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Prediction of Fetal Acidemia in Placental Abruption Yoshio Matsuda1,2,3*, Masaki Ogawa1,2, Jun Konno1, Minoru Mitani1,2 and Hideo Matsui1

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Prediction of Fetal Acidemia in Placental Abruption Yoshio Matsuda1,2,3*, Masaki Ogawa1,2, Jun Konno1, Minoru Mitani1,2 and Hideo Matsui1 Matsuda et al. BMC Pregnancy and Childbirth 2013, 13:156 http://www.biomedcentral.com/1471-2393/13/156 RESEARCH ARTICLE Open Access Prediction of fetal acidemia in placental abruption Yoshio Matsuda1,2,3*, Masaki Ogawa1,2, Jun Konno1, Minoru Mitani1,2 and Hideo Matsui1 Abstract Background: To determine the major predictive factors for fetal acidemia in placental abruption. Methods: A retrospective review of pregnancies with placental abruption was performed using a logistic regression model. Fetal acidemia was defined as a pH of less than 7.0 in umbilical artery. The severe abruption score, which was derived from a linear discriminant function, was calculated to determine the probability of fetal acidemia. Results: Fetal acidemia was seen in 43 survivors (43/222, 19%). A logistic regression model showed bradycardia (OR (odds ratio) 50.34, 95% CI 11.07 – 228.93), and late decelerations (OR 15.13, 3.05 – 74.97), but not abnormal ultrasonographic findings were to be associated with the occurrence of fetal acidemia. The severe abruption score was calculated for the occurrence of fetal acidemia, using 6 items including vaginal bleeding, gestational age, abdominal pain, abnormal ultrasonographic finding, late decelerations, and bradycardia. Conclusions: An abnormal FHR pattern, especially bradycardia is the most significant risk factor in placental abruption predicting fetal acidemia, regardless of the presence of abnormal ultrasonographic findings or gestational age. Keywords: Bradycardia, Fetal acidemia, Fetal heart rate monitoring, Placental abruption, Severe abruption score Background compared the simultaneous use of these two modalities Placental abruption is one of the serious complications in cases of placental abruption. of late pregnancy, because it leads to both poor maternal Pathological acidemia is defined as a pH of less than and fetal/neonatal outcome [1]. The diagnosis of placen- 7.0 and it is an objective measure of intrapartum tal abruption usually depends on the clinical manifesta- hypoxia-ischemia and has been correlated with the oc- tions, and confirmed the placental detachment after currence of hypoxic ischemic encephalopathy (HIE) [8]. delivery [2,3]. The usefulnesses of ultrasonography [4,5] It has been reported that placental abruption is as a reli- and fetal heart rate (FHR) monitoring have been able factor for fetal acidemia as well as FHR abnormality reported as the adjunctive diagnosis, and they are both in both preterm and term infants [9,10], although the widely used for this purpose. But controversy exists as to rate of the occurrence of fetal acidemia has not been whether ultrasonographic findings are useful in deter- well described in placental abruption. mining the diagnosis, management and the relation to The purpose of this study was therefore to determine fetal outcome. On the other hand, abnormal FHR pat- the important factors and to establish the predictive terns are also common in severe cases [6], reflecting score for acidemia in placental abruption, by evaluating uteroplacental insufficiency resulting from interruption clinical assessments as well as adjunctive laboratory tests of placental blood flow [7]. However; few studies have such as ultrasonographic findings and FHR patterns. * Correspondence: [email protected] Methods 1Department of Obstetrics and Gynecology, Tokyo Women’s Medical The approval of the institutional review board (Tokyo University, Kawada-cho, 8-1, Shinjuku-ku, Tokyo 162-8666, Japan ’ 2 Women s Medical University) was obtained before the Perinatal Medical Center, Tokyo Women’s Medical University, Kawada-cho, 8- – 1, Shinjuku-ku, Tokyo 162-8666, Japan start of this retrospective, case control study. All single- Full list of author information is available at the end of the article ton births, born between 24 and 40 weeks of gestation © 2013 Matsuda et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Matsuda et al. BMC Pregnancy and Childbirth 2013, 13:156 Page 2 of 7 http://www.biomedcentral.com/1471-2393/13/156 between January, 1st, 2009, and December 31st, 2009 An adverse outcome for the neonate was defined as were included. The medical records of mothers and neo- the occurrence of death before hospital discharge or a nates in the 94 institutes where these infants were born, diagnosis of cerebral palsy. The outcome of pregnancy comprising the Perinatal Research Network in Japan was classified as poor (cases) and good (controls), with a (PRNJ) listed in the ‘Acknowledgements’ were reviewed. poor outcome defined as a fetal arterial cord blood pH Gestational age was determined based on the mother’s of less than 7.0, irrespective of neonatal outcome. The last menstrual period and first and second trimester ob- results were expressed as mean ± standard deviation stetric ultrasonography. More than 30 variables were (SD), medians with range, or numbers with the percent- assessed, including pregestational and perinatal factors. age. Statistical analyses were performed with the Statflez Preeclampsia/superimposed preeclampsia was diag- 6.0 software package (Archtech Co., Ltd., Osaka, Japan. nosed according to the criteria of National High Blood URL:http://www.statflex.Net/) and were carried out Pressure Education Program Working Group on High using the chi-square test, Fisher’s exact probability test, Blood Pressure in Pregnancy [11]. Details of the diagno- and the Mann–Whitney U test. p values of less than sis, onset place, time from onset of symptoms to admis- 0.05 were considered to be significant. The odds ratio sion/delivery, and clinical management of any relevant (OR) and 95% confidence intervals (CI) were calculated condition were recorded. to estimate the relative risk between cases and controls The diagnosis of placental abruption was based pri- with regard to risk factors for fetal acidemia. They marily on the one or more of the following clinical man- were compared in both univariate and multivariate ana- ifestations: vaginal bleeding, abdominal pain, uterine lyses. Logistic regression models were used to assess tenderness, with/without an abnormal FHR tracing [2], confounding effects and to construct a discriminant and confirmed the placental detachment after delivery. function. Receiver operating characteristic (ROC) curves The presence of hematoma during a cesarean section or were constructed to evaluate the relationship between coagulation/massive genital bleeding during vaginal de- the sensitivity and false positive rate (1-specificity) for livery was considered to indicate placental detachment. the indicators of fetal acidemia. The optimal cut-off Women found to have a healthy placenta, and those point was determined to be the point corresponding with chronic abruption, were excluded from this study. to the highest sensitivity in relation to the highest Chronic abruption-oligohydramnios sequence (CAOS) specificity. was defined by the following criteria: (1) clinically sig- nificant vaginal bleeding in the absence of placenta Results previa or other identifiable source of bleeding, (2) amni- There were 355 patients complicated by placental abrup- otic fluid volume initially documented as normal and (3) tion. The overall number of deliveries in 94 institutes oligohydramnios (amniotic fluid index < or = 5) eventu- was 54,628 and the rate of placental abruption was ally developing without concurrent evidence of ruptured 0.65%. Eighty-nine fetuses were dead on admission membranes [12]. (intrauterine fetal death), while the remaining 266 fe- Ultrasonographic findings were reported as follows; tuses were alive. The latter cases were included in the preplacental collection under the chorionic plate, in- analysis for this study. Although eighty three cases were creased heterogenous placental thickness (more than not recorded mainly due to the emergency nature of the 5 cm), retroplacental collection, marginal hematoma, situation without CTG recordings, rapid frequent con- subchorionic hematoma, or intra-amniotic hematoma [5]. tractions with no resting tone were observed in 72 out FHR patterns were defined as abnormal when one of the of the remaining 183 cases. The mean gestational age at following patterns was detected: persistent late decelera- delivery was 34.1 ± 3.4 weeks (preterm: 200 patients, tions, severe atypical deceleration, prolonged deceleration, term: 66 patients). In spite of resuscitation, an Apgar or bradycardia [13]. The same patterns were also used for score of 0 at five minutes was seen in 7 cases, which the assessment of preterm fetuses. A baseline FHR of less resulted in adverse outcome. than 100 bpm was noted as bradycardia (>3 mins) [13]. Abnormal ultrasonographic findings were observed in This includes FHR detected only by hand-held Doppler 183 patients (68.8%), mainly indicating retroplacental fetal heart detectors or auscultation in some cases. anechoicity (121 cases), and increased placental thick- The live fetuses were delivered by cesarean section be- ness (117 cases). cause of abnormal FHR patterns or maternal indications, Abnormal FHR patterns were observed in 166 patients such as massive genital bleeding. At delivery, the umbil- (62.4%). The main abnormal FHR results were as ical cord was double clamped. 0.2 ml of arterial blood follows: persistent late decelerations, 51 cases
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