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Placental abruption (query bank)

Published: 29/11/2013

Question

What are the recommendations for women in future pregnancies who have suffered a placental abruption? Is aspirin of value or contraindicated?

Answer

A Cochrane review(1) of antithrombotic therapy for improving maternal or infant health outcomes in women considered at risk of placental dysfunction included women with a past history of placental abruption. The authors concluded that:

“Treatment with heparin for women considered at particularly high risk of adverse pregnancy complications secondary to placental insufficiency was associated with a statistically significant reduction in risk of perinatal mortality, preterm birth before 34 and 37 weeks' gestation, and infant birthweight below the 10th centile for gestational age, when compared with no treatment. However, important information about infant and long-term childhood growth and development is currently unavailable. Furthermore, the interpretation of these findings and potential clinical use of heparin should be confined to women who are considered to be at particularly high risk of adverse pregnancy outcomes, often based on past pregnancy history.” Four of the included studies reported the risk of placental abruption in women administered heparin (alone or with other medications) and there were no significant differences in the risk of placental abruption (four studies; 551 women; RR 0.38; 95% CI 0.10 to 1.40.

(Evidence level 1a)

Ten studies of pregnancy outcomes after placental abruption in a previous pregnancy were identified. (3-12) The management of the subsequent pregnancies is described in one of these(3), and most report the rate of recurrence of placental abruption (3-10).

In a controlled study of 72 women with severe pregnancy complications and placental vasculopathy in an earlier pregnancy, including women with severe placental abruption, Kupferminc et al (4) examined the effect of treatment with low molecular weight heparin and found: “The incidences of severe preeclampsia and placental abruption in the study group in the index pregnancy were significantly lower than the control group (3.13 versus 20%, P = 0.03; and 0 versus 15%, P = 0.03, respectively). The respective incidence of fetal growth restriction was 6.25 versus 22.5%, and of overall adverse outcome was 9.4 versus 60% (P = 0.001).”

One study assessed the risk of small for gestational age (SGA), preterm birth, pregnancy induced hypertension (PIH), and perinatal death(11) and concluded “A pregnancy following a placental abruption (PA) must be considered a high risk pregnancy, not only in terms of excess risk of recurrence, but also due to excess risk of SGA, preterm birth, and PIH irrespective of recurrence of PA. Consequently, all pregnancies following a pregnancy with PA should be offered close antenatal surveillance and care”.

A population-based cohort study including 894,631 pairs of pregnancies (12) found that abruptio placentae is strongly associated with later stillbirth.

Rasmussen et al (9) report the gestational age in the second pregnancy at which placental abruption, or complication (defined as preterm delivery, SGA or perinatal death) occurred. They found: “In women with a complicated (preterm, small for gestational age, or perinatal death) first delivery, the risks of an initial and recurrent complicated placental abruption in the second pregnancy were 7/1000 and 33/1000, respectively (relative risk 4.9). To reduce the recurrence risk in a second pregnancy to 7/1000, special surveillance six weeks prior to the gestational age of the initial abruption would be necessary. In women with an uncomplicated first delivery, the risks in the second pregnancy of an initial and recurrent complicated abruption were 3 and 19/1000, respectively (relative risk 7.1). To reduce the recurrence risk to 3/1000, surveillance at least 12 weeks prior would be necessary.”

(Evidence level III)

The RCOG green-top guideline(2) on antepartum haemorrhage (APH) notes that the most predictive risk factor for placental abruption is abruption in a previous pregnancy. A large observational study from Norway reported a 4.4% incidence of recurrent abruption (adjusted OR 7.8, 95% CI 6.5–9.2). Abruption recurs in 19–25% of women who have had two previous pregnancies complicated by abruption. Other risk factors for placental abruption include: pre-eclampsia, fetal growth restriction, non-vertex presentations, polyhydramnios, advanced maternal age, multiparity, low body mass index (BMI), pregnancy following assisted reproductive techniques, intrauterine infection, premature rupture of membranes, abdominal trauma (both accidental and resulting from domestic violence), smoking and drug misuse (cocaine and amphetamines) during pregnancy, first-trimester bleeding and maternal thrombophilias. Women should be assessed for these factors at each antenatal contact. This information may be used to assign women to high-risk or low-risk antenatal care.

