Women with a history of placental abruption: when in a subsequent pregnancy should special surveillance for a recurrent placental abruption be initiated?

BACKGROUND: It is common to admit to hospital or start intensive ambulatory antenatal care of pregnant women with a previous placental abruption using the gestational age of the previous placental abruption as a starting point. In some instances, close surveillance may be commenced much earlier. There is no consensus when in a subsequent pregnancy such measures should be initiated. OBJECTIVE: The analyses aimed at the prevention of complicated (preterm, small for gestational age, or perinatal death) recurrent placental abruptions, assessing at which time in a subsequent pregnancy special surveillance should start in order to anticipate and prevent a recurrence. DESIGN: A cohort study based on the Medical Birth Registry of Norway. Calculation of gestational age specific risks of placental abruption in a second pregnancy and estimation of when to initiate surveillance in order to reduce an increased risk of recurrent placental abruption to the initial level of initial abruption in the second pregnancy. RESULTS: In women with a complicated (preterm, small for gestational age, or perinatal death) first delivery, the risks of an initial and recurrent complicated placental abruption in the second pregnancy were 7/1000 and 33/1000, respectively (relative risk 4.9). To reduce the recurrence risk in a second pregnancy to 7/1000, special surveillance six weeks prior to the gestational age of the initial abruption would be necessary. In women with an uncomplicated first delivery, the risks in the second pregnancy of an initial and recurrent complicated abruption were 3 and 19/1000, respectively (relative risk 7.1). To reduce the recurrence risk to 3/1000, surveillance at least 12 weeks prior would be necessary. CONCLUSION: The increased recurrence rate would necessitate increased awareness in terms of special surveillance in the second pregnancy. In pregnancies at risk of a recurrent placental abruption, monitoring up to three months before the gestational age of the initial abruption is necessary.

Predicting preeclampsia in the second pregnancy from low birth weight in the first pregnancy.

OBJECTIVE: To evaluate the effect of low birth weight adjusted for gestational age in first pregnancies on preeclampsia in second pregnancies and to estimate the proportion of preeclampsia in second pregnancies attributable to histories of LBW for gestational age. METHODS: We conducted a cohort study based on linked data from the Medical Birth Registry of Norway, which covered all births in 1967-1992. RESULTS: Women who delivered infants under the third percentile birth weight were three times more likely to have initial or recurrent preeclampsia in second pregnancies than those who delivered infants at or above the tenth percentile. After adjusting for maternal age, year of birth, interpregnancy interval, education, chronic hypertension, diabetes mellitus, and change of partner, the increased risk persisted. Birth weight below the tenth percentile in the first delivery accounted for 10% of the total cases of preeclampsia in the second pregnancy and 30% of recurrent cases. CONCLUSION: A history of low birth weight adjusted for gestational age is associated significantly with subsequent occurrence as well as recurrence of preeclampsia. These findings are consistent with the hypothesis of a shared etiologic factor or recurrent pathophysiologic mechanism for preeclampsia and fetal growth restriction. A history of fetal smallness for gestational age is found in a substantial proportion of all cases of preeclampsia and thus seems to be important in the etiology of preeclampsia.

Outcome of pregnancies subsequent to placental abruption: a risk assessment.

OBJECTIVE: To assess the risk of small for gestational age (SGA), preterm birth, pregnancy induced hypertension (PIH), and perinatal death in the pregnancy immediate subsequent to a placental abruption (PA) in the same mother. DESIGN: A cohort study based on the Medical Birth Registry of Norway. RESULTS: Odds ratios of SGA in subsequent PA- and non-PA deliveries were 2.8 (absolute risk = 18.5%) and 2.0 (13.9%), respectively, compared with non-PA deliveries without a history of previous PA among siblings (7.5%) after exclusion of cases with SGA in the immediate previous birth. After exclusion of cases with spontaneous preterm birth in the immediate previous delivery, odds ratios of spontaneous preterm birth in subsequent PA- and non-PA deliveries were 17.0 (36.3%) and 2.1 (6.6%), compared with non-PA deliveries without a history of previous PA among siblings (3.2%). After exclusion of cases with PIH in the immediate previous pregnancy, odds ratios of PIH in subsequent PA- and non-PA pregnancies were 2.9 (6.3%) and 1.6 (3.4%), compared with non-PA deliveries without a history of previous PA among siblings (2.3%). After adjustment for demographic variables and obstetrical complications, the increased risks persisted. CONCLUSION: A pregnancy following a PA must be considered a high risk pregnancy, not only in terms of excess risk of recurrence, but also due to excess risk of SGA, preterm birth, and PIH irrespective of recurrence of PA. Consequently, all pregnancies following a pregnancy with PA should be offered close antenatal surveillance and care.

