http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3368363/
Clinical Significance of
Preterm Singleton Pregnancies Complicated by Placental Abruption following
Preterm Premature Rupture of Membranes Compared with Those without p-PROM
Abstract
The purpose
of this paper was to examine the obstetric and neonatal outcomes of preterm
singleton pregnancies complicated by placental abruption following preterm
premature rupture of membranes (p-PROM) compared with those without p-PROM. We
reviewed the obstetric records of 95 singleton deliveries complicated by
placental abruption at 22–36 weeks' gestation. The incidence of placental
abruption in singleton pregnancies with p-PROM was 4.7%, and the crude odds
ratio of placental abruption for women following p-PROM was 6.50 (P <
0.01). Of the 95 cases of placental abruption in preterm singleton deliveries,
64 cases (67.4%) occurred without p-PROM and 31 cases (32.6%) occurred
following p-PROM. The incidence of histological chorioamnionitis stage III in
the patients following p-PROM was significantly higher than that in the
patients without p-PROM (P = 0.02). The rate of emergency Cesarean
deliveries associated with nonreassuring fetal status (NRFS) in the patients
following p-PROM was significantly lower than that in the patients without
p-PROM. However, there were no significant differences in the maternal and
neonatal outcomes between the patients with and without p-PROM. Although p-PROM
may be one of important risk factors for placental abruption associated with
chorioamnionitis, it may not influence the perinatal outcomes in preterm
placental abruption.
1. Introduction
Placental
abruption or premature separation of the normally implanted placenta is a
serious and life-threatening obstetric complication for both mother and fetus [1–3].
Although the cause of placental abruption remains elusive, the presence of
inflammation and infection has been suggested to be the primary cause of
placental abruption [2, 4–8].
Some previous studies have observed an association between intrauterine
infection, especially chorioamnionitis (CAM), and placental abruption [2, 4–8].
In addition, evidence from prior studies suggests that women exposed to
prolonged preterm premature rupture of membranes (p-PROM) are at increased risk
of placental abruption [9–11],
because recent evidence has linked neutrophil infiltration into the deciduas
with preterm placental abruption [2, 7].
In our earlier studies [12, 13],
for example, the incidence of preterm delivery, p-PROM, and low birth weight in
the cases of placental abruption with chorioamnionitis were higher than in
cases without chorioamnionitis: however there were no significant differences
in the incidence of other outcomes between the cases of placental abruption
with and without histological chorioamnionitis. However, there have been few
examinations concerning the influence of precedent p-PROM on the severity of
placental abruption at preterm only.
In this
study, we examined the obstetric and neonatal outcomes of preterm singleton
pregnancies complicated by placental abruption following p-PROM compared with
those without p-PROM.
2. Patients and Methods
The protocol
for this paper was approved by the Ethics Committee of the Japanese Red Cross
Katsushika Maternity Hospital. In addition, informed consent concerning
analysis from a retrospective database was obtained from each subject at their
first hospital visit.All subjects in this study had received care at Japanese
Red Cross Katsushika Maternity Hospital between April 2002 and March 2011. We
reviewed the obstetric records of 95 singleton deliveries complicated by
placental abruption, defined as complete or partial separation of a normally
implanted placenta indicated by evidence of retro-placental bleeding at 22–36
weeks' gestation. (In our hospital, there were 65 cases complicated by
placental abruption after 37 weeks' gestation during the 9-year period.) We
excluded the cases referred from other hospitals after the onset of placental
abruption. In this paper, we examined the incidence of hypertensive disorders
such as gestational hypertension and preeclampsia, emergency Cesarean delivery,
disseminated intravascular coagulation (DIC), maternal blood loss requiring
hemotransfusion, small-for-gestational-age infants, fetal demise, nonreassuring
fetal status (NRFS), Apgar score <4 at 1 and 5 minutes and umbilical artery
pH < 7. Infants who were small-for-gestational-age were defined as those
with sex- and age-adjusted birth weights below the tenth percentile according
to the neonatal birth weight standards for gestational age in Japanese [14]. In addition, microscopic histological
analyses of the placentas were performed to diagnose chorioamnionitis (CAM).
The severity of CAM, that is, inflammation of the placental surface, was determined
by the degree of maternal polymorphonuclear lymphocyte infiltration into either
the subchorionic space (intervillositis: stage I), the intervillous space
(chorionitis: stage II) or the amniotic cavity (CAM in a narrow sense: stage
III) according to Blanc's criteria [15].
