Ablatio placentae in hypertensive and normotensive pregnants: perinatal and neonatal outcomes

Objective

 To compare the effect of abruptio placentae on the neonatal outcomes of hypertensive and normotensive pregnancies. Methods

Methods

 115 cases of placental abruption between January 2002 and February 2004 were reviewed in our study. These cases were grouped as normotensives (n=50) and hypertensives (n=65). The case groups were compared for demographic features, the degree of placental abruption, the type of delivery, intrauterine growth restriction, oligohydramnios, preterm delivery, intrauterine fetal demise, umbilical artery Doppler measurements, birth weight, gender, Apgar scores, necrotizing enterocolitis (NEC), respiratuar distress syndrome (RDS), sepsis, mechanical ventilation, intensive care unit admission (NICU), and neonatal mortality.

Results 

 Incidence of placental abruption was determined as 0,26%. Grade 1 placental abruption was more frequent in the normotensive group while grade 2 abruption was more frequent among hypertensives (p<0.001; p<0.001). The rate of grade 3 placental abruption was not significantly different between the case groups (p=0.64). Intrauterine growth restriction and fetal distress were more frequent in the hypertensive case group (p<0.001, p<0.001 respectively). There was no significant difference between the case groups for either birth weight, oligohydramnios, preterm delivery, and stillbirth or the mode of delivery (p=0.26). 

Conclusion

Among pregnancies complicated with placental abruption, intrauterine growth restriction and fetal distress rate was significantly higher in the hypertensive group when compared with the normotensive group. There was no significant difference between hypertansive and normotensive pregnancies for other perinatal and neonatal parameters.

Keywords

Placental abruption, hypertension, perinatal, neonatal outcomes

Introduction

Ablatio placentae is an obstetric complication which is so heavy and endangers both mother’s and baby’s life. The reason for ablatio placentae is unknown and its pathophysiology is not understood very well.(1) It is thought that some factors such maternal age, parity, smoking habit, presentations out of vertex, intrauterine growth retardation (IUGR), early membranous rupture and ablatio placentae history in previous gestations increase the risk for ablatio placentae.(1,2 )Also, hypertensive disorders of gestation have a high incidence in all ablatio placentae cases.(3) Our aim within this study is to compare perinatal and neonatal outcomes of complicated gestations with ablatio placentae having or not having hypertensive disorder.

Methods

It is a cohort study based on 42.889 deliveries executed between January 2002 and February 2004 in Istanbul Bakirkoy Obstetrics and Children Illness of Training and Research Hospital. Perinatal and neonatal data is based on our computer database. Single gestations exceeding 23rd week were included to the study. Cases diagnosed as ablatio placentae were separated into two groups as hypertensive and normotensive. Perinatal and neonatal records include maternal age, gestational week at delivery, delivery mood, IUGR, intrauterine fetal death, oligohydroamnios, ultrasonographic Doppler studies, fetal distress, neonatal sexuality, birth weight, Apgar score, acceptance to newborn intensive care unit, necrotizing enterocolitis (NEC), sepsis, respiratory distress syndrome (RDS), mechanical ventilation and neonatal mortality. Ablatio placentae grade is determined in three different ways. It is graded as grade 1 ablatio placentae only in the existence of maternal bleeding, as grade 2 ablatio placentae only in the existence of fetal distress regardless of maternal bleeding and as grade 3 ablatio placentae only in case of fetal death. MedCalc statistical software 8.2.1.0 was used for statistics. T test for parametric data, chisquare and Fisher’s absolute test for categorical data were used where statistical analysis is appropriate. Statistical significance is accepted as p value < 0.05

Results

Ablatio placentae was observed 115 (0.26%) of all gestations over 23 weeks. While 65 (56%) of these 115 cases with ablatio placentae diagnosis were in hypertensive group, other 50 (44%) cases were in normotensive group. Both case groups were similar in terms of age, gravida and parity during delivery (p=0.59; p=0.23; p=0.12). Rates for grade 3 ablatio placentae were same in both case groups (p=0.64). When groups were evaluated in terms of grade 1 and 2; normotensive group had 22 (44%) cases with grade 1 ablatio placentae and hypertensive group had 9 (13.8%) cases with grade 1 ablatio placentae. Difference between both groups was significant (p<0.001). Grade 2 ablatio placentae was observed in 13 cases (26%) within normotensive group and in 39 cases (60%) within hypertensive group. The difference between both groups was statistically significant (p<0.001) (Table 1).
When both groups were compared in terms of gestational week, delivery mood, intrauterine fetal death and oligohydroamnios, it was observed that possibility of hypertensive pregnants for delivering before 37th gestational week was higher. Rate for abdominally delivery of normotensive pregnants was frequent. Oligohydroamnios and intrauterine fetal death incidences of normotensive pregnant group were higher but the difference between two groups was not significant (=0.18; p=0.26; p=0.23; p=0.64). Also, IUGR and fetal distress incidences in hypertensive group was significantly high (41.5%; 39%, p<0.001; p<0.001) (Table 2). Application rate to the newborn intensive care unit was higher in normotensive group when both case groups were compared in terms of neonatal outcomes, but the difference was not significant (p=0.06). Birth weights, RDS and neonatal mortality rates of newborns within normotensive group was higher than hypertensive group; but there was not significant difference between both case groups (p=0.52 and p=0.18; p=0.29). No significant difference was observed between neonatal parameters of two case groups (Table 3).
 

