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Low molecular weight heparin (LMWH) treatment has been recommended for pregnant women with previous adverse pregnancy and who were diagnosed as having a thrombophilia. We now examined the effect of LMWH on pregnant women without thrombophilias who had severe pregnancy complications and placental vasculopathy in an earlier pregnancy. Seventy-two women with a history of severe preeclampsia, fetal growth restriction (FGR) less than fifth percentile, severe placental abruption and/or stillbirth after 20 weeks, whose thrombophilia workup was negative, were enrolled. Placental vasculopathy was defined as villous infarcts, fibrinoid necrosis of decidual vessels, fetal vessel thrombosis, evidence of placental abruption and perivillous fibrin deposition. The study group consisted of 32 pregnant women who were treated with LMWH and 40 pregnant women who were not treated with LMWH (control group) in their ensuing pregnancy in our institution between 2003 and 2007. The incidences of severe preeclampsia, FGR, placental abruption and stillbirth in the previous pregnancies were similar for both groups. 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 FGR was 6.25 versus 22.5%, and of overall adverse outcome was 9.4 versus 60% (P = 0.001). Treatment with LMWH may reduce the rate of the recurrence of severe pregnancy complications and significant placental vasculopathy in women without thrombophilias.

Isolated persistent lower abdominal pain in women with previous cesarean is a poor indicator of uterine rupture. However, the positive predictive value for uterine rupture is 57% when an additional sign or symptom is present. Dehiscence of the uterine scar is relatively common and it is not associated with persistent abdominal pain.

Lignes directrices pour la prise en charge d'une patiente enceinte ayant subi un traumatisme Avis: La présente directive clinique est publiée officiellement dans le Journal d'obstétrique et gynécologie du Canada. Par conséquent, la date de parution pourrait ne pas correspondre à la date de publication originale. Aucune modification n'a été apportée au contenu.La présente directive clinique a été rédigée par le comité de médecine foeto-maternelle, analysée par le comité de pratique clinique -obstétrique, le comité médico-juridique et le comité consultatif de médecine familiale, et approuvée par le comité exécutif et le conseil d'administration de la Société des obstétriciens et gynécologues du Canada.

(Birth. 2016;43(1):36–41) Postpartum hemorrhage (PPH) is one of the main risk factors of a prolonged third stage of labor, which is usually 5 to 20 minutes; only 8% of placentae remain undelivered by 20 minutes. The incidence of PPH worldwide is about 6% for >500 mL of blood loss and 1.86% for >1000 mL of blood loss despite active management of the third stage. The objective of this study was to determine the optimal time until undertaking manual placental removal in an uncomplicated third stage while taking into consideration the risk for blood transfusion.

OBJECTIVE: We aimed to assess the risk for intrapartum cesarean delivery (CD) in pregnancies complicated by small for gestational age (SGA). STUDY DESIGN: A retrospective cohort study of all women who underwent a trial of labor in a University-affiliated tertiary hospital (2010-2016). Cases of SGA (neonatal birthweight<10 th centile according to local customized growth curves) were compared to non-SGA controls. Additionally, risk factors for intrapartum CD were explored in women with SGA infants. Exclusion criteria included women who underwent CD without a trial of labor, multiple gestation, stillbirths or delivery <24 weeks of gestation. RESULTS: 1. Overall, 55,089 women underwent a trial of labor during the study period. Of them 2,501 (4.5%) were complicated by SGA infants. 2. Mean maternal age was similar in both groups. Compared to the non-SGA group, women in the SGA group were more often nulliparous (65.2 vs. 44.0%, p<0.001) had higher rate of hypertensive disorders (6.7 vs. 3.7%, p<0.001)) and higher rates of preterm deliveries <37 weeks (PTD37) (7.8 vs. 4.5%, p<0.001). 3. In multivariate logistic regression, after controlling for potential confounders, SGA was associated with an increased risk for intrapartum CD (OR, 95%CI) (1.51, 1.29-1.76). 4. Of all the SGA group (n¼2,501), the mean gestational age at delivery was 38.6AE2.2 weeks with mean birthweight (BW) of 2,430AE352g and mean BW centile was 5.9AE2.9. An inverse relation was observed between BW-centile and the rate of CD as well as the CD due to fetal distress when stratifying the SGA group according to BW-centiles (Figure). 6. In multivariate logistic regression, after controlling for maternal age, parity, hypertensive disorders, diabetes, induction of labor, epidural analgesia, meconium and gestational age at delivery, factors that were significantly associated with increased risk for CD were nulliparity (2.02, 1.41-2.99), PTD37 (3.32, 2.12-5.19), induction of labor (11.76, 8.27-16.72) and meconium (