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PubMed2004

Screening and management of inherited thrombophilias in the setting of adverse pregnancy outcome.

Inherited thrombophilic conditions are associated with adverse pregnancy outcomes, including severe pre-eclampsia, fetal loss, abruptio placentae, and intauterine growth restriction. Although the prevalence of these complications is approximately 8% in the general population, their presence is associated with a significantly increased recurrence risk. Thrombophilic conditions most strongly associated with adverse pregnancy outcome include factor V Leiden, prothrombin gene mutation, and deficiencies of protein S, protein C, and antithrombin. Other thrombophilic conditions, such as protein Z deficiency, also appear to be associated with an increased risk of pregnancy complications. Antenatal administration of heparin to prevent pregnancy complications has shown promise in small studies, but a randomized, placebo-controlled trial is necessary to determine whether heparin administration is beneficial in preventing adverse pregnancy outcome.

Abruptio Placentae↗

PubMed2001

Disseminated intravascular coagulation.

Healthy pregnancy is accompanied by changes in the haemostatic system which convert it into a hypercoagulable state vulnerable to a spectrum of disorders ranging from venous thromboembolism to disseminated intravascular coagulation (DIC). This latter is always a secondary phenomenon triggered by specific disorders such as abruptio placentae and amniotic fluid embolism due to release of thromboplastin intravascularly or endothelial damage resulting from pre-eclampsia and sepsis. In modern obstetric practice the most common cause is haemorrhagic shock with delay in resuscitation leading to endothelial damage. The initial management of massive obstetric haemorrhage is the same whether associated with coagulopathy initially or not. Low-grade DIC, associated with pre-eclampsia, is monitored haematologically by serial platelet counts and serum fibrin degradation products (FDPs). Supportive measures and removal of the triggering mechanism are the key to successful management. Outcome depends primarily on our ability to deal with the trigger and not on direct attempts to correct the coagulation deficit.

Abortion, Therapeutic↗

PubMed2006

Thrombophilia and adverse maternal-perinatal outcome: controversies in screening and management.

A recent review of the literature on thrombophilia and adverse pregnancy outcome reveals contradictory findings. There are retrospective and prospective studies that recommend testing for genetic and acquired markers of thrombophilia for those with the enumerated adverse pregnancy outcome. Based on our review, routine screening for thrombophilias in women with a history of adverse pregnancy outcome (preeclampsia, abruptio placenta, intrauterine growth restriction, and fetal loss) is not justified. Based on data from observational studies and few randomized trials with inadequate number of subjects, there is consensus that women with true antiphospholipid antibody syndrome should receive low-dose aspirin plus adjusted-dose heparin in subsequent pregnancies. Some authors also recommend heparin prophylaxis in subsequent pregnancies in women with genetic thrombophilia with previous adverse pregnancy outcome. However, this recommendation is not based on randomized trials. Hence, a randomized double-blind, controlled trial is urgently needed to evaluate the benefit of heparin during pregnancy in women with a history of adverse pregnancy outcome in association with genetic thrombophilia.

Abruptio Placentae↗

PubMed2002

[Estimate of expected cesarean section rate for maternal indications in a population of pregnant women in West Africa (MOMA survey)].

OBJECTIVES: There is still some debate about the optimal rate of cesarean section (CS) needed to achieve better outcome for both mothers and infants in developing countries. We examine here two aspects of the question: i) a simple method to estimate the expected rate of CS according to obstetrical risk; ii) a test of the method to estimate the appropriate rate for maternal indications in a general population of pregnant women in West Africa. METHODS: This population-based study was conducted in a cohort of pregnant women in six West African countries (MOMA survey): Abidjan (Ivory Coast), Bamako (Mali), Niamey (Niger), Nouakchott (Islamic Republic of Mauritania), Ouagadougou (Burkina Faso), and in three areas of Senegal, two small towns (Fatick and Kafrine, Kaolack region), and one major city (Saint-Louis). 19,459 women with singleton pregnancies with expected breech presentation were followed to delivery and puerperium. Maternal indications for CS were defined as dystocia (prolonged labor over 12 hours), malpresentation, previous cesarean section, abruptio placentae, placenta paevia and eclampsia. A standardized method was used to calculate the number of expected CS in the MOMA population, according to the level of the obstetrical risk. RESULTS: The minimal needs for Cs for maternal indications were estimated between 3.6 and 6.5 per 100 deliveries. However, we observed a rate of 1.3 CS per 100 deliveries. DISCUSSION: These findings underline the lack of CS for maternal indications in urban West Africa. The method of standardization we propose could help policy makers, health planners and obstetricians to design programs to reach the appropriate level of CS and to monitor and follow-up these programs.

