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The purpose of this Committee Opinion is to offer guidance about indications for and timing and frequency of antenatal fetal surveillance in the outpatient setting. Antenatal fetal surveillance is performed to reduce the risk of stillbirth. However, because the pathway that results in increased risk of stillbirth for a given condition may not be known and antenatal fetal surveillance has not been shown to improve perinatal outcomes for all conditions associated with stillbirth, it is challenging to create a prescriptive list of all indications for which antenatal fetal surveillance should be considered. This Committee Opinion provides guidance on and suggests surveillance for conditions for which stillbirth is reported to occur more frequently than 0.8 per 1,000 (the false-negative rate of a biophysical profile) and which are associated with a relative risk or odds ratio for stillbirth of more than 2.0 compared with pregnancies without the condition. Table 1 presents suggestions for the timing and frequency of testing for specific conditions. As with all testing and interventions, shared decision making between the pregnant individual and the clinician is critically important when considering or offering antenatal fetal surveillance for individuals with pregnancies at high risk for stillbirth or with multiple comorbidities that increase the risk of stillbirth. It is important to emphasize that the guidance offered in this Committee Opinion should be construed only as suggestions; this guidance should not be construed as mandates or as all encompassing. Ultimately, individualization about if and when to offer antenatal fetal surveillance is advised.

OBJECTIVE To evaluate whether use of the B-Lynch suture is associated with subsequent adverse pregnancy outcomes. METHODS This is a cohort study of women who experienced postpartum hemorrhage between January 2000 and June 2010 and had a subsequent pregnancy at a single university hospital. Women who had postpartum hemorrhage and B-Lynch suture were compared with those complicated by postpartum hemorrhage but no B-Lynch suture placement. The primary outcome was a composite adverse outcome related to placentation abnormalities and included placenta previa, placenta accreta, preeclampsia, preterm birth, or a small-for-gestational-age neonate. The study was powered to detect a twofold difference in the frequency of the composite outcome. RESULTS Two hundred fifty-two patients met inclusion criteria, 63 of whom had a prior B-Lynch suture. Women with a prior B-Lynch had a higher mean estimated blood loss (1,800 mL compared with 1,200 mL, P

To compare placental lesions for stillbirth cases and live birth controls in a population-based study.Pathologic examinations were performed on placentas from singleton pregnancies using a standard protocol. Data were analyzed overall and within gestational age groups at delivery.Placentas from 518 stillbirths and 1,200 live births were studied. Single umbilical artery was present in 7.7% of stillbirths and 1.7% of live births, velamentous cord insertion was present in 5% of stillbirths and 1.1% of live births, diffuse terminal villous immaturity was present in 10.3% of stillbirths and 2.3% of live births, inflammation (eg, acute chorioamnionitis of placental membranes) was present in 30.4% of stillbirths and 12% of live births, vascular degenerative changes in chorionic plate were present in 55.7% of stillbirths and 0.5% of live births, retroplacental hematoma was present in 23.8% of stillbirths and 4.2% of live births, intraparenchymal thrombi was present in 19.7% of stillbirths and 13.3% of live births, parenchymal infarction was present in 10.9% of stillbirths and 4.4% of live births, fibrin deposition was present in 9.2% of stillbirths and 1.5% of live births, fetal vascular thrombi was present in 23% of stillbirths and 7% of live births, avascular villi was present in 7.6% of stillbirths and 2.0% of live births, and hydrops was present in 6.4% of stillbirths and 1.0% of live births. Among stillbirths, inflammation and retroplacental hematoma were more common in placentas from early deliveries, whereas thrombotic lesions were more common in later gestation. Inflammatory lesions were especially common in early live births.Placental lesions were highly associated with stillbirth compared with live births. All lesions associated with stillbirth were found in live births but often with variations by gestational age at delivery. Knowledge of lesion prevalence within gestational age groups in both stillbirths and live birth controls contributes to an understanding of the association between placental abnormality and stillbirth.II.

OBJECTIVE: To compare prevalence, indications, risk indicators, and outcomes of emergency peripartum hysterectomy across income settings. DATA SOURCES: PubMed, MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases up to March 30, 2015. METHODS OF STUDY SELECTION: Studies including emergency peripartum hysterectomies performed within 6 weeks postpartum. Not eligible were comments, case reports, elective hysterectomies for associated gynecologic conditions, studies with fewer than 10 inclusions, and those reporting only percentages published in languages other than English or before 1980. Interstudy heterogeneity was assessed by χ test for heterogeneity; a random-effects model was applied whenever I exceeded 25%. TABULATION, INTEGRATION, AND RESULTS: One hundred twenty-eight studies were selected, including 7,858 women who underwent emergency peripartum hysterectomy, of whom 87% were multiparous. Hysterectomy complicated almost 1 per 1,000 deliveries (range 0.2-10.1). Prevalence differed between poorer (low and lower middle income) and richer (upper middle and high income) settings: 2.8 compared with 0.7 per 1,000 deliveries, respectively (relative risk 4.2, 95% confidence interval [CI] 4.0-4.5). Most common indications were placental pathology (38%), uterine atony (27%), and uterine rupture (26%). Risk indicators included cesarean delivery in the current pregnancy (odds ratio [OR] 11.38, 95% CI 9.28-13.97), previous cesarean delivery (OR 7.5, 95% CI 5.1-11.0), older age (mean difference 6.6 years between women in the case group and those in the control group, 95% CI 4.4-8.9), and higher parity (mean difference 1.4, 95% CI 0.7-2.2). Having attended antenatal care was protective (OR 0.12, 95% CI 0.06-0.25). Only 3% had accessed arterial embolization to prevent hysterectomy. Average blood loss was 3.7 L. Mortality was 5.2 per 100 hysterectomies (reported range 0-59.1) and higher in poorer settings: 11.9 compared with 2.5 per 100 hysterectomies (relative risk 4.8, 95% CI 3.9-5.9). CONCLUSION: Emergency peripartum hysterectomy is associated with considerable morbidity and mortality and is more frequent in lower-income countries, where it contains a higher risk of mortality. A (previous) cesarean delivery is associated with a higher risk of emergency peripartum hysterectomy.

