective study, the Doppler examinations of the fetal umbilical artery (UA) and middle cerebral artery (MCA) recorded after 32 weeks were collected in pregnancies subsequently developing PA. The BW centiles were calculated and the MCA pulsatility indices (PI), and UA PI were converted into multiples of the median (MoM). Afterwards, a comparison was made with a group of fetuses, which did not develop PA. Logistic regression was used to adjust for potential confounders and evaluate the feasibility of the prediction model.
Results: Pregnancies complicated by late-onset PA (n = 31) presented lower MCA PI (p = 0.015) and were smaller (p < 0.001) than those who did not (n = 1294). Logistic regression analysis indicated that cerebral vasodilation was more important than umbilical flow in the explanation of PA (MCA PI OR = 0.106, p = 0.014 and UA PI OR 1.901, p = 0.32). In addition, the influence of BW exerted was residual (BW centile OR = 0.989, p = 0.15).
Conclusions: Fetuses developing late-onset PA demonstrate significant cerebral vasodilation with scarce placental dysfunction, suggesting the existence of some kind of chronic hypoxemia that follows the late-onset pattern.
Objective:
Determining the depth of villous invasiveness before delivery is pivotal in planning individual management of placenta accreta (PA). We have evaluate the value of the various ultrasound signs described in the literature for the diagnosis of PA and in the assessment of the depth of villous invasiveness.
Data sources:
We undertook a PubMed and MEDLINE search of the relevant studies published between the first prenatal ultrasound description of PA in 1982 and 30 March 2016 using key words "placenta accreta", "placenta increta", "placenta percreta", "abnormally invasive placenta", "morbidly adherent placenta" and "placenta adhesive disorder" as related to "sonography", "ultrasound diagnosis", "prenatal diagnosis", "grey-scale imaging", three-dimensional (3D) ultrasound and "colour Doppler imaging".
Study eligibility criteria:
All articles which correlated prenatal ultrasound imaging with pregnancy outcome.
Study appraisal and synthesis methods:
Eighty-three studies, including 30 cases reports describing 38 cases of PA and 53 series describing 1078 cases were analysed. PA was subdivided in placenta creta (PC) to describe superficially adherent placentation and placenta increta (PI) and percreta (PP) to describe invasive placentation.
Results:
Out of 53 study series, 23 did not provide data on the depth of villous myometrial invasion on ultrasound imaging or at delivery. Detailed correlations between ultrasound findings and PA grading were found in 72 cases. A loss of clear zone (62.1%) and the presence of bridging vessels (71.4%) were the most common ultrasound signs found in cases of PC. In PI, a loss of clear zone (84.6%) and subplacental hypervascularity (60%) were the most common ultrasound signs whereas, placental lacunae (82.4%) and subplacental hypervascularity (54.5%) were the most common ultrasound signs in PP. No ultrasound sign or a combination of ultrasound signs were specific of the depth of accreta placentation.
Conclusions:
The wide heterogeneity in terminology used to describe the grades of accreta placentation and differences in study design limits the evaluation of the accuracy of ultrasound imaging in the screening and diagnosis of PA. This review emphasizes the need for further prospective studies using a standardised evidence-based approach including a systematic correlation between ultrasound signs of PA and detailed clinical and pathologic examinations at delivery.
We report a case of a preterm neonate born to a mother with giant placental chorioangioma. The baby had microangiopathic haemolytic anaemia, thrombocytopenia and cardiac failure at birth. In addition, she had a disseminated intravascular coagulation-like picture and had bleeding from multiple sites, which was treated with transfusion of multiple blood products. She also developed transient hypertension and required antihypertensive drugs for 3 weeks. The baby was successfully managed and discharged home, though with signs of neurosensory impairment.
Aim:
Placental abruption is a severe obstetric complication of pregnancy that can cause disseminated intravascular coagulation and progress to massive post-partum hemorrhage. Coagulation disorder due to extreme consumption of fibrinogen is considered the main pathogenesis of disseminated intravascular coagulation in patients with placental abruption. The present study sought to determine if the pre-delivery fibrinogen level could predict adverse maternal or neonatal outcomes in patients with placental abruption.
