Premature birth with maternal-fetal indications

Abstract

The risk of premature birth is high both in serious maternal diseases (immune and autoimmune diseases, neoplasties, infectious diseases), and in obstetrical complications: gestational hyper blood pressure, preeclampsy, uterine-placental apoplexy, placenta praevia.

The intensity of the hemorrhage determined by the breaking of the spiraled arterioles of the decidua basalis also causes the placental abruption and the forming of the retroplacental hematoma. In the uteroplacental apoplexy, the retroplacental hematoma is formed while the fetus is still in the uterus. Placenta praevia with bleeding, together with the utero-placental apoplexy and uterine rupture, are serious obstetrical complications and they require urgent interventional therapy. Arterial hyper blood pressure (HBP) is a determinant factor for the onset of serious obstetrical complications: eclampsy, retroplacental hematoma, HELLP syndrome, restriction of intrauterine growth, prematurity, in utero fetal death. The purpose of this paper was to emphasize the materno-fetal prognosis in various circumstances of pathology associated to pregnancy or to obstetrical complications. The patients presenting gestational hyper blood pressure and those suffering from preeclampsy have had a good materno-fetal prognosis. The fetal prognosis depends on the gestational age, on the weight and on the degree of fetal maturation. The results in the cases with utero-placental apoplexy are satisfactory as regards the vital maternal prognosis, and unfavorable as regards the fetal prognosis. The fetal-maternal prognosis in patients with placenta praevia has been good, but it depended on the gestational age when the hemorrhage occurred, and on the degree of fetal maturation.

 

Tablet of Contents:

1. Introduction

2. Materials and Methods

3. Results Discussion

4. Conclusions

 

1. Introduction

Between 30-35% of premature births have a materno-fetal indication, 40-45% are due to the premature spontaneous labor, and 30-35% are determined by membrane rupture [1]. Great part of the increase of premature birth rate is explained by the increase of the number of premature births with materno-fetal indication [2]. The risk of premature birth is high both in serious maternal diseases (immune and autoimmune diseases, neoplasties, infectious diseases), and in obstetrical complications: gestational hyper blood pressure, preeclampsy, uterine-placental apoplexy, placenta praevia. In such circumstances, the identification of the biochemical markers for labor and premature birth prediction [3] remains secondary, as the maternal vital prognosis has priority. The genetic modifications, the polymorphisms associated with the production of collagen, inherited genetic mutations referring to the assembly of collagen may give a predisposition to cervical insufficiency or to the premature rupture of membranes, hence to premature birth [4, 5, 6, 7].

The uteroplacental apoplexy is the severe form of retroplacental hematoma, determined by the breaking of the spiraled arterioles of the decidua basalis. The intensity of the hemorrhage causes the placental abruption and the forming of the retroplacental hematoma. In the uteroplacental apoplexy, the retroplacental hematoma is formed while the fetus is still in the uterus. In uteroplacental apoplexy, the fetal death is of 100% and the maternal mortality may reach 5% [8, 9]. The retroplacental hematoma consumes the maternal coagulation factors and determines secondary fibrinolysis until afibrinogenemia. The incriminated etiyopathogenic factors are: age over 35, multiple pregnancies, hypertension, preeclampsy, prematurely ruptured membranes, smoking, uterine leiomyoma [10, 11, 12, 13, 14, 15]. As regards placenta praevia, a certain degree of spontaneous placental abruption is an inevitable consequence of the reshaping of the inferior uterine segment and of cervical dilatation.

Placenta praevia has in average an incidence of 0.3% [16]. The factors that increase the risk of placenta praevia are: multi-fetal pregnancy, maternal age, multiple pregnancy, abnormally implanted placenta, uterine scars. Placenta praevia and the co-existing syndromes of placenta accreta contribute to the rates of maternal morbidity and mortality [17]. A tripling of the rate of maternal mortality has been described in pregnant women with placenta praevia. [18].

The pregnant women that register an increase of the systolic tension by 30 mm Hg or of the diastolic tension by 15 mm Hg must be carefully monitored, because they may develop eclampsy convulsions even at values of BP below 140/90 mm Hg [19]. An abrupt increase of the medium blood pressure occurring late in the pregnancy may have similar risks to preeclampsy even though BP is below 140/90 mm Hg [20, 21]. Eclampsy, together with utero-placental apoplexy, uterine rupture and HELLP syndrome, represent major accidents in pregnancy [22, 23].

The purpose of this paper was to emphasize the materno-fetal prognosis in various circumstances of pathology associated to pregnancy or to obstetrical complications.