Discussion

Hypertensive disorders during gestation (chronic hypertension and hypertension induced by the gestation) are significant etiological indicators of ablatio placentae and it may reach to 10% in hypertensive pregnants depending on the severity of the actual disorder.4,5 Lindqvist et al6 found that ablatio placentae risk increased 3.4 times in pregnants with preeclampsia.
Hypertensive disorders during gestation (chronic hypertension and hypertension induced by the gestation) are significant etiological indicators of ablatio placentae and it may reach to 10% in hypertensive pregnants depending on the severity of the actual disorder.4,5 Lindqvist et al6 found that ablatio placentae risk increased 3.4 times in pregnants with preeclampsia case groups as neonatal care conditions which was developed and improved within the elapsed period. While perinatal mortality rate was 36% in hypertensive pregnants with ablatio placentae, this rate was found as 26% in normotensive pregnants in our study. No significant difference was observed between both groups in terms of perinatal mortality.
Abdella et al14 found positive correlation between increasing ablatio placentae grade and maternal morbidity; but Kayani et al11 found a rare maternal morbidity and they interpreted it as good and intensive post-partum care. In our study, grade 1 ablatio placentae in normotensive group and grade 2 ablatio placentae in hypertensive group were significantly high. There was no difference between hypertensive and normotensive pregnants in terms of grade 3 ablatio placentae.
Heavy ablatio placentae together with fetal bradycardia exist together with bad perinatal outcomes.11 We observed fetal distress in hypertensive group in significantly higher rate; but we found both case groups similar in terms of intrauterine fetal death and neonatal mortality rates. This can be partially explained by increased cesarean rates. In fact, Witlin et al12 showed that cesarean delivery decreased neonatal mortality and they also showed that being dead of fetus during application increased maternal morbidity. Cesarean was applied to 48 cases in normotensive group and to 58 cases in hypertensive group in our study. We can explain the similarity of neonatal mortality rates within case groups by increased cesarean rate within case groups.  

Conclusion

Among pregnants complicated with ablatio placentae, intrauterine growth retardation and fetal distress rate was significantly higher in the hypertensive group when compared with the normoten.sive group. There was no significant difference between hypertensive and normotensive pregnants for other perinatal and neonatal parameters.
 

Referances

1. Sheiner E, Shoham-Vardi I, Hallak M, Hadar A, Gortzak-Uzan L, Katz M, Mazor M. Placental abruption in term prenancies: clinical and obstetric risk factors. J Matern Fetal Neonatal Med 2003; 13: 45-9.
2. Conde-Agudelo A, Kafury-Goeta AC. Case control study of risk factors for complicated eclampsia. Obstet Gynecol 1997; 90: 172-5.
3. Witlin AG, Sade GR, Mattar F, Sibai BM. Risk factors for abruptio placenta and eclampsia: Analysis of 445 consecutively managed women with severe preeclampsia and eclampsia. Am J Obstet Gynecol 1999; 180: 1322-9.
4. Kramer MS, Usher RH, Pollack R, Boyd M, Usher S. Etiologic determinants of abruptio placenta. Obstet Gynecol 1997; 89: 221-6.
5. Sibai BM. Dagnosis and Management of chronic hypertension in pregnancy. Obstet Gynecol 1991; 78: 451-61.
6. Lindqvist PG, Happach C. Risk and risk estimation of placental abruption. EJOG 2006; 126: 160-164.
7. Ananth CV, Wilcox AJ. Placenta abruption and perinatal mortality in the United States. Am J Epidemol 2001; 153: 332-7.
8. Yalınkaya A, Önen A, Özçelik SM, Değertekin B, Ecer S, Yayla M. Dicle Üniversitesinde bir yıllık perinatal mortalite. Perinatoloji Dergisi 2002; 10: 324-7.
9. James DK, Steer P, Weiner C, Gonic B. High risk pregnancy, management options. London: Saunders, 1995.
10. Toivonen S, Heinonen S, Anttila M, Kosma VM, Saarikoski S. Reproductive risk factors, Doppler findings, and outcome of affected births in placental abruption: a population-based analysis. Am J Perinatol 2002; 19: 451-60.
11. Kayani SI, Walkinshaw SA, Preston C. Perinatal and maternal outcome following abruptio placentae. BJOG 2003; 110: 679-83.
12. Witlin AG, Sibai BM. Hypertens Pregnancy. 2001; 20: 195-203.
13. Köse MF, Meydanlı M, Güzel Y, Dölen İ, Haberal A. Incidence of abruptio placentae and associated perinatal mortality. GORM 1997; 3: 344-50.
14. Abdella TN, Sibai BM, Hays JM Jr, Anderson GD. Relationship of hypertensive disease to abruptio placentae. Obstet Gynecol 1984; 63: 365-70.
15. Morgan MA, Berkowitz KM, Thomas SJ, Reimbold P, Quilligan EJ. Abruptio placentae: perinatal outcome in normotensive and hypertensive patients. Am J Obstet Gynecol 1994; 170: 1595-9.

	File/Dsecription
	Table 1. Demographic qualities of cases with ablatio placentae.
	Table 2. Perinatal outcomes of cases with ablatio placentae.
	Table 3. Neonatal outcomes of cases with ablatio placentae.