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Clinical Characteristics of Pregnancies Complicated by Both Fetal Growth Restriction (FGR) and Placenta Previa Or Low-Lying Placenta (PPLLP)

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Clinical Characteristics of Pregnancies Complicated by Both Fetal Growth Restriction (FGR) and Placenta Previa Or Low-Lying Placenta (PPLLP) Hypertension Research 70 Fetal growth restrictionIn Pregnancy with placental insertion abnormality ORIGINAL ARTICLE Reprint request to: Shunji Suzuki, Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika Clinical characteristics of Maternity Hospital, 5-11-12 Tateishi, Katsushika-ku, Tokyo pregnancies complicated by both 124-0012, Japan. fetal growth restriction and E-mail: [email protected] Key words: fetal growth restriction, low-lying placenta previa or low-lying placenta, massive bleeding, placenta placenta previa Received: May 29, 2019 Revised: September 18, 2019 Jun Ogawa, Shunji Suzuki Accepted: September 30, 2019 J-STAGE Advance published date: October 19, 2019 Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity DOI:10.14390/jsshp.HRP2019-009 Hospital, Tokyo, Japan Aim: This study aimed to examine the clinical characteristics of pregnancies complicated by both fetal growth restriction (FGR) and placenta previa or low-lying placenta (PPLLP). Methods: A retrospective cohort study was performed to compare clinical characteristics of pregnancies complicated by FGR and/or PPLLP in women who do not habitually smoke or consume alcohol and who underwent delivery of singletons at ≥ 22 weeks’ gestation at Japanese Red Cross Katsushika Maternity Hospital between 2002 and 2015. Assessed factors related to patients and perinatal outcomes included maternal age, parity, history of in vitro fertilization, hypertensive disorders, delivery mode, fetal ultrasonographic findings, delivery mode, gestational age at delivery, neonatal asphyxia, and postpartum hemorrhage. Results: There were 24,118 singleton deliveries assessed for eligibility. Of these, 7 were complicated by both FGR and PPLLP. The development of FGR was not associated with the presence of PPLLP (odds ratio 1.12, 95% confidence interval 0.54–2.4, P = 0.69). Multivariate logistic regression analysis revealed that the incidence of preterm cesarean delivery due to massive bleeding in pregnancies complicated by both FGR and PPLLP was higher than that in pregnancies complicated by PPLLP or FGR alone (vs. PPLLP alone: adjusted OR 7.11, P = 0.03; vs. FGR alone: adjusted OR 195, P < 0.01). Conclusion: Obstetricians should be aware of the increased risk of preterm delivery related to antepartum massive bleeding in pregnancies complicated by both FGR and PPLLP. Introduction complications in women with PPLLP. The authors recommended the careful surveillance of women with Fetal growth restriction (FGR) is a serious obstetrical PPLLP to minimize maternal, fetal, and neonatal complication associated with placental insufficiency complications.5) Based on other reports examining the constituting the syndrome of ischemic placental disease association of PPLLP with preterm delivery and/or and continues to be a leading cause of preventable FGR,6–8) the association between low birth weight and stillbirth and poor neurodevelopmental outcomes.1,2) PPLLP has been suggested to be mainly attributed to Placental insertion abnormalities such as placenta preterm delivery and, to a lesser extent, FGR. Therefore, previa and low-lying placenta (PPLLP) require strict these latter reports have recommended the management management of labor and delivery and carry the risk of of PPLLP with a main focus on maternal hemodynamic massive maternal bleeding.3,4) complications such as massive bleeding, rather than fetal To date, there is no consensus on whether PPLLP conditions. contributes to placental insufficiency leading to FGR. Against this backdrop, the present study aimed to A recent study by Baumfeld et al.5) demonstrated an examine the clinical characteristics of pregnancies increased rate of placental insufficiency-associated complicated by both FGR and PPLLP. 70 Hypertens Res Pregnancy 2019; 7: 70–74 Hypertension Research in Pregnancy © 2019 Japan Society for the Study of Hypertension in Pregnancy J. Ogawa and S. Suzuki Methods ≥ 2,300 g delivered at ≥ 36 weeks’ gestation, pathological examination was not performed even for cases with This retrospective cohort study analyzed data from the PPLLP. Accordingly, villous damage (chronic villitis) total population of women who underwent delivery of was examined as the sign of placental insufficiency singletons at ≥ 22 weeks’ gestation at Japanese Red associated with FGR in some cases complicated by FGR Cross Katsushika Maternity Hospital between 2002 and with and without PPLLP.11,12) 2015. The protocol for this study was approved by the Additional potential risk factors for massive bleeding Ethics Committee of the Japanese Red Cross Katsushika requiring