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PubMed2004

The thick heterogeneous (jellylike) placenta: a strong predictor of adverse pregnancy outcome.

OBJECTIVE: To present a series of cases with a sonographic thick and heterogeneous placenta, and to review the literature. METHODS: A series of 16 cases were analyzed. A heterogeneous placenta was defined as a thick placenta with a patchy decrease of echogenicity, which quivered like jelly to sharp abdominal pressure. A comprehensive morphologic and Doppler evaluation of the fetus and the uteroplacental circulation was performed. The pregnancy course and the neonatal outcome of the present series and of those reported in the literature were reviewed. RESULTS: Placental thickness was greater than the 95th centile in all cases. The placenta was located laterally in 13 (81.3%) cases. Twelve women delivered earlier than 34 weeks either spontaneously or because of deteriorating maternal and/or fetal conditions (n = 10). Perinatal death occurred in eight cases. The uterine artery Doppler and the umbilical artery were abnormal in eight and eight cases respectively. A discordancy between the umbilical artery size was present in six cases. Abruptio placentae occurred in three cases. A strong association between hypertensive disorders and fetal growth restriction was found in our series and in literature. CONCLUSIONS: The sonographic presence of thick heterogeneous placenta is strongly associated with an adverse pregnancy outcome and often with perinatal death.

Adult↗

PubMed2001

Unexplored territories in the nonsurgical patient: a look at pregnancy.

Venous thromboembolism (VTE) remains the most common cause of maternal death during pregnancy and the puerperium. The risk is increased in women older than 35 years and those with obesity, previous VTE, operative delivery, and underlying thrombophilia. Anticoagulant therapy is indicated for short-term treatment of VTE and as thromboprophylaxis in high-risk patients. Warfarin is contraindicated during the first trimester because of fetotoxicity; unfractionated heparin (UFH) is associated with practical disadvantages and a risk of heparin-induced thrombocytopoenia (HIT) and osteoporosis with long-term use. Low-molecular-weight heparins (LMWHs) are convenient to use, do not cross the placenta, carry a lower risk of HIT and osteoporosis, and have been shown to be safe and effective during treatment of approximately 500 pregnant women. LMHWs are increasingly replacing UFH as the anticoagulant of choice during pregnancy; further studies are required to determine optimal therapeutic and thromboprophylactic doses. Women with inherited or acquired thrombophilia are at increased risk of severe pregnancy complications, including recurrent miscarriage, pre-eclampsia, fetal growth restriction, abruptio placentae, and stillbirth; uteroplacental microvascular thrombosis caused by thrombophilia appears to be the pathophysiologic link. LMWHs have been shown to improve pregnancy outcome in women with a history of obstetric complications and confirmed thrombophilia.

Anticoagulants↗

PubMed1998

[Arterial hypertension and pregnancy: diagnostic criteria and therapeutic approach].

Arterial hypertension is a relatively common complication of pregnancy, affecting about 10% of all normal pregnancies. The American College of Obstetric and Gynecology established in 1972 four different forms of arterial hypertension during pregnancy: a) arterial hypertension related to pregnancy, the so-called pre-eclampsia; b) arterial hypertension unrelated to pregnancy or chronic arterial hypertension; c) Pre-eclampsia superimposed on chronic arterial hypertension, and d) Transient or late arterial hypertension (third trimester). Pre-eclampsia and arterial hypertension are two different illnesses with different approaches and treatments. The mechanisms involved in arterial hypertension and pre-eclampsia of pregnant women are presently very well known, including genetic causes, alterations on the renin-angiotensin system, imbalance between vasoconstrictor and vasodilator agents derived from endothelial activity of the spiral arteries of the placenta, such as; prostacyclins, thromboxane A2, nitric oxide, endothelin-1, etc. The placenta is the key factor in inducing pre-eclampsia, and its expulsion during delivery or cesarean section is the definite cure of the process. All hypertensive forms during pregnancy increase the risks on both the mother and the fetus. Maternal risk is based on renal, metabolic and haematologic disorders, leading in some cases to cerebral haemorrhage or hepatic rupture. In the fetus, pre-eclampsia significantly increases the risk of still-birth, abruptio placentae, hypocalvaria, intrauterine growth retardation, and prematurity. Clinical, biochemical and haematologic manifestations of pre-eclampsia are very typical, facilitating an early and easy diagnosis.