Obstetric history and the risk of placenta previa.

OBJECTIVE: To evaluate secular trends in the occurrence of placenta previa and whether placenta previa is associated with the outcome of previous pregnancies, cesarean section, and sociodemographic factors. DESIGN: A cohort study based on the Medical Birth Registry of Norway. Placenta previa in the second pregnancy was investigated for associations with outcomes in the first pregnancy and sociodemographic factors. RESULTS: In birth orders 1 and 2 the occurrence of placenta previa was 1.2 and 2.2 per 1,000, respectively, with no secular trend. The occurrence increased with maternal age and was lowest in women aged 20-29 years. The recurrence rate was 23 per 1,000 (adjusted odds ratio (OR) of recurrence=9.7). In women with prior delivery at < or =25 gestational weeks the risk of placenta previa was 6.7 per 1,000 (adjusted OR=3.0). In women with prior placental abruption the risk was 5.8 per 1,000 (OR=2.6). In women with prior perinatal death the risk was 4.4 per 1,000 (adjusted OR= 1.8). No independent relationship emerged with socio-economic factors, previous birthweight, and a history of pregnancy induced hypertension. Cesarean section was associated with subsequent development of placenta previa (adjusted OR= 1.3). CONCLUSIONS: We found no secular trends in the occurrence of placenta previa. Placenta previa is associated with previously described risk factors for placental abruption. The increased risk of placenta previa subsequent to placental abruption supports the theory of a shared etiologic factor. However, placenta previa and placental abruption do not share a common etiology in relation to a history of pregnancy induced hypertension, fetal growth retardation, and socio-economic factors.

Treatment with 2% clindamycin vaginal cream prior to first trimester surgical abortion to reduce signs of postoperative infection: a prospective, double-blinded, placebo-controlled, multicenter study.

BACKGROUND: Bacterial vaginosis (BV) and intermediate flora is known risk-factor for postoperative infection after surgical termination of pregnancy. Vaginal application of 2% clindamycin cream is an efficacious treatment for BV, but it is not known whether preoperative administration of clindamycin cream might reduce the signs of post-abortion infection after surgical termination of pregnancy. AIM: To evaluate whether preoperative treatment with clindamycin cream might reduce the signs of post-abortion infection after legal abortion. DESIGN: Prospective, double-blinded, placebo-controlled, multicenter study. MATERIAL AND METHODS: Consecutive women attending for surgical termination prior to 11+4 gestational weeks were approached. We randomized participants to preoperative vaginal treatment with 2% clindamycin cream or placebo cream in a double-blinded fashion. At all visits vaginal smears were air dried on microscopy slides to be stored. The rate of postoperative pelvic infection according to our definition was the main outcome variable, the cure rates of BV and of intermediate flora were secondary outcome variables. RESULTS: Of 1655 enrolled women, 1102 were evaluable for analyses. Fifty-eight women developed signs of post-abortion infection. Preoperative treatment with clindamycin cream significantly (RR: 4.2, 95% C.I. 1.2-15.9) reduced the risk of post-abortion infection among women with abnormal vaginal flora (BV and intermediate flora). Treatment with clindamycin cream in women with normal lactobacilli flora did not demonstrate any difference compared to the non-treatment group. CONCLUSION: Preoperative treatment for at least three days with clindamycin cream significantly reduced the risk for developing signs of post-abortion infection only among women with preoperative abnormal vaginal flora (BV and intermediate flora).

A history of placental dysfunction and risk of placental abruption.

