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PubMed2005

A protocol for the use of enoxaparin during pregnancy: results from 85 pregnancies including 13 multiple gestation pregnancies.

Many practitioners consider low-molecular-weight heparin (LMWH) an alternative to unfractionated heparin, although there are limited safety data regarding maternal and fetal outcomes in patients using an LMWH during pregnancy. A retrospective chart review was performed on 72 patients with thrombophilia exposed to the LMWH, enoxaparin, during pregnancy. Eighty-five pregnancies resulted in 93 of 99 potential live births. Eleven of 12 twin pregnancies and one triplet pregnancy were successful. One preterm live birth infant of 33 weeks' gestation did not survive. Three patients with thrombophilia spontaneously aborted. A patient receiving injectable fertility treatment had spontaneously aborted one twin at 5 weeks' gestation. One patient terminated the pregnancy after discovering the presence of Down's syndrome. The mean maximum dose required to achieve a therapeutic anti-Xa level of 0.2-0.4 IU/mL at 5 to 6 hours following administration, was 38.1 mg every 12 hours (median 35 mg, range 30-75 mg every 12 hours). The mean anti-Xa level was 0.28 IU/mL (median 0.3, range 0.05-0.8 IU/mL). A total of nine patients experienced bleeding events, two requiring discontinuation of enoxaparin for the remainder of the pregnancy. Two patients experienced injection site reactions requiring discontinuation of enoxaparin. Three patients developed preeclampsia, two placenta abruptio, and one placenta previa. No thromboembolic complications or osteoporotic fractures had occurred. Enoxaparin was safe and effective for preventing thromboembolism and adverse obstetrical complications in our patients, including 12 of 13 multiple gestation pregnancies.

Adult↗
PubMed1986

Ethnic differences in preterm and very preterm delivery.

Ethnic differences in preterm (less than 37 weeks) and very preterm (less than 33 weeks) delivery were evaluated in a prospective cohort of 28,330 women. Blacks had the highest rate of preterm and very preterm delivery, followed by Mexican-Americans, Asians, and Whites. Adjustment for maternal age, education, marital status, employment, parity, number of previous spontaneous or induced abortions, smoking and drinking during pregnancy, infant sex, and gestational age at initiation of prenatal care resulted in the following odds ratios for preterm delivery: 1.79 (1.55-2.08) for Blacks, 1.40 (1.19-1.63) for Mexican-Americans, 1.40 (1.16-1.69) for Asians, and 1.00 for Whites. The corresponding odds ratios for very preterm delivery were 2.35 (1.72-3.22) for Blacks, 1.31 (0.88-1.94) for Mexican-Americans, 1.10 (0.67-1.83) for Asians, and 1.00 for Whites. Exclusion of cases of premature rupture of membranes, placenta previa, and abruptio placenta did not explain the large ethnic differences. Although Whites and Mexican-Americans had similar birthweight distributions, Mexican-Americans had an increased risk for preterm delivery. Fifty-five per cent of low birthweight babies in Kaiser were preterm and this fraction did not vary substantially by ethnic group.

Adult↗
PubMed2005

Change in cesarean section rate as a reflection of the present malpractice crisis.

OBJECTIVE: To examine the potential effect of the malpractice crisis on the cesarean section rates of practicing obstetricians. METHODS: We reviewed the medical records of primagravid women, from both clinic and private practice settings, having singleton deliveries at Hartford Hospital from 1994 to 2003. The records of cesarean sections due to fetal distress and cephalopelvic disproportion (CPD) were further analyzed for three different two-year periods; 1994-1995, 1999-2000, and 2002-2003. Cases with accepted indications for elective cesarean sections were excluded. These included breech position, HIV, herpes, preeclampsia, placenta previa, and abruptio placenta. RESULTS: The private cesarean rate in 1994-1995 was 15.6%, 1999-2000 15.7%, and in 2002-2003 24.8%, a 58% increase. This is a significant increase that was not equally seen in the clinic population during the same period. CONCLUSION: The private, primagravid cesarean section rate has increased significantly in the last two years. A concurrent rise in medical malpractice actions and malpractice insurance premiums, without other attributable explanations, suggests this may be a major factor.