Abruptio Placentae↗

PubMedDate not supplied

Retinal pigment epithelium tear following toxemia of pregnancy.

A 28-year-old woman with toxemia during the 34th week of pregnancy complained of visual loss in one eye. Two weeks after abruptio placentae and delivery a retinal pigment epithelium (RPE) tear which presumably followed a RPE detachment (PED) was found in the macular region of the right eye. Visual acuity was 0.8 at the time of diagnosis but was 1.0 in both eyes one year after the delivery. Some authors have described peculiar choroidal lesions associated with central serous chorioretinopathy (CSC) in pregnancy and ischemic exudative choroidal lesions during severe toxemia. However, the findings we describe are highly unusual, indicating that the mechanisms of choroidal and RPE pathology are still poorly understood. We also demonstrate that a pathological tear following toxemia of pregnancy is compatible with good acuity in spite of the anatomical damage.

Abruptio Placentae↗

PubMed2003

Fibrinogen Poissy II (gammaN361K): a novel dysfibrinogenemia associated with defective polymerization and peptide B release.

A fibrinogen variant was identified in a pregnant patient with disseminated intravascular coagulation and abruptio placentae. This dysfibrinogen was also found in four asymptomatic members of the patient's family. Coagulation studies showed prolongation of both the thrombin and reptilase times, and discrepancy was noted between the levels of plasma fibrinogen as determined by a kinetic versus an immunological determination or light-scattering assay. Studies on purified fibrinogen revealed an impaired release of fibrinopeptide B by thrombin related to a delayed thrombin-induced fibrin polymerization. DNA sequencing revealed a heterozygous T <-- A point mutation in position 9373 of the gamma-chain gene (exon 9), which substituted a K for an N at position 361.

Abruptio Placentae↗

PubMedDate not supplied

[Retroplacental hematoma overseas].

Abruptio placentae is a rather frequent syndrome in overseas countries. Leading to foetus death most of the time, it often endangers prognosis for the mother's life. Serious complications may be found such as shock due to hypovolaemia, coagulopathy among which process of disseminated intravascular coagulation prevail, organic renal insufficiency that may become unrecoverable because of the cortical atrophy of the kidney. The treatment combines obstetrical means with medical ones. Spontaneous uterine voiding will be tried for, since caesarian operation, often unavoidable, is not free from complication. Rehydration will be carried out by transfusing fresh blood and unfrozen plasma, the amount of which often enormous has to be dealt out in accordance with the central venous pressure.

Abruptio Placentae↗

PubMed1996

Is pregnancy-related acute renal failure a disappearing clinical entity?

The actual disappearance of pregnancy-related acute renal failure (PR-ARF) is a common "feeling" for nephrologists. The aim of this study was to exactly quantify this event by evaluating epidemiology and the extent of renal damage in PR-ARF. From 1958 to 1994, 84 cases of PR-ARF were observed (5.8% of total number of ARF needing dialysis). In four successive periods (1956-67, 1968-77, 1978-87, 1988-94), the incidence of PR-ARF fell from 43% to 0.5% with respect to the total number of ARF, and from 1/3000 to 1/18,000 with respect to the total number of pregnancies. Maternal mortality in the past was high (31%), but no cases of death in the last period were seen. Irreversible renal damage was recorded in 11.1% of PR-ARF, and, in particular, in 18.7% of cases of preeclampsia-eclampsia (PE-E). The worst maternal and renal prognosis occurred in PE-E that was complicated by abruptio placentae (AP). Neither disseminated intravascular coagulation (DIC), microangiopathic hemolytic anemia, nor prostacyclin imbalance were significantly related to the severity of renal damage. Heparin therapy did not modify DIC evolution and renal outcome and was aggravated by severe hemorragic complications. Support therapy with plasma infusion, antithrombin III, and antiplatelet agents seems to be helpful. In conclusion, PR-ARF has become a rare occurrence and, in our experience, no cases of death or irreversible renal damage were observed in the last 7 years. The most important reasons for this favorable evolution seem to be an improved medical care and more effective measures of careful prevention, mainly regarding tempestive delivery.

Abruptio Placentae↗

PubMed2003

Pulmonary embolization by chorionic villi causing maternal death after a car crash.