2.1. Analysis
Data are presented as number (%) or mean ± SD. For
statistical analysis, the χ2 test with Yates' correction for
categorical variables was used. While the Student's t-test for
continuous variables was used. Odds ratios (ORs) and 95% confidence intervals
(CIs) were also calculated. Differences with P < 0.05 were considered
significant.
3. Results
Of the 95
cases of placental abruption in deliveries at 22–36 weeks' gestation, 64 cases
(67.4%) occurred without p-PROM and 31 cases (32.6%) occurred following p-PROM.
During the
9-year period, there were 17,667 singleton deliveries after 22 weeks' gestation
in our hospital. Of these, 655 cases were complicated by p-PROM (3.7%). In our
hospital, therefore, the incidence of placental abruption in singleton
pregnancies with p-PROM was 4.7% and the crude OR of placental abruption for
women following p-PROM was 6.50 (95% CI: 4.4–9.7, P < 0.01).
Table 1 shows the perinatal outcomes of preterm
singleton pregnancies complicated by placental abruption with and without p-PROM.
The incidence of histological CAM stage III in the patients following p-PROM
was significantly higher than that in the patients without p-PROM (crude OR:
5.22, 95% CI: 1.4–19, P = 0.02). On the other hand, the rate of
emergency Cesarean deliveries due to NRFS in the patients following p-PROM was
significantly lower than that in the patients without p-PROM (emergency
Cesarean delivery, crude OR: 0.13, 95% CI: 0.05–0.33, P < 0.01; NRFS,
crude OR: 0.34, 95% CI: 0.13–0.87, P = 0.04). However, there were no significant
differences in the maternal and neonatal outcomes between the patients with and
without p-PROM.
Obstetric
complications and perinatal outcomes of preterm singleton pregnancies
complicated by placental abruption with and without preterm premature rupture
of membranes (p-PROM).
4. Discussion
The major
findings of the current study are: (1) the preterm singleton pregnancies
complicated by placental abruption following p-PROM was strongly associated
with the presence of histological CAM more than those without p-PROM, and (2)
the perinatal outcomes of preterm placental abruption following p-PROM were not
different from those without p-PROM at preterm.
Some previous
studies have reported that p-PROM is a common obstetric complication, occurring
in approximately 1-2% of pregnancies, and it is one of important risk factors
for placental abruption [9–11].
Our current results also support these previous studies.
Histological
CAM, defined as inflammation of the extraplacental membrane, has been
consistently linked with prematurity and low birth weight of neonates [16].
In addition, the relationship between histological CAM and infection (positive
culture) of the chorioamnion has been reported to be strongest among preterm
deliveries [17, 18].
In cases with histological CAM, because the prematurely delivered placentas
have been observed to be often accompanied by an acute marginal hemorrhage that
undermines the edge of the placenta and that originates from deciduitis [2]. This hemorrhage process can cause premature
labor and/or p-PROM and has been reported to differ from the typical placental
abruption due to other causes such as preeclampsia [5].
Vintzileos et al. [8] also suggested that true placental abruption
following the presence of CAM usually occurs after PROM. On the other hand,
Nelson et al. [9] speculated that an acute reduction in the
uterine volume and intrauterine surface as a consequence of p-PROM could
ultimately lead to disruption of the site of placental attachment in the
decidual spongiosa layer, thereby predisposing to abruption. In this study,
unfortunately, we could not examine the intervals between p-PROM and onset of
placental abruption. However, the progress of placental abruption in the cases
following p-PROM may not tend to be acute; because the rate of cases with NRFS
requiring cesarean operation in women following p-PROM was lower than those
without p-PROM. Therefore, our results support the previous studies suggesting
the association among CAM, p-PROM, and placental abruption [10,
11].
In this study,
the perinatal outcomes of preterm placental abruption following p-PROM were not
different from those without p-PROM at preterm, although the rate of emergency
Cesarean delivery due to NRFS in cases following p-PROM was lower than in those
without p-PROM. One reason may be the small sample size in this study. The
other possible reason is that a more rapid Cesarean delivery might tend to be
carried out in cases without PROM due to more typical symptoms, (bleeding,
abdominal pain, and NRFS) and more easy diagnosis of placental abruption
compared with cases following PROM [19]. Because rupture of membranes (amniotomy) has
been supposed to decrease bleeding from the implantation site of the placenta
and reduce entry of thromboplastin into the maternal circulation [19]. In our series, therefore, the influence of
placental abruption on maternal and fetal conditions might be larger in cases
without PROM than those following PROM; however, a rapid delivery of the fetus
by Cesarean section might prevent serious complications in many cases without
PROM.
