Placental Histopathology and Pregnancy Outcomes in "Early" vs. "Late" Placental Abruption.

Placenta-associated pregnancy complications (fetal growth restriction and preeclampsia) are traditionally classified as "early" and "late" due to their different pathophysiology, histopathology, and pregnancy outcomes. As placental abruption (PA) represents another placenta-associated complication, we aimed to study if this categorization can be applied to PA as well. Pregnancy and placental reports of all pregnancies complicated by PA between November 2008 and January 2019 were reviewed. Maternal background, pregnancy outcomes, and placental histopathology were compared between cases of PA < 34 weeks (early PA group) vs. > 34 weeks (late PA group). Placental lesions were classified according to the "Amsterdam" criteria. The primary outcome was severe neonatal morbidity (≥ 1 severe neonatal complications: seizures, IVH, HIE, PVL, blood transfusion, NEC, or death). Included were 305 cases of PA, 71 (23.3%) in the early group and 234 (76.7%) in the late group. The early PA group was characterized by higher rates of vaginal bleeding upon presentation (p = 0.003), DIC (p = 0.018), and severe neonatal morbidity (p < 0.001). The late PA group was characterized by a higher rate of urgent Cesarean deliveries (p < 0.001). The early PA group was characterized by higher rates of placental maternal vascular malperfusion (MVM) lesions (p < 0.001), maternal inflammatory response (MIR) lesions (p < 0.001), placental hemorrhage (p < 0.001), and a lower feto-placental ratio (p < 0.001). Using regression analysis, we found that severe neonatal morbidity was independently associated with early abruption (aOR = 5.3, 95% CI = 3.9-7.6), placental MVM (aOR = 1.5, 95% CI = 1.2-1.9), placental MIR (aOR = 1.9, 95% CI = 1.4-2.3), and inversely associated with antenatal corticosteroids (aOR = 0.9, 95% CI = 0.6-0.98). "Early" and "late" PA significantly differ in their presentation, placental pathology, and pregnancy outcomes.

Placental Abruption and Child Mortality.

BACKGROUND AND OBJECTIVES: Placental abruption causes asphyxia and leads to high perinatal mortality. Our objective was to study the overall mortality and causes of death among children born after placental abruption. METHODS: Data on children born from singleton pregnancies complicated by placental abruption between 1987 and 2005 were collected from the Finnish Medical Birth Register, the Hospital Discharge Register, and the Cause-of-Death Register. A reference group consisted of children born from pregnancies without placental abruption. After excluding stillbirths, the final study sample comprised 3888 children born after placental abruption (index children) and 12 530 referent children. The main outcome measure was overall mortality. RESULTS: By the end of 2013, there were 280 deaths among the index children and 107 deaths among the referent children. Compared with the referent children, the overall mortality among the index children was significantly increased (hazard ratio: 8.70; 95% confidence interval 6.96-10.90). During the neonatal period (0-27 days) the mortality was nearly 15-fold (14.8; 10.9-20.0), birth-related asphyxia being the leading cause of death (108; 34-341). The mortality remained high during days 28 to 365 (10.3; 4.83-21.8) and beyond 365 days (1.70; 1.03-2.79). Furthermore, the overall mortality was increased among the index children born at 32 to 36 + 6 gestational weeks (2.77; 1.54-4.98) and at ≥37 weeks (4.98; 3.54-6.99) and among children with a birth weight of 2500 g or more (5.94; 4.33-8.14). CONCLUSIONS: The impact of abruption on offspring mortality extends far beyond the perinatal period. This is mainly due to birth-related asphyxia and prematurity-related consequences.

Intrapartum fetal deaths and unexpected neonatal deaths in the Republic of Ireland: 2011 - 2014; a descriptive study.