emergency cesarean section in cases of PPLLP Maternity Hospital. Informed consent to analyze data were also examined. In addition to FGR, the classification from a retrospective database was obtained from all of PPLLP, the presence of placental insufficiency, and the subjects at the first perinatal visit. presence of (awareness of) regular uterine contractions Gestational ages were determined by ultrasonographic were also examined. examination of the fetal crown-rump length at 9–11 Data are expressed as number (percentage). SPSS weeks’ gestation in cases of spontaneous conception, and Statistics software version 20 (IBM Corp., Armonk, NY, embryo transfer dates when pregnancy was achieved by USA) was used for statistical analyses. The X2 test with in vitro fertilization (IVF). The presence of PPLLP was and without Yates correction or Fisher’s exact test was confirmed by transvaginal ultrasonography just prior used for categorical variables. A multivariate logistic to delivery according to the Guidelines for Obstetrical regression analysis was conducted to compare factors for Practice in Japan.9) PPLLP was defined as complete, pregnancies complicated by both FGR and PPLLP vs. partial, and marginal previa and a low-lying placenta pregnancies complicated by FGR or PPLLP alone. Odds (Japan Society of Obstetrics and Gynecology, Glossary ratios (ORs) and 95% confidence intervals (CIs) were of Obstetrics and Gynecology, The fourth edition, 2018). calculated. Differences with P < 0.05 were considered FGR was defined as fetuses with sex- and age-adjusted significant. birth weights < −1.5 SD according to the fetal growth curve for Japanese.9,10) Exclusion criteria were as follows: Results women who habitually smoked and/or consumed alcohol during pregnancy, cases of fetal abnormalities During the study period, there were 24,118 Japanese such as chromosomal aberration, cases with vertical women without habitual smoking or alcohol consumption infection leading to congenital abnormalities such as with singleton deliveries at ≥ 22 weeks’ gestation. Of congenital cytomegalovirus infection, and cases of cord these, 291 (1.2%) and 528 (2.2%) who were diagnosed abnormalities such as velamentous cord insertion. with PPLLP and FGR, respectively, were assessed for Clinical characteristics of pregnancies complicated eligibility. Of these, 7 were complicated by both PPLLP by FGR and/or PPLLP were compared in this study. and FGR. The OR for FGR in pregnancies with PPLLP Assessed factors related to patients and perinatal was 1.12 (95% CI 0.54–2.4, P = 0.69). outcomes included maternal age, parity, history of Table 1 shows the clinical characteristics of the 7 IVF, hypertensive disorders, fetal ultrasonographic pregnancies complicated by both FGR and PPLLP. There findings such as cerebroplacental Doppler ratio and were no cases with serious complications or past histories oligohydramnios, delivery mode, gestational age at associated with the development of FGR. The placental delivery (preterm delivery due to massive bleeding), position, such as classification and location, in these cases neonatal asphyxia, and postpartum hemorrhage requiring did not differ from those in cases complicated by PPLLP transfusion. The first diagnosis of hypertensive disorders alone (P = 0.25 and 0.20). Table 2 shows a comparison was defined as blood pressure ≥ 140/90 mmHg measured of clinical characteristics of pregnancies complicated by at the upper arm by maintaining the arm-cuff position both FGR and PPLLP and those complicated by FGR at heart level with the patient in a sitting position in the or PPLLP alone. Using multivariate logistic regression outpatient examination room. For hospitalized patients, analysis, the incidence of preterm cesarean delivery due hypertension was confirmed on two or more occasions to massive bleeding in pregnancies complicated by both at least 6 hs apart with the patient under bed rest. The FGR and PPLLP was higher than that in pregnancies presence of neonatal asphyxia was defined by umbilical complicated by PPLLP or FGR alone (vs. PPLLP alone: artery pH < 7.0. Massive bleeding was clinically adjusted OR 7.11, 95% CI 1.7–31, P = 0.03; vs. FGR diagnosed as hemorrhage that was expected to continue alone: adjusted OR 195, 95% CI 22–1,600, P < 0.01). for an amount greater than 200 ml. In pathological examinations of placentae, rates of During the study period, only neonates requiring villous damage in cases complicated by FGR with and hospitalization were pathologically examined. For without PPLLP were 71.4 and 34.4% (5/7 and 96/279, example, for healthy neonates with a birth weight P = 0.10), respectively. Hypertens Res Pregnancy 2019; 7: 70–74 71 Fetal growth restriction with placental insertion abnormality Table 1. Clinical characteristics of 7 pregnancies complicated by fetal growth restriction and placenta previa or low-lying placenta (PPLLP) Apgar Gestational Classification
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