Cerebrovascular disease after placental abruption: A population-based prospective cohort study

Sex-based difference in selected stroke etiologies: cerebral dural sinus venous thrombosis, reversible cerebral vasoconstriction syndrome, dissection, migraine, pregnancy/puerperium/OC use

Females are at higher risk than males for a multitude of cerebrovascular conditions, both common and rare; partially resulting from a complex interplay between differing process involving genetics, hormonal influences, common cerebrovascular risk factors among others. Specific topics including cervical artery dissection, cerebral dural sinus venous thrombosis, reversible cerebral vasoconstriction syndrome, migraine, along with these disorders in the setting of pregnancy, puerperium and oral contraceptive utilization. Epidemiology, pathophysiology, presentation, basics of management and outcomes are presented, with sex differences throughout.

Placental Abruption and Cardiovascular Event Risk (PACER): Design, data linkage, and preliminary findings

BACKGROUND

Obstetrical complications impact the health of mothers and offspring along the life course, resulting in an increased burden of chronic diseases. One specific complication is abruption, a life-threatening condition with consequences for cardiovascular health that remains poorly studied.

OBJECTIVES

To describe the design and data linkage algorithms for the Placental Abruption and Cardiovascular Event Risk (PACER) cohort.

POPULATION

All subjects who delivered in New Jersey, USA, between 1993 and 2020.

DESIGN

Retrospective, population-based, birth cohort study.

METHODS

We linked the vital records data of foetal deaths and live births to delivery and all subsequent hospitalisations along the life course for birthing persons and newborns. The linkage was based on a probabilistic record-matching algorithm.

PRELIMINARY RESULTS

Over the 28 years of follow-up, we identified 1,877,824 birthing persons with 3,093,241 deliveries (1.1%, n = 33,058 abruption prevalence). The linkage rates for live births-hospitalisations and foetal deaths-hospitalisations were 92.4% (n = 2,842,012) and 70.7% (n = 13,796), respectively, for the maternal cohort. The corresponding linkage rate for the live births-hospitalisations for the offspring cohort was 70.3% (n = 2,160,736). The median (interquartile range) follow-up for the maternal and offspring cohorts was 15.4 (8.1, 22.4) and 14.4 (7.4, 21.0) years, respectively. We will undertake multiple imputations for missing data and develop inverse probability weights to account for selection bias owing to unlinked records.

CONCLUSIONS

Pregnancy offers a unique window to study chronic diseases along the life course and efforts to identify the aetiology of abruption may provide important insights into the causes of future CVD. This project presents an unprecedented opportunity to understand how abruption may predispose women and their offspring to develop CVD complications and chronic conditions later in life.

Risk of Stroke Hospitalization After Infertility Treatment

Importance

Stroke accounts for 7% of pregnancy-related deaths in the US. As the use of infertility treatment is increasing, many studies have sought to characterize the association of infertility treatment with the risk of stroke with mixed results.

Objective

To evaluate the risk of hospitalization from hemorrhagic and ischemic strokes in patients who underwent infertility treatment.

Design, Setting, and Participants

This population-based, retrospective cohort study used data abstracted from the Nationwide Readmissions Database, which stores data from all-payer hospital inpatient stays from 28 states across the US, from 2010 and 2018. Eligible participants included individuals aged 15 to 54 who had a hospital delivery from January to November in a given calendar year, and any subsequent hospitalizations from January to December in the same calendar year of delivery during the study period. Statistical analysis was performed between November 2022 and April 2023.

Exposure

Hospital delivery after infertility treatment (ie, intrauterine insemination, assisted reproductive technology, fertility preservation procedures, or use of a gestational carrier) or after spontaneous conception.

Main Outcomes and Measures

The primary outcome was hospitalization for nonfatal stroke (either ischemic or hemorrhagic stroke) within the first calendar year after delivery. Secondary outcomes included risk of stroke hospitalization at less than 30 days, less than 60 days, less than 90 days, and less than 180 days post partum. Cox proportional hazards regression models were used to estimate associations, which were expressed as hazard ratios (HRs), adjusted for confounders. Effect size estimates were corrected for biases due to exposure misclassification, selection, and unmeasured confounding through a probabilistic bias analysis.