BACKGROUND: Intrapartum fetal death, the death of a fetus during labour, is a tragic outcome of pregnancy. The intrapartum death rate of a country is reflective of the care received by mothers and babies in labour and it is through analysing these cases that good aspects of care, as well as areas for improvement can be identified. Investigating unexpected neonatal deaths that may be associated with an intrapartum event is also helpful to fully appraise intrapartum care. This is a descriptive study of intrapartum fetal deaths and unexpected neonatal deaths in Ireland from 2011 to 2014. METHODS: Anonymised data pertaining to all intrapartum fetal deaths and unexpected neonatal deaths for the study time period was obtained from the national perinatal epidemiology centre. All statistical analyses were conducted using Statistical package for the Social Sciences (SPSS). RESULTS: There were 81 intrapartum fetal deaths from 2011 to 2014, and 36 unexpected neonatal deaths from 2012 to 2014. The overall intrapartum death rate was 0.29 per 1000 births and the corrected intrapartum fetal death rate was 0.16 per 1000 births. The overall unexpected neonatal death rate was 0.17 per 1000 live births. Major Congenital Malformation accounted for 36/81 intrapartum deaths, chorioamnionitis for 18/81, and placental abruption accounted for eight babies' deaths. Intrapartum asphyxia accounted for eight of the intrapartum deaths. With respect to the neonatal deaths over half (21/36, 58.3%) of the babies died as a result of hypoxic ischaemic encephalopathy. Information is also reported on both maternal and individual baby demographics. CONCLUSIONS: This is the first detailed descriptive analysis of intrapartum deaths and unexpected intrapartum event related neonatal deaths in Ireland. The corrected intrapartum fetal death rate was 0.16 per 1000 births. Despite our results being based on the best available national data on intrapartum deaths and unexpected neonatal deaths, we were unable to identify if any of these deaths could have been prevented. A more formal confidential inquiry based system is necessary to fully appraise these cases.

Mortality and causes of death among women with a history of placental abruption.

INTRODUCTION: Women with a history of placental abruption have an increased later morbidity, but not much is known of the later mortality. MATERIAL AND METHODS: Data on women with placental abruption (index cohort) between 1969 and 2005 (n = 7805) were collected from the Finnish Hospital Discharge Register and the Finnish Medical Birth Register. A matched reference cohort consisted of women without placental abruption (n = 23 523). The causes of death were retrieved from the Cause-of-Death Register. Cause-specific mortality was compared by hazard ratios (HR). Standardized mortality ratios were calculated to compare both cohorts with the general female population. The main outcome measure was subsequent mortality. RESULTS: By the end of 2013 there were 395 deaths in the index cohort and 863 deaths in the reference cohort. The overall mortality was increased in the index cohort compared with the reference cohort [HR 1.39, 95% confidence interval (CI) 1.24-1.57]. The index cohort had an increased risk of death from respiratory tract malignancies (HR 1.72, 95% CI 1.05-2.82), alcohol-related causes (HR 1.84, 95% CI 1.25-2.72), and external causes (HR 1.63, 95% CI 1.19-2.22), especially suicide (HR 1.71, 95% CI 1.07-2.74). The mortality from cardiovascular diseases did not differ. The standardized mortality ratio was increased in the index cohort compared with the general Finnish female population (HR 1.13, 95% CI 1.02-1.24), especially for respiratory tract malignancies (HR 1.79, 95% CI 1.16-2.64). The index cohort women tended to die younger than referent women (p < 0.001). CONCLUSIONS: Overall mortality among women with a history of placental abruption is increased. These women tend to die younger than referent women do.

Cardiovascular Disease in Relation to Placental Abruption: A Population-Based Cohort Study from Denmark.