Circadian Rhythm↗

PubMed1982

Epidemiologic study of necrotizing enterocolitis among low-birth-weight infants. Absence of identifiable risk factors.

Necrotizing enterocolitis has been associated with a variety of perinatal problems which have been purported to be risk factors predisposing the neonate to NEC. The present investigation compares the perinatal histories of 48 low-birth-weight infants (less than 1,500 gm) with NEC to those of 553 high-risk infants of equivalent birth weight who did not have NEC but who were present in the nursery during a four-year observation period. The two populations were equivalent with regard to maternal factors such as socioeconomic status, education, race, and age. Both the antenatal and intrapartum risk scores were similar, as were the position of presentation and mode of delivery. The incidence of pre-eclampsia, prolonged rupture of the membranes, and placenta previa was also equivalent. Birth weight and gestational age were identical, as well as intrauterine growth retardation and low Apgar scores. The placement of umbilical artery catheters or the performance of exchange transfusions were not more frequent among patients with NEC. Infants who developed NEC demonstrated significantly different incidences of only three variables. Mothers of these infants were usually married, and their infants had less respiratory distress syndrome; the only adverse factor present more frequently was abruptio placenta. These data raise further questions concerning the significance of previously reported risk factors of NEC.

Adult↗

PubMed1991

[Accumulation of two different hydroxyethyl starch preparations in the placenta after hemodilution in patients with fetal intrauterine growth retardation or pregnancy hypertension].

In a prospective clinical study the safety of two hydroxyethylstarch preparations (HES steril 10%, Fresenius AG, Oberursel = HES-A; Haemufusin, Kabi-Pfrimmer, Erlangen = HES-B) were assessed. In 60 patients with fetal growth retardation and/or gestational hypertension, hematocrit, aPTT, factor VIIIR: Ag, fibrinogen, uric acid, cord blood hemoglobin, hematocrit, pH-value and the fetal/maternal hydroxyethylstarch concentration before and after eight (HES-B) or nine (HES-A) days of treatment were monitored. 500 ml HES-A (n = 36) or HES-B (n = 24) together with the same volume electrolyte solution, were infused daily. Both substances lowered significantly the maternal and fetal hematocrit. Histopathological changes of placenta (trophoblast cells and stroma) taking place after the infusion of HES-A or HES-B were depicted by light microscopy. Administration of HES-A or HES-B was associated with lower values of factor VIIIR: Ag and a prolongation of aPTT, but only HES-B demonstrated a significant effect (31% vs. 12%, p less than 0.01). We observed in 4 (16.7%) cases severe uterine bleeding complications and one woman (4.2%) with abruptio placentae in the group HES-B. Light microscopy shows vacuoled trophoblast and stroma cells after HES infusions. The marked vacuolisation of the placenta after HES-B is due to differences in the physicochemical characteristics of HES-A and HES-B. For this reason, we prefer to administer HES-A in the dilution treatment of patients with placental insufficiency.

Adolescent↗

PubMed2005

Clinico-pathological profile of 12 cases of chorangiosis.

Chorangiosis is one of the vascular lesions that involves terminal chorionic villi. It is commonly associated with various feto-maternal conditions like pre-eclampsia, diabetes etc. However, the clinical significance of this pathological finding has not been studied extensively. The aim of this study was to identify the various conditions associated with chorangiosis and to determine its clinical significance. A retrospective study to identify the cases of placentas diagnosed with chorangiosis was carried out and the clinical and morphological details of these cases were reviewed. Immunostaining for CD34 and muscle-specific actin was also performed to confirm chorangiosis and to exclude chorangiomatosis. A total of 12 cases of chorangiosis were retrieved, most of them were of term gestation. Five of these 12 cases were associated with various maternal conditions including syphilis (2 cases) and single cases of pre-eclampsia, diabetes and jaundice. One case in each had abruptio placenta and non-immune hydrops. Of these 12 cases, seven were stillborn. Microscopically, all 12 cases showed extensive chorangiosis involving terminal villi. In addition, two cases showed focal infarction and one had extensive calcification. Immunostaining for CD34 confirmed increased number of capillaries while muscle-specific actin was negative, excluding chorangiomatosis. The clinico-pathological profile presented in this study suggests that chorangiosis has characteristic pathological features for its recognition and needs to be differentiated from similar conditions like chorangioma and chorangiomatosis. Also, chorangiosis has potential clinical significance and should be mentioned in the pathology report and the patient should be investigated for associated conditions like syphilis, pre-eclampsia, diabetes etc.