Objective To define the frequency, risk factors, and outcomes of massive transfusion in obstetrics. Methods The State Inpatient Dataset for New York (1998-2007) was used to identify all delivery hospitalizations for hospitals that reported at least one delivery-related transfusion per year. Multivariable logistic regression analysis was performed to examine the relationship between maternal age, race, and relevant clinical variables and the risk of massive blood transfusion defined as 10 or more units of blood recorded. Results Massive blood transfusion complicated 6 of every 10,000 deliveries with cases observed even in the smallest facilities. Risk factors with the strongest independent associations with massive blood transfusion included abnormal placentation (1.6/10,000 deliveries, adjusted odds ratio [OR] 18.5, 95% confidence interval [CI] 14.7-23.3), placental abruption (1.0/10,000, adjusted OR 14.6, 95% CI 11.2-19.0), severe preeclampsia (0.8/10,000, adjusted OR 10.4, 95% CI 7.7-14.2), and intrauterine fetal demise (0.7/10,000, adjusted OR 5.5, 95% CI 3.9-7.8). The most common etiologies of massive blood transfusion were abnormal placentation (26.6% of cases), uterine atony (21.2%), placental abruption (16.7%), and postpartum hemorrhage associated with coagulopathy (15.0%). A disproportionate number of women who received a massive blood transfusion experienced severe morbidity including renal failure, acute respiratory distress syndrome, sepsis, and in-hospital death. Conclusion Massive blood transfusion was infrequent, regardless of facility size. In the presence of known risk for receipt of massive blood transfusion, women should be informed of this possibility, should deliver in a well-resourced facility if possible, and should receive appropriate blood product preparation and venous access in advance of delivery. Level of evidence : II.

To compare maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team with similar cases managed by standard obstetric care.This was a retrospective cohort study of all cases of placenta accreta identified in the State of Utah from 1996 to 2008. Cases of placenta accreta were identified using International Classification of Diseases (ICD-9) codes for placenta accreta, placenta previa, and cesarean hysterectomy. Maternal morbidity was compared for cases managed by a multidisciplinary care team in two tertiary care centers and similar cases managed at 26 other hospitals using multivariable logistic regression analysis.One-hundred forty-one cases of placenta accreta were identified including 79 managed by a multidisciplinary care team and 62 cases managed by standard obstetric care. Women managed by a multidisciplinary care team were less likely to require large-volume blood transfusion (4 or more units of packed red blood cells) (43% compared with 61%, P=.031) and reoperation within 7 days of delivery for bleeding complications (3% compared with 36%, P.001) compared with women managed by standard obstetric care. Women with suspected placenta accreta managed by a multidisciplinary team were less likely to experience composite early morbidity (prolonged maternal admission to the intensive care unit, large-volume blood transfusion, coagulopathy, ureteral injury, or early reoperation) than women managed by standard obstetric care (47% compared with 74%, P=.026). The odds ratio of composite early morbidity in women managed by a multidisciplinary team was 0.22, (95% confidence interval, 0.07- 0.70) in the multivariable model.Maternal morbidity is reduced in women with placenta accreta who deliver in a tertiary care hospital with a multidisciplinary care team.II

Hemostasis for placenta previa is notoriously difficult because of the poor contractility of the lower segment. A hemostatic gel offers a new type of hemostatic matrix, which may have advantages.A 35-year-old woman had a postpartum hemorrhage despite the use of uterotonics 2 hours after cesarean delivery for major placenta previa. On relaparotomy, heavy oozing from the placental site was found. Difficult accessibility and profuse bleeding prompted the consideration of alternative treatment with the topical application of hemostatic gel over the lower segment, which achieved hemostasis within minutes.Hemostatic gel is easily applicable and provides quick and effective hemostatic control in the lower segment, where surgical intervention may be difficult.

