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100: Placental abruption: critical analysis of risk factors, trends and perinatal outcomes
www.AJOG.org
Clinical Obstetrics, Neonatology, Physiology-Endocrinology
were randomly assigned to one of two groups and had either continuous access to drinking water only (H2O) or drinking water plus fluoxetine (H2O⫹FLX) (4mg/50mL). Plugged dams were sacrificed, weighed, dissected, and analyzed on day 14 to verify pregnancy and assess for litter size and evidence of altered embryo implantation. RESULTS: Seventy-six mice were confirmed to be pregnant by copulatory plug. Litter size was decreased in H2O⫹FLX dams (4.10 pups ⫾ 1.30/litter) compared to H2O dams (5.50 pups ⫾ 1.90/litter), P ⫽ 0.0222. Live birth rates were decreased in dams exposed to H2O⫹FLX, 30.6% (11/36), compared to dams exposed to H2O alone, 52.5% (21/ 40), P ⫽ 0.0497. There was a trend towards decreased mean weight at day 14 in H2O⫹FLX dams (4.88 ⫾ 1.04 grams) compared to H2O dams (6.13 ⫾ 2.44 grams), P ⫽ 0.1160. Uterine horn dissection to assess for nonviable pregnancy tissue or missed abortion revealed an 18.2% (2/11) rate in H2O⫹FLX dams compared to a 0.0% (0/21) rate in H2O dams, P ⫽ 0.2000. CONCLUSION: These results suggest a possible relationship between antenatal fluoxetine, decreased litter size, and spontaneous loss in mice. The underlying mechanism remains unclear and warrants further investigation. Pregnancy outcomes H2O (nⴝ40) Mean litter size (pups / litter)
5.50 ⫾ 1.90
H2O ⴙ FLX (nⴝ36) 4.10 ⫾ 1.30
P value 0.0222
Poster Session I
CONCLUSION: Placental abruption is an independent risk factor for
perinatal mortality. Since the incidence of placental abruption has increased during the last decade, risk factors should be carefully evaluated in an attempt to improve surveillance and outcome.
Figure 1: Frequency of placental abruption by gestational age (weeks) 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.115
..........................................................................................................................................................................................
Live birth rate (pregnant/plugged) 52.5% (21/40) 30.6% (11/36) 0.0497 .......................................................................................................................................................................................... Mean weight at day 14 (grams) 6.13 ⫾ 2.44 4.88 ⫾ 1.04 0.1160 .......................................................................................................................................................................................... Missed abortion rate 0.0% (0/21) 18.2% (2/11) 0.2000 ..........................................................................................................................................................................................
101 Elective caesarean hysterectomy vs. conservative surgery in patients with invasive placentation Hagai Amsalem1, John CP Kingdom1, Farine Dan1, Yoav Yinon1, John Kachura2, Lisa Allen3, Sophia Pantazi4, R. Windrim1
0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.114
100 Placental abruption: critical analysis of risk factors, trends and perinatal outcomes Gali Parietne1, Arnon Wiznitzer1, Ruslan Sergienko2, Moshe Mazor3, Gershon Holcberg4, Eyal Sheiner1 1
Soroka University Medical Center, Ben Gurion University of the Negev, Department of Obstetrics and Gynecology, Beer-Sheva, Israel, 2Ben-Gurion University of the Negev, Epidemiology and Health Services Evaluation, BeerSheva, Israel, 3Soroka University Medical Center, Obstetrics and Gynecology, Beer-Sheva, Israel, 4Soroka University Medical Center, Beer-Sheva, Israel
OBJECTIVE: To investigate risk factors and pregnancy outcome of patients with placental abruption. STUDY DESIGN: A population-based study comparing all pregnancies of women with and without placental abruption was conducted. Stratified analysis using multiple logistic regression models was performed to control for confounders. RESULTS: During the study period there were 185,476 deliveries, of which 0.7% (1365) occurred in patients with placental abruption. The incidence of placental abruption increased between the years 1998 to 2006 from 0.6% to 0.8%. Placental abruption was more common at earlier gestational age (Figure 1). The following conditions were significantly associated with placental abruption, using a multivariable analysis with backward elimination: hypertensive disorders (OR 2.0; 95% CI 1.7-2.4), prior cesarean section (OR 1.3; 95% CI 1.2-1.6), maternal age (years; OR 1.02; 95% CI 1.01-1.03) and gestational age (weeks; OR 0.7; 95% CI 0.7- 0. 8). Placental abruption was significantly associated with adverse perinatal outcomes such as Apgar scores ⬍7 at 1 and 5 minutes ( 44.6% vs. 5.7%; P⬍0.001, and 21.6% vs. 2.5%; P⬍0.001, respectively), and perinatal mortality (19.4% vs. 1.1%; P⬍0.001). Patients with placental abruption were more likely to have cesarean deliveries (67.7% vs. 12.8%; P⬍0.001), and cesarean hysterectomy (0.4% vs. 0.1%; P⬍0.001). Using another multivariate analysis, with perinatal mortality as the outcome variable, controlling for gestational age, hypertensive disorders etc., placental abruption was noted as an independent risk factor for perinatal mortality (weighted OR 2.7; 95% CI 2.2-3.3; P⬍0.001).
