The predictive value of pre-delivery laboratory test results for the severity of placental abruption and pregnancy outcome

Obstetric and neonatal outcomes in clinically diagnosed placental abruption with and without placental histopathologic confirmation-A retrospective study

OBJECTIVE

Placental abruption is a major obstetrical complication bearing potentially life-threatening consequences. Though the diagnosis of placental abruption is a clinical one, the nonspecific nature of common presenting symptoms, mainly vaginal bleeding and contractions, pose a challenge, and the contribution of placental pathology has been debated. In this study, we assessed the clinical significance of related placental lesions by comparing obstetric and neonatal outcomes among cases of placental abruption with versus without supporting histopathologic placental lesions.

METHODS

We retrospectively analyzed placental abruption cases diagnosed during an 8-year period at a single tertiary center. Maternal, neonatal, and placental outcomes were compared between cases of placental abruption with versus without histopathologic placental lesions. The primary outcome was a composite of severe neonatal morbidity and included 1 ≤ of the following: seizures, intraventricular hemorrhage, hypoxic-ischemic encephalopathy, periventricular leukomalacia, necrotizing enterocolitis, blood transfusion or neonatal death.

RESULTS

A total of 305 clinical placental abruption cases were included: 95 in the placental abruption with histopathologic lesions group (31.3%) and 210 without such lesions (68.8%). The group with histopathologic lesions was characterized by higher rates of vaginal bleeding at presentation and prematurity (P = 0.012 and P < 0.001, respectively). Additionally, this group had substantially higher rates of composite severe neonatal outcomes (the primary outcome) (P = 0.005) and concurrent maternal vascular malperfusion lesions (P < 0.001).

CONCLUSION

Our findings shed light on the association between placental abruption-related histopathologic lesions and adverse obstetric and neonatal outcomes. Thus, histopathologic examination can be advocated in suspected placental abruption, as patients with related placental lesions may require closer follow-up in subsequent pregnancies.

Changes in Fibrinogen and D-Dimer During Complicated and Uncomplicated Pregnancy

INTRODUCTION

The increase in fibrinogen levels is vital for the formation of a prothrombotic state during gestation to counter-bleeding challenges at delivery. However, pregnancy complications characterized by systemic inflammatory response syndrome may consume fibrinogen, resulting in elevated D-dimer levels.

METHODS

Our study is based on a total of 16 768 pregnant women who delivered between December 1, 2013, and December 1, 2018, to study fibrinogen and D-dimer changes during gestation under normal and multiples of pathogenic states.

RESULT

Compared with nonpregnant women (3.04[3.02-3.08]), pregnant women depicted higher fibrinogen levels throughout gestation (p < 0.001). In the uncomplicated group, fibrinogen levels increased throughout the first (3.28[3.26-3.29]), second (4.04[4.01-4.07]), and third trimesters (4.40[4.38-4.41]) but dropped at delivery (4.30[4.28-4.31]), similar to the changing pattern of the pregnancy-related complication group and pre-existing disorder group. Women with pregnancy-related complications showed significantly higher mean fibrinogen levels throughout gestation (p < 0.001), except for placental abruption, where, it decreased from the third trimester and was lower than that of uncomplicated pregnancies (3.89[3.60-4.17] vs. 4.40 [4.38-4.41], p = 0.001). Among uncomplicated pregnancies, D-dimer grew rapidly throughout the first trimester (0.09[0.06-0.15]), second trimester (0.28[0.19-0.40]), third trimester (0.51[0.36-0.78]), and delivery (0.70[0.47-1.03]).

CONCLUSION

Women with pregnancy-related complications and pre-existing disorders shared similar changing patterns; however, the D-dimer of women with placenta accreta presented higher levels than those with uncomplicated pregnancies since the first trimester. We concluded that fibrinogen levels are expected to increase steadily, but in patients with placental abruption, fibrinogen levels dropped during the third trimester. D-dimer levels typically rise consistently throughout pregnancy, yet in patients with placenta accreta, they show abnormal elevation since an early stage of pregnancy.

Clinical implications of a Couvelaire uterus with placental abruption: A retrospective study

OBJECTIVE

This study aimed to clarify the maternal and neonatal outcomes based on the presence or absence of a Couvelaire uterus with placental abruption.

METHODS

This single-center retrospective study was conducted at a tertiary perinatal center in Japan, including patients diagnosed with acute placental abruption who delivered live births via cesarean section between 2016 and 2023. Patients were divided into two groups based on the presence or absence of a Couvelaire uterus during surgery: the Couvelaire and normal uterus groups. Maternal and neonatal outcomes were assessed.