In a population-based historic cohort study, we assessed the possible association of fetal growth retardation, preterm birth and pregnancy-induced hypertension in the immediately preceding pregnancy with placental abruption in the current pregnancy, which would suggest a shared aetiological factor. We also assessed whether chronic hypertension, diabetes mellitus and a history of Caesarean section are associated with placental abruption. Preterm birth and small-for-gestational-age (SGA) in the immediately preceding delivery were associated with an increased risk of placental abruption with unadjusted odds ratios (ORs) of 2.1 [95% CI = 1.9, 2.4] and 1.6 [95% CI = 1.5, 1.8] respectively. Women with a history of an SGA preterm birth in the immediately preceding delivery and an appropriate-for-gestational-age infant in the current had an adjusted OR of 3.2 [95% CI = 2.3, 4.5]. The adjusted odds ratio of placental abruption in women who had pregnancy-induced hypertension in the previous pregnancy, but not in the current, was 1.4 [95% CI = 1.2, 1.7]. Women who delivered a preterm or SGA infant in the previous delivery and had chronic hypertension or diabetes mellitus in the current had adjusted ORs of 2.3-5.7 and 2.5-6.0 respectively. Caesarean section in the previous delivery increased the risk of placental abruption by 40%. These results suggest that pregnancy-induced hypertension, intrauterine growth retardation, preterm delivery and placental abruption share an aetiological factor or represent different clinical expressions of recurring placental dysfunction. Chronic hypertension and diabetes mellitus may cause or aggravate such dysfunction thus causing placental abruption. A history of Caesarean section is associated with an increased risk of placental abruption.

Perinatal mortality in breech presentation sibships.

OBJECTIVE: To compare perinatal mortality in breech presentation delivered vaginally and by cesarean in individual births and in sibships. METHODS: A national, population registry-based study, 1967-1994, was conducted, with maternal record linkage of sibships, comprising the first to the third birth of a mother. The main outcome was perinatal mortality. Odds ratios of perinatal mortality were calculated and adjusted by logistic regression analysis. RESULTS: The overall relative perinatal mortality was 4.3 (95% confidence interval [CI] 4.1, 4.5) in breech compared with nonbreech presentation and 5.4 (95% CI 4.7, 6.2) in vaginal compared with cesarean delivery. The relative perinatal mortality in breech compared with nonbreech presentation was lowest in birth order one compared with birth orders two and three. In breech vaginal delivery compared with cesarean delivery, the opposite effect of birth order was found. The highest perinatal mortality was found in a current breech presentation of a sibship with no previous breech births. In birth subsequent to breech births, perinatal mortality was more or less independent of current presentation, without respect to delivery method. The increased perinatal mortality in breech presentation is explained partly by its association with other risk factors for perinatal death. CONCLUSION: Women with recurring breech presentation represent a lower risk of adverse perinatal outcome. This might be explained by a biologic mechanism or by increased quality of antenatal care. An increased mortality in subsequent nonbreech siblings after a breech presentation was surprising.

Reproductive career after breech presentation: subsequent pregnancy rates, interpregnancy interval, and recurrence.

OBJECTIVE: To assess subsequent pregnancy rates and recurrence of breech, as well as interpregnancy interval after a breech presentation. METHODS: We conducted a national population registry-based study using data from 1967 to 1994, with maternal record linkage of sibships, comprising the first to the fourth birth of a mother. RESULTS: The subsequent pregnancy rate after a surviving breech birth was lower than after a surviving nonbreech birth. Women with two births, of which one was a perinatal loss, had a higher subsequent pregnancy rate, compared with those who had surviving infants. The subsequent pregnancy rate was lower after a cesarean delivery irrespective of presentation. The interpregnancy interval was shorter if the previous infant died, whereas presentation did not influence the interval. The adjusted odds ratio of recurrence of breech increased from 4.32 (95% confidence interval [CI] 4.08, 4.59) after one previous breech delivery to 28.1 (95% CI 12.2, 64.8) after three. CONCLUSION: Breech and cesarean delivery lowered the subsequent pregnancy rate, probably because of the women's decision not to reproduce. Thus, preconceptional counseling with information, support, and reassurance regarding future pregnancies and deliveries might reduce the discouraging effect. A high odds ratio of recurrence of breech suggests effects of recurring specific causal factors of either genetic or more permanent environmental origin.