1 Mount Sinai Hospital, Obstetrics and Gynecology; Division of Maternal Fetal Medicine, Toronto, Ontario, Canada, 2Mount Sinai Hospital, Department of Medical Imagin Mount Sinai Hospital, Toronto, Ontario, Canada, 3Mount Sinai Hospital, Obstetrics and Gynecology, Toronto, Ontario, Canada, 4Mount Sinai Hospital, Department of Medical Imaging, Ontario, Canada
OBJECTIVE: The more serious forms of invasive placentation (increta
or percreta) present significant challenges at caesarean delivery, largely due to the maternal pelvic angiogenic response to placental invasion. Caesarean hysterectomy in such circumstances may result in massive blood loss despite surgical expertise. We reviewed 2 divergent surgical approaches: elective Caesarean hysterectomy (CH) vs. a “conservative approach” (CA) where following Caesarean delivery the placenta was initially left in-situ. STUDY DESIGN: Single-center retrospective review of all patients delivered with an antenatal diagnosis of invasive placentation between 2000 –2009. Ultrasound diagnosis was followed by MRI in all cases. RESULTS: 26 patients met inclusion criteria. CH was planned in 16 patients and CA in 10. All had pre-operative internal iliac balloons and post-partum embolization of the uterine arteries. All women survived. Blood loss, coagulopathy and bladder injury were all less common among the CA group although this difference was not statistical significant. Table 1 summarizes these early morbidities. 4/10 patients initially treated conservatively required a subsequent hysterectomy for; severe vaginal bleeding due to uterine AV malformation (2), coagulopathy (1) or sepsis (1). No subsequent pregnancies have been reported yet in the conservative approach group. CONCLUSION: In this single centre cohort of antenatally diagnosed invasive placentation, CS and planned placental non-delivery with uterine conservation had similar outcomes to planned Cesarean hysterectomy. A conservative approach is an option in patients with extensive bladder involvement or those requesting preservation of fertility.
Supplement to DECEMBER 2009 American Journal of Obstetrics & Gynecology
S53
Clinical Obstetrics, Neonatology, Physiology-Endocrinology
were randomly assigned to one of two groups and had either continuous access to drinking water only (H2O) or drinking water plus fluoxetine (H2O⫹FLX) (4mg/50mL). Plugged dams were sacrificed, weighed, dissected, and analyzed on day 14 to verify pregnancy and assess for litter size and evidence of altered embryo implantation. RESULTS: Seventy-six mice were confirmed to be pregnant by copulatory plug. Litter size was decreased in H2O⫹FLX dams (4.10 pups ⫾ 1.30/litter) compared to H2O dams (5.50 pups ⫾ 1.90/litter), P ⫽ 0.0222. Live birth rates were decreased in dams exposed to H2O⫹FLX, 30.6% (11/36), compared to dams exposed to H2O alone, 52.5% (21/ 40), P ⫽ 0.0497. There was a trend towards decreased mean weight at day 14 in H2O⫹FLX dams (4.88 ⫾ 1.04 grams) compared to H2O dams (6.13 ⫾ 2.44 grams), P ⫽ 0.1160. Uterine horn dissection to assess for nonviable pregnancy tissue or missed abortion revealed an 18.2% (2/11) rate in H2O⫹FLX dams compared to a 0.0% (0/21) rate in H2O dams, P ⫽ 0.2000. CONCLUSION: These results suggest a possible relationship between antenatal fluoxetine, decreased litter size, and spontaneous loss in mice. The underlying mechanism remains unclear and warrants further investigation. Pregnancy outcomes H2O (nⴝ40) Mean litter size (pups / litter)
5.50 ⫾ 1.90
H2O ⴙ FLX (nⴝ36) 4.10 ⫾ 1.30
P value 0.0222
Poster Session I
CONCLUSION: Placental abruption is an independent risk factor for
perinatal mortality. Since the incidence of placental abruption has increased during the last decade, risk factors should be carefully evaluated in an attempt to improve surveillance and outcome.
Figure 1: Frequency of placental abruption by gestational age (weeks) 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.115
..........................................................................................................................................................................................
Live birth rate (pregnant/plugged) 52.5% (21/40) 30.6% (11/36) 0.0497 .......................................................................................................................................................................................... Mean weight at day 14 (grams) 6.13 ⫾ 2.44 4.88 ⫾ 1.04 0.1160 .......................................................................................................................................................................................... Missed abortion rate 0.0% (0/21) 18.2% (2/11) 0.2000 ..........................................................................................................................................................................................
101 Elective caesarean hysterectomy vs. conservative surgery in patients with invasive placentation Hagai Amsalem1, John CP Kingdom1, Farine Dan1, Yoav Yinon1, John Kachura2, Lisa Allen3, Sophia Pantazi4, R. Windrim1
0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.114
100 Placental abruption: critical analysis of risk factors, trends and perinatal outcomes Gali Parietne1, Arnon Wiznitzer1, Ruslan Sergienko2, Moshe Mazor3, Gershon Holcberg4, Eyal Sheiner1 1
Soroka University Medical Center, Ben Gurion University of the Negev, Department of Obstetrics and Gynecology, Beer-Sheva, Israel, 2Ben-Gurion University of the Negev, Epidemiology and Health Services Evaluation, BeerSheva, Israel, 3Soroka University Medical Center, Obstetrics and Gynecology, Beer-Sheva, Israel, 4Soroka University Medical Center, Beer-Sheva, Israel
OBJECTIVE: To investigate risk factors and pregnancy outcome of patients with placental abruption. STUDY DESIGN: A population-based study comparing all pregnancies of women with and without placental abruption was conducted. Stratified analysis using multiple logistic regression models was performed to control for confounders. RESULTS: During the study period there were 185,476 deliveries, of which 0.7% (1365) occurred in patients with placental abruption. The incidence of placental abruption increased between the years 1998 to 2006 from 0.6% to 0.8%. Placental abruption was more common at earlier gestational age (Figure 1). The following conditions were significantly associated with placental abruption, using a multivariable analysis with backward elimination: hypertensive disorders (OR 2.0; 95% CI 1.7-2.4), prior cesarean section (OR 1.3; 95% CI 1.2-1.6), maternal age (years; OR 1.02; 95% CI 1.01-1.03) and gestational age (weeks; OR 0.7; 95% CI 0.7- 0. 8). Placental abruption was significantly associated with adverse perinatal outcomes such as Apgar scores ⬍7 at 1 and 5 minutes ( 44.6% vs. 5.7%; P⬍0.001, and 21.6% vs. 2.5%; P⬍0.001, respectively), and perinatal mortality (19.4% vs. 1.1%; P⬍0.001). Patients with placental abruption were more likely to have cesarean deliveries (67.7% vs. 12.8%; P⬍0.001), and cesarean hysterectomy (0.4% vs. 0.1%; P⬍0.001). Using another multivariate analysis, with perinatal mortality as the outcome variable, controlling for gestational age, hypertensive disorders etc., placental abruption was noted as an independent risk factor for perinatal mortality (weighted OR 2.7; 95% CI 2.2-3.3; P⬍0.001).
1 Mount Sinai Hospital, Obstetrics and Gynecology; Division of Maternal Fetal Medicine, Toronto, Ontario, Canada, 2Mount Sinai Hospital, Department of Medical Imagin Mount Sinai Hospital, Toronto, Ontario, Canada, 3Mount Sinai Hospital, Obstetrics and Gynecology, Toronto, Ontario, Canada, 4Mount Sinai Hospital, Department of Medical Imaging, Ontario, Canada
OBJECTIVE: The more serious forms of invasive placentation (increta
or percreta) present significant challenges at caesarean delivery, largely due to the maternal pelvic angiogenic response to placental invasion. Caesarean hysterectomy in such circumstances may result in massive blood loss despite surgical expertise. We reviewed 2 divergent surgical approaches: elective Caesarean hysterectomy (CH) vs. a “conservative approach” (CA) where following Caesarean delivery the placenta was initially left in-situ. STUDY DESIGN: Single-center retrospective review of all patients delivered with an antenatal diagnosis of invasive placentation between 2000 –2009. Ultrasound diagnosis was followed by MRI in all cases. RESULTS: 26 patients met inclusion criteria. CH was planned in 16 patients and CA in 10. All had pre-operative internal iliac balloons and post-partum embolization of the uterine arteries. All women survived. Blood loss, coagulopathy and bladder injury were all less common among the CA group although this difference was not statistical significant. Table 1 summarizes these early morbidities. 4/10 patients initially treated conservatively required a subsequent hysterectomy for; severe vaginal bleeding due to uterine AV malformation (2), coagulopathy (1) or sepsis (1). No subsequent pregnancies have been reported yet in the conservative approach group. CONCLUSION: In this single centre cohort of antenatally diagnosed invasive placentation, CS and planned placental non-delivery with uterine conservation had similar outcomes to planned Cesarean hysterectomy. A conservative approach is an option in patients with extensive bladder involvement or those requesting preservation of fertility.
Supplement to DECEMBER 2009 American Journal of Obstetrics & Gynecology
S53