In
conclusion, although p-PROM may be one of important risk factors for placental
abruption associated with CAM, it may not influence the perinatal outcomes in
preterm placental abruption.
References
1. Benirschke
K, Kaufmann P, Baergen RN. Infarcts. In: Benirschke K, Kaufmann P, Baergen RN,
editors. Pathology of the Human Placenta. 5th edition. New York, NY,
USA: Springer; 2006. pp. 612–615.
2. Benirschke
K, Kaufmann P, Baergen RN. Chorioamnionitis. In: Benirschke K, Kaufmann P,
Baergen RN, editors. Pathology of the Human Placenta. 5th edition. New
York, NY, USA: Springer; 2006. pp. 657–694.
3. Usui R,
Matsubara S, Ohkuchi A, et al. Fetal heart rate pattern reflecting the severity
of placental abruption. Archives of Gynecology and Obstetrics.
2008;277(3):249–253. [PubMed]
4. Ananth
CV, Getahun D, Peltier MR, Smulian JC. Placental abruption in term and preterm
gestations: evidence for heterogeneity in clinical pathways. Obstetrics and
Gynecology. 2006;107(4):785–792. [PubMed]
5. Harris
BA, Jr., Gore H, Flowers CE. Peripheral placental separation: a possible
relationship to premature labor. Obstetrics and Gynecology.
1985;66(6):774–778. [PubMed]
6. Harris
BA., Jr. Peripheral placental separation: a review. Obstetrical and
Gynecological Survey. 1988;43(10):577–581. [PubMed]
7. Nath CA, Ananth
CV, Smulian JC, Shen-Schwarz S, Kaminsky L. Histologic evidence of inflammation
and risk of placental abruption. American Journal of Obstetrics and
Gynecology. 2007;197(3):319.e1–319.e6. [PubMed]
8. Vintzileos
AM, Campbell WA, Nochimson DJ, Weinbaum PJ. Preterm premature rupture of the
membranes: a risk factor for the development of abruptio placentae. American
Journal of Obstetrics and Gynecology. 1987;156(5):1235–1238. [PubMed]
9. Nelson
DM, Stempel LE, Zuspan FP. Association of prolonged, preterm premature rupture
of the membranes and abruptio placentae. Journal of Reproductive Medicine
for the Obstetrician and Gynecologist. 1986;31(4):249–253. [PubMed]
10. Ananth
CV, Savitz DA, Williams MA. Placental abruption and its association with
hypertension and prolonged rupture of membranes: a methodologic review and
meta-analysis. Obstetrics and Gynecology. 1996;88(2):309–318. [PubMed]
11. Ananth
CV, Oyelese Y, Srinivas N, Yeo L, Vintzileos AM. Preterm premature rupture of membranes,
intrauterine infection, and oligohydramnios: risk factors for placental
abruption. Obstetrics and Gynecology. 2004;104(1):71–77. [PubMed]
12. Suzuki
S, Hiraizumi Y, Yamashita E, Yonezawa M, Shirokane M, Satomi M. Clinical
significance of singleton pregnancies complicated by placental abruption
associated with histological chorioamnionitis. Journal of Nippon Medical
School. 2010;77(4):204–208.
13. Suzuki
S, Satomi M, Hiraizumi Y, Miyake H. Clinical significance of singleton
pregnancies complicated by placental abruption occurred at preterm compared
with those occurred at term. Archives of Gynecology and Obstetrics.
2011;283(4):761–764. [PubMed]
14. Ogawa Y,
Iwamura T, Kuriya N, et al. Birth size standards by gestational age for
Japanese neonates. Acta Neonatol Japonica. 1998;34:624–632. (Jpn).
15. Blanc
WA. Amniotic infection syndrome: pathogenesis morphology, and significance in
circumnatal mortality. Clinical Obstetrics and Gynecology.
1959;2:705–734.
16. Gibbs
RS, Romero R, Hillier SL, Eschenbach DA, Sweet RL. A review of premature birth
and subclinical infection. American Journal of Obstetrics and Gynecology.