Results

Of 31 339 991 patients, 287 813 (0.9%; median [IQR] age, 32.1 [28.5-35.8] years) underwent infertility treatment and 31 052 178 (99.1%; median [IQR] age, 27.7 [23.1-32.0] years) delivered after spontaneous conception. The rate of stroke hospitalization within 12 months of delivery was 37 hospitalizations per 100 000 people (105 patients) among those who received infertility treatment and 29 hospitalizations per 100 000 people (9027 patients) among those who delivered after spontaneous conception (rate difference, 8 hospitalizations per 100 000 people; 95% CI, -6 to 21 hospitalizations per 100 000 people; HR, 1.66; 95% CI, 1.17 to 2.35). The risk of hospitalization for hemorrhagic stroke (adjusted HR, 2.02; 95% CI, 1.13 to 3.61) was greater than that for ischemic stroke (adjusted HR, 1.55; 95% CI, 1.01 to 2.39). The risk of stroke hospitalization increased as the time between delivery and hospitalization for stroke increased, particularly for hemorrhagic strokes. In general, these associations became larger for hemorrhagic stroke and smaller for ischemic stroke following correction for biases.

Conclusions and Relevance

In this cohort study, infertility treatment was associated with an increased risk of stroke-related hospitalization within 12 months of delivery; this risk was evident as early as 30 days after delivery. Timely follow-up in the immediate days post partum and continued long-term follow-up should be considered to mitigate stroke risk.

Placental abruption at near-term and term gestations: pathophysiology, epidemiology, diagnosis, and management

Placental abruption is the premature separation of the placenta from its uterine attachment before the delivery of a fetus. The clinical manifestations of abruption typically include vaginal bleeding and abdominal pain with a wide variety of abnormal fetal heart rate patterns. Clinical challenges arise when pregnant people with this condition present with profound vaginal bleeding, necessitating urgent delivery, especially when there is a concern for maternal and fetal compromise and coagulopathy. Abruption occurs in 0.6% to 1.2% of all pregnancies, with nearly half of abruption occurring at term gestations. An exposition of abruption at near-term (defined as the late preterm period from 34 0/7 to 36 6/7 weeks of gestation) and term (defined as ≥37 weeks of gestation) provides unique insights into its direct effects, as risks associated with preterm birth do not impact outcomes. Here, we explore the pathophysiology, epidemiology, and diagnosis of abruption. We discuss the interaction of chronic processes (decidual and uteroplacental vasculopathy) and acute processes (shearing forces applied to the abdomen) that underlie the pathophysiology. Risk factors for abruption and strengths of association are summarized. Sonographic findings of abruption and fetal heart rate tracings are presented. In addition, we propose a management algorithm for acute abruption that incorporates blood loss, vital signs, and urine output, among other factors. Lastly, we discuss blood component therapy, viscoelastic point-of-care testing, disseminated intravascular coagulopathy, and management of abruption complicated by fetal death. The review seeks to provide comprehensive, clinically focused guidance during a gestational age range when neonatal outcomes can often be favorable if rapid and evidence-based care is optimized.

Association between preeclampsia in daughters and risk of cardiovascular disease in parents