Cesarean Section↗
PubMed1990

Ranking the risk factors for cesarean: logistic regression analysis of a nationwide study.

The risk factors that influenced the decision to perform cesarean were ranked in a nationwide census of deliveries conducted in Israel. The study encompassed 22,815 women who gave birth between November 1, 1983 and January 31, 1984 in the 30 maternity departments in the country; 2179 deliveries were by emergency cesarean. Multivariate stepwise logistic regression technique indicated that the most important risk factors affecting the decision were the presentation of the fetus and the presence of a uterine scar, followed in descending order by placenta previa or abruptio placentae, maternal disease, primiparity, low birth weight, twins, and advanced maternal age. The mother's ethnic background and type of hospital played an insignificant role in the decision-making process. The specific statistical method applied in this work permits listing the indicators that constitute risk factors for cesarean and provides the net effect of each factor on the decision-making process.

Cesarean Section↗
PubMed1994

Perinatal and infant mortality: trends and risk factors in Norway 1967-90.

Neither the infant nor the under 24 hours mortality rates in Norway improved in the 1980s. The late neonatal mortality rate did not improve significantly in either the 1980s or the 1970s. The postneonatal mortality rate rose steadily throughout the last 15 years. The major mortality declines for all age groups took place in the 1970s. In the 1980s, only the 1-7-day mortality improved significantly. As a result, Norway fell behind in the international ranking of perinatal and infant mortality. Disparities among the perinatal mortality rates of Norwegian counties diminished throughout the 1970s. In the 1980s, the county disparities intermittently increased. Postneonatal deaths represented an increasing proportion; in the late 1980s, they amounted to half of the infant deaths and one-third of the total perinatal and infant deaths. In 1988, the postneonatal mortality rate was about twice as high in Norway as in Finland, Iceland, or Sweden. Birth injuries and infections almost disappeared as causes of perinatal and infant death. Other perinatal causes also diminished substantially. The incidence of congenital anomalies remained stable. The incidence of sudden infant death syndrome (SIDS), the single cause with continuous rate rise, more than doubled. In the late 1980s, SIDS caused one-quarter of the infant and more than half of the postneonatal deaths. The share of perinatal deaths from placentoumbilical causes (mostly placenta previa and abruptio placentae) and maternal diseases increased substantially. The affluence of Norway surged in the late 1970s and the 1980s, but health care was not given a higher priority. About 80% of fertile women used contraceptives. The use of modern methods increased substantially; oral contraceptives, in particular. About 60,000 confinements and 15,000 legally induced abortions took place in Norway each year. The number of induced abortions increased in women in their twenties, but decreased in all other age groups. As the total fertility decreased, each woman, on average, gave birth to 1.9 children and experienced 0.5 legally induced abortion. Maternal mortality was reduced to nil. Fewer marriages were contracted, and the divorce rate more than doubled. As a result, more than 35% of all births now occur out of wedlock, as compared with 5% in the late 1960s. The individual importance of birth out of wedlock as a risk factor has been reduced substantially. The mean maternal age increased from 26 to 28 years. The proportion of births by teenage mothers dropped from 8 to 3%.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1994

[Paroxystic complications in vasculo-renal syndromes during pregnancy and puerperium at the CHU of Dakar].

In a comparative study issued in 1989 in Gynecology in Dantec (a Medical Hospital School) in Dakar (Senegal), the authors made a retrospective analysis of 206 cases of abruptio placenta (3.3%) and 56 cases of eclampsia (0.9%). After a physiopathologic overview of the vascular renal syndromes, they point out the risk factors of paroxistic accidents represented mainly by the age and the parity, knowing that young age and primiparity appear as new risk factors for abruptio placenta. Finally, they insisted on the prevention of these accidents because of their impact on fetal and maternal mortalities.