The occurrence of breech presentation in Norway 1967-1994.

BACKGROUND: To study the occurrence of breech presentation and its association with demographic and geographic variables. METHOD: Population based cohort study from the Medical Birth Registry of Norway comprising all singleton deliveries 1967-1994, a total of 1,592,064 deliveries. Of these, 45,921 in breech presentation. RESULTS: From 1967 through 1994, the breech presentation proportion increased from 2.2% (95% CI 2.1-2.3) to 3.4% (95% CI 3.2-3.5). Breech presentation was associated with high maternal age and low birth order, as well as low gestational age and birthweight. The secular trend was mainly due to demographic changes in terms of increasing proportions of births with low birth order and high maternal age. Breech presentation was most frequent in urban areas. CONCLUSIONS: Strong associations were observed between breech presentation and low birth order as well as high maternal age. The findings are compatible with both intrinsic as well as environmental mechanisms. A full understanding of the birth order effect necessitates further studies based on sibship data. Prevention of premature delivery would be an effective measure for reducing the breech presentation proportion.

Factors influencing delivery method in breech presentation.

BACKGROUND: To study factors influencing delivery method in breech presentation. METHODS: Population based cohort study from The Medical Birth Registry of Norway, comprising all singleton deliveries in Norway, 1967-1994, 1,592,064 deliveries of which 45,921 (2.9%) were in breech presentation. RESULTS: The proportion of cesarean section in breech presentation increased from 3.6 per 100 in 1969 to 58.8 in 1994. The relative risk for delivery by cesarean section in breech presentation compared to the nonbreech population increased from 2.0 (95% CI 1.5-2.7) in 1967 to 5.9 (95% CI 5.6-6.2) in 1994. It declined by maternal age, increased by gestational age and was lowest among mothers with urban residence. A negative association was observed between the annual number of births at the delivery department and the cesarean section proportion. However, during the observation period, the centralization of breech deliveries to the largest departments was reduced. CONCLUSIONS: Vaginal delivery in breech presentation was particularly observed in large delivery departments and among mothers with urban residence. Since experience and practical competence are prerequisites for successful vaginal delivery, this centralization seems justified. Further centralization of all breech presentation births should be pursued. However, preparedness as to vaginal delivery should be established also at the smaller units, e.g. by a routine providing periodical centralized training for obstetricians working in smaller institutions.

The effect on the likelihood of further pregnancy of placental abruption and the rate of its recurrence.

OBJECTIVE: To assess the effect of having a placental abruption on 1. the probability of having further pregnancies, and 2. the rate of recurrence in such pregnancies. DESIGN: A cohort study based on the Medical Birth Registry of Norway. RESULTS: From 1967 to 1989, placental abruption occurred in 218/4951 subsequent deliveries after a placental abruption index case. After placental abruption with perinatal survival in the first delivery 59% of women had a further delivery, compared with 71% who did not have placental abruption at delivery. After a perinatal loss corresponding rates were 83% and 85%, respectively. Odds ratios of recurrence of abruption, crude and adjusted for maternal age, birth order and time period were 7.1 and 6.4, respectively. No secular trends were found. Caesarean section rates increased and were higher in pregnancies with recurrent placental abruption and in subsequent pregnancies without placental abruption than in the total birth population. CONCLUSIONS: Women who have placental abruption are less likely than other women to have another pregnancy. For women who do have subsequent pregnancies placental abruption occurs significantly more frequently.

Evaluation of a protocol for selecting fetuses in breech presentation for vaginal delivery or cesarean section.

OBJECTIVE: Our purpose was to evaluate, with respect to obstetric intervention and neonatal outcome, a protocol for selecting fetuses in breech presentation for vaginal delivery or cesarean section. STUDY DESIGN: A clinical follow-up study was performed between 1984 and 1992 of all term singleton deliveries in breech presentation. Each case selected for vaginal delivery had a matched control in vertex presentation. RESULTS: A total of 1212 infants presented as breech. Vaginal delivery increased from 45% to 57% (p = 0.004), and cesarean section for failure of vaginal delivery declined from 21% to 6% (p < 0.00001). None, however, died or had long-term sequelae because of a complicated or failed vaginal breech delivery. A total of 8.8% of those delivered vaginally in breech versus 5.0% of those in vertex presentation were admitted to the neonatal intensive care unit (p = 0.009). Among those with vaginal delivery, 2.5% in breech presentation were given the clinical diagnosis of birth asphyxia versus none in the vertex position (p = 0.0001). CONCLUSION: Breech presentation at term may be selected for vaginal delivery if properly managed.