Preeclampsia and cardiovascular disease (CVD) might share heritable underlying mechanisms. We investigated whether preeclampsia in daughters is associated with CVD in parents. In a register-based cohort study, we used Cox regression to compare rates of CVD (ischemic heart disease, ischemic stroke, myocardial infarction) in parents with ≥ 1 daughters who had preeclampsia and parents whose daughters did not have preeclampsia in Denmark, 1978-2018. Our cohort included 1,299,310 parents, of whom 87,251 had ≥ 1 daughters with preeclampsia and 272,936 developed CVD during 20,252,351 years of follow-up (incidence rate 135/10,000 person-years). Parents with one daughter who had preeclampsia were 1.19 times as likely as parents of daughters without preeclampsia to develop CVD at age < 55 years (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.13-1.25). Having ≥ 2 daughters who had preeclampsia yielded an HR of 1.88 (95% CI 1.39-2.53). The corresponding HRs for CVD at ≥ 55 years of age were 1.13 (95% CI 1.12-1.15) and 1.27 (95% CI 1.16-1.38). Patterns of association were similar for all CVD subtypes. Effect magnitudes did not differ for mothers and fathers (p = 0.52). Analyses by timing of preeclampsia onset in daughters suggested a tendency toward stronger associations with earlier preeclampsia onset, particularly in parents < 55 years. Preeclampsia in daughters was associated with increased risks of CVD in parents. Increasing strength of association with increasing number of affected daughters, equally strong associations for mothers and fathers, and stronger associations for CVD occurring before age 55 years suggest that preeclampsia and CVD share common heritable mechanisms.

The Association of Placental Abruption and Pediatric Neurological Outcome: A Systematic Review and Meta-Analysis

Placental histopathology provides insights, or "snapshots", into relevant antenatal factors that could elevate the risk of perinatal brain injury. We present a systematic review and meta-analysis comparing frequencies of adverse neurological outcomes in infants born to women with placental abruption versus without abruption. Records were sourced from MEDLINE, Embase, and the CENTRAL Trials Registry from 1946 to December 2019. Studies followed the PRISMA guidelines and compared frequencies of neurodevelopmental morbidities in infants born to pregnant women with placental abruption (exposure) versus women without placental abruption (comparator). The primary endpoint was cerebral palsy. Periventricular and intraventricular (both severe and any grades of IVH) and any histopathological neuronal damage were the secondary endpoints. Study methodologic quality was assessed by the Ottawa-Newcastle scale. Estimated odds ratios (OR) and hazards ratio (HR) were derived according to study design. Data were meta-analyzed using a random effects model expressed as pooled effect sizes and 95% confidence intervals. We included eight observational studies in the review, including 1245 infants born to women with placental abruption. Results of the random effects meta-analysis show that the odds of infants born to pregnant women with placental abruption who experience cerebral palsy is higher than in infants born to pregnant women without placental abruption (OR 5.71 95% CI (1.17, 27.91); I² = 84.0%). There is no statistical difference in the odds of infants born to pregnant women with placental abruption who experience severe IVH (grade 3+) (OR 1.20 95% CI (0.46, 3.11); I² = 35.8%) and any grade of IVH (OR 1.20 95% CI (0.62, 2.32); I² = 32.3%) vs. women without placental abruption. There is no statistically significant difference in the odds of infants born to pregnant women with placental abruption who experience PVL vs. pregnant women without placental abruption (OR 6.51 95% CI (0.94, 45.16); I² = 0.0%). Despite our meta-analysis suggesting increased odds of cerebral palsy in infants born to pregnant women with placental abruption versus without abruption, this finding should be interpreted cautiously, given high heterogeneity and overall poor quality of the included studies.

Prospective evaluation of placental abruption in nulliparous women

INTRODUCTION

Because most data on placental abruption are derived from retrospective studies, multiple sources of bias may have affected the results. Thus, we aimed to characterize risk factors and outcomes for placental abruption in a large prospective cohort of nulliparous women.

METHODS

This was a secondary analysis of women enrolled in the Nulliparous Pregnancy Outcomes Study Monitoring-to-be (nuMom2b) study, a prospective observational cohort. Participants were recruited in their first trimester of pregnancy from 8 sites and had 4 study visits, including at delivery. Placental abruption was defined by confirmed clinical criteria. The primary analysis was restricted to abruption identified antepartum and intrapartum. As a secondary analysis, we examined antepartum and intrapartum abruptions separately. We compared risk factors (maternal demographic and clinical characteristics) and outcomes in women with and without placental abruption using univariable and multivariable analyses as appropriate.