Adult↗

PubMed1992

Prenatal diagnosis by amniocentesis in 82 pregnancies after in vitro fertilization.

We report on the outcome of 82 amniocenteses (AC) carried out during pregnancies after in vitro fertilization (IVF) from 1-1-1985 to 31-12-1989. The main indication for amniocentesis was a maternal age of greater than or equal to 35 years. In 48 cases, we found an anterior placenta and assumed that this was related to the position in which the uterine embryo transfer was performed. In six pregnancies, we found an abnormal karyotype, including two cases of trisomy 21; the two couples decided for abortion. Four aberrations in the fetal karyotypes were also present in either the mother or the father, the resulting children are healthy. The further course of pregnancies after IVF and AC was characterized by a higher incidence of toxemia, uterine bleeding before the 28th week of gestation, abruptio placentae, and premature deliveries, when compared to the course of pregnancies after spontaneous conception. We believe that these occurrences were not caused by AC, as the incidence was higher in all our pregnancies after IVF (without AC) and has also been reported in pregnancies after ovarian hyperstimulation without IVF. Therefore, we see no reason to renounce AC after IVF. However, the special risks inherent in pregnancies after IVF must always be discussed with the couple.

Adult↗

PubMed2004

[Recurrent spontaneous miscarriages and hyperhomocysteinemia].

AIM: Recurrent fetal loss is defined as the number of consecutive miscarriages which is not less than 2 occurred within the 16th week of gestation and it is a very interesting pathology of pregnancy. Further to thrombophilia, very important causes have been identified, since the damage of the vascular system supporting the placenta may cause a deficiency of placenta functions and development, leading to a loss of the conception product, also in a condition of hyperhomocystinemia, causing a damage to the vascular endothelium. Hyperhomocystinemia seems to be a risk factor for artero-venous thrombotic diseases, even not in pregnancy. METHODS: We have examined 40 patients referred to our Institute for unexplained fetal loss (at least 2 consecutive miscarriages within the 16th week of gestation) and the same number of patients who had at least 1 spontaneous delivery with a healthy and alive newborn and none abortion nor fetal death nor abruptio placentae. RESULTS: The mean levels of homocystinemia observed were significantly different in the 2 groups (p = or < 0.05). In the control group the values of plasmatic homocysteine were 10+/-4 micromol/L, corresponding to normal range, while in the other group the values of plasmatic homocysteine were 21+/-6 micromol/L, values certainly elevated, also because during the 1st trimester of pregnancy the levels of homocysteine decrease, reaching the lowest value during the 2nd trimester of pregnancy. In particular, high levels of homocysteine have been found in 25% (10) of women with unexplained early fetal loss. CONCLUSION: Hypercystinemia, as a consequence of an interaction between a primary genetic defect and a nutrition condition (folate deficiency), may be a cause of recurrent miscarriages. Therefore, in these cases, a possible hypercystinemia should be searched and an association of folic acid and vitamin B6, a non teratogenic treatment, should be useful to restore the metabolic picture and to favour the pregnancy outcome.

Abortion, Habitual↗

PubMed2006

Emergency peripartum hysterectomy in a tertiary obstetric center: 8-year evaluation.