OBJECTIVE To estimate the effects of prenatal diagnosis and delivery planning on outcomes in patients with placenta accreta. METHODS A review was performed of all patients with pathologically confirmed placenta accreta at the University of California, San Diego Medical Center from January 1990 to April 2008. Cases were divided into those with and without predelivery diagnosis of placenta accreta. Patients with prenatal diagnosis of placenta accreta were scheduled for planned en bloc hysterectomy without removal of the placenta at 34-35 weeks of gestation after betamethasone administration. Maternal and neonatal outcomes were assessed. RESULTS Ninety-nine women with placenta accreta were identified, of whom 62 were diagnosed before delivery and 37 were diagnosed intrapartum. Comparing women with predelivery diagnosis with those diagnosed at the time of delivery, there were fewer units of packed red blood cells transfused (4.7+/-2.2 compared with 6.9+/-1.8 units, P=.02) and a lower estimated blood loss (2,344+/-1.7 compared with 2,951+/-1.8 mL, P=.053), although this trend did not reach statistical significance. Comparison of neonatal outcomes demonstrated a higher rate of steroid administration (65% compared with 16%, P

BACKGROUND: The management of an abnormally invaded placenta presents a challenging obstetric problem. Recent reports have suggested that a conservative approach to the treatment of this condition is appropriate in selected cases. We present the courses of two women with suspected placenta percreta who were managed conservatively and the complications that ensued. CASES: Two multiparous women underwent elective repeat cesarean deliveries and were found to have clinical evidence of placenta percreta with bladder invasion. In both cases, the placenta was left in situ and medical management was attempted with methotrexate. Both women developed significant delayed complications requiring reoperation and hysterectomy, and both required multiple transfusions. CONCLUSION: Conservative management of the abnormally invaded placenta should be undertaken with caution, and complications should be anticipated.

To estimate the incidence of gestational trophoblastic disease in Nova Scotia and to evaluate the effect of time and maternal age on these rates.Information on women with a pathologically confirmed diagnosis of gestational trophoblastic disease was extracted from the Nova Scotia Gestational Trophoblastic Disease Registry between 1990 and 2005. The total numbers of deliveries and pregnancies were determined from the Nova Scotia Atlee Perinatal Database and consensus data derived from Statistics Canada.Four-hundred twenty-eight women were identified with gestational trophoblastic disease. Hydatidiform moles showed rates of 220/100,000 pregnancies, 264/100,000 total births, and 266/100,000 live births. Rates of partial mole were twofold higher than complete mole (P.001). The rates of hydatidiform mole were highest in both younger (younger than 20 years old, P=.02) and older age groups (30-34 years old, P=.04, and at least 35 years old, P=.02). The rates of hydatidiform mole were highest in both younger (less than 20 years old, P=.02) and older age groups (30-34 years old, P .04, and 35 or more years old P=.02). The rates of partial moles were significantly higher in women older than 20 years of age (P.001) and increased with increasing age (P.001); the reverse trend was seen in complete mole (P.001). There was no temporal change in rates or average age of hydatidiform mole during the study period.The rates of hydatidiform mole in Nova Scotia estimated by this population-based study using comprehensive validated information, are higher than most previously reported. Maternal age was a significant factor in the risk for molar pregnancies.

Background A twin gestation comprising a complete hydatidiform mole and a coexisting normal fetus is a rare and high-risk condition. Only a few such gestations have resulted in live infants. We report a case with a very large molar component presenting as a placenta previa. Case A live infant was delivered by cesarean at 31 weeks of gestation. The delivery incorporated prophylactic temporary balloon occlusion of the internal iliac arteries. The patient did not develop persistent gestational trophoblastic disease. Conclusion We recommend that intra-arterial balloon catheters be considered before cesarean delivery in cases of complete hydatidiform mole with a coexisting normal fetus if the molar pregnancy presents as a previa. The size of the molar gestation is not an independent risk factor for persistent or metastatic disease.

Hemorrhage is a serious threat with placenta accreta, often requiring aggressive operative intervention by hysterectomy and resuscitative measures with large-volume blood replacement to ensure survival. Refusal to accept transfusion makes management especially difficult.We report a Jehovah's Witness patient who had 9 previous cesarean deliveries and presented with anemia and placenta previa percreta invading the bladder wall. Management objectives were to enhance the patient's status, using erythropoietin and autologous transfusion, and to minimize the chance of hemorrhage by prophylactic uterine artery embolization. The placenta was left in situ after the delivery with no untoward consequences. Methotrexate was held in readiness, but was not required as adjuvant therapy.Effective care of such patients requires close collaborative team effort and advanced planning to ensure a good outcome.

Background Control of bleeding is the goal of management for placenta accreta, which usually necessitates hysterectomy. A Committee Opinion of The American College of Obstetricians and Gynecologists (ACOG) has addressed the difficulties of conservative treatments. Cases Placentas of 2 primiparous women with placenta accreta were removed operatively from their uteri. One woman underwent a low transverse cesarean delivery, and the other had delivered vaginally. In each case, the anterior uterine wall was incised vertically between the lower segment and fundus before manual removal. After eversion of the uterus, the placenta was successfully detached from the uterine wall after intramyometrial administration of oxytocin. Conclusion A vertical incision in the anterior uterine wall and subsequent eversion of the uterus may aid in avoiding hysterectomy with placenta accreta.