Abruptio Placentae↗
PubMed1993

Risk of intracranial hemorrhage and other adverse outcomes after cocaine exposure in a cohort of 323 very low birth weight infants.

We conducted a prospective cohort study of 323 consecutively born very low birth weight infants (< or = 1499 gm) to determine any association between prenatal cocaine exposure and (1) intracranial ultrasonographic abnormalities and (2) other adverse perinatal outcomes. The infants were assigned to either a cocaine-exposed group (n = 86) or a cocaine-nonexposed group (n = 146) on the basis of combined detection methods for prenatal maternal cocaine abuse including maternal history, maternal and infant urine immunoassay (Emit), and meconium analysis (high-performance liquid chromatography and gas chromatography-mass spectrometry). Ninety-one infants were not assigned because of early death before complete testing (n = 80) or missed tests (n = 11). The detected incidence of cocaine exposure in the assigned population was 37% (86/232). Meconium testing with high-performance liquid chromatography and gas chromatography-mass spectrometry was the sole means of detection in 30% (26/86) of cases. The cocaine-nonexposed infants did not differ from the cocaine-exposed infants in the incidence of intraventricular hemorrhage (36% vs 35%), grades III and IV intraventricular hemorrhage (14% vs 14%), or periventricular leukomalacia (4% vs 2%). Adverse outcomes increased by cocaine exposure were abruptio placentae (8% vs 18%; p = 0.046), surgical ligation of a patent ductus arteriosus (1% vs 7%; p = 0.02), and seizures (5% vs 17%; p = 0.004). We conclude that prenatal cocaine exposure does not increase the incidence or severity of intracranial hemorrhage or periventricular leukomalacia but does increase the risk of abruptio placentae, surgical ligation of a patent ductus arteriosus and seizures in very low birth weight infants.

Abruptio Placentae↗
PubMed1993

Prevention of preeclampsia with low-dose aspirin in healthy, nulliparous pregnant women. The National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units.

BACKGROUND: Although low-dose aspirin has been reported to reduce the incidence of preeclampsia among women at high risk for this complication, its efficacy and safety in healthy, nulliparous pregnant women are not known. METHODS: We studied 3135 normotensive nulliparous women who were 13 to 26 weeks pregnant to determine whether treatment with aspirin reduced the incidence of preeclampsia. Of this group, 1570 women received 60 mg of aspirin per day and 1565 received placebo for the remainder of their pregnancies. We also evaluated the effect of aspirin on maternal and neonatal morbidity. RESULTS: Of the original group of 3135 women, 2985 (95 percent) were followed throughout pregnancy and the immediate puerperium. The incidence of preeclampsia was lower in the aspirin group (69 of 1485 women [4.6 percent]) than in the placebo group (94 of 1500 women [6.3 percent]) (relative risk, 0.7; 95 percent confidence interval, 0.6 to 1.0; P = 0.05), whereas the incidence of gestational hypertension was 6.7 and 5.9 percent, respectively. There were no significant differences in the infants' birth weight or in the incidence of fetal growth retardation, postpartum hemorrhage, or neonatal bleeding problems between the two groups. Subgroup analysis showed that preeclampsia occurred primarily in women whose initial systolic blood pressure was 120 to 134 mm Hg (incidence among such women, 5.6 percent in the aspirin group vs. 11.9 percent in the placebo group; P = 0.01). The incidence of abruptio placentae was greater among the women who received aspirin (11 women, vs. 2 in the placebo group; P = 0.01). CONCLUSIONS: Low-dose aspirin decreases the incidence of preeclampsia among nulliparous women, primarily through its effect in those who have elevated systolic blood pressure initially. This treatment does not decrease perinatal morbidity but increases the risk of abruptio placentae.