OBJECTIVE: The aim of the study was to present the incidence, indications, and operative morbidity and mortality in pregnant women undergoing emergency peripartum hysterectomy (EPH) at a tertiary obstetric institution. METHODS: In this retrospective clinical study, performed during the period 1995-2003, 17 EPH procedures were recorded in a total of 21,659 deliveries carried out at Department of Gynecology and Obstetrics, Osijek Clinical Hospital in Osijek, Croatia. Data on the incidence of EPH in total number of deliveries, rate of EPH in vaginal delivery and cesarean section, indications for EPH, and maternal and fetal/early neonatal morbidity and mortality were derived from operative protocols and medical records of hospitalized patients. RESULTS: During the 8-year study period, the incidence of EPH in total number of deliveries was 0.078%. Out of 17 EPH procedures, 5 (29.41%) were performed after vaginal delivery and 12 (70.59%) during cesarean section, elective in five and urgent in seven cases. The indications for EPH included severe peripartum hemorrhage with placenta previa in four, placenta previa percreta in four, various forms of invasive malplacentation (placenta accreta, increta, percreta) in five, uterine rupture in two cases, and atony along with massive retroperitoneal hematoma due to rupture of periuterine vascular bundle during cesarean section in one multipara. EPH was carried out in 12 multipara and five primipara. Lesions of urinary bladder occurred in three cases and were managed by suture. Twelve patients received blood transfusion, whereas development of hemorrhagic shock necessitated transfer to Intensive Care Unit in three patients. No late complications or maternal mortality were recorded. Sixteen total hysterectomies and one supracervical hysterectomy were performed. One case of intrauterine fetal death was caused by total abruptio placenta and uterine rupture during the patient's transport from a primary obstetric institution. CONCLUSION: Invasive malplacentation is a major isolated risk factor for EPH, as shown in the present study. Other risk factors for EPH are massive hemorrhage because placenta previa, uterine atony and uterine rupture associated with multiparity, and previous cesarean section. A great proportion of EPH procedures can be prevented by the introduction of compressive operative methods such as B-Lynch suture in the obstetric algorithms, which will certainly favorably reflect in future fertility and genital health of the female population.

Algorithms↗

PubMed1990

Feto-maternal haemorrhage in Kenya.

Six hundred and twenty antenatal, 40 post normal delivery 40 post caesarian section, 4 patients with placenta previa and 3 with fresh still section, 4 patients with placenta previa and 3 with fresh still births were investigated for feto maternal haemorrhage. The prevalence of feto maternal haemorrhage was 32.2% for antenatal patients, 45% for post caesarian section ones and 25% after normal delivery. All the values were higher than in Caucasian studies. Antenatal prevalence increased with gestation being 15.4% in first trimester, 29.5% in second and 38% in third trimester (p 0.05). Maternal age, parity, number of previous abortions and marital status did not influence the prevalence. Increased feto maternal haemorrhage was associated with history of vaginal bleeding or trauma but not pre-eclampsia. Feto maternal macrotransfusion was detected in 1% of antenatal patients, two patients with abruptio placenta, one with still birth and eight delivered by caesarian section. The mode of delivery did not influence the frequency but affected the volume of feto maternal transfusion. Probable changes in the timing of prophylactic anti D-gammaglobulin are discussed.

Cesarean Section↗

PubMed2001

Local cold stress to the soles induces retroplacental hemorrhage in rats.

The aim of this study was to investigate the effect of local cold stress to the soles on placental histology in rats. Pregnant rats were subjected to a cold provocation (0 degrees C, 12 degrees C) and room temperature (23 degrees C) for 15 and 30 minutes. During cold stimulation and at the control temperature, uterine blood flow and uterine contraction were measured simultaneously. Histological studies of the placentas of these rats were also performed. Cold stress at 0 degrees C and 12 degrees C significantly decreased uterine blood flow (P < .005, P < .02) compared with controls (23 degrees C). The decrease in uterine blood flow was greater at 0 degrees C than at 12 degrees C stress. Cold-induced stress (0 degrees C) also evoked an isometric tension with increased frequency and amplitude in the rat uterus (P < .003, P < .0002) compared with controls (23 degrees C). Stimulation at 12 degrees C did not induce any uterine contractions. Placental histology of rats stressed at 0 degreesC revealed hemorrhages into the decidua basalis. These findings suggest that local cold stress decreases uterine blood flow and increases uterine contraction, resulting in retroplacental hemorrhage in rats. This model may account for human abruptio placentae.

Animals↗

PubMed1978

Neonatal anaemia secondary to blood loss.