To determine whether the increased risk of placenta previa at delivery in patients with a prior cesarean results from an increased risk of abnormal implantation or a lower likelihood of resolution.A hospital-based, case-control study was performed. Cases were defined as singleton pregnancies with a placenta previa on second-trimester ultrasonography. Controls, chosen randomly from patients without a placenta previa on second-trimester ultrasonography, were matched 3:1 with cases. Odds ratios (OR) were calculated, controlling for other independent risk factors for previa: age, parity, race, and smoking.There were 88 cases identified and 264 controls. Twenty cases (22.7%) and 35 controls (13.3%) had a history of prior cesarean delivery. Previous cesarean delivery was an independent risk factor for previa on second-trimester ultrasonography (OR 1.92, 95% confidence interval [CI] 1.04-3.55), as was the number of cesareans (OR 1.62, 95% CI 1.12-2.34). However, neither retained their significance after adjusting for other known risk factors for previa (OR 1.50, 95% CI 0.77-2.92, and OR 1.40, 95% CI 0.93-2.10, respectively). At delivery, a history of cesarean was associated with a 3-fold increased risk of previa.A previous cesarean delivery did not increase the odds for detecting a placenta previa on second-trimester ultrasonography. At delivery, a previous cesarean was associated with a previa, suggesting a lower likelihood of resolution.

To compare the impact of conservative and extirpative strategies for placenta accreta on maternal morbidity and mortality.We retrospectively reviewed the medical records of all patients diagnosed with placenta accreta admitted to our tertiary center from January 1993 through December 2002. Two consecutive periods, A and B, were compared. During period A (January 1993 to June 1997), our written protocol called for the systematic manual removal of the placenta, to leave the uterine cavity empty. In period B (July 1997 to December 2002), we changed our policy by leaving the placenta in situ. The following outcomes over the 2 periods were compared: need for blood transfusion, hysterectomy, intensive care admission, duration of stay in intensive care, and postpartum endometritis.Thirty-three cases of placenta accreta were observed among 31,921 deliveries (1.03/1,000). During period B, there was a reduction in the hysterectomy rate (from 11 [84.6%] to 3 [15%]; P.001), the mean number of red blood cells transfused (3,230 +/- 2,170 mL versus 1,560 +/- 1,646 mL; P.01), and disseminated intravascular coagulation (5 [38.5%] versus 1 [5.0%]; P =.02), compared with period A. There were 3 cases of sepsis in period B and none in period A (P =.26). At least 2 women with conservative management subsequently had successful pregnancies.Leaving the placenta accreta in situ appears to be a safe alternative to removing the placenta.

OBJECTIVE: The purpose of the study was to characterize the perinatal outcome of pregnancies complicated by placenta accreta. METHODS: We conducted a case-control analysis of all deliveries between the years 1990 and 2000 that were complicated by placenta accreta. Perinatal variables included in the analysis were gestational age at delivery, birth weight, Apgar scores, and perinatal mortality. Statistical analysis was performed using both the unpaired and paired approach. P

Background Medical therapy for thrombosed valve in pregnancy has become an acceptable alternative to surgery, especially in hemodynamically compromised patients. Placental changes after thrombolytic therapy have rarely been reported. Cases Sonograms were done within 24 hours after administration of thrombolytic agents at 15 and 26 weeks of gestation, respectively, in 2 women whose pregnancies were complicated with thrombosis of prosthetic mitral valves. Both patients developed massive subchorionic hematomas, which persisted in 1 patient who underwent cesarean delivery at 34 weeks of gestation for cardiac indications (Apgar scores 9 and 10 at 1 minute and 5 minutes, respectively). The hematomas resolved in the other patient, who delivered at term. Conclusion Massive subchorionic hematomas may be observed in patients after thrombolytic therapy. Other reports are needed to establish whether such placental findings are common lesions after such therapy and to determine their impact on pregnancy outcome.

Background A rare type of placentation leading to cesarean delivery and hysterectomy is described. Case A young multigravida in the 26th week of gestation was referred to our department with a history of vaginal bleeding and suspected placenta previa. Three previous children were delivered by elective cesarean. Ultrasonographic examination suggested placenta previa increta with hypervascularization and with pulsatile lacunar flow. In the 38th week of gestation, an elective cesarean delivery and hysterectomy were performed. Morphological studies showed that most of the placenta developed in the anterior portion of the cervix. The implantation took place in the scar tissue, promoting infiltration of the increted growth and thus ensuring the normal development of the amnionic sac and fetus in the uterine cavity. Conclusion Variations in placental implantation may result in unique situations at birth.

Background Information is limited regarding the preferred method of delivery when the placenta is underlying the site of the uterine incision. Cases Three patients with placenta previa illustrate the successful use of a technique that avoids incising the underlying placenta. An iatrogenic partial separation of the placenta is created to rupture the membranes and deliver the infant. Conclusion This reproducible technique is offered as an alternative to transecting the underlying placenta at cesarean delivery.