[Norwegian Society of Gynecology and Obstetrics--guidelines in obstetrics. Structure, process, results and evaluation]. / Norsk gynekologisk forening--veileder i fødselshjelp. Struktur, prosess, resultat og evaluering.

This paper describes structure, process, results, and evaluation of the Norwegian Society of Gynaecology and Obstetrics' Guidelines in obstetrics. This work, which lasted for 2 1/2 years, involved almost all obstetrical departments in Norway and 1/4 of all members of the Norwegian Society of Gynaecology and Obstetrics. All members of the Norwegian Society of Gynaecology and Obstetrics were invited to answer 24 questions. Of the 63% who replied to the questionnaire, 44% and 48% respectively stated that the Guidelines in obstetrics were very good or good. The introduction of the Guidelines in obstetrics led to changes in routines in more than 70% of the hospitals, and the different categories of hospital physicians changed their routines as well (55-65%). 83% of the heads of the departments stated that the Guidelines in obstetrics served partly or totally as the model for the obstetrical management guidelines. The evaluation and the experience of this quality assessment handbook serve as perspectives for future work.

The occurrence of placental abruption in Norway 1967-1991.

STUDY OBJECTIVE: To study secular trends of placental abruption (PA), the effects of demographic variables and the use of cesarean section (CS) associated with PA. DESIGN: A population based cohort study. SETTING: The Medical Birth Registry of Norway. PATIENTS: 9,592 cases of PA of a total of 1,446,154 births notified, i.e. all births in Norway 1967-1991. MAIN RESULTS: The PA proportion was 6.6 per 1000 births of a gestational age of 16 weeks or more, ranging from 5.3 in 1971 to 9.1 in 1990. Birth order two had the lowest proportion and it increased by maternal age. The PA proportion decreased by gestational age from 86.4 per 1000 below 28 weeks to 3.4 in term pregnancies. The PA proportion per 10,000 pregnancies at risk increased from 1.3 in the 28th week to 14.1 in the 42nd week. A secular trend of a decreasing but still high relative risk of PA in SGA-births at any gestational age increased from 1967 through 1991. The relative risk of PA of Apgar score <7 after five minutes, adjusted for gestational age, was 7.8. CONCLUSIONS: Inspite of an increasing CS rate, an increasing proportion of PA was noted from 1967 through 1991. The proportion was lowest for birth order two and increased by maternal age. To an increasing extent, PA births were centralized. SGA, prematurity and asphyxia were major problems associated with PA. A tendency towards larger infants and a decreasing relative risk of PA in SGA-births might be attributable to improvements in antenatal care.

Perinatal mortality and case fatality after placental abruption in Norway 1967-1991.

STUDY OBJECTIVE: To study national secular trends in Norway of perinatal mortality and case fatality to placental abruption (PA) and associations with cesarean section (CS). DESIGN: A population based cohort study. SETTING: The Medical Birth Registry of Norway. PATIENTS: 9,592 cases of placental abruption (PA) of a total of 1,446,154 births notified in Norway 1967-1991. MAIN MEASURES: Comprehensive perinatal mortality (all stillbirths > or = 16 weeks of gestation and early neonatal deaths) and standard perinatal mortality (all stillbirths > or = 28 weeks of gestation and all early neonatal deaths). Case fatality rate. MAIN RESULTS: From 1967 through 1991, the standard perinatal mortality rate due to placental abruption (PA) in Norway decreased from 2.5 per 1000 births (13.5% of all deaths) in 1967 to 0.9 (13.2%) in 1991. The comprehensive perinatal mortality rate due to placental abruption (PA) in Norway decreased from 3.2 to 1.7 per 1000. The proportion of all perinatal deaths due to PA increased from 11.4% in 1967-1971 to 217.0 in 1987-91 and decreased in all gestational age categories. Case fatality in PA with cesarean section (CS) was generally lower than in PA without CS, regardless of gestational age. CONCLUSIONS: Placental abruption is an important cause of perinatal mortality in Norway. Our results are in favor of an active approach with frequent use of cesarean section, also at lower gestational ages. The decreasing case fatality rate by year of birth in all gestational age groups may be attributed to improved obstetric and perinatal care.

