Yinka Oyelese, Cande V Ananth
Placental abruption.
Obstet Gynecol. 2006 Oct;108(4):1005-16. doi: 10.1097/01.AOG.0000239439.04364.9a.
Abstract/Text
Placental abruption complicates about 1% of pregnancies and is a leading cause of vaginal bleeding in the latter half of pregnancy. It is also an important cause of perinatal mortality and morbidity. The maternal effect of abruption depends primarily on its severity, whereas its effect on the fetus is determined both by its severity and the gestational age at which it occurs. Risk factors for abruption include prior abruption, smoking, trauma, cocaine use, multifetal gestation, hypertension, preeclampsia, thrombophilias, advanced maternal age, preterm premature rupture of the membranes, intrauterine infections, and hydramnios. Abruption involving more than 50% of the placenta is frequently associated with fetal death. The diagnosis of abruption is a clinical one, and ultrasonography and the Kleihauer-Betke test are of limited value. The management of abruption should be individualized on a case-by-case basis depending on the severity of the abruption and the gestational age at which it occurs. In cases where fetal demise has occurred, vaginal delivery is preferable. Disseminated intravascular coagulopathy should be managed aggressively. When abruption occurs at or near term and maternal and fetal status are reassuring, conservative management with the goal of vaginal delivery may be reasonable. However, in the presence of fetal or maternal compromise, prompt delivery by cesarean is often indicated. Similarly, abruption at extremely preterm gestations may be managed conservatively in selected stable cases, with close monitoring and rapid delivery should deterioration occur. Most cases of placental abruption cannot be predicted or prevented. However, in some cases, maternal and infant outcomes can be optimized through attention to the risks and benefits of conservative management, ongoing evaluation of fetal and maternal well-being, and through expeditious delivery where appropriate.
Cunningham FG, Leveno KJ, Bloom SL et al： Williams Obstetrics 23 rd ed. NewYork:McGraw-Hill, 2009;761-769.
日本妊娠高血圧学会編：妊娠高血圧症候群(PIH)管理ガイドライン 2009、 p 149-150、メジカルビュー社、 2009.
日本産科婦人科学会、日本産婦人科医会編：産婦人科診療ガイドライン―産科編 2023、p173-175、2023.
ACOG educational bulletin. Obstetric aspects of trauma management. Number 251, September 1998 (replaces Number 151, January 1991, and Number 161, November 1991). American College of Obstetricians and Gynecologists.
Int J Gynaecol Obstet. 1999 Jan;64(1):87-94.
Abstract/Text
E W PAGE, E B KING, J A MERRILL
Abruptio placentae; dangers of delay in delivery.
Obstet Gynecol. 1954 Apr;3(4):385-93.
Abstract/Text
W W Hurd, M Miodovnik, V Hertzberg, J P Lavin
Selective management of abruptio placentae: a prospective study.
Obstet Gynecol. 1983 Apr;61(4):467-73.
Abstract/Text
Antenatal diagnosis and selective management of abruptio placentae were studied prospectively over a 17-month period. Diagnosis was confirmed by placental inspection in 59 (1.3%) of 4545 deliveries. Among the 50 patients admitted with a living fetus, the diagnosis was made antenatally in 31 (62%). Fifteen were delivered vaginally and 16 by cesarean section. When these infants were compared to all other liveborn infants delivered during this period using a weight-adjusted chi 2 analysis, no significant difference was found in neonatal mortality or duration of hospitalization. There was a significant increase in the incidence of both respiratory distress syndrome and low Apgar scores among the study infants (P less than .005), but these increases were not correlated with mode of delivery or diagnosis-to-delivery interval. It is concluded that optimal fetal survival and an acceptable cesarean section rate may be obtained by selective management, especially in infants weighing more than 1500 g.
Chris Glantz, Leslie Purnell
Clinical utility of sonography in the diagnosis and treatment of placental abruption.
J Ultrasound Med. 2002 Aug;21(8):837-40.