The newborn has a limited capacity to tolerate acute haemorrhage. Prompt diagnosis and therapy are essential for survival. Blood loss can occur in the newborn due to occult haemorrhage, prior to birth or during delivery, obstetric accidents, maternal haemorrhage, or secondary to recurrent blood sampling. Special precautions must be taken when events known to cause fetal haemorrhage have occurred during pregnancy. These include a maternal history of transfusion reaction in the absence of a transfusion, third trimester bleeding with placenta praevia, placenta abruptio and vasa praevia, emergency caesarean sections, twin pregnancies and amniocentesis. The clinical manifestations of post-haemorrhagic anaemia at birth depend on the extent and duration of blood loss. When acute massive blood loss has occurred, the infant is extremely pale and requires immediate transfusions or volume expanders. Although the haemoglobin may be normal initially, it rapidly falls within six to eight hours after birth. Other causes of extreme pallor in the newborn include asphyxia and anaemia secondary to haemolysis. Infants who have developed acute post-haemorrhagic anaemia are hypovolaemic, are neither jaundiced nor cyanotic, and respond to therapy with volume expanders. The clinical picture with chronic blood loss is usually mild and responds to conservative therapy with iron alone. Internal haemorrhage should be suspected when a 24 to 72 hour newborn rapidly deteriorates and has evidence for hypovolaemic shock without signs of external blood loss. The blood withdrawn for laboratory evaluation in the high risk newborn must be carefully monitored so that it can be replaced before the newborn becomes compromised.

Adult↗

PubMed2003

Outcome of twin pregnancy in booked versus unbooked cases.

OBJECTIVE: To assess the outcome of twin pregnancy in booked versus unbooked cases. DESIGN: Comparative study. PLACE AND DURATION OF STUDY: This study was conducted in Khyber Teaching Hospital, Gynae A unit, Peshawar, over a period of two years from 1st January 1996 to 31st December 1997. SUBJECTS AND METHODS: A total of 96 patients with twin pregnancy were included. The inclusion criteria were all those patients who had completed twenty-eight weeks of pregnancy with twin gestation. Evaluation was done by a detailed history and data was collected. Antenatal, intrapartum and postnatal complications as well as perinatal mortality and morbidity was noted in the two groups. RESULTS: Out of 96 cases, 65 patients were unbooked and 31 patients were booked cases. Majority of the unbooked cases came from rural areas and belonged to age group of 18 to 38 years. The rate of instrumental deliveries was high in unbooked cases (18.46%) as compared to booked cases (9.67%). Obstructed labour (9.23%), abruptio placenta (6.15%) and postpartum haemorrhage (21.35%) were common in unbooked cases. Caesarean section was performed in 25 unbooked cases as compared to 4 booked cases. Similarly, the perinatal mortality was high in unbooked cases with 26.93% of cases requiring admission in nursery and 15.3% were stillborn. CONCLUSION: Twin pregnancy is a high risk pregnancy. Diagnosis before delivery is important. The patient should be provided with sufficient information regarding advantages of regular antenatal visits.

Adolescent↗

PubMed1998

Risk factors for low birth weight: results from a case-control study in southern Spain.

The main objective of this study is to examine the effect of several variables, including altitude of maternal residence, on delivering a low birth weight (LBW) newborn. A case-control study was done. Two hundred forty cases (single newborn weighing less than 2,500 g) and 374 controls (single newborn weighing more than 2,499 g) were included. Information was gathered from the clinical chart of delivering women, through a personal interview and the Spanish Census Bureau (for altitude). Predictors of LBW were assessed through stepwise logistic regression analysis. Several well-known LBW risk factors were identified: hypertension, weight gain during pregnancy, body size (mainly maternal prepregnancy weight), low social class, primiparity, and several conditions (spontaneous delivery, abruptio placentae). Altitude was an independent predictor of LBW at term (more than 37 weeks of gestational age) but not for preterm LBW. Nevertheless, a relationship between altitude and birth weight was not found in controls, although a moderate decreasing gradient with altitude was observed. The limitations of these findings are discussed.

Adult↗

PubMed1999

Peripartum cocaine use and adverse pregnancy outcome.