To evaluate gestational age at ultrasound detection of placenta previa as a predictor of previa persistence until delivery, and to estimate the effects of previa type, parity, and prior cesarean delivery on previa persistence.This was a retrospective cohort study of pregnancies with placenta previa detected during transabdominal or endovaginal ultrasound examination. Previa was categorized as complete if the placenta completely covered the internal cervical os or incomplete if the inferior placental edge partially covered or reached the margin of the os. Gestational age was grouped into 4-week intervals from 15 to 36 weeks. The outcome was cesarean delivery for persistent previa.Previa was detected during 940 ultrasound examinations in 714 pregnancies. Of those with placenta previa at 15-19 weeks, 20-23 weeks, 24-27 weeks, 28-31 weeks, and 32-35 weeks, previa persisted until delivery in 12%, 34%, 49%, 62%, and 73%, respectively. At each interval, complete previa was more likely to persist than incomplete previa, all P.001. Prior cesarean delivery was an independent risk factor for persistent previa among women diagnosed with previa in the second trimester, P.05. However, parity was not an independent risk factor for persistence at any gestational age interval after adjusting for prior cesarean delivery.Gestational age at ultrasound detection of placenta previa may be used to predict likelihood of previa persistence. After midpregnancy, risk of persistence appears to be higher than previously reported. Type of placentation and prior cesarean delivery are important factors that modify the risk that previa will complicate delivery.

BACKGROUND: Mesenchymal stem villous hyperplasia of the placenta is a rare placental anomaly characterized by placental vascular malformation and the appearance of a partial mole. CASE: A multiparous woman presented with fetal growth restriction (FGR) at 35 weeks’ gestation. Ultrasonographic examination showed multiple anechoic lesions on the placental surface. Cesarean delivery was performed at 37 weeks’ gestation, and a healthy 1536-g female was delivered. The placenta had aneurysmal dilatations of the chorionic vessels. Unlike other cases, it also showed subamniotic hemorrhage and had no features of a partial mole. Histologic examination established the diagnosis of mesenchymal stem villous hyperplasia of the placenta with severe thrombosis. CONCLUSION: Fetal growth restriction can be caused by severe thrombosis in this placental anomaly.

Objective: To identify neonatal complications associated with placenta previa. Methods: This was a population-based, retrospective cohort study involving all singleton deliveries in Nova Scotia from 1988 to 1995. The study group consisted of all completed singleton pregnancies complicated by placenta previa; all other singleton pregnancies were considered controls. Patient information was collected from the Nova Scotia Atlee perinatal database. Neonatal complications were evaluated while controlling for potential confounders. The data were analyzed using χ2, Fisher exact test, and multiple logistic regression. Results: Among 92,983 pregnancies delivered during the study period, 305 cases of placenta previa were identified (0.33%). After controlling for potential confounders, neonatal complications significantly associated with placenta previa included major congenital anomalies (odds ratio [OR] 2.48), respiratory distress syndrome (OR 4.94), and anemia (OR 2.65). The perinatal mortality rate associated with placenta previa was 2.30% (compared with 0.78% in controls) and was explained by gestational age at delivery, occurrence of congenital anomalies, and maternal age. Although there was a higher rate of preterm births in the placenta previa group (46.56% versus 7.27%), there was no difference in birth weights between groups after controlling for gestational age at delivery. Conclusion: Neonatal complications of placenta previa included preterm birth, congenital anomalies, respiratory distress syndrome, and anemia. There was no increased occurrence of fetal growth restriction.

Objective: Although retroplacental hemorrhage is a major cause of fetal death, its etiology often remains obscure. In some reports, cocaine use by pregnant women has been associated with retroplacental hemorrhage and clinical abruptio placentae. This study was designed to assess the occurrence of chorionic villus hemorrhage, an entity shown recently to be associated with retroplacental hemorrhage, in the placentas of cocaine users. Methods: Twenty-nine placentas from cocaine users and 15 placentas from drug-free controls, as determined by questionnaire and urine toxicology screen, were examined prospectively, and pathological findings documented. The prevalence of retroplacental hemorrhage, chorionic villus hemorrhage, edema, chorioamnionitis, funisitis, infarction, fetal vessel thrombosis, and intervillus hemorrhage was examined in the two groups. Results: Chorioamnionitis was the most frequent finding in both groups (58% of cocaine users, 66% of controls). Edema of moderate severity or greater was found only in the cocaine-using group (17%). The prevalence of chorionic villus hemorrhage among women using cocaine also was 17%. Conclusion: Cocaine use during pregnancy may be associated with chorionic villus hemorrhage and villus edema, even in the absence of clinical abruptio placentae. The relationship between abnormal placental morphology and adverse perinatal outcomes remains to be determined.

Objective To test the hypothesis that a range of severity of placental vascular lesions underlies preeclampsia and that the likelihood of its clinical diagnosis increases with the extent and severity of uteroplacental vascular lesions. Methods Four hundred sixty-five consecutive placentas of singleton, nonanomalous, live-born infants born before 32 weeks' gestation were examined prospectively, and uteroplacental vascular and related villous lesions were assigned a semiquantitative lesion score based on severity and extent of lesions. The summed scores of individual lesions yielded a total uteroplacental vascular lesion score, ranging from 0 to 21, that was correlated with the odds of a clinical diagnosis of preeclampsia, as well as with potential confounders, including maternal age, race, gestational age at delivery, and birth weight centile. Statistical analysis was performed using contingency tables, one-way analysis of variance, multiple logistic regression, and receiver operating characteristic curve. P Results A clinical diagnosis of preeclampsia was present in 78 of 465 (17%) cases. Logistic regression demonstrated that the total uteroplacental vascular lesion score related significantly to the diagnosis of preeclampsia (odds ratio 1.43, 95% confidence interval 1.31, 1.57) and this association was independent of gestational age at delivery and birth weight centile. Preeclampsia was diagnosed in 12 of 284 (4%) cases with no or minimal histologic evidence of placental vascular injury (total score less than 4). Conversely, the diagnosis was not made in 4% of cases despite the presence of extensive placental vascular injury (total score at least 14). Conclusion The likelihood of clinical diagnosis of preeclampsia before 32 weeks increases with progressive impairment of the uteroplacental circulation. Histopathologic examination of the placenta can be used to confirm the diagnosis of preeclampsia.