Emergency McDonald cerclage with application of stay sutures.

OBJECTIVE: To evaluate the efficiency of emergency cervical cerclage, and the use of stay sutures. STUDY DESIGN: Retrospective review of patients who were treated with emergency cervical cerclage at our department between January 1984 and April 1994. McDonald cerclage, after traction of the cervix with 6-10 stay sutures, was inserted in 16 women between 16 and 28 weeks gestation, presenting with dilated cervix and protruding membranes. Tocolytics and prophylactic antibiotics were given to most patients. RESULTS: All cerclage operations were primarily performed without complications, except in one case where membranes ruptured during operation. Two reoperations were necessary, and were successfully performed. The median duration of pregnancy after the procedure was 4.5 weeks (range 1 day-18 weeks), and the median birth weight was 1250 g (range 130-4330 g). In 10 of 16 patients (63%), the duration of pregnancy prolongation was between 2.5 and 18 weeks (median 7.0 weeks) following cerclage, with a median birth weight of 2145 g (range 995-4330 g). Four of these patients (25%) delivered at term. In the other six patients, pregnancy lasted seven days or less, resulting in four abortions, and two surviving infants. Eleven of the 16 pregnancies (69%) resulted in live infants. CONCLUSION: Pregnancy can be significantly prolonged following emergency cervical cerclage, and the procedure may contribute to improved neonatal outcome.

Retinal detachment in association with preeclampsia and abruptio placentae.

Retinal detachment is a rare complication of preeclampsia, eclampsia and abruptio placentae. We report a case of bilateral retinal detachment in association with severe preeclampsia complicated with abruptio placentae, intrauterine fetal death and disseminated intravascular coagulation. In obstetric complications, placental thromboplastin may release into maternal circulation and activate the extrinsic coagulation system with resultant disseminated intravascular coagulation. This may be responsible for choroidal ischemia and consequent serous retinal detachment.

[If the woman giving birth had her choice... Results of a consumer study in the region of Bergen]. / Hvis de fødende selv kunne velge... Resultat fra en brukerundersøkelse i Bergens-regionen.

In the region around Bergen, Norway, 792 women answered a questionnaire during their pregnancy or postnatal period. The purpose was to obtain their view of the obstetric care provided during labour. This survey demonstrates that the women expect a high level of medical response. In order to feel secure during their labour, the majority want an obstetrician, a paediatrician and an anesthesia-team to be immediately available. Most of the women consider investigations by ultrasound and electronic foetal heart rate monitoring to be reassuring. 86% of them feel assured when paid a visit regularly by the obstetrician when in the labour ward. Most of the women would like to see the structure of our delivery department reorganized in order to have combined labour and postnatal wards.

[Breech presentation--classification and nomenclature]. / Seteleie--klassifikasjon og nomenklatur.

In Norway the nomenclature used for the various types of breech presentation differs. In this paper the authors describe the common types of breech presentation and the nomenclature used in the Norwegian textbooks in obstetrics. Using different nomenclature can lead to misinterpretation of the different types of breech presentation which could influence the choice method of delivery. The authors propose an unambiguousness Norwegian nomenclature for the most common types of breech presentation.

Outcome of pregnancy and childbirth following laryngectomy.

OBJECTS: Pregnancy and delivery in two laryngectomized women. RESULTS: One woman had a pregnancy complicated by hypothyroidism and stenosis of the tracheostoma, she was delivered by cesarean section. The other had an uneventful pregnancy and a spontaneous vaginal delivery. CONCLUSIONS: Individualized handling of the delivery. By modifying the technique of bearing down spontaneous vaginal delivery is possible.