RESULTS

9450 women were included in the primary analysis. Abruption was identified in 0.66% (n = 62), of which 35 (56%) were antepartum and 27 (44%) intrapartum. For women with abruption, the mean gestational age at delivery was 35.6 ± 4.4 weeks and 38.8 ± 2.2 weeks for women without abruption. Gravidity was associated with abruption (OR 3.1, 95% CI: 1.6-6.0). In univariate analysis, abruption was associated with cesarean delivery (OR 3.7, 95% CI: 2.2-6.0), blood transfusion (OR 3.8, 95% CI: 1.4-10.7), PPROM (OR 9.0, 95% CI: 5.4-15.1), preterm birth (OR 8.5, 95% CI: 5.1-14.2), SGA (OR 4.0, 95% CI: 2.3-6.95), RDS (OR 5.5, 95% CI: 2.6-11.2), IVH 20.2 (OR 20.2, 95% CI: 5.9-68.8) and ROP (OR 12.2, 95% CI: 2.8-52.6). However, after adjustment for confounders including gestational age, abruption was only associated with increased odds of cesarean delivery and blood transfusion. Results were similar when restricted to antepartum and intrapartum abruptions.

CONCLUSION

Abruption was identified in <1% of nulliparous women. However, few maternal risk factors were identified. Neonatal morbidities were associated with an abruption and were primarily driven by gestational age due to preterm birth.

Women with Adverse Pregnancy Outcomes Have Higher Odds of Midlife Stroke: The Population Assessment of Tobacco and Health Study

Background: A history of adverse pregnancy outcomes (APOs) is associated with increased risk of future cardiovascular disease, including stroke. Few large U.S. population-based surveys included data on APOs. Methods: The Population Assessment of Tobacco and Health study is a nationally representative survey of 45,971 U.S. respondents. Female respondents ≥50 years old who reported pregnancy history at the 2013-2014 baseline interview were included in this cross-sectional analysis (n = 3,175; weighted n = 35,783,619). The primary exposure was a history of ≥1 APO, including preterm delivery, low birth weight, preeclampsia, placental abruption, and stillbirth. The primary outcomes were (1) stroke before age 60 and (2) any stroke. We used weighted logistic regression models to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for the association between APO and stroke, adjusting for age, race/ethnicity, socioeconomic status, parity, and vascular risk factors. Results: Among stroke-free respondents, 15% reported ≥1 APO. Among women who reported a stroke before age 60, 39% reported ≥1 APO (p < 0.001); among women reporting stroke at any age, 25% reported ≥1 APO (p = 0.01). Controlling for covariates, women with APOs had increased odds of stroke before age 60 (adjusted OR 2.66, 95% CI 1.49, 4.75). The association of APOs with stroke at any age was not significant after controlling for covariates (adjusted OR 1.57, 95% CI 0.93, 2.64). Conclusion: In this analysis of U.S. nationally representative survey data, APOs were independently associated with midlife stroke. Women with APOs have higher odds of midlife stroke and warrant targeted prevention strategies.

Maternal Cardiovascular and Cerebrovascular Health After Placental Abruption: A Systematic Review and Meta-Analysis (CHAP-SR)

Placental abruption and cardiovascular disease (CVD) have common etiological underpinnings, and there is accumulating evidence that abruption may be associated with future CVD. We estimated associations between abruption and coronary heart disease (CHD) and stroke. The meta-analysis was based on the random-effects risk ratio (RR) and 95% confidence interval (CI) as the effect measure. We conducted a bias analysis to account for abruption misclassification, selection bias, and unmeasured confounding. We included 11 cohort studies comprising 6,325,152 pregnancies, 69,759 abruptions, and 49,265 CHD and stroke cases (1967-2016). Risks of combined CVD morbidity-mortality among abruption and nonabruption groups were 16.7 and 9.3 per 1,000 births, respectively (RR = 1.76, 95% CI: 1.24, 2.50; I2 = 94%; τ2 = 0.22). Women who suffered abruption were at 2.65-fold (95% CI: 1.55, 4.54; I2 = 85%; τ2 = 0.36) higher risk of death related to CHD/stroke than nonfatal CHD/stroke complications (RR = 1.32, 95% CI: 0.91, 1.92; I2 = 93%; τ2 = 0.15). Abruption was associated with higher mortality from CHD (RR = 2.64, 95% CI: 1.57, 4.44; I2 = 76%; τ2 = 0.31) than stroke (RR = 1.70, 95% CI: 1.19, 2.42; I2 = 40%; τ2 = 0.05). Corrections for the aforementioned biases increased these estimates. Women with pregnancies complicated by placental abruption may benefit from postpartum screening or therapeutic interventions to help mitigate CVD risks.