The objective of the study was to analyze possible adverse effects of peripartum cocaine use on maternal and fetal outcomes. Informed consent was given by 720 (97%) of 740 women who delivered consecutively at a large urban public hospital to test an umbilical cord blood sample for the presence of non-medically administered drugs of abuse and alcohol and to be interviewed for the study. Samples were tested for the presence of a cocaine metabolite (benzoylecgonine-BZE) by radioimmunoassay. The presence of other substances of abuse (alcohol, methamphetamine, opiates) resulted in exclusion from the sample of 143 subjects. Thus, in this cohort analysis, drug-free controls (N = 469) were compared to those positive for cocaine only (N = 108). Peripartum exposure to cocaine only, and no other substances of abuse, was associated with an increased frequency of abruptio placentae (1.9% vs 0% for control, P < 0.004), thick meconium stained amniotic fluid (3.9% vs 0.7% for controls, P < 0.006), premature rupture of membranes (P < 0.02), genitourinary anomalies (OR = 3.6, P < 0.05), abdominal wall defects (OR = 4.4, P < 0.01) and increased frequency of low birth weight (OR = 2.0, P < 0.02). These are important findings because previous studies have been complicated by the confounding effects of other substances of abuse. Am. J. Hum. Biol. 11:598-602, 1999. Copyright 1999 Wiley-Liss, Inc.

Journal Article↗

PubMed1985

Non-Hodgkin's lymphoma associated with pregnancy. A report of six cases, with a review of the literature.

Six patients with non-Hodgkin's lymphoma diagnosed during late pregnancy or shortly thereafter are reported. Three patients had high-grade lymphoma and three, intermediate-grade histologic features. Five of the six patients were in Stage 4 and one was Stage 1. Only three had the diagnosis of non-Hodgkin's lymphoma during pregnancy, and in these three cases the disease appeared to progress rapidly after delivery. The other three women probably had lymphoma during pregnancy; lymphoma was widespread at the time of their diagnosis, but the diagnosis was only established on biopsy specimens after delivery in all three instances. Five patients had full-term natural deliveries with normal infants. A single patient with Burkitt's lymphoma had a premature delivery with a cesarean section in the 29th week because of abruptio placentae probably due to lymphoma of the uterine wall. In this case both mother and child died within 48 hours of delivery. The other five patients were treated soon after delivery. Published literature dealing with this topic is scanty and inconclusive; accordingly this report attempts to discuss management of lymphoma in pregnancy, based on the authors' limited experience with these six patients.

Adult↗

PubMed1984

Rh immune globulin after genetic amniocentesis: impact on pregnancy outcome.

Although Rh immune globulin is commonly given to Rh-negative women undergoing genetic amniocentesis, there is little documentation of the necessity, efficacy, or safety of this policy. In this study, reproductive outcomes in 147 women each receiving 150 micrograms of Rh immune globulin after genetic amniocentesis were compared with those of an equal number of Rh-positive amniocentesis control women. No significant differences were found in the incidence of midtrimester pregnancy loss, mean gestational age at delivery, mean birth weight, or frequency of preterm deliveries (P greater than 0.05 for all parameters). While two antepartum stillbirths occurred in the study group and none in the control population, causes unrelated to Rh immune globulin administration were apparent for both fetal deaths (one multiple congenital anomaly syndrome, one abruptio placentae at 38 weeks). Of the 103 Rh-negative women giving birth to Rh-positive infants, none were overtly sensitized at the time of delivery. It is concluded that second trimester Rh immune globulin administration does not increase the risk of pregnancy loss.

Abortion, Spontaneous↗

PubMed1992

Elevated second trimester maternal serum beta-HCG concentrations and subsequent adverse pregnancy outcome.

Previous studies have found an association between elevated second trimester maternal serum alpha-fetoprotein (MS-AFP), in the absence of fetal anomalies, and adverse pregnancy outcome. We studied the association between elevated second trimester maternal serum beta-HCG, now also routinely measured by prenatal screening programs, and adverse pregnancy outcome by reviewing retrospectively the pregnancy outcomes among women with markedly elevated midtrimester beta-HCG in our prenatal screening program. Seven (0.23%) of 3,000 consecutively screened women had a serum beta-HCG above 5 MOM. Four (57%) of these 7 women had an adverse pregnancy outcome including severe preeclampsia (n = 2), abruptio placentae (n = 1), or preterm labor (n = 1). A concurrently elevated MS-AFP was found in only one of these 4 patients. Elevated mid-trimester maternal serum beta-HCG may be an independent risk factor for subsequent adverse pregnancy outcomes.

Chorionic Gonadotropin↗