Methods:
This retrospective medical chart review was conducted in a center for maternal, fetal, and neonatal medicine in Japan with 61 patients with placental abruption. Fibrinogen levels prior to delivery were collected and evaluated for the prediction of maternal and neonatal outcomes. The main outcome measures for maternal outcomes were disseminated intravascular coagulation and hemorrhage, and the main outcome measures for neonatal outcomes were Apgar score at 5 min, umbilical artery pH, and stillbirth.
Results:
The receiver-operator curve and multivariate logistic regression analyses indicated that fibrinogen significantly predicted overt disseminated intravascular coagulation and the requirement of ≥6 red blood cell units, ≥10 fresh frozen plasma units, and ≥20 fresh frozen plasma units for transfusion. Moderate hemorrhage occurred in 71.5% of patients with a decrease in fibrinogen levels to 155 mg/dL. Fibrinogen could also predict neonatal outcomes. Umbilical artery pH < 7.00 occurred in 77.1% of patients with a decrease in fibrinogen levels to ≤ 250 mg/dL.
Conclusion:
Pre-delivery fibrinogen can predict adverse maternal as well as neonatal outcomes with placental abruption. © 2016 Japan Society of Obstetrics and Gynecology.
Background
Previous studies have shown a higher risk of birth defects and preterm birth (PTB) in singletons born after blastocyst transfer as compared to singletons born after cleavage-stage transfer. Few studies have investigated the maternal outcomes.
Objective
We sought to analyze the neonatal and maternal outcome after blastocyst transfer (day 5-6) compared to transfer of cleavage-stage embryos (day 2-3) and spontaneous conception.
Study Design
This was a population-based retrospective registry study including all singleton deliveries after blastocyst transfer in Sweden from 2002 through 2013. The in vitro fertilization register was cross-linked with the Swedish Medical Birth Register, the Register of Birth Defects, and the National Patient Register. Deliveries after blastocyst transfer were compared with deliveries after cleavage-stage transfer and deliveries after spontaneous conception. Outcome measures included birth defects, PTB, low birthweight, small for gestational age, large for gestational age, perinatal mortality, placenta previa, placental abruption, and preeclampsia. Crude and adjusted odds ratios (AOR) with 95% confidence interval (CI) were calculated. Adjustment was made for year of birth of child, maternal age, parity, smoking, body mass index, years of involuntary childlessness, and child’s sex and, for cleavage stage, also for number of oocytes retrieved, number of embryos transferred, and fresh/frozen embryo transfer.
Results
There were 4819 singletons born after blastocyst transfer, 25,747 after cleavage-stage transfer, and 1,196,394 after spontaneous conception. Singletons born after blastocyst transfer had no increased risk of birth defects compared to singletons born after cleavage-stage transfer (AOR, 0.94; 95% CI, 0.79–1.13) or spontaneous conception (AOR, 1.09; 95% CI, 0.92–1.28). Perinatal mortality was higher in the blastocyst vs the cleavage-stage group (AOR, 1.61; 95% CI, 1.14–2.29). When comparing singletons born after blastocyst transfer to singletons born after spontaneous conception, a higher risk of PTB (<37 weeks) was seen (AOR, 1.17; 95% CI, 1.05–1.31). Singletons born after blastocyst transfer had a lower rate of low birthweight (AOR, 0.83; 95% CI, 0.71–0.97) as compared to cleavage-stage transfer. The rate of being small for gestational age was lower in singletons born after blastocyst transfer as compared to both cleavage-stage and spontaneous conception (AOR, 0.71; 95% CI, 0.56–0.88 and AOR, 0.70; 95% CI, 0.57–0.87, respectively). The risk of placenta previa and placental abruption was higher in pregnancies after blastocyst transfer as compared to pregnancies after cleavage-stage (AOR, 2.08; 95% CI, 1.70–2.55 and AOR, 1.62; 95% CI, 1.15–2.29, respectively) and spontaneous conception (AOR, 6.38; 95% CI, 5.31–7.66 and AOR, 2.31; 95% CI, 1.70–3.13, respectively).
