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Concept: Placental abruption

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During cesarean delivery in patients with placenta previa, hemorrhaging after removal of the placenta is often challenging. In this condition, the extraordinarily high concentration of tissue factor at the placenta site may constitute a principal of treatment as it activates coagulation very effectively. The presumption, however, is that tissue factor is bound to activated factor VII (FVIIa).

Concepts: Placental abruption, Obstetrics, Factor VII, Caesarean section, Placenta praevia, Placenta accreta, Childbirth

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OBJECTIVE: To evaluate the risk of placenta praevia accreta following primary (first) elective or primary emergency caesarean section in a pregnancy complicated by placenta praevia. DESIGN: Retrospective matched case-control study, employing variable matching. SETTING: Tertiary referral centre between 1993 and 2008. POPULATION: Sixty-five cases and 102 controls were used for the analysis from a total of 82 667 births during the study period. METHODS: Relevant data were abstracted from clinical records. Matching of cases with controls was based on co-existing placenta praevia, number of previous caesarean sections, and age, with one or two controls per case. Results are presented as odds ratios (ORs) with 95% confidence intervals (95% CIs). MAIN OUTCOME MEASURES: Placenta accreta in a pregnancy complicated by placenta praevia following a primary elective or emergency caesarean section, and morbidity associated with pregnancies complicated by placenta accreta. RESULTS: Significantly more cases than controls had an elective caesarean section for their primary caesarean delivery (46.2 versus 18.6%; P < 0.001). There were no differences between groups for previous pregnancy loss, uterine surgery, and vaginal delivery, before or after the primary caesarean section. Compared with primary emergency caesarean section, primary elective caesarean section significantly increased the risk of placenta accreta in a subsequent pregnancy in the presence of placenta praevia (OR 3.00; 95% CI 1.47-6.12; P = 0.025). CONCLUSIONS: Our results suggest that women with a primary elective caesarean section without labour are more likely, compared with those undergoing primary emergency caesarean section with labour, to develop an accreta in a subsequent pregnancy with placenta praevia.

Concepts: Placental abruption, Epidural, Caesarean delivery on maternal request, Placenta praevia, Placenta accreta, Caesarean section, Obstetrics, Childbirth

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Objective  To estimate the incidence of multiple repeat caesarean section (MRCS) (five or more) in the UK and to describe the outcomes for women and their babies relative to women having fewer repeat caesarean sections. Design  A national population-based prospective cohort study using the UK Obstetric Surveillance System (UKOSS). Setting  All UK hospitals with consultant-led maternity units. Population  Ninety-four women having their fifth or greater MRCS between January 2009 and December 2009, and 175 comparison women having their second to fourth caesarean section. Methods  Prospective cohort and comparison identification through the UKOSS monthly mailing system. Main outcome measures  Incidence, maternal and neonatal complications. Relative risk, unadjusted (OR) and adjusted (aOR) odds ratio estimates. Results  The estimated UK incidence of MRCS was 1.20 per 10 000 maternities [95% confidence interval (CI), 0.97-1.47]. Women with MRCS had significantly more major obstetric haemorrhages (>1500 ml) (aOR, 18.6; 95% CI, 3.89-88.8), visceral damage (aOR, 17.6; 95% CI, 1.85-167.1) and critical care admissions (aOR, 15.5; 95% CI, 3.16-76.0), than women with lower order repeat caesarean sections. These risks were greatest in the 18% of women with MRCS who also had placenta praevia or accreta. Neonates of mothers having MRCS were significantly more likely to be born prior to 37 weeks of gestation (OR, 6.15; 95% CI, 2.56-15.78) and therefore had higher rates of complications and admissions. Conclusions  MRCS is associated with greater maternal and neonatal morbidity than fewer caesarean sections. The associated maternal morbidity is largely secondary to placenta praevia and accreta, whereas higher rates of preterm delivery are most likely a response to antepartum haemorrhage.

Concepts: Epidemiology, Placental abruption, Relative risk, Caesarean section, Placenta praevia, Placenta accreta, Obstetrics, Childbirth

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To compare the difference in maternal outcomes between early and late use of transverse annular compression sutures (TACS) during cesarean delivery among women with complete placenta previa (CPP).

Concepts: Epidural, Placenta, Placental abruption, Obstetrics, Caesarean section, Placenta accreta, Placenta praevia, Childbirth

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OBJECTIVE: To evaluate characteristics of placenta accreta (PA) in patients without previous cesarean section. MATERIAL AND METHODS: Retrospective cohort study from December 1993 to April 2010 in two departments of obstetrics in university hospitals, Marseille, France. Comparison of clinical characteristics, circumstances of diagnosis, maternal morbidity and treatment was performed between PA diagnosed in patients with (n=63) and without prior cesarean section (n=35). RESULTS: In group of patients without previous caesarean section, rate of placenta praevia, and antenatal diagnosis were lower (16/35 [46 %] vs. 44/63 [70 %], [P: 0.02]) and (4/35 [11 %] vs. 28/63 [44 %], [P<0.001]) and rate of pregnancies obtained by IVF was higher (5/35 [15 %] vs. 2/63 [3 %], [P=0.05]). In this group, no hysterectomy was performed but risk of uterus necrosis following embolization was increased (3/35 [8.6 %] patients vs. 0/63 patients [P: 0.02]). CONCLUSIONS: Patients without previous caesarean section have specific characteristics in terms of risk factor and of management.