RESULTS

This study included 76 patients: 24 in the Couvelaire group and 52 in the normal uterus group. No patients underwent hysterectomies. The Couvelaire group had significantly higher intraoperative blood loss (median 1152 vs 948 g, P = 0.010), blood transfusion rates (58% vs 31%, P = 0.022), fibrinogen administration rates (38% vs 13%, P = 0.038), intensive care unit/high care unit admission rates (29% vs 7.7%, P = 0.013), and disseminated intravascular coagulation complication rates (25% vs 7.7%, P = 0.038). There were no differences in birth weight, gestational age (median 2387 vs 2065 g, P = 0.082), Apgar score <4 at 5 min (4.2% vs 3.9%, P = 0.95), umbilical artery blood pH <7.1 (25% vs 22%, P = 0.82), and neonatal death (4.2% vs 1.9%, P = 0.57).

CONCLUSION

A Couvelaire uterus indicated adverse maternal outcomes but not neonatal ones. Its presence necessitates preparation for blood transfusions and/or intensive patient follow-up.

The correlation between placental growth factor and small for gestational age infants: a matched case-control study

BACKGROUND

At present, research has not found easily accessible, accurate, and safe clinical biomarkers that can effectively predict the occurrence of infants born small for gestational age (SGA). The aim of this study is to explore the predictive role of maternal placental growth factor (PIGF) levels on the occurrence of SGA infants.

METHOD

We conducted a matched case-control study on 226 SGA infants and 226 non-SGA infants born in the Department of Obstetrics, Peking University People's Hospital, from January 2021 to December 2022, with regular monitoring of maternal serum PIGF levels in second trimester during pregnancy. Apply multiple logistic regression analysis and receiver operating characteristic (ROC) curve analysis to determine whether PIGF is an independent influencing factor for the occurrence of SGA in infants, and evaluate whether PIGF can predict the occurrence of SGA in infants.

RESULTS

Multiple logistic regression analysis found that multipara (HR = 0.484, 95% CI = 0.250-0.937, p = 0.031), maternal pre-pregnancy underweight (HR = 4.710, 95% CI = 1.881-11.792, p = 0.001), pre-eclampsia(HR = 2.291, 95% CI = 1.068-4.913, p = 0.033), low levels of PIGF (HR = 26.417, 95% CI = 12.850-54.311, p < 0.001) and oligohydramnios (HR = 4.764, 95% CI = 1.845-12.301, p = 0.001) were independent factors affecting the occurrence of infants born SGA. In addition, ROC curve analysis showed that the area under the curve (AUC) predicted by PIGF level and four other influencing factors for the occurrence of SGA infants were 0.834 and 0.723, respectively. In addition, the combination of PIGF and four other independent influencing factors improved the predictive value (AUC 0.902) for the birth of SGA infants, with enhanced sensitivity and specificity.

CONCLUSION

Low levels of PIGF in second trimester during pregnancy are an independent risk factor for SGA infants. Compared with other indicators, PIGF levels PIGF in second trimester are a better predictor of SGA in infants.

Maternal postpartum depressive symptoms: The predictive role of objective and subjective birth experience and hair glucocorticoids

BACKGROUND

Having a negative childbirth experience is a known risk-factor for developing postpartum depression (PPD). Alterations of the hypothalamus-pituitary-adrenal (HPA)-axis have been discussed as a potential underlying mechanism. However, research on the association between negative birth experiences and long-term integrated glucocorticoids (GCs) is lacking. This study aimed to examine whether objective and subjective birth experience predicted long-term GCs and PPD symptoms.

METHODS

Measures of objective and subjective birth experience, PPD symptoms, and hair strands for the assessment of hair cortisol concentrations (HairF), hair cortisone concentrations (HairE), and HairF/HairE ratio, were provided eight weeks after childbirth by 235 mothers participating in the study DREAMHAIR.

RESULTS

A negative objective birth experience predicted a higher HairF/HairE ratio but was not associated with HairF or HairE. The subjective birth experience did not explain additional variance in hair GCs but was a significant predictor for PPD symptoms. A higher HairF/HairE ratio predicted PPD symptoms when controlling for prepartum depressive symptoms and number of lifetime traumatic events.

LIMITATIONS

Analyses were based on a relatively homogeneous sample and women reported in general positive birth experiences and low levels of depressive symptoms. Therefore, results should be applied to the broader population with caution.

CONCLUSIONS

Our results suggest that negative objective birth experience is associated with an altered HairF/HairE ratio, which in turn, seems to be a promising biomarker to identify women at risk for developing PPD. A negative subjective birth experience may be less critical for alterations of the HPA-axis but remains an essential risk factor for PPD.