BACKGROUND: Cardiovascular (CVD) complications stemming from vascular dysfunction have been widely explored in the setting of preeclampsia. However, the impact of abruption, a strong indicator of microvascular disturbance, on the risk of CVD mortality and morbidity remains poorly characterised. METHODS: We designed a cohort analysis of 828 289 women who delivered singletons in Denmark between 1978 and 2010. We linked the National Patient Registry and the Registry of Causes of Death to the Danish Birth Registry to ascertain CVD events. We estimated CVD risks in relation to abruption from Cox proportional hazards regression following adjustments for confounders. RESULTS: With 13 231 562 person-years of follow-up of women with at least one delivery, 11 829 pregnancies were complicated by abruption. The median (interquartile range) follow-up in the non-abruption and abruption groups was 16 (8, 24) and 18 (10, 25) years, respectively. CVD mortality rates in women with and without abruption were 0.9 and 0.3 per 10 000 person-years, respectively (adjusted hazard ratio (HR) 2.7, 95% confidence interval (CI) 1.5, 5.0). The corresponding CVD morbidity complication rates were 16.7 and 10.0 per 10 000 person-years, respectively (HR 1.5, 95% CI 1.4, 1.8). The increased risks were evident for ischaemic heart disease, acute myocardial infarction, hypertensive heart disease, non-rheumatic valvular disease, and congestive heart failure. CONCLUSIONS: This study shows increased hazards of CVD morbidity and mortality in relation to abruption. A better understanding of the pathogenesis of distorted placental microvasculature is needed as this appears to be a harbinger of CVD later in life.

Prediction of perinatal outcomes based on primary symptoms in women with placental abruption.

AIMS: Placental abruption is an important cause of perinatal mortality and morbidity. Although there are many reports on the risk factors for placental abruption, there are few on its classification. Our aim is to evaluate the associations between primary symptoms and the outcomes of placental abruption. MATERIAL AND METHODS: We carried out a retrospective cohort study of 12,474 births at the Perinatal Center for Maternity and Neonates of the Yokohama City University Medical Center between January 2000 and December 2012. There were 151 women with placental abruption, 136 of whom were included in this study. The subjects were classified into two groups according to their primary symptoms: those with bleeding (external bleeding group) and those with abdominal pain (abdominal pain group). Maternal and neonatal outcomes were compared between the two groups. RESULTS: Both fetal and maternal outcomes were significantly poorer in the abdominal pain group than in the external bleeding group in terms of intrauterine fetal death (6.5% vs 33.3%, P < 0.001), perinatal mortality (8.1% vs 33.3%, P = 0.001), umbilical arterial pH < 7.1 (15.7% vs 57.1%, P < 0.001), bleeding volume, rate of blood transfusion, and disseminated intravascular coagulation incidence. CONCLUSIONS: This classification based on primary symptoms was found to be useful for predicting both maternal and neonatal outcomes of placental abruption.

Risk factors for perinatal mortality in patients admitted to the hospital with the diagnosis of placental abruption.

OBJECTIVE: Placental abruption is a clinical term used when premature separation of the placenta from the uterine wall occurs prior to delivery of the fetus. Hypertension, substance abuse, smoking, intrauterine infection and recent trauma are risk factors for placental abruption. In this study, we sought for clinical factors that increase the risk for perinatal mortality in patients admitted to the hospital with the clinical diagnosis of placental abruption. MATERIALS AND METHODS: We identified all placental abruption cases managed over the past 6 years at our Center. Those with singleton pregnancies and a diagnosis of abruption based on strict clinical criteria were selected. Eleven clinical variables that had potential for increasing the risk for perinatal mortality were selected, logistic regression analysis was used to identify variables associated with perinatal death. RESULTS: Sixty-one patients were included in the study with 16 ending in perinatal death (26.2%). Ethnicity, maternal age, gravidity, parity, use of tobacco, use of cocaine, hypertension, asthma, diabetes, hepatitis C, sickle cell disease and abnormalities of amniotic fluid volume were not the main factors for perinatal mortality. Gestational age at delivery, birthweight and history of recent trauma were significantly associated with perinatal mortality. The perinatal mortality rate was 42% in patients who delivered prior to 30 weeks of gestation compared to 15% in patients who delivered after 30 weeks of gestation (p < 0.05). A three-fold increase in severe trauma was reported in the group of patients with perinatal mortality than in the group with perinatal survivors (25% versus 7%, respectively, p < 0.05). CONCLUSIONS: In patients admitted to hospital for placental abruption delivery prior to 30 weeks of gestation and a history of abdominal trauma are independent risk factors for perinatal death.

Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania.

BACKGROUND: The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications. METHODS: We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital in Dar es Salaam, Tanzania. Cases were assessed individually to determine their association with CS. Main outcome measures included MNM ratio; maternal mortality ratio; proportion of MNM and death associated with CS complications; and the risk for such outcomes per 1,000 operations. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was calculated. RESULTS: We identified 467 MNM events and 77 maternal deaths. The MNM ratio was 36 per 1,000 live births (95% CI 33-39) and the maternal mortality ratio was 587 per 100,000 live births (95% CI 460-730). Major causes were eclampsia and postpartum haemorrhage, but we also detected nine MNM events and five deaths from iatrogenic complications. CS complications accounted for 7.9% (95% CI 5.6-11) of the MNM events and 13% (95% CI 6.4-23) of the maternal deaths. The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital (22/1,000 operations, 95% CI 12-37) compared to the university hospital (7.0/1,000 operations, 95% CI 3.8-12) (risk ratio 3.2, 95% CI 1.5-6.6). CONCLUSIONS: The occurrence of MNM and death at the two hospitals was high, and many cases were associated with CS complications. The maternal risks of CS in low-resource settings must not be overlooked, and measures should be taken to avoid unnecessary CSs. More comprehensive training of staff, improved postoperative surveillance, and a more even distribution of resources within the health care system might reduce the risks of CS.

Ischemic placental disease and risks of perinatal mortality and morbidity and neurodevelopmental outcomes.

Preeclampsia, intrauterine growth restriction, and placental abruption are serious obstetrical complications that constitute the syndrome of ischemic placental disease and account for a disproportionate degree of perinatal morbidity and mortality. We review the risks of stillbirth and neonatal and infant mortality in relation to ischemic placental disease, focusing on population-based studies. We also review the risks of neonatal morbidity and neurodevelopmental outcomes in relation to ischemic placental disease. A synthesis of the findings of the relevant studies relating ischemic placental disease to adverse perinatal outcomes underscores two important observations. First, despite the low prevalence of each of the three obstetrical complications, all are associated with increased risks of adverse perinatal and infant outcomes, as well as neurodevelopmental deficits. Second, the burden of increased perinatal risks appears strongest during the preterm period. Efforts to reduce the risks of ischemic placental disease remain critically important and developing effective clinical interventions will be a target worthy for consideration.

Placental abruption as a significant risk factor for long-term cardiovascular mortality in a follow-up period of more than a decade.

BACKGROUND: To investigate the risk for subsequent cardiovascular events in women having placental abruption during a follow-up period of more than 10 years. METHODS: A population-based study of the incidence of cardiovascular events in women who had placental abruption with women without placental abruption during 1988-99 and with follow-up until 2010. Associations between placental abruption and maternal long-term cardiovascular morbidity and mortality were investigated. Kaplan-Meier survival curves and multivariable Cox regression were used to estimate cumulative incidence of cardiovascular mortality. RESULTS: During the study period, there were 47 585 deliveries meeting the inclusion criteria; of these, 653 occurred in patients with placental abruption. No significant association was noted between placental abruption and subsequent long-term hospitalisations because of cardiovascular causes. However, placental abruption was associated with long-term cardiovascular mortality [odds ratio (OR) = 6.6; 95% confidence interval (CI) 2.3, 18.3]. The cardiovascular case fatality rate for the placental abruption group was 13.0% vs. 2.5% in the comparison group (P < 0.001). Patients with a history of placental abruption had a significantly higher risk for cardiovascular mortality during the follow-up period (Log-rank test P = 0.017). Using Cox multivariable regression models, placental abruption remained an independent risk factor for long-term maternal cardiovascular mortality [adjusted hazard ratio (HR) = 4.3; 95% CI 1.1, 18.6). CONCLUSION: Placental abruption is a significant risk factor for long-term cardiovascular mortality in a follow-up period of more than a decade.