 

2. Materials and Methods

23 pregnant women have been included in this study, between January-June 2018, with gestational ages between 28 and 36 weeks. From among them, 15 cases have been diagnosed with gestational hyper blood pressure and preeclampsy, 2 cases with retro-placental hematoma and 6 cases with placenta praevia.

In the 2 cases of retroplacental hematoma, the major hemorrhage that occurred abruptly has determined us to establish and practice a surgical intervention of emergency. The positive diagnosis has been clinical, as this was a major emergency. The 2 patients were over 30 years old and had a gestational age of 30, respectively 34 weeks.

The 6 pregnant women with placenta praevia had a gestational age between 32 and 36 weeks. The tocolytic medication administered was of the type: β-mimetic, magnesium sulphate, progestative, prostaglandin inhibitors. This allowed us to administer cortico-therapy for pulmonary function maturation. The occurrence of hemorrhage, which could not be controlled by drugs and by intensive care, has caused the necessity for surgical intervention.

The 15 cases with gestational hyper blood pressure and preeclampsy had the gestational age between 28 and 34 weeks and BP between 160/95-220/110 mmHg. The following hypo- tensors have been administered: Dopegyt, Enap, Trinitrosan. When BP has not been controlled by drugs, the surgical intervention was planned and performed.

 

3. Results Discussion

The uteroplacental apoplexy is one of the most serious accidents encountered in medical practice. After extracting the dead fetuses by segmental-transversal Caesarian section, we performed total hysterectomy with annexectomy. The fetus, the placenta, as well as the extirpated pieces-uterus and ovaries, were sent for histopathological examination. The maternal vital prognosis was good. As regards the abruption of the extended placenta, which triggers the fetal death, the incidence was of 0.24% in 1967 [24]. The decreasing number of multiparous pregnant women that give birth and the increasing accessibility to prenatal care have determined the decrease of the frequency of placental abruption. In minor and intermediate forms, the fetus is alive, but suffering [23]. In serious forms, the fetus is dead [22].

Placenta praevia with bleeding, together with utero-placental apoplexy and uterine rupture represent serious obstetrical complications and they require urgent interventional therapy. The fetuses weighted between 1700-2400 grams and had an Apgar score between 7-9. The post- surgical evolution of the mother was in normal parameters. The management of pregnant women with placenta praevia depends on the fetal age, on the presence of labor, on the severity of bleeding and of the fetal maturation degree. The vital and functional fetal-maternal prognosis was good.

The opinion that women with placenta praevia are best managed by elective delivery at 36-37 gestational weeks has been stated [25]. Premature birth is a major cause of perinatal death [26], and for USA, a tripling of the neonatal mortality rate has been reported in cases of placenta praevia, caused by premature births [27].

Out of the 15 cases of preeclampsy, in 11 pregnant women, the fetuses have been extracted by Cesarean section, and the other 4 pregnant women had vaginal births. The Apgar score was between 6-9. The vital and functional maternal-fetal prognosis was good.

The hyper blood pressure (HTA) is a determinant factor for the onset of serious obstetrical complications: eclampsy, retroplacental hematoma, HELLP syndrome, intrauterine growth restriction, prematurity, in utero fetal death. In the developed countries, 16% of the causes of maternal mortality are due to hypertensive disorders [28]. HTA occupies the first place among factors that determine maternal mortality, after hemorrhage 13%, abortion 8% and sepsis 2%.

USA reports 12.3% of cases of maternal mortality due to preeclampsy or eclampsy [29], and France, a rate of 10% of maternal mortality cases [30]. More than half of these deaths caused by hypertension in pregnancy could have been prevented [31].

 

4. Conclusions

The patients with gestational hypertension and those with preeclampsy had a good maternal-fetal prognosis. The fetal prognosis depends on the gestational age, on weight and on the degree of fetal maturation. The results in the cases of utero-placental apoplexy are satisfactory as regards the maternal vital prognosis and unfavorable as regards the fetal prognosis. The fetal-maternal prognosis in patients with placenta praevia has been good, but it depended on the gestational age when the hemorrhage occurred and on the degree of fetal maturation.

 

Contributo selezionato da Filodiritto tra quelli pubblicati nei Proceedings “4th Congress of the Romanian Society for Minimal Invasive Surgery in Ginecology – Annual Days of the National Institute for Mother and Child Health Alessandrescu-Rusescu - 2018”

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Contribution selected by Filodiritto among those published in the Proceedings “4th Congress of the Romanian Society for Minimal Invasive Surgery in Ginecology – Annual Days of the National Institute for Mother and Child Health Alessandrescu-Rusescu - 2018”

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