Abruptio Placentae↗
PubMed2001

[Severe maternal complications associated with pre-eclampsia: an almost forgotten pathology?].

Pre-eclampsia is a pregnancy-specific hypertensive syndrome associated with significant morbidity and mortality in mother and baby. With the increasing understanding of the disease process, the number of complications, and the maternal and perinatal deaths have fallen over the last few decades in the developed countries. In other parts of the world, the rates of mortality and morbidity remain high. We present eight cases of pre-eclamptic women with severe complications (eclampsia, HELLP syndrome, acute pulmonary edema, acute renal failure...) that were treated at our hospital in only a year, when we had not seen these pathologies in the last nine years. There was fetal death in three of the cases, related to abruptio placentae. There were no maternal deaths, but four mothers needed to be transferred to the intensive care unit, and required life-support techniques. The causes of these new events remain unclear. Can they be due to increase in maternal age or to the high incidence of abruptio placentae? Or maybe can they occur only by chance? These women with pre-eclampsia and severe complications that can have potentially devastating consequences are not an easily identified group. We concluded that women with pregnancy hypertension must be carefully managed by expert physicians, particularly if they are more than 30-35 years old, overweight, with previous history of hypertension or nulliparous, in order to decrease these several complications.

Abruptio Placentae↗
PubMed1990

[Thrombotic and hemostatic problems in pregnancy and labor and their significance for the fetus and newborn infant].

The following problems are considered: Thrombosis: Safe diagnosis with phlebographic verification is recommended. Heparin has been an established treatment with the great advantage that it does not enter the fetal blood stream. In selected cases surgery or thrombolytic therapy has to be considered. Owing to the high risk of recurrence, prophylactic treatment with Heparin is required throughout pregnancy. Coumarol derivatives traverse the placental membrane to the foetus and have to be avoided because of a risk for teratogenetic injury and intracranial hemorrhage in the foetus. During the puerperium, warfarin might be given because its concentration in breastmilk is low. However, administration of vitamin K1 is recommended to prematures. Attention should be given to the side-effects of Heparin i.e. thrombocytopenia and osteoporosis. The possibility of antithrombin III deficiency should not be overlooked. In such cases it is also risk of thrombosis in the newborn. Premature separation of placenta: In most cases of abruptio placenta immediate delivery by caesarean section is necessary. In cases with partial separation of placenta and immature foetus, treatment with the fibrinolytic inhibitor tranexamic acid (Cyklokapron) has proved useful to prolong pregnancy with maturation of the foetus. Thrombocytopenia: Severe hemorrhage seldom occurs above a level of 50 x 10(9)/l. Treatment with Prednisolon has proved to be of great value. The risk of the child having thrombocytopenia is about 50%. Intraventricular bleedings: Such bleedings mainly occur in prematures. Preliminary results have shown decreased concentrations of specific plasminogen activator inhibitors.

Abnormalities, Drug-Induced↗
PubMed1976

Current concepts of defibrination in the pregnant woman.

The possible predisposing causes of difibrination in the pregnant woman are discussed. Coagulation profiles and qualitative and quantitative assessment of fibrinolytic activity during labor, delivery and the early puerperium in normal pregnancies are presented. These factors were also studied in patients with abruptio placentae and prolonged intrauterine fetal death and in women whose pregnancies were terminated with intraamniotic infusion of hypertonic saline or prostaglandin F2alpha. The findings suggest that a minor degree of physiologic defibrination develops during normal labor that is qualitatively similar to, but of much lesser magnitude than, the pathologic defibrination syndrome commonly associated with abruptio placentae or prolonged intrauterine fetal death. Some degree of defibrination occurs in women undergoing saline abortion, similar to that of women during normal parturition, but does not usually reach clinically significant levels. The coagulation changes seen during prostaglandin abortion suggest that a minor degree of defibrination occurs that is substantially less than that seen during saline abortion. The findings presented form a basis for the rational management of defibrination in the pregnant woman.