Background : Although the clinical presentation and imaging techniques can raise suspicion for placenta previa percreta, this potentially catastrophic condition may remain undiagnosed or its extent underappreciated until delivery. The decision to proceed with definitive surgery in cases of placenta previa percreta should be carefully considered. Case : A case of placenta previa percreta with bladder invasion was diagnosed prenatally. This case illustrates the magnitude of complications that can arise despite aggressive multidisciplinary perioperative management. Conclusion : When possible, hysterectomy performed for placenta previa percreta is best avoided under anything other than ideal conditions. A multidisciplinary approach for preoperative, intraoperative, and postoperative management of placenta previa percreta optimizes maternal outcome.

To assess the potential for recurrence of placental hemorrhagic endovasculitis and to identify clinical or pathologic cofactors that might influence recurrence of this lesion or subsequent pregnancy outcome.Ninety-seven women with a placenta affected by hemorrhagic endovasculitis, who also had at least one placenta referred to the Michigan Placental Tissue Registry from a subsequent pregnancy, were identified from 10,531 referrals between 1978 and 1988. Histologic slides from 209 placentas and clinical data from 211 infants (two sets of twins) from initial (first) and subsequent referrals were analyzed. Placentas were graded for the presence, extent, and severity of hemorrhagic endovasculitis and chronic villitis of unknown etiology; for placental lesions indicative of hypertensive maternal vessel disease; and for intravascular nucleated erythrocytes and chorionic thrombi. Maternal data included age, gravidity, number of previous losses, and history of toxemia or hypertension. All data were analyzed for significance using chi2 and t tests. Outcome assessment was based on recurrence of hemorrhagic endovasculitis and infant viability with the second referral.With first referrals, 80 of 98 infants (81.6%) were stillborn. Among second referrals, 26 of 98 infants (26.5%) were stillborn. Hemorrhagic endovasculitis recurred in 28 second placentas (28.9%); of these, 18 infants (64.3%) were stillborn. Higher rates of recurrence were found with progressively higher first-referral chronic villitis severity scores (P.02), higher hypertensive placental lesion scores (P.001), and first referrals with a history of toxemia or hypertension (P.02). Recurrence of hemorrhagic endovasculitis was higher in patients with two or more of these factors in first referrals (P.001). Subsequent stillbirth was more frequent with progressively higher first-referral hypertensive placental lesion scores (P.01) and in first placentas with two or more risk factors (P = .064). Hemorrhagic endovasculitis severity scores, intravascular nucleated erythrocytes, and chorionic thrombi were associated with stillbirth in index pregnancies only. Maternal age, gravidity, or history of prior losses were not predictive.Placental hemorrhagic endovasculitis is associated with pregnancy loss and can recur in some patients. Interrelations among placental hemorrhagic endovasculitis, chronic villitis, maternal hypertension, and adverse outcomes in subsequent pregnancies are apparent. This information may be useful in patient counseling.

Objective: To evaluate the clinical significance of placenta previa at 12–16 weeks' gestation found by transvaginal sonographic screening. Methods: An unselected population of 6428 pregnant women was scanned by transvaginal sonography during 1993–1994 to assess the gestational age and to diagnose major fetal anomalies. The location of the placenta was also recorded systematically. If the edge of the placenta extended over the internal cervical os, this distance was measured with electronic calipers. Results: In 156 of 6428 patients (2.4%), the placental edge extended 15 mm or more over the internal cervical os at 12–16 weeks' gestation. Eight of these patients had placenta previa at delivery. Using this criterion at screening, two cases of placenta previa at delivery were missed. The frequency of placenta previa at delivery in this nonselected population was ten of 6428 (0.16%). Conclusions: The likelihood of placenta previa at delivery is 5.1% (95% confidence interval 2.2, 9.9) if the placenta extends at least 15 mm over the internal cervical os at 12–16 weeks' gestation.

Objective To investigate the frequency of placenta previa among Asian women. Methods We conducted a population-based case-control study using Washington state birth certificate data from 1984–1987. Our study population included 810 women with pregnancies complicated by placenta previa and 2917 randomly selected controls. Unconditional logistic regression was used to estimate odds ratios (OR) and their 95% confidence intervals (CI), and interaction terms were used to examine effect modification. Potential confounding by maternal age, gravidity and parity, maternal smoking during pregnancy, and a history of abortion or cesarean delivery was adjusted for in the analysis. Results The frequency of placenta previa during the study period was 3.3 per 1000 live births. Women of Asian origin were 86% more likely (OR 1.86, 95% CI 1.38–2.51) to have a delivery complicated by placenta previa than were white women. This association was stronger among women without a previous live birth (OR 2.51, 95% CI 1.57–4.01) than those who previously had experienced a live birth (OR 1.50, 95% CI 1.01–2.25). Conclusion Asian women residing in the United States are at increased risk of placenta previa. If confirmed by others, our results suggest that obstetricians should consider meticulous ultrasound evaluations during pregnancy to rule out the presence of placenta previa in Asian-American women.