1992;166(5):1515–1528. [PubMed]
17. Dong Y,
Clair PJ, Ramzy I. A microbiologic and clinical study of placental inflammation
at term. Obstetrics and Gynecology. 1987;70(2):175–182. [PubMed]
KETUBAN
PECAH DINI
Penelitian ini dilakukan berdasar pada angka kejadian ketuban pecah dini
setiap bulannya dapat mencapai 20% dari seluruh persalinan dan 21% dari seluruh
kejadian ketuban pecah dini mengalami infeksi. Jenis penelitian yang dilakukan
adalah deskriptif kuantitatif. Pengambilan sampel menggunakan accidental
sampling sebanyak 32 kegiatan penatalaksanaan ketuban pecah dini yang
terhitung mulai tanggal 15 Desember 2010 – 6 Januari 2011. Tehnik pengumpulan
data dengan observasi non partisipatif metode checklist, dilakukan
sebanyak 2 kali. Sedangkan analisis data menggunakan skor dikotomi tehnik
persentase.
Berdasarkan observasi didapatkan hasil penelitian, yaitu pelaksanaaan
kegiatan monitoring rata-rata dilaksanakan dengan cukup baik (56,6%),
dikategorikan dengan baik (9,4 %), cukup baik (50%), dan kurang baik(40,6%).
Pelaksanaaan kegiatan tindakan rata-rata dilaksanakan dengan cukup baik
(58,2%), dikategorikan dengan cukup baik (65,6%), dan kurang baik (34,4%).
Sedangkan pelaksanaaan kegiatan kolaborasi rata-rata dilaksanakan dengan kurang
baik (30%), dengan cukup baik (3,1%), dan kurang baik (96,9%).
Etiologi :
1. Serviks inkompeten.
2. Ketegangan rahim berlebihan : kehamilan
ganda, hidramion.
3. Kelainan letak janin dan rahim : letak
sungsang, letak lintang.
4. Kemungkinan kesempitan panggul : bagian
terendah belum masuk PAP (sepalo pelvic disproporsi).
5. Infeksi yang menyebabkan terjadinya
biomekanik pada selaput ketuban dalam
bentuk preteolitik sel sehingga memudahkan ketuban pecah. (Amnionitis/
Korioamnionitis).
6. Faktor keturunan (ion
Cu serum rendah, vitamin C rendah, kelainan genetik)
7. Masa interval sejak ketuban
pecah sampai terjadi kontraksi disebut fase laten
a. Makin panjang
fase laten, makin tinggi kemungkinan infeksi
b. Makin muda kehamilan, makin sulit upaya pemecahannya
tanpa menimbulkan morbiditas janin
Komplikasi ketuban pecah dini
1. Infeksi intrapartum
(korioamnionitis)
2. Persalinan preterm,
jika terjadi pada usia kehamilan preterm
3. Prolaps tali pusat
4. Oligohidramnion
Penatalaksanaan
Perlu dilakukan pertimbangan tentang tata laksana yang
paling tinggi mencapai well born baby dan well health mother. Masalah berat
dalam menghadapi ketuban pecah dini adalah apabila kehamilan kurang dari 26
minggu karena untuk mempertahankannya memerlukan waktu lama. Bila berat janin
sudah mencapai 2000 gram, induksi dapat dipertimbangkan. Kegagalan induksi
disertai dengan infeksi yang diikuti histerektomi.
Selain itu, dapat dilakukan pemberian kortikosteroid
dengan pertimbangan. Tindakan ini akan menambah reseptor pematangan paru,
meningkatnya maturitas paru janin. Pemberian betametason 12 minggu dilakukan
dengan interval 24 jam dan 12 minggu tambahan, maksimum dosis 24 minggu, masa
kerjanya sekitar 2-3 hari. Bila janin setelah satu minggu belum lahir,
pemberian berakortison dapat diulang lagi.
Indikasi melakukan pada ketuban pecah dini adalah
sebagai berikut :
1. Pertiimbangan waktu
dan berat janin dalam rahim. Pertimbangan waktu apakah 6, 12, atau 24 jam.
Berat janin sebaiknya lebih dari 2000 gram.
2. Terdapat tanda
infeksi intra uteri. Suhu meningkat lebih dari 38°c, dengan pengukuran
per rektal. Terdapat tanda infeksi melalui hasil pemeriksaan laboratorium dan
pemeriksaan kultur air ketuban.
Di blog ini juga Saya membagikan beberapa hasil karya tulis Saya seperti yang bisa sobat baca secara gratis. Harapan Saya yaitu semoga blog ini dapat memberikan kontribusi yang bermanfaat bagi sobat semua.
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