The guideline notes that there is limited evidence to support interventions to prevent APH, and includes the good practice point that women should be advised, encouraged and helped to change modifiable risk factors (such as smoking and drug misuse).

(Evidence level IV)

References

1. Dodd JM, McLeod A, Windrim RC, Kingdom J. Antithrombotic therapy for improving maternal or infant health outcomes in women considered at risk of placental dysfunction. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD006780. DOI: 10.1002/14651858.CD006780.pub3. Abstract and full text (Restricted in some countries). Full text available to RCOG Fellows, Members and Trainees here.

2. RCOG. Antepartum haemorrhage. RCOG Green-top guideline 63. 2011.

3. Sakikawa M. Adachi T. Nakabayashi Y. Matsui D. Urano A. Tang X. Tsuruga K. Kawana Y. Takeda Y. Nakayama S. Sakamoto H. Nakabayashi M. Clinical management and outcome of pregnancies complicated by previous abruption. Hypertension in Pregnancy. 30(4):457-64, 2011. Abstract. Full text available to RCOG Fellows, Members and Trainees here.

4. Kupferminc M. Rimon E. Many A. Maslovitz S. Lessing JB. Gamzu R. Low molecular weight heparin versus no treatment in women with previous severe pregnancy complications and placental findings without thrombophilia. Blood Coagulation & Fibrinolysis. 22(2):123-6, 2011 Mar. Abstract.

5. Rasmussen S. Irgens LM. Occurrence of placental abruption in relatives.[Erratum appears in BJOG. 2009 May;116(6):870] BJOG: An International Journal of Obstetrics & Gynaecology. 116(5):693-9, 2009 Apr.

6. Matsaseng T. Bagratee JS. Moodley J. Pregnancy outcomes in patients with previous history of abruptio placentae. International Journal of Gynaecology & Obstetrics. 92(3):253-4, 2006 Mar.

7. Toivonen S. Heinonen S. Anttila M. Kosma VM. Saarikoski S. Obstetric prognosis after placental abruption. Fetal Diagnosis & Therapy. 19(4):336-41, 2004 Jul-Aug. Abstract.

8. Furuhashi M. Kurauchi O. Suganuma N. Pregnancy following placental abruption. Archives of Gynecology & Obstetrics. 267(1):11-3, 2002 Nov. Abstract.

9. Rasmussen S. Irgens LM. Albrechtsen S. Dalaker K. Women with a history of placental abruption: when in a subsequent pregnancy should special surveillance for a recurrent placental abruption be initiated?. Acta Obstetricia et Gynecologica Scandinavica. 80(8):708-12, 2001 Aug. Abstract. Full text available to RCOG Fellows, Members and Trainees here.

10. Rasmussen S. Irgens LM. Dalaker K. The effect on the likelihood of further pregnancy of placental abruption and the rate of its recurrence. British Journal of Obstetrics & Gynaecology. 104(11):1292-5, 1997 Nov. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9386031

11. Rasmussen S. Irgens LM. Dalaker K. Outcome of pregnancies subsequent to placental abruption: a risk assessment. Acta Obstetricia et Gynecologica Scandinavica. 79(6):496-501, 2000 Jun. Abstract. Full text available to RCOG Fellows, Members and Trainees here.

12. Rasmussen S, Irgens LM, Skjaerven R, Melve KK. Prior adverse pregnancy outcome and the risk of stillbirth. Obstet Gynecol. 2009 Dec;114(6):1259-70. Abstract.

Search date

November 2013

Classification of evidence levels

  • Ia: Evidence obtained from meta-analysis of randomised controlled trials.
  • Ib: Evidence obtained from at least one randomised controlled trial.
  • IIa: Evidence obtained from at least one well-designed controlled study without randomisation.
  • IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study.
  • III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
  • IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

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