Conclusion
No increased risk of birth defects was found in singletons born after blastocyst transfer. Perinatal mortality and risk of placental complications were higher in the blastocyst group as compared to the cleavage-stage group, observations that need further investigations.
Background:
Cesarean scar pregnancy (CSP) is a serious complication of pregnancy, which consists of implantation of the gestational sac in the hysterotomy scar. This condition is increasing in frequency and often poses a diagnostic challenge. Its diagnosis is dependent on visual assessment of the uterus on the longitudinal sagittal ultrasound plane. Misdiagnosing a low intrauterine chorionic sac as a CSP, or a true scar pregnancy as an intrauterine pregnancy (IUP), may lead to adverse outcomes including hysterectomy.
Objective:
The objective of the study is to describe a sonographic method for the differential diagnosis of CSP vs IUP in early gestation. The current study tests the hypothesis that on a first-trimester ultrasound performed between 5-10 weeks of gestation, the relative location of the center of gestational sac to the midpoint of the uterus along a longitudinal line between the external cervical os and the fundus can be used for early detection of CSPs.
Study design:
This is a retrospective review of electronically archived ultrasound images of IUP and CSP between 5-10 weeks of gestation. A total of 242 ultrasound images were analyzed: 185 cases of normal IUPs (including 128 in anteverted uteri, 31 in retroverted uteri, and 26 IUPs with history of cesarean delivery) and 57 cases of CSPs diagnosed from 2004 through 2015 in a single institution. The following measurements were made for each case: distance from the external cervical os to the uterine fundus, the midpoint axis of the uterus, the distance from the external cervical os to the center of gestational sacs, and the distance from the external cervical os to the most distant edge of the gestational sacs from the cervix.
Results:
The location of the center of the gestational sac relative to the midpoint axis of the uterus between 5-10 weeks of gestation differentiated between IUP and CSP (mean 17.8 vs -10.6 mm, respectively, P = .0001), indicating that most CSPs are located proximally to the midpoint axis of the uterus whereas most normal IUPs are located distally from the midpoint of the uterus. Using location of the center of the gestational sac as a marker of CSPs between 5-10 weeks of gestation yielded the following characteristics of diagnostic accuracy: sensitivity 93.0% and specificity 98.9%. The likelihood ratio of the positive test was 84.5. The likelihood ratio of the negative test was 0.07.
Conclusion:
The location of the center of the gestational sac relative to the midpoint axis of the uterus can be used as an easy method for sonographic differentiation of IUP and CSP between 5-10 weeks of gestation.
Objectives:
To assess the efficacy of ultrasound-guided suction curettage for management of pregnancies implanted into the lower uterine segment Cesarean section scar.
Methods:
This was a retrospective study including women diagnosed with Cesarean section scar pregnancy at two large tertiary referral early pregnancy units between 1997 and 2014. Surgical evacuation was offered to selected women presenting in the first trimester ≤ 14 weeks' gestation. All procedures were performed transcervically under ultrasound guidance using suction curettage. A modified Shirodkar cervical suture was used in women who required additional measures to secure hemostasis.
Results:
A total of 232 women with Cesarean section scar pregnancy were seen at the referral units; 191/232 (82.3%) women were treated surgically. The median intraoperative blood loss was 100 mL (range, 10-3000 mL); 9/191 (4.7% (95% CI, 1.7-7.7%)) women required blood transfusion and, in one (0.5% (95% CI, 0-1.5%)), life-saving hysterectomy had to be performed because of uncontrollable intraoperative bleeding. Of the women who attended for follow-up, 7/116 (6.0% (95% CI, 1.7-10.3%)) required a repeat surgical procedure because of retained products of conception. Multivariable analysis showed that the gestational sac diameter (odds ratio (OR), 1.10 (95% CI, 1.03-1.17)) and pregnancy vascularity on Doppler examination (OR, 3.41 (95% CI, 1.39-8.33)) were significant predictors of heavy intraoperative blood loss (> 1000 mL).