Maternal and fetal prognosis in abruptio placentae at Korle-Bu Teaching Hospital, Ghana.

The study provided baseline data of abruptio placentae in Korle-Bu Teaching Hospital (KBTH), Ghana, and gave recommendations to minimize poor outcomes. A prospective cross sectional study was conducted at the Maternity Department of the KBTH between February 2008 and January 2010. Two hundred women with diagnosis of placental abruption were studied using a pretested standardized structured questionnaire. Statistical Package for Social Sciences (SPSS) version 17 was used to analyse the data. Fifteen thousand five hundred and ten (15,510) deliveries were recorded during the study period out of which 1.4% abruptio placentae cases were confirmed. The perinatal and maternal mortality rates were 65% and 2% respectively. The key risk factors identified were low socio-economic status, grandmultiparity and hypertensive disorders in pregnancy. Intrauterine foetal death, (IUFD) and maternal shock were significantly associated with coagulopathy (p=0.001 and 0.004 respectively). Early diagnoses of placental abruption will significantly improve foetal and maternal survival.

Intrapartum hemorrhage.

Intrapartum hemorrhage is a serious and sometimes life-threatening event. Several etiologies are known and include placental abruption, uterine atony, placenta accreta, and genital tract lacerations. Prompt recognition of blood loss, identification of the source of the hemorrhage, volume resuscitation, including red blood cells and blood products when required, will result in excellent maternal outcomes.

Decreasing perinatal mortality in placental abruption.

OBJECTIVE: To study perinatal mortality associated with placental abruption. DESIGN: Retrospective population study using the Finnish Hospital Discharge Register and Medical Birth Register data. SETTING: Finland, 1987-2005. POPULATION: Pregnancies with placental abruption and all other births without placental abruption. METHODS: The national Hospital Discharge Register and Medical Birth Register were used to identify all pregnancies with placental abruption. Demographic data and delivery outcomes were collected retrospectively. Perinatal mortality associated with placental abruption was compared with that in other births. Potential risk factors were analysed. MAIN OUTCOME MEASURES: Perinatal mortality in placental abruption. RESULTS: The study consisted of 618 735 women with 1.14 million pregnancies, 4336 of whom had placental abruption. Overall perinatal mortality with abruption was 119 per 1000 births. Placental abruption explained 7% of all perinatal deaths. The mortality among singleton births (125 per 1000) was higher than among multiple births (40 per 1000). The majority of deaths (77%) occurred in utero. Singleton perinatal mortality with abruption decreased from 173 per 1000 in 1987-1990 to 98 per 1000 in 2000-2005 (p < 0.001). In singleton births at <32 gestational weeks, overall perinatal mortality was high (345 per 1000) and was not increased by placental abruption. Prematurity, low birthweight, male fetal sex and maternal smoking were independent risk factors for placental abruption-related perinatal mortality. CONCLUSIONS: Although mortality associated with placental abruption decreased during the study period, placental abruption still remains an important cause of perinatal mortality.

Perinatal morbidity and risk of hypoxic-ischemic encephalopathy associated with intrapartum sentinel events.