Throughout the last century, there has been a marked decline in obstetric maternal deaths, resulting in an increase in the proportion of nonobstetric deaths among pregnant women. Trauma, in particular, has become a leading cause of maternal death. We report the case of a 20-year-old primigravid woman who was involved in a motor vehicle crash at 36 weeks gestation. The woman developed abruptio placentae, followed by disseminated intravascular coagulation, adult respiratory distress syndrome, and shock, and died the day after the crash. Widespread pulmonary embolization by chorionic villi was identified at autopsy. This report discusses traumatic maternal deaths, with emphasis on the differences in injury pattern observed in pregnant trauma victims in comparison with other adults. It is important that the pathologist be aware of these problems so that an accurate cause of death can be identified in cases of maternal death after trauma. Also discussed is the relationship between trauma and placental abruption and the mechanism of death in the patient. To the authors' knowledge, this is the first reported case of extensive embolism of chorionic villi to the lungs after trauma.

Abruptio Placentae↗

PubMed1994

Monitored outpatient management of mild gestational hypertension remote from term.

OBJECTIVE: Our purpose was to test the hypothesis that monitored outpatient management of mild gestational hypertension remote from term reduces maternal hospitalization without adversely affecting maternal and perinatal outcome. STUDY DESIGN: Five hundred ninety-two patients at 24 to 36 weeks' gestation with mild gestational hypertension were monitored on an outpatient basis with four times daily automated blood pressure measurement and daily assessment of weight, proteinuria, and fetal movement. Maternal and perinatal outcomes were compared with previously published results from inpatient management of mild gestational hypertension. RESULTS: The mean gestational age at enrollment was 32.5 +/- 3.2 weeks with a mean gestational age at delivery of 36.7 +/- 3.6 weeks. The mean pregnancy prolongation was 27.4 +/- 3.3 days, which is similar to previously reported inpatient studies. The mean antepartum hospitalization for all patients during management was only 1.7 days. Three pregnancies were complicated by abruptio placentae, six by the syndrome of hemolysis, elevated liver enzymes, and low platelet count, and none by eclampsia. The mean birth weight was 2757 +/- 555 gm, with a birth weight of > or = 2000 gm achieved in 84% of managed patients. Eighty-seven percent of infants required a newborn hospitalization of < or = 7 days. Fifty-four percent of patients with significant proteinuria at enrollment were delivered at < 37.0 weeks' gestation, whereas only 29% of patients without proteinuria were delivered prematurely. The corrected perinatal mortality rate was 3.4 in 1000 total births. CONCLUSION: Properly monitored outpatient management of mild gestational hypertension remote from term reduces the number of days of maternal hospitalization with similar maternal and perinatal outcome compared with previously published results from inpatient management.

Abruptio Placentae↗

PubMed2004

Kidney disease is an independent risk factor for adverse fetal and maternal outcomes in pregnancy.

BACKGROUND: Kidney disease has long been recognized to adversely affect fetal and maternal outcomes during pregnancy. The goal of this study is to better describe the population of women with kidney disease and provide a contemporary assessment of their risk for adverse events caused by kidney disease after adjustment for other contributing factors. METHODS: We used Colorado birth and death certificate data for 1989 to 2001. Of 747,368 births during this period, 911 births from women with kidney disease were identified, and 4,606 births from women without kidney disease were randomly selected for comparison. Adverse fetal outcomes included fetal prematurity, low birth weight, or neonatal death, whereas adverse maternal outcomes included preeclampsia, eclampsia, or abruptio placenta. RESULTS: Women with kidney disease were more likely to have comorbid illnesses, including chronic hypertension, anemia, diabetes, and lung and cardiac disease. Women with kidney disease had a greater frequency of adverse fetal (18.2% versus 9.5%) and maternal outcomes (13.7% versus 4.3%) compared with women without kidney disease (P < 0.0001). The presence of kidney disease independently increased the likelihood of adverse fetal outcomes (adjusted odds ratio [OR], 1.76; 95% confidence interval [CI], 1.40 to 2.21) and occurrence of adverse maternal outcomes, especially in the middle 1990s, among nulliparous women (adjusted OR, 4.07; 95% CI, 2.17 to 7.66). CONCLUSION: This analysis shows that independent of other risk factors, kidney disease significantly increases the likelihood of unfavorable pregnancy outcomes for both mother and child.

Abruptio Placentae↗

PubMed1993

[Trauma and pregnancy].