Conclusions:
Ultrasound-guided suction curettage is an effective method for the treatment of pregnancies implanted into a lower uterine segment Cesarean section scar and is associated with a low risk of blood transfusion and hysterectomy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Objectives:
TNF-related apoptosis-inducing ligand receptor-2 (TRAIL-R2) is produced both by decidual and trophoblast cells during pregnancy and known to participate in apoptosis. In this study, we aimed to determine and to compare maternal serum and placental TRAIL-R2 levels in patients with placenta accreta, non-adherent placenta previa and in healthy pregnancies. We also aimed to analyze the association of placenta accreta with the occurrence of previous C-sections.
Study design:
A total of 82 pregnant women were enrolled in this case-control study (27 placenta accreta patients, 26 non-adherent placenta previa patients and 29 age-, and BMI-matched healthy, uncomplicated pregnant controls). TRAIL-R2 levels were studied in both maternal serum and placental tissue homogenates. Determining the best predictor(s) which discriminate placenta accreta was analyzed by multiple logistic regression analyses. Adjusted odds ratios and 95% confidence intervals were also calculated.
Results:
Both placental and serum TRAIL-R2 levels were significantly lower in placenta accreta group (median 34.82 pg/mg and 19.85 pg/mL, respectively) when compared with both non-adherent placenta previa (median 39.24 pg/mg and 25.99 pg/mL, respectively) and the control groups (median 41.62 pg/mg and 25.87 pg/mL, respectively) (p < 0.05). Placental TRAIL-R2 levels and previous cesarean section were found to be significantly associated with placenta accreta (OR: 0.934 95% CI 0.883-0.987, p = 0.016 and OR:7.725 95% CI: 2.717-21.965, p < 0.001, respectively). Placental and serum TRAIL-R2 levels were positively correlated.
Conclusion:
Decreased levels of placental TRAIL-R2 and previous history of cesarean section were found to be significantly associated with placenta accreta, suggesting a possible role of apoptosis in abnormal trophoblast invasion.
Objectives:
The purpose of this study was to evaluate the clinical characteristics, imaging features, pregnancy complications, prenatal management of patients with placenta chorioangioma.
Methods:
This was a retrospective study of 26 cases with histologically proven placenta chorioangima, in which the natural history, pregnancy complications, and clinical characteristics including ultrasonography were evaluated.
Results:
Twelve of the twenty-six cases had a wide range of maternal-fetal complications including polyhydramnios (7), fetal growth restriction (3), fetal distress (2), pre-eclampsia (3), fetal anemia-thrombocytopenia (2), congestive heart failure (1) and fetal abnormality (1).
Conclusions:
Placenta chorioangioma was associated with series of pregnancy complications such as polyhytramnios, premature delivery, maternal pre-eclampsia, fetal growth restriction, fetal distress, even fetal anemia and cardiomegaly. With regular prenatal examination, necessary treatment, and timely delivery, the majority had a good pregnancy outcome.
Abnormal placentation is a potential cause of maternal morbidity and mortality from massive postpartum bleeding. The objective of this study was to investigate the efficacy of occlusive balloons when used as an adjunct to surgery in reducing blood loss and transfusion requirements. A retrospective study of 42 patients was performed involving consecutive cases of abnormal placentation who delivered with either conventional surgery with preoperatively placed occlusive balloons or conventional surgery alone. No differences were noted between the control group and the group of patients who had occlusive balloons with regard to estimated blood loss (P = 0.767), packed red blood cells transfused (P = 0.799), amount of crystalloids infused (P = 0.435), total procedure duration (P = 0.076), and length of ICU stay (P = 0.315) or total hospital stay (P = 0.254). Prophylactic intravascular balloon catheters did not benefit women with abnormal placentation when compared with conventional surgery alone.