Background : To our knowledge, fetoplacental thromboembolism has been described only in autopsy specimens. We report the antepartum diagnosis of an umbilical artery occlusion and neonatal diagnosis of an aortic thrombus and placental emboli. Case : A gravida at 31 weeks' gestation was referred for evaluation of decreased fetal movement and an enlarged fetal bladder. A two-vessel umbilical cord with a collapsed, echogenic third vessel was noted, whereas views of a normal three-vessel cord were available from an examination 5 weeks earlier. A positive oxytocin contraction test prompted delivery. Neonatal color flow Doppler imaging demonstrated an aortic thrombus below the renal arteries and above the bifurcation. Gross and microscopic study of the placenta demonstrated necrosis of the collapsed umbilical artery and numerous placental emboli. The aortic thrombus resolved gradually, and the infant went home on the 39th day of life. Conclusion : Umbilical artery occlusion can be diagnosed ultrasonographically and may be a sign of fetoplacental thromboembolism. Assessment of fetal oxygenation status by biophysical profile or contraction stress test may be helpful in the evaluation of umbilical artery occlusion.

Pregnancy complicated by maternal human immunodeficiency virus (HIV) infection is increasing in frequency. This report describes a maternal malignancy associated with HIV infection that may complicate pregnancy.A 33-year-old primigravida was delivered by cesarean. Histologic examination of the placenta revealed the presence of metastatic non-Hodgkin lymphoma of B-cell origin. The patient was then found to be infected with HIV. Nine months postpartum, she was diagnosed with immunoblastic lymphoma. She is currently undergoing chemotherapy.Non-Hodgkin lymphoma of B-cell origin is an indication of AIDS. Pregnancies associated with maternal HIV infection may be complicated by this malignancy, which may metastasize to the products of conception. Careful examination of the placenta can detect metastases in women with non-Hodgkin B-cell lymphoma.

Maternal malignancy may complicate as many as one in 1000 pregnancies. Rarely, the tumor may metastasize to the products of conception. We here describe a case of medulloblastoma metastatic to the placenta.A 21-year-old woman who had previously undergone resection of a posterior fossa medulloblastoma was admitted at 20 weeks' gestation complaining of low back pain. Investigation revealed medulloblastoma metastatic to the bone marrow. The pregnancy was prolonged to 29 weeks' gestation, at which time she was delivered by cesarean. The postoperative course was complicated by coagulopathy, massive bleeding, and pneumonia leading to death. Autopsy showed medulloblastoma metastatic to the bone marrow and placenta.Primary intracranial neoplasms may metastasize to the products of conception. The dramatic course of the disease in this patient may suggest that medulloblastoma is responsive to hormonal therapy.

Necrotizing funisitis is an umbilical cord lesion characterized by perivascular bands of necrotic Wharton jelly containing inflammatory cells in various stages of degeneration. Sixty cases were reviewed histologically. Clinical information was available in 45. Forty-five age-matched infants with acute (nonspecific) funisitis only were used as controls. Infants with necrotizing funisitis had more stillbirths, birth weights below the tenth percentile (small for gestational age [SGA]), infectious complications, and necrotizing enterocolitis. No consistent infectious agents or predisposing maternal factors were found. Cord neovascularization correlated with SGA infants. Necrotizing funisitis occurred in 0.1% of deliveries greater than 20 weeks' gestation. The perivascular bands, likened to the pattern of an Ouchterlony diffusion plate, suggest the presence of a diffusible toxin in the amniotic fluid. The stillbirths and SGA infants may represent the toxin's effect on the fetus. The lack of perivascular necrotic bands around vessels on the placental surface suggests neutralization or more effective clearing of the agent in this region, for reasons as yet undetermined. The factors underlying the cord lesion may contribute to superimposed acute nonspecific vasculitis and chorioamnionitis.

Sonography of a fetus, later proved to have congenital syphilis, revealed hepatosplenomegaly, noncontinuous gastrointestinal tract obstruction, and placentomegaly. This unusual constellation of sonographic findings should raise suspicion of syphilis infection of the fetus.

Circumvallate placenta, a form of placenta extrachorialis, should be included in the differential diagnosis of vaginal bleeding in the second trimester with a normally implanted placenta. Heretofore, the diagnosis was made after delivery. This report presents a case of circumvallate placenta diagnosed prenatally by ultrasound. Key features included an infolding of the fetal membrane upon the fetal surface of the placenta during the middle of the second trimester. By the third trimester, only a bright border at the periphery of the placenta was noted. Antenatal diagnosis can be made and pregnancy outcome potentially altered.

Genetic predisposition and abnormal trophoblastic function are thought to contribute to the development of preeclampsia. A multipara developed severe preeclampsia and subsequently delivered a live growth-retarded infant with trisomy 13. Biopsy of the placental bed taken immediately after delivery demonstrated inadequate trophoblastic remodeling of the maternal uterine vasculature, with an absence of normal physiologic changes in the spiral arteries. This case suggests that fetal trisomy 13 can be associated with preeclampsia in multiparous women and that abnormal trophoblastic invasion may contribute to the pathophysiology.