The medical care provided to a pregnant trauma patient by a trauma specialist should be supplemented by a careful evaluation of the pregnant woman by an obstetrician. Motor vehicle accidents account for two-thirds of all trauma events during pregnancy, and both blunt abdominal trauma and trauma to the skull are associated with high mortality of the fetus. The severity of the trauma is an important prognostic factor for survival of both mother and fetus. Fetal injury can be caused even by apparently mild forms of maternal trauma. For early diagnosis of an abruptio placentae after blunt trauma to the abdomen, continuous monitoring of the fetal heart rate and uterine contractions is very useful. Monitoring should be continued for at least 4 h, and whenever the frequency of uterine contractions exceeds one per 15 min or tenderness of the abdomen or vaginal bleeding is present, the pregnant trauma patient should be carefully monitored under hospital conditions for at least 24 h. Extensive burns are rarely encountered during pregnancy. There is a direct correlation between the extent of the burns and survival of the fetus. When more 30% of the maternal body surface is affected by burns, fetal mortality exceeds 50%. In the third trimester, when survival chances of the fetus are better than 50%, premature delivery of the fetus should be considered whenever the mother has suffered extensive burns.

Abdominal Injuries↗

PubMed1975

The effect of intrauterine hypoxia on the child surviving to 4 years.

Intrauterine hypoxia/asphyxia is an unchallenged cause of perinatal death, but whether sublethal degrees of hypoxia result frequently in brain damage in surviving infants is less certain. To test this hypothesis, obstetric patients with abruptio placentae, placenta previa, and prolapse of the umbilical cord were computer matched on several factors with normal control patients to determine the degree of risk of lower 4 year Stanford-Binet I. Q. scores or abnormalities on the 4 year fine motor and gross motor testings. The mean I. Q. score of babies born of mothers with one of these complications was no different from that of the normal controls. Similarly negative results were recorded on the 4 year fine motor and gross motor testings. Children of low birth weight in either group experienced lower I. Q. scores and higher risk of abnormal findings on the motor tests at 4 years than the babies of mature birth weight. Intrauterine hypoxia/asphyxia apparently is not a major cause of neurologic dysfunction in the surviving child.

Abruptio Placentae↗

PubMed1999

Second-trimester maternal serum marker screening: maternal serum alpha-fetoprotein, beta-human chorionic gonadotropin, estriol, and their various combinations as predictors of pregnancy outcome.

OBJECTIVE: We evaluated the value of all 3 common biochemical serum markers, maternal serum alpha-fetoprotein, beta-human chorionic gonadotropin, and unconjugated estriol, and combinations thereof as predictors of pregnancy outcome. STUDY DESIGN: A total of 60,040 patients underwent maternal serum screening. All patients had maternal serum alpha-fetoprotein measurements; beta-human chorionic gonadotropin was measured in 45,565 patients, and 24,504 patients had determination of all 3 markers, including unconjugated estriol. The incidences of various pregnancy outcomes were evaluated according to the serum marker levels by using clinically applied cutoff points. RESULTS: In confirmation of previous observations, increased maternal serum alpha-fetoprotein levels (>2.5 multiples of the median) were found to be significantly associated with pregnancy-induced hypertension, miscarriage, preterm delivery, intrauterine growth restriction, intrauterine fetal death, oligohydramnios, and abruptio placentae. Increased beta-human chorionic gonadotropin levels (>2.5 multiples of the median [MoM]) were significantly associated with pregnancy-induced hypertension, miscarriage, preterm delivery, and intrauterine fetal death. Finally, decreased unconjugated estriol levels (<0.5 MoM) were found to be significantly associated with pregnancy-induced hypertension, miscarriage, intrauterine growth restriction, and intrauterine fetal death. As with increased second-trimester maternal serum alpha-fetoprotein levels, increased serum beta-human chorionic gonadotropin and low unconjugated estriol levels are significantly associated with adverse pregnancy outcomes. These are most likely attributed to placental dysfunction. CONCLUSION: Multiple-marker screening can be used not only for the detection of fetal anomalies and aneu-ploidy but also for detection of high-risk pregnancies.

Abruptio Placentae↗

PubMed1998

Delayed-interval delivery in multifetal pregnancy.

OBJECTIVE: Our goal was to review a single subspecialty practice experience with a uniform approach to delayed-interval delivery. STUDY DESIGN: A 66-month retrospective review of our maternal-fetal medicine practice database was completed. Fifty-nine sets of twins or triplets delivered at < 30 weeks' gestation were identified. No cases of twins or triplets who came to our care, either in consultation or as primary providers, were excluded. RESULTS: Forty-three patients were excluded as candidates for delayed-interval delivery because of monochorionicity, abruptio placentae, severe preeclampsia, and the need for hysterotomy. Sixteen pregnancies were identified as candidates for delayed-interval delivery, and we actually attempted to delay delivery in 9 of them. The details of the interval deliveries are summarized; there was a mean latency interval of 34 days with a range of 3 to 76 days. Pregnancies in which delayed-interval deliveries wer attempted were significantly less mature at the time of presentation than those managed by delivery of all infants initially. Perinatal mortality was significantly lower in the retained fetuses. CONCLUSIONS: This retrospective consecutive case review from a single maternal-fetal practice documents that selected multichorionic pregnancies may benefit from delayed-interval delivery. Modest intervals between siblings during critical gestational ages can improve newborn survival and decrease neonatal morbidity.