Objective:
To examine the effect of prophylactic balloon catheters on bleeding morbidity among women with a prenatal diagnosis of placenta accreta.
Methods:
In a randomized trial, women with a prenatal diagnosis of placenta accreta were randomized to either preoperative prophylactic balloon catheters (intervention group) or to a control group. Other than placement of the prophylactic balloon catheters in the anterior division of the internal iliac arteries, the same multidisciplinary approach was used in both groups. The primary study outcome was the number of packed red blood cell (RBC) units transfused. To detect a mean reduction of three packed RBC units with the prophylactic balloon catheters, 12 women in each group were needed.
Results:
Between January 2009 and March 2015, 27 women were randomized: 13 in the intervention group and 14 in the control group. Demographic and obstetric characteristics were similar between the groups. Six (46.2%) women in the intervention and seven (50.0%) in the control group underwent cesarean hysterectomy (P=.84). There were no significant differences between the intervention and control groups in the mean number of packed RBC units transfused, 5.2 (±6.2) and 4.1 (±3.8), respectively (P=.90), or in the calculated blood loss, 4,950 (±5,051) and 4,709 (±3,434) mL (P=.72). The number of women with blood loss greater than 2,500 mL, number of plasma products transfused, duration of surgery, peripartum complications, and hospitalization length did not differ significantly between the groups. Reversible adverse effects related probably to prophylactic balloon catheter insertion were noted in 2 of 13 (15.4%) women.
Conclusion:
In women with preoperative suspicion of placenta accreta, preoperative placement of prophylactic balloon catheters did not affect the number of packed RBC units transfused.
Clinical trial registration:
ClinicalTrials.gov, www.clinicaltrials.gov, NCT01373255.
Level of evidence:
I.
We sought to evaluate the extent of the association between placental implantation abnormalities (PIA) and preterm delivery in singleton gestations. We conducted a systematic review of English-language articles published from 1980 onward using PubMed, MEDLINE, EMBASE, CINAHL, LILACS, and Google Scholar, and by identifying studies cited in the references of published articles. Search terms were PIA defined as 1 of the following: placenta previa, placenta accreta, vasa previa, and velamentous cord insertion. Observational and experimental studies were included for review if data were available regarding any of the aforementioned PIA and regarding gestational age at delivery or preterm delivery. Case reports and case series were excluded. Studies were reviewed and data extracted. The primary outcome was gestational age at delivery or preterm delivery <37 weeks' gestation. Secondary outcomes included birthweight, 1- and 5-minute Apgar scores, neonatal intensive care unit (NICU) admission, neonatal and perinatal death, and small for gestational age. Of the 1421 studies identified, 79 met the defined criteria; 56 studies were descriptive and 23 were comparative. Based on the descriptive studies, the preterm delivery rates for low-lying/marginal placenta, placenta previa, placenta accreta, vasa previa, and velamentous cord insertion were 26.9%, 43.5%, 57.7%, 81.9%, and 37.5%, respectively. Based on the comparative studies using controls, there was decreased pregnancy duration for every PIA; more specifically, there was an increased risk for preterm delivery in patients with placenta previa (risk ratio [RR], 5.32; 95% confidence interval [CI], 4.39-6.45), vasa previa (RR, 3.36; 95% CI, 2.76-4.09), and velamentous cord insertion (RR, 1.95; 95% CI, 1.67-2.28). Risks of NICU admissions (RR, 4.09; 95% CI, 2.80-5.97), neonatal death (RR, 5.44; 95% CI, 3.03-9.78), and perinatal death (RR, 3.01; 95% CI, 1.41-6.43) were higher with placenta previa. Perinatal risks were also higher in patients with vasa previa (perinatal death rate RR, 4.52; 95% CI, 2.77-7.39) and velamentous cord insertion (NICU admissions [RR, 1.76; 95% CI, 1.68-1.84], small for gestational age [RR, 1.69; 95% CI, 1.56-1.82], and perinatal death [RR, 2.15; 95% CI, 1.84-2.52]). In singleton gestations, there is a strong association between PIA and preterm delivery resulting in significant perinatal morbidity and mortality.