Air Pollution and Risk of Placental Abruption: A Study of Births in New York City, 2008-2014

We evaluated the associations of exposure to fine particulate matter (particulate matter with an aerodynamic diameter ≤2.5 μm (PM2.5) at concentrations of <12 μg/m3, 12-14 μg/m3, and ≥15 μg/m3) and nitrogen dioxide (at concentrations of <26 parts per billion (ppb), 26-29 ppb, and ≥30 ppb) with placental abruption in a prospective cohort study of 685,908 pregnancies in New York, New York (2008-2014). In copollutant analyses, these associations were examined using distributed-lag nonlinear models based on Cox models. The prevalence of abruption was 0.9% (n = 6,025). Compared with a PM2.5 concentration less than 12 μg/m3, women exposed to PM2.5 levels of ≥15 μg/m3 in the third trimester had a higher rate of abruption (hazard ratio (HR) = 1.68, 95% confidence interval (CI): 1.41, 2.00). Compared with a nitrogen dioxide concentration less than 26 ppb, women exposed to nitrogen dioxide levels of 26-29 ppb (HR = 1.11, 95% CI: 1.02, 1.20) and ≥30 ppb (HR = 1.06, 95% CI: 0.96, 1.24) in the first trimester had higher rates of abruption. Compared with both PM2.5 and nitrogen dioxide levels less than the 95th percentile in the third trimester, rates of abruption were increased with both PM2.5 and nitrogen dioxide ≥95th percentile (HR = 1.44, 95% CI: 1.15, 1.80) and PM2.5 ≥95th percentile and nitrogen dioxide <95th percentile (HR = 1.43 95% CI: 1.23, 1.66). Increased levels of PM2.5 exposure in the third trimester and nitrogen dioxide exposure in the first trimester are associated with elevated rates of placental abruption, suggesting that these exposures may be important triggers of premature placental separation through different pathways.

Subtypes of Preeclampsia: Recognition and Determining Clinical Usefulness

The concept that preeclampsia is a multisystemic syndrome is appreciated in both research and clinical care. Our understanding of pathophysiology recognizes the role of inflammation, oxidative and endoplasm reticulum stress, and angiogenic dysfunction. Yet, we have not progressed greatly toward clinically useful prediction nor had substantial success in prevention or treatment. One possibility is that the maternal syndrome may be reached through different pathophysiological pathways, that is, subtypes of preeclampsia, that in their specificity yield more clinical utility. For example, early and late onset preeclampsia are increasingly acknowledged as different pathophysiological processes leading to a common presentation. Other subtypes of preeclampsia are supported by disparate clinical outcomes, long-range prognosis, organ systems involved, and risk factors. These insights have been supplemented by discovery-driven methods, which cluster preeclampsia cases into groups indicating different pathophysiologies. In this presentation, we review likely subtypes based on current knowledge and suggest others. We present a consideration of the requirements for a clinically meaningful preeclampsia subtype. A useful subtype should (1) identify a specific pathophysiological pathway or (2) specifically indicate maternal or fetal outcome, (3) be recognizable in a clinically useful time frame, and (4) these results should be reproducible and generalizable (but at varying frequency) including in low resource settings. We recommend that the default consideration be that preeclampsia includes several subtypes rather than trying to force all cases into a single pathophysiological pathway. The recognition of subtypes and deciphering their different pathophysiologies will provide specific targets for prevention, prediction, and treatment directing personalized care.