OBJECTIVE: To examine perinatal morbidity and rate of hypoxic-ischemic encephalopathy in infants exposed to intrapartum sentinel events. STUDY DESIGN: Retrospective cohort study from 2000-2005. Perinatal mortality, perinatal morbidity and rate of hypoxic-ischemic encephalopathy were compared in 3 groups of infants exposed to different risk factors for perinatal asphyxia (sentinel events, nonreassuring fetal status, elective cesarean section). RESULTS: Five hundred eighty-six infants were studied. Perinatal mortality was 6% in the sentinel event group and 0.3% in the nonreassuring fetal status group (relative risk, 2.4; 95% confidence interval, 1.95-2.94). Perinatal morbidity was 2-6 times more frequent in infants exposed to sentinel events; the incidence of hypoxic-ischemic encephalopathy was 10%, compared with 2.5% in the nonreassuring fetal status group (relative risk, 1.93; 95% confidence interval, 1.49-2.52). No infant in the elective cesarean section group died, had perinatal morbidity, or developed encephalopathy. CONCLUSION: Intrapartum sentinel events are associated with a high incidence of perinatal morbidity and hypoxic-ischemic encephalopathy.

Placental abruption and perinatal mortality with preterm delivery as a mediator: disentangling direct and indirect effects.

The authors use recent methodology in causal inference to disentangle the direct and indirect effects that operate through a mediator in an exposure-response association paradigm. They demonstrate how total effects can be partitioned into direct and indirect effects even when the exposure and mediator interact. The impact of bias due to unmeasured confounding on the exposure-response association is assessed through a series of sensitivity analyses. These methods are applied to a problem in perinatal epidemiology to examine the extent to which the effect of abruption on perinatal mortality is mediated through preterm delivery. Data on over 26 million US singleton births (1995-2002) were utilized. Risks of mortality among abruption and nonabruption births were 102.7 and 6.2 per 1,000 births, respectively. Risk ratios of the natural direct and indirect (preterm delivery-mediated) effects of abruption on mortality were 10.18 (95% confidence interval: 9.80, 10.58) and 1.35 (95% confidence interval: 1.33, 1.38), respectively. The proportion of increased mortality risk mediated through preterm delivery was 28.1%, with even higher proportions associated with deliveries at earlier gestational ages. Sensitivity analyses underscore that the qualitative conclusions of some mediated effects and substantial direct effects are reasonably robust to unmeasured confounding of a fairly considerable magnitude.

[Intrauterine transfusión in alloimmunization Rh in México 1987-2008]. / Transfusión intrauterina en aloinmunización rhD en México 1987-2008.

BACKGROUND: Diagnosis, care and prevention of hemolytic disease in fetuses and newborns is the most prominent historical example of a successful medical procedure aimed to abate perinatal morbidity and mortality caused by a disease which for centuries was described only unknown origin. OBJECTIVE: To review the perinatal outcome with intrauterine transfusion (IUT) in severe alloimmunization RhD over 21 years in a referral center of Mexico. The overall survival rate of fetuses and the relations with gestational age, and presence or absence of hydrops was analyzed. The authors present data about alloimmunization and a historical synopsis about IUT in México. MATERIAL AND METHOD: A retrospective study was conducted from January 1, 1987, to January 31, 2008. It was collected only RhD immunizations. Primary outcome variables included gestational age and presence or absence of hydrops, type and number of IUT in each case, and we studied fetal and neonatal morbidity. RESULTS: A total of 531 IUTs were performed in 150 fetuses. Severe hydrops was found at start of intrauterine treatment in 67 cases (45%). The survival rate was closely related to absence or presence of hydrops (88 and 60%), respectively. There were 123 liveborn fetuses and the procedure-related fetal loss rate was low (1.9%). CONCLUSIONS: This study confirmed good outcome with IUT for fetal anemia and the loss rate was low and similar to another publications. The hydrops was the principal factor in the survival rate because late detection and referral of fetuses is critical for fetal and neonatal outcome.

Risk factors and clinical outcome of placental abruption: a retrospective analysis.