Abruptio Placentae↗

PubMed1988

Eclampsia and placental abruption: basic patterns, management and morbidity.

The clinical analysis of 46 cases of abruptio placentae complicating eclampsia showed that, (1) the severity of the eclamptic symptoms influenced the extension of the placental separation, (2) older and multiparous women had more complications, larger placental separations and higher mortality, (3) there were ten maternal deaths due to the additive effects of various complications, (4) total perinatal mortality was 44.7% and it was 40.5% for fetuses above 1000 g, (5) optimum timing of delivery by cesarean operation offered slightly better prognosis, even in cases with antepartum fetal death, (6) the dominant factor for morbidity was the stage reached by the combined pathology before receiving qualified medical care, and (7) the wide variability of these cases suggested that the basis for the complete management should be a series of sound and individually tailored decisions to be carried out in a reasonably short time.

Abruptio Placentae↗

PubMed2003

Longitudinal analysis of serum insulin-like growth factor-I and insulin-like growth factor binding protein-1 in antiphospholipid syndrome and in healthy pregnancy.

OBJECTIVE: The purpose of this study was to determine the concentrations of serum insulin-like growth factor-I and insulin-like growth factor binding protein-1 in pregnancies that are complicated with primary antiphospholipid syndrome. STUDY DESIGN: Longitudinal blood samples were collected from 8 weeks of gestation in 28 women with treated primary antiphospholipid syndrome and 19 control women. Serum insulin-like growth factor-I and insulin-like growth factor binding protein-1 were measured by immunoradiometric assay. RESULTS: Three antiphospholipid syndrome pregnancies miscarried, four pregnancies had intrauterine growth restriction and preeclampsia, six pregnancies had a thrombotic event, and one pregnancy had abruptio placentae. Mean (+/-SD) birth weight in antiphospholipid syndrome group was 2867 +/- 914 g (control, 3492 +/- 527 g; P =.02), and the mean gestation at delivery was 36.5 +/- 5.2 weeks (control, 40.3 +/- 0.7 weeks; P =.002). Insulin-like growth factor binding protein-1 and insulin-like growth factor-I concentrations increased with gestational age in both groups (2.8% and 2.4% per week), but insulin-like growth factor binding protein-1 was 61% higher in the antiphospholipid syndrome group (95% CI, 16%-122%; P =.004). Insulin-like growth factor-I was not significantly different (8% higher in antiphospholipid syndrome; 95% CI, -10% to 30%; P =.41). CONCLUSION: Serum concentrations of insulin-like growth factor binding protein-1 are abnormal in the antiphospholipid syndrome group and may reflect abnormalities in trophoblast invasion.

Abortion, Spontaneous↗

PubMed1984

Pregnancy outcome in 303 cases with severe preeclampsia.

The purpose of the present clinical investigation was to determine the influence of aggressive management, associated medical/obstetric complications, race, and gestational age on fetal, neonatal, and maternal risks associated with severe preeclampsia. Three hundred and three consecutive pregnancies complicated by severe preeclampsia were studied. All patients were delivered within 48 hours after admission to the perinatal center. In 91 patients the disease was superimposed on chronic hypertension. There was a significant difference between patients with and those without prior chronic hypertension regarding perinatal mortality (32 versus 7.7%), incidence of abruptio placentae (10 versus 4%), and frequency of small-for-gestational-age infants (33 versus 14%). Fifty-one patients (17%) had thrombocytopenia, 26 (8.5%) had hemolysis, elevated liver enzymes and low platelet count syndrome, and 22 (7.3%) had disseminated intravascular coagulopathy. There was significant difference between white and black patients regarding the frequency of thrombocytopenia (28 versus 13%), hemolysis, elevated liver enzymes, and low platelet count syndrome (19.7 versus 5.3%), and coagulopathy (13 versus 1.4%). However, most of this apparent racial difference resulted from higher incidence of abnormal hematologic findings among patients who had conservative management by private physicians before transfer. Perinatal survival was zero when severe preeclampsia developed at or before 28 weeks, whereas it was 100% when disease developed after 36 weeks' gestation. The above factors should be considered in counselling patients with severe preeclampsia.

Abruptio Placentae↗