Abstract/Text
OBJECTIVE: To determine the sensitivity and specificity of sonography for detection of placental abruption and whether sonographic results correlate with management or outcome.
METHODS: We identified 149 consecutive patients who underwent sonography at 24 weeks' gestational age or later for ruling out abruption or vaginal bleeding. Obstetric and neonatal data were obtained from the hospital perinatal database. Sonographic results, pathologic reports, and hospital charts were reviewed. Sonographic sensitivity, specificity, and positive and negative predictive values were calculated, and regression was used to determine independence of associations.
RESULTS: Of the 149 patients, 17 (11%) had sonographic evidence of abruption, and 32 (21%) had evidence of abruption at delivery. As the scan-to-delivery interval decreased, the positive predictive value increased and the negative predictive value decreased. Of 55 patients who gave birth within 14 days of sonography, 8 (15%) had scans consistent with abruption, and 29 (53%) had abruption at delivery; the sensitivity, specificity, and positive and negative predictive values of sonography were 24%, 96%, 88%, and 53%, respectively. Positive sonographic findings were univariately associated with 2- to 3-fold greater subsequent tocolysis, betamethasone use, duration of hospitalization, follow-up sonograms, preterm delivery, low birth weight, and neonatal intensive care unit admission. All but low birth weight and neonatal intensive care unit admission remained independently significant after adjustment for gestational age (P < .05).
CONCLUSIONS: Sonography is not sensitive for detection of placental abruption, but a positive finding is associated with more aggressive management and worse neonatal outcome.
C V Towers, R A Pircon, M Heppard
Is tocolysis safe in the management of third-trimester bleeding?
Am J Obstet Gynecol. 1999 Jun;180(6 Pt 1):1572-8.
Abstract/Text
OBJECTIVE: Expectant management is among the current treatment options for pregnancies complicated by third-trimester bleeding at <36 weeks' gestation. The use of tocolytic agents to stop associated contractions is still somewhat controversial, however, and the number of cases reported to date is small. The purpose of our study was to find a large number of cases of preterm third-trimester bleeding that was treated with tocolytic agents and evaluate them for any evidence of potential harm related to the use of these agents.
STUDY DESIGN: Every case of third-trimester bleeding for a 6-year period was obtained from a perinatal database that was created as patients were hospitalized. Only cases of patients with onset of bleeding between 23 and 36 weeks' gestation were analyzed. Data collected included the gestational age at the time of first bleeding, the gestational age at delivery, whether tocolytic agents were used, the need for transfusion, maternal morbidity, and neonatal outcome.
RESULTS: A total of 236 cases, consisting of 131 cases of abruptio placentae and 105 cases of placenta previa, met the study criteria. In the abruptio placentae group 95 women (73%) were treated with tocolytic agents. In this group the mean gestational age at the time of first bleeding was 28.9 weeks, the mean time from bleeding until delivery was 18.9 days, the median time from bleeding until delivery was 7 days, and the neonatal mortality rate was 51 deaths/1000 live births. In the placenta previa group 76 patients (72%) were treated with tocolytic agents. In this group the mean gestational age at first bleeding was 29.5 weeks, the mean time from bleeding until delivery was 29.3 days, the median time from bleeding until delivery was 22 days, and the neonatal mortality rate was 39 deaths/1000 live births. In both groups the need for transfusion and the incidence of fetal distress were not increased by the use of tocolytic agents. Among the 171 combined patients who underwent tocolysis, no maternal morbidity related to the tocolytic agents was found and no stillbirths occurred after admission. The neonatal deaths were all related to complications of prematurity.
CONCLUSIONS: This is the largest series to date evaluating the use of tocolytic agents in preterm patients with third-trimester bleeding. From these data there does not appear to be any increased morbidity or mortality associated with tocolytic agent use in a controlled tertiary setting. A prospective randomized trial would be necessary to determine whether tocolytic use carries any benefits.