OBJECTIVE: To determine frequency, obstetrical risk factors and the subsequent feto-maternal outcome in women suffering from placental abruption. METHODS: A retrospective case series study was carried out in the Department of Obstetrics and Gynaecology Unit One, Liaquat University Hospital Hyderabad, Pakistan from 1st January 2006 to 31st December 2006. All women with the diagnosis of placental abruption having more than 24 weeks gestation were included in the study. RESULTS: Of the 2224 delivered women 106 (4.7%) had placental abruption. All of the 106 women were unbooked, with 67 (63%) in the age group 20-35 years, 68 (64%) belonged to rural areas. 98 (92%) patients were multiparous and 57 (54%) were preterm. The commonest medical disorders observed were anaemia in 84 (79%), Diabetes Mellitus in 8 (8%) and gestational hypertension in 8 (8%) patients. There were five maternal deaths, showing case fatality rate of 5%. The foetal prognosis was characterized by low birth weight seen in 74 (70%), low apgar score in 30 (28%) and high still birth rate in 54 (51%), constituting perinatal mortality rate of 25.62/1000 deliveries. CONCLUSION: Abruptio placentae is associated with adverse maternal and foetal outcome. Multiparity, un-booked status, rural residence and maternal anaemia are important risk factors.

Maternal deaths in Finland: focus on placental abruption.

OBJECTIVE. To study placental abruption-associated maternal deaths out of all maternal deaths in Finland. DESIGN. Register-based study. SETTING. The Finnish Medical Birth Register (MBR), the Hospital Discharge Register (HDR), and the Cause-of-Death Register data during 1972-2005. METHODS. The maternal deaths were identified by linking data from the MBR, the HDR, and the Cause-of-Death Register. The clinical data were collected from the case records and death certificates. MAIN OUTCOME MEASURES. Cause-specific maternal death with special reference to placental abruption. RESULTS. During the study period, a total of 2,104,436 live births and 117 direct maternal deaths (caused by a disease or its management unique to the pregnancy) occurred in Finland. The direct maternal mortality ratio (MMR) was 5.6 per 100,000 live births. The two leading causes were thromboembolism (24.0%) and hemorrhage (22.3%) representing almost half of all maternal deaths. Altogether 7,735 placental abruptions were identified with three maternal deaths giving a case fatality rate of 0.4 per 1,000 cases. The MMR (38.8 per 100,000) was nearly seven times higher than the overall MMR (5.7 per 100,000) (p=0.010). CONCLUSION. The direct MMR in Finland is at the level generally seen in Western Europe. The main causes to maternal death are thromboembolism and obstetric hemorrhage. Deaths to placental abruption are rare, but still seven times higher than the overall MMR.

The association of maternal chronic hypertension with perinatal death in male and female offspring: a record linkage study of 866,188 women.

OBJECTIVE: The purpose of this study was to determine whether there is a difference, by gender, in perinatal mortality in chronically hypertensive women compared with normotensive women. DESIGN: Population-based prospective cohort study. SETTING: Sweden. POPULATION: A total of 866,188 women with singleton pregnancies registered in the Swedish Medical Birth Registry 1992-2004, of which 4749 were diagnosed with chronic hypertension. METHODS: Multivariate logistic regression analysis was performed. In a first step, we adjusted for maternal characteristics and in a second step for mild and severe pre-eclampsia, gestational diabetes, placental abruption and small for gestational age. An effect modification by gender was included in the model. MAIN OUTCOME MEASURES: Odds ratios (OR) for intrauterine death, neonatal death and post-neonatal death with respect to gender of offspring. RESULTS: The unadjusted OR of intrauterine death was 4.12 (95% CI: 2.84-5.96) and 1.29 (95% CI: 0.67-2.48) for male and female offspring, respectively, and of neonatal death, it was 3.45 (95% CI: 2.13-5.59) and 2.17 (95% CI: 1.08-4.35) for male and female offspring, respectively. After multivariate analysis, the OR of intrauterine death was 3.07 (95% CI: 2.12-4.46) and neonatal death was 2.99 (95% CI: 1.84-4.85) for male offspring. For female offspring, the OR of intrauterine death was 0.98 (95% CI: 0.51-1.89) and neonatal death was 1.88 (95% CI: 0.93-3.79). CONCLUSION: Mothers with chronic hypertension have an increased risk of perinatal mortality of their male offspring.