Abortion, Induced↗
PubMed2000

Massive obstetric haemorrhage.

Massive obstetric haemorrhage is a major cause of maternal death and morbidity; abruptio placentae, placenta praevia and postpartum haemorrhage being the main causes. A delay in the correction of hypovolaemia, a delay in the diagnosis and treatment of defective coagulation and a delay in the surgical control of bleeding are the avoidable factors in most maternal deaths caused by haemorrhage. The degree of hypotension is the first guide to the level of blood loss, except in abruptio placentae. A protocol incorporating the guidelines is shown. The rapid correction of hypovolaemia with crystalloids and red cells is the first priority, followed by blood component therapy as indicated by the haematocrit, coagulation tests, platelet count and clinical features. Serial monitoring of the response to treatment is essential. Oxytocin and prostaglandin will correct uterine atony, and appropriate surgical intervention is required for traumatic bleeding. Ligation of the uterine arteries, ovarian arteries and internal iliac arteries will usually control uterine bleeding, arterial embolization also being effective. Hysterectomy should be considered as well. Catastrophic bleeding may also arise in complications such as rupture of the liver and acute fatty liver of pregnancy. These rare complications are best managed by a multidisciplinary team involving the obstetrician, anaesthetist, haematologist, hepatologist and renal physician. The rupture of aneurysms in the splenic artery and in other branches of the aorta can result in massive haemorrhage during pregnancy and following delivery.

Abruptio Placentae↗
PubMed1993

Maternal plasma D-dimer levels in normal and complicated pregnancies.

OBJECTIVE: To evaluate D-dimer as a marker for fibrinolysis in normal and complicated pregnancies using an enzyme-linked immunosorbent assay (ELISA) technique. METHODS: Four groups of pregnant women were enrolled: 17 normal women followed longitudinally from 28-40 weeks' gestation, 14 patients with preterm labor at 28-34 weeks, 17 patients with preeclampsia at term (37-40 weeks), and 14 patients with abruptio placentae (32-40 weeks). We assayed peripheral venous blood samples from each patient for D-dimer levels using a commercial ELISA kit. D-dimer values were calculated by regression analysis using internal standards and controls for each assay. Data were compared using Student t test or analysis of variance with repeated measures. RESULTS: D-dimer values increased slightly with increasing gestational age. Patients with preterm labor, preeclampsia, and abruptio placentae had mean D-dimer values significantly greater than those of controls (P < .003). D-dimer values of the abruption group were approximately twice those of the control group (3393 +/- 2086 versus 1750 +/- 839 ng/dL). CONCLUSION: An increase in fibrinolysis may be associated with the pregnancy complications studied, as reflected by alterations in maternal plasma D-dimer levels.

Abruptio Placentae↗
PubMed2003

Soluble HLA-DR levels in the maternal circulation of normal and pathologic pregnancy.

OBJECTIVE: The purpose of this study was to determine that circulating HLA-DR molecules are important candidates for the monitoring of maternal immunostimulation and immunosuppression. STUDY DESIGN: Concentrations of soluble HLA-DR molecules were estimated in EDTA plasma samples of 61 nonpregnant women, 123 healthy pregnant women in the second trimester, 66 healthy women who were delivered at term, and 136 women who were delivered because of complications such as uncontrollable preterm intrauterine activation, abruptio placentae, intrauterine growth retardation, preeclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. RESULTS: In comparison to nonpregnant women, the normal course of pregnancy was associated with strongly increasing levels of soluble HLA-DR from second trimester on until term. In comparison to women who were delivered preterm because of uncontrollable intrauterine activation, increased soluble HLA-DR concentrations were detected in case of HELLP syndrome (P <.05), although decreased levels were detected in the case of intrauterine growth retardation, preeclampsia (P <.01), and abruptio placentae (P <.01). CONCLUSION: Dysregulation of the maternal immune response to pregnancy may play an important role in the cause of complicated pregnancies.