日本妊娠高血圧学会編：妊娠高血圧症候群(PIH)管理ガイドライン 2009、 p 152-153、メジカルビュー社、2009.
日本妊娠高血圧学会編：妊娠高血圧症候群の診療指針 2015, p161-168 メジカルビュー社 2015.
Salma Imran Kayani, Stephen A Walkinshaw, Carrol Preston
Pregnancy outcome in severe placental abruption.
BJOG. 2003 Jul;110(7):679-83.
Abstract/Text
OBJECTIVE: To determine the relationship between decision to delivery interval and perinatal outcome in severe placental abruption.
DESIGN: A case-control study.
SETTING: Large inner city teaching hospital.
METHODS: Retrospective case note review of pregnancies terminated following severe placental aburption and fetal bradycardia. One year paediatric follow up by case note review or postal questionnaire. The differences in outcome (death or cerebral palsy) were examined using non-parametric and univariate analysis for the following time periods--times from onset of symptoms to delivery, onset of symptoms to admission, admission to delivery, onset bradycardia to delivery and decision to delivery interval.
MAIN OUTCOME MEASURES: Prenatal death or survival with cerebral palsy.
RESULTS: Thirty-three women with singleton pregnancies over 28 weeks of gestation, admitted with clinically overt placental abruption, where delivery was effected for fetal bradycardia. Eleven of the pregnancies had a poor outcome (cases), eight infants died and three surviving infants have cerebral palsy. Twenty-two pregnancies had a good outcome (controls): survival with no developmental delay. No statistically significant relationship was found between maternal age, parity, gestation, or birthweight and a poor outcome. A statistically significant relationship between time from decision to delivery was identified (P = 0.02, Mann-Whitney U test). The results of a univariate logistic regression for this variable suggest that the odds ratio of a poor outcome for delivery at 20 minutes compared with 30 minutes is 0.44 (95% CI 0.22-0.86). Fifty-five percent of infants were delivered within 20 minutes of the decision to deliver. Serious maternal morbidity was rare.
CONCLUSION: In this small study of severe placental abruption complicated by fetal bradycardia, a decision to delivery interval of 20 minutes or less was associated with substantially reduced neonatal morbidity and mortality.
日本産科婦人科学会、日本産婦人科医会、日本周産期・新生児医学会、日本麻酔科学会、日本輸血・細胞治療学会、日本IVR学会編：産科危機的出血への対応指針 2022.
J A Pritchard, F G Cunningham, S A Pritchard, R A Mason
On reducing the frequency of severe abruptio placentae.
Am J Obstet Gynecol. 1991 Nov;165(5 Pt 1):1345-51.
Abstract/Text
At Parkland Memorial Hospital the frequency of abruptio placentae so severe as to kill the fetus has decreased from 1 in 420 deliveries during 1956 through 1969 to 1 in 830 during 1974 through 1989. Major factors in this reduction were elimination of very high parity and a marked increase in the percentage of Latin American women, in whom the risk was 1 in 1473 deliveries compared with 1 in 595 for black women and 1 in 876 for white women. Abdominal trauma was encountered rarely, as was fetoplacental-to-maternal hemorrhage sufficient to impair fetal perfusion seriously. Abnormal development of Müllerian ducts and uterine myomas were encountered rarely. Neither red blood cell macrocytosis characteristic of folate deficiency nor iron deficiency could be implicated in the genesis of severe abruptio placentae. Abruptio placentae recurred in 12% of subsequent pregnancies and proved fatal to the fetus in 7%, unchanged from our earlier experience.
日本産科婦人科学会、日本産婦人科医会編：産科婦人科診療ガイドライン―産科編 2020、p164-167、2020.
川名有紀子，安達知子，中林正雄: 常位胎盤早期剥離胎児死亡例における分娩様式の選択基準．産婦人科の実際, 2011;60:571-574.
関博之，村山敬彦: 帝切のタイミングとIUFDの取り扱い．臨床婦人科産科, 2011;65:1352-1356.