Placental implantation abnormalities, including placenta previa, placenta accreta, vasa previa, and velamentous cord insertion, can have catastrophic consequences for both mother and fetus, especially as pregnancy progresses to term. In these situations, current recommendations for management usually call for an indicated preterm delivery even in asymptomatic patients. However, the recommended gestational age(s) for delivery in asymptomatic patients are empirically determined without consideration of the recent literature regarding the usefulness of specific ultrasound findings to help individualize management. The purpose of this article is to propose literature-supported guidelines to the current opinion-based management of asymptomatic patients with placental implantation abnormalities based on relevant and specific ultrasound findings such as cervical length, distance between the internal cervical os and placenta, and placental edge thickness.
Vasa previa occurs when fetal blood vessels unprotected by the umbilical cord or placenta run through the amniotic membranes and traverse the cervix. If membranes rupture, these vessels may rupture, with resultant fetal hemorrhage, exsanguination, or even death. Prenatal diagnosis of vasa previa by ultrasound is approximately 98%. Approximately 28% of prenatally diagnosis cases result in emergent preterm delivery. Management of prenatally diagnosis vasa previa includes antenatal corticosteroids between 28-32 weeks of gestation, considerations for preterm hospitalization at 30-34 weeks of gestation, and scheduled delivery at 34-37 weeks of gestation.
Copyright © 2015 Elsevier Inc. All rights reserved.
The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.
Population-based cohort study.
A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS).
In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.
Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.
A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia.
Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.
An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.
© 2015 Royal College of Obstetricians and Gynaecologists.
Abnormally invasive placenta (AIP) is a clinical term used to describe a placenta that does not separate spontaneous during normal delivery and cannot be removed without causing high blood loss. Maternal outcome in cases with AIP is improved by antenatal diagnosis that currently relies on subjective interpretation of imaging signs. There is no accepted consensus on the definition of the commonly used ultrasound markers for AIP. The studies included in a recently published systematic review of antenatal sonographic diagnosis of AIP were analysed for the ultrasound descriptors. Different wordings used for each sign were identified, analysed and discussed by an expert panel (European Working Group on AIP). Consensus was reached, leading to a unified, detailed descriptor for each sign. Characteristic ultrasound images of these descriptors and normal findings are provided. Twenty-three papers were examined for wording used to describe AIP signs. These were extracted and grouped by ultrasound modality, and synonymous or identical terms identified. The group agreed on six unified descriptors for 2D greyscale signs, four for 2D colour Doppler and one for 3D power Doppler. Four papers included descriptions that were considered to be not sufficiently comprehensive or not clear regarding their meaning. We present an analysis of terms describing the sonographic appearance of AIP commonly used in the literature. We unified these terms and propose unambiguous descriptors accompanied by characteristic ultrasound images to promote understanding and guide future use in AIP.
This article is protected by copyright. All rights reserved.
Primary nontrophoblastic tumors of a placenta are very uncommon with the majority being of vascular origin such as chorangiomas and chorangiomatosis. Rare examples of tumor-like collections of liver tissue, morphologically consistent with hepatocellular adenomas, have been reported. We report the co-occurrence of a chorangioma and hepatic angioma as a grossly single lesion on the fetal surface of a diamniotic dichorionic twin placenta.
A heterotopic pregnancy in the vicinity of a previous Caesarean section scar (HSP) occurs frequently after fertility treatment. In spite of the low incidence to date, the increasing numbers of Caesarean sections as well as IVF treatment will probably lead to a higher prevalence in the future. Up to now the literature contains only isolated case reports on therapeutic options. These range from conservative management through selective termination of the HSP by injections of methotrexate or potassium chloride into the amniotic sac to invasive methods such as resectoscopic removal or laparoscopy. In the case presented here we describe the successful excision of the HSP by laparotomy with a subsequent uncomplicated Caesarean section and delivery of a healthy baby at the 37 + 0 week of pregnancy.