The pregnancy of a patient with placenta membranacea associated with placenta increta and a live-born infant is described, and the literature covering placenta membranacea is reviewed. A total of 26 cases of placenta membranacea in the second and third trimesters have been reported. The condition appears to have an incidence of 1:20,000-40,000, and there have been 14 reported live births associated with this rare placental anomaly. Antepartum and postpartum hemorrhage were reported to complicate 83 and 50% of the cases, respectively. Approximately 30% of the cases involved some form of abnormal placental adherence.

Maternal serum alpha-fetoprotein (MSAFP) screening is widely used for the detection of open neural tube defects (NTDs) and a variety of other anomalies and complications. We examined the outcomes of 44 pregnancies with MSAFP elevations of 8 or more multiples of the median (MoM) from among 40,676 screened pregnancies. At the initial evaluation by ultrasound, 82% of the patients had at least one finding that may have accounted for the elevation. Approximately 45% of the fetuses had a major fetal anomaly, 25% died, 16% had an identifiable placental abnormality, and 5% had an underestimation of gestational age; 18% of the elevations remained unexplained after ultrasound. In follow-up of the pregnancies, all of those with an unexplained elevation after initial ultrasound had at least one obstetric complication or placental abnormality. The overall positive predictive value of an MSAFP value of 8 or more MoM for NTDs was 22.7%. The proportion of infants born alive in the overall group was low, with only 16 live births among 46 fetuses. The majority of the nonviable outcomes were associated with a fetus with a major anomaly that was terminated or died before 20 weeks. Of the live-born infants, 31% had a major anomaly, 19% had intrauterine growth retardation (IUGR) and an anomaly, 12.5% had IUGR without an anomaly, and 25% were preterm. Eighty-eight percent of those pregnancies with a live-born infant had at least one obstetric complication. Among pregnancies with MSAFP of 8 or more MoM, the majority are associated with large structural fetal anomalies or fetal death before 20 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemorrhage during or after surgery, pelvic abscess, bowel obstruction, and prolonged febrile morbidity can complicate the puerperal course of the gravida after removal of an extrauterine fetus with nondisturbance of the extrauterine placenta. In this report we describe the successful angiographic arterial gelfoam embolization of the placental vascular bed to control heavy postoperative hemorrhage in a mother suffering adult respiratory distress syndrome after removal of the fetal portion of her abdominal pregnancy. Six weeks later, computed tomography (CT)-directed drainage by catheter of a placental abscess was performed. Selective angiographic transcatheter embolization with gelfoam is a useful tool for the control of hemorrhage in the gravida who is an unfavorable operative candidate or who may present technical hemostasis problems peculiar to the placenta with abdominal pregnancy. Later use of CT-directed catheter drainage of the infected residual placental mass provided a nonoperative means of treatment.

Determination of maternal serum alpha-fetoprotein (MSAFP) has become an important screening test for a variety of fetal and maternal abnormalities. A 33-year-old multiparous white woman had a markedly elevated MSAFP level (140 multiples of the median). Extensive antepartum work-up for fetal anomalies, fetal-maternal transfusion, or maternal etiology revealed no explanation. The patient subsequently delivered a healthy male infant. Pathologic examination of the placenta demonstrated a small, discrete area of choriocarcinoma. Computed tomography showed a solitary pulmonary metastasis. Because the patient did not desire future pregnancies, a total abdominal hysterectomy was performed, followed by four courses of EMA-CO chemotherapy. Her serum hCG levels subsequently became undetectable. Choriocarcinoma of the placenta must be considered in the differential diagnosis of an otherwise unexplained elevated MSAFP level.

Blood transfusion during or after delivery is a serious and sometimes predictable event. An analysis of 30,621 consecutive deliveries showed that previous abortion, bleeding during pregnancy, polyhydramnios, oligohydramnios, operative delivery, multiple pregnancy, abnormal placentation, and primary cesarean were each associated with unexpectedly high transfusion rates. Most women who were transfused received 2 U of blood or fewer. Only 0.09% of pregnant women received more than 8 U. There has been a temporal reduction in the rate of blood transfusion in obstetric practice over the past 10 years. Currently, it appears that approximately 2% of women may require blood transfusion during the peripartum period.

The metabolic clearance rate of dehydroisoandrosterone sulfate (MCRDS) was determined prospectively in gravidas with and without chronic essential hypertension. In normotensive patients, the MCRDS increased in linear fashion throughout pregnancy. In patients with chronic essential hypertension the MCRDS also increased progressively, but at higher values than in normotensive subjects. In normotensive gravidas who ultimately developed pregnancy-induced hypertension, the MCRDS increased progressively at a higher level than in gravidas who remained normotensive until approximately 4 weeks prior to the onset of clinical symptoms, at which time the MCRDS slowly decreased. Similarly, in gravidas with chronic hypertension who developed superimposed pregnancy-induced hypertension, the MCRDS increased progressively at higher levels than all groups studied until approximately 4 weeks prior to onset of hypertension, when a progressive decline in the MCRDS began.