Concepts: Placental abruption, Pregnancy, Hysterectomy, Childbirth, Placenta praevia, Caesarean section, Placenta accreta, Obstetrics

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Abstract Objective. To investigate if maternal asthma is associated with an increased risk of maternal and placental complications in pregnancy. Methods. Electronic databases were searched for the following terms: (asthma or wheeze) and (pregnan* or perinat* or obstet*). Cohort studies published between 1975 and March 2012 were considered for inclusion. 40 publications met the inclusion criteria, reporting at least one maternal or placental complication in pregnant women with and without asthma. Relative risk (RR) with 95% confidence intervals (CI) was calculated. Results. Maternal asthma was associated with a significantly increased risk of cesarean section (RR=1.31, 95%CI=[1.22, 1.39]), gestational diabetes (RR=1.39, 95%CI=[1.17, 1.66]), hemorrhage (antepartum: RR=1.25, 95%CI=[1.10, 1.42]; postpartum: RR=1.29, 95%CI=[1.18, 1.41]), placenta previa (RR=1.23, 95%CI=[1.07, 1.40]), placental abruption (RR=1.29, 95%CI=[1.14, 1.47]), and premature rupture of membranes (RR=1.21, 95%CI=1.07, 1.37). Moderate to severe asthma significantly increased the risk of cesarean section (RR=1.19, 95%CI=[1.09, 1.31]) and gestational diabetes (RR=1.19, 95%CI=[1.06, 1.33]) compared to mild asthma. Bronchodilator use was associated with a significantly lowered risk of gestational diabetes (RR=0.64, 95%CI=[0.57, 0.72]). Conclusions. Pregnant women with asthma are at increased risk of maternal and placental complications, and women with moderate/severe asthma may be at particular risk. Further studies are required to elucidate whether adequate control of asthma during pregnancy reduces these risks.

Concepts: Fetus, Placental abruption, Placenta, Asthma, Caesarean section, Pregnancy, Childbirth, Obstetrics

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Context:Thyroid diseases are inconsistently reported to increase risk for pregnancy complications.Objective:The objective of this study was to study pregnancy complications associated with common and uncommon thyroid diseases.Design, Setting, and Participants:We analyzed singleton pregnancies (N = 223 512) from a retrospective US cohort, the Consortium on Safe Labor (2002-2008). Thyroid diseases and outcomes were derived from electronic medical records. Multivariable logistic regression with generalized estimating equations estimated adjusted odds ratios (ORs) with 99% confidence intervals (99% CI).Main Outcome Measures:Hypertensive diseases, diabetes, preterm birth, cesarean sections, inductions, and intensive care unit (ICU) admissions were analyzed.Results:Primary hypothyroidism was associated with increased odds of preeclampsia (OR = 1.47, 99% CI = 1.20-1.81), superimposed preeclampsia (OR = 2.25, 99% CI = 1.53-3.29), gestational diabetes (OR = 1.57, 99% CI = 1.33-1.86), preterm birth (OR = 1.34, 99% CI = 1.17-1.53), induction (OR = 1.15, 99% CI = 1.04-1.28), cesarean section (prelabor, OR = 1.31, 99% CI = 1.11-1.54; after spontaneous labor OR = 1.38, 99% CI = 1.14-1.66), and ICU admission (OR = 2.08, 99% CI = 1.04-4.15). Iatrogenic hypothyroidism was associated with increased odds of placental abruption (OR = 2.89, 99% CI = 1.14-7.36), breech presentation (OR = 2.09, 99% CI = 1.07-4.07), and cesarean section after spontaneous labor (OR = 2.05, 99% CI = 1.01-4.16). Hyperthyroidism was associated with increased odds of preeclampsia (OR = 1.78, 99% CI = 1.08-2.94), superimposed preeclampsia (OR = 3.64, 99% CI = 1.82-7.29), preterm birth (OR = 1.81, 99% CI = 1.32-2.49), induction (OR = 1.40, 99% CI = 1.06-1.86), and ICU admission (OR = 3.70, 99% CI = 1.16-11.80).Conclusions:Thyroid diseases were associated with obstetrical, labor, and delivery complications. Although we lacked information on treatment during pregnancy, these nationwide data suggest either that there is a need for better thyroid disease management during pregnancy or that there may be an intrinsic aspect of thyroid disease that causes poor pregnancy outcomes.

Concepts: Hypothyroidism, Fetal distress, Placental abruption, Breech birth, Pregnancy, Caesarean section, Obstetrics, Childbirth

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Women with a history of previous caesarean delivery, presenting with a placenta previa have become the largest group with the highest risk for placenta previa accreta.

Concepts: Placental abruption, Prenatal diagnosis, Caesarean section, Placenta praevia, Medical ultrasonography, Placenta accreta, Obstetrics, Childbirth

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Placenta previa, one of the most severe obstetric complications, carries an increased risk of intraoperative massive hemorrhage. Several risk factors for intraoperative hemorrhage have been identified to date. However, the correlation between birth weight and intraoperative hemorrhage has not been investigated. Here we estimate the correlation between birth weight and the occurrence of intraoperative massive hemorrhage in placenta previa.

Concepts: Placental abruption, Placenta accreta, Caesarean section, Placenta praevia, Obstetrics, Childbirth

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Recent evidence suggests that assisted reproductive technology (ART) increases the risk of adverse pregnancy outcomes, including placental disorders. Similarly, endometriosis resulted detrimental on placenta previa. However, up to 50% of women with endometriosis suffer from infertility, thus requiring ART. The aim of our metanalysis is to compare women with and without endometriosis undergoing ART in terms of placenta disorders events, to establish if ART itself or endometriosis, as an indication to ART, increases the risk of placenta previa.

Concepts: Childbirth, Systematic review, Caesarean section, Placental abruption, Assisted reproductive technology, Infertility, Pregnancy, Placenta