Abruptio Placentae↗
PubMed2006

Predictions for the decision-to-delivery interval for emergency cesarean sections in Norway.

BACKGROUND: To explain the variation in decision-to-delivery intervals in emergency cesarean sections in Norway. METHODS: A seven-month prospective registration of all emergency cesareans provided by 24 maternity units. The clinician in charge filled in a predesigned form for each delivery that obtained detailed information about obstetric history, the pregnancy, indication, the date and time of delivery, decision-to-delivery interval, seniority of the surgeon, and neonatal outcome until hospital discharge. To take account of the clustered nature of our observations, data were analyzed by multilevel regression. RESULTS: 1,511 singleton emergency cesarean sections with known decision-to-delivery interval were included. The average decision-to-delivery interval for all emergency cesarean sections was 52.4 min, for acute cesarean sections 58.7 min, and for urgent emergency operations 11.8 min. Most of the decision-to-delivery interval variation was at patient level, not between departments. Several significant decision-to-delivery interval predictors were identified: 1. abruptio placentae (-54 min), umbilical cord prolapse (-37 min), and fetal stress (-35 min); 2. general anesthesia (versus regional) (-15 min), 3. cesarean sections performed during night-time (-10 min), 4. seniority of the surgeon (-6 min), and 5. cervical opening (for each cm: -6 min). CONCLUSIONS: The variance in the decision-to-delivery interval was mainly explained by the different nature of the cesarean sections. The most important predictors, which all acted to reduce decision-to-delivery interval, were the three indications abruptio placentae, cord prolapse, and fetal stress. Sections performed during night-time had significantly reduced decision-to-delivery interval. The size of the maternal units as measured by number of deliveries per year was not a significant predictor.

Abruptio Placentae↗
PubMed2001

The association of abnormal alpha-fetoprotein and adverse pregnancy outcome: does increased fetal surveillance affect pregnancy outcome?

OBJECTIVE: Our purpose was to investigate whether adverse outcomes associated with elevated maternal serum alpha-fetoprotein levels may be prevented by intensive antenatal monitoring. STUDY DESIGN: Records of patients with elevated maternal serum alpha-fetoprotein values of > or =2.0 multiples of the median between 1995 and 1999 were reviewed. Pregnancy histories were analyzed to determine whether intensive antenatal monitoring (twice-weekly nonstress tests and determinations of the amniotic fluid index) would have detected the adverse outcomes when routine obstetric care would have missed them. Women with elevations explained by multiple gestations, structural abnormalities, or a fetal death were excluded. RESULTS: The study enrolled 136 patients. Twenty-three patients were excluded because of multiple gestations, structural or chromosomal abnormalities, or fetal death or for lack of available follow-up. Seventy-eight patients had no perinatal complications, but 12 of these patients underwent heightened surveillance. One of these patients was subjected to an induction of labor. Thirty-five pregnancies had complications (21 with preterm labor, 7 with pregnancy-induced hypertension, 6 with growth restriction or oligohydramnios, 1 with abruptio placentae, and 1 with vasa previa). Of these 35 pregnancies, 22 were followed up with routine obstetric care and 13 with heightened surveillance. Heightened surveillance did not achieve earlier or improved detection in this group. These results suggest that routine pregnancy management is an adequate strategy for providing care to pregnant patients with unexplained elevated maternal serum alpha-fetoprotein levels. Adverse outcomes were detected with routine pregnancy management or were undetectable even with intensive management. CONCLUSION: Increased risks of pregnancy-induced hypertension, preterm delivery, intrauterine growth restriction, intrauterine fetal death, oligohydramnios, and abruptio placentae are associated with elevated maternal serum alpha-fetoprotein levels. However, in our study, routine pregnancy management was an acceptable method of detecting these adverse outcomes when they were detectable.

Abruptio Placentae↗