Association of white blood cell count after operative vaginal delivery with maternal adverse outcome: A retrospective cohort study

BACKGROUND

The white blood cell count is often used to assess the maternal condition after an operative vaginal delivery. However, it remains unknown whether the maternal white blood cell count on the day after delivery is associated with sequential maternal adverse outcomes, especially infectious complications. The aim of this study was to investigate the association between maternal white blood cell count on the day after operative vaginal delivery and sequential maternal adverse events.

METHODS

The study was a retrospective cohort study using the Medical Data Vision claims database containing administrative claims data, discharge abstracts, and laboratory values in Japan. We identified all patients who underwent operative vaginal delivery with data on maternal white blood cell count from December 2011 to November 2020. The main composite outcome was maternal adverse outcomes, comprising additional treatment for maternal injuries, postpartum intravenous antibiotic use, and intensive care unit use during hospitalization. We conducted a restricted cubic spline analysis to investigate the nonlinear association between white blood cell count and the primary outcome.

RESULTS

There were 485 eligible patients including 73 patients with occurrence of the primary outcome. The median (interquartile range) white blood cell count on the day after delivery in all eligible women was 15,170 (12,610-18,300)/mL. In the restricted cubic spline analysis, there was no significant association of white blood cell count with the primary outcome.

CONCLUSION

White blood cell count on the day after operative vaginal delivery was not significantly associated with maternal adverse outcomes during hospitalization.

The Effect of Maternal Coagulation Parameters on Fetal Acidemia in Placental Abruption

This study aimed to identify factors predicting the probability of serious fetal acidemia at delivery in placental abruption. We identified 5769 women who delivered at >22 weeks’ gestation at two institutions in a tertiary referral unit specializing in neonatal infant care between January 2007 and December 2011. Ninety-one abruption cases were identified based on clinical and histological diagnoses. Serious fetal acidemia was defined as a pH < 7.0 in the umbilical arterial blood at delivery. Using a linear discriminant function, we calculated the score to determine the probability of serious fetal acidemia. Serious fetal acidemia was observed in 34 patients (37.4%). A logistic regression model showed that abnormal fetal heart rate patterns (bradycardia and late decelerations), uterine spasm, and maternal plasma concentration of fibrinogen less than 288 ng/dL were significantly associated with the occurrence of serious fetal acidemia. We suggest that the implementation of maternal fibrinogen in patients with placental abruption is a prognostic factor for serious fetal acidemia at delivery.

The indicators for early blood transfusion in patients with placental abruption with intrauterine fetal death: a retrospective review

Background

Placental abruption (PA) with intrauterine fetal death (IUFD) is associated with a high risk of postpartum hemorrhage (PPH) resulting from severe disseminated intravascular coagulation (DIC). Therefore, blood products that are sufficient for coagulation factor replacement must be prepared, and delivery should occur at referral medical institutions that are equipped with sufficient blood products and emergency transfusion protocols. We retrospectively reviewed the records of patients with PA and IUFD (PA-IUFD) to identify possible factors that may indicate the need for early blood transfusion and investigated whether the Japanese scoring system for PPH can be applied in such cases.

Methods

We used a database of 16,058 pregnant patients who delivered at Yokohama City University Medical Center between January 2000 and February 2016. Thirty-three patients were diagnosed with PA-IUFD before delivery and categorized into two groups–blood transfusion and non-transfusion–to compare the maternal characteristics and pregnancy outcomes.

Results

In patients with PA-IUFD, the transfusion group exhibited significantly more blood loss; lower fibrinogen levels and platelet counts; higher levels of fibrin degradation products (FDP), D-dimer, and prothrombin time; and a tendency for tachycardia on admission, compared to the non-transfusion group. Many patients in the transfusion group had normal fibrinogen levels on admission but later displayed markedly decreased fibrinogen levels. The Japan Society of Obstetrics and Gynecology (JSOG) DIC score was significantly higher in the transfusion than in the non-transfusion group.

Conclusions

In PA-IUFD, the fibrinogen level, platelet count, D-dimer, FDP, heart rate, and JSOG DIC score on admission may indicate the need for blood transfusion. However, even with normal fibrinogen levels on admission, continuous monitoring is indispensable for identifying progressive fibrinogen reductions in patients with PA-IUFD.

The main features of placental abruption: Clinical presentation and treatment

Placental abruption is defined as the premature separation of the placenta from the uterus. Rapid diagnosis and adequate medical intervention provide a good outcome, which is not possible in all countries. Any bleeding that occurs in the second half of pregnancy raises the suspicion of placental abruption, which is associated with fetal and maternal morbidity and mortality. The clinical picture and consequences for the fetus depend on the degree of bleeding and the amount of blood. Complete abruption leads to the disruption of fetal circulation and oxygenation, asphyxia, and stillbirth. In case of partial abruption, the consequences for the fetus depend on the degree of bleeding. In complete abruption, fetal death is inevitable unless an emergency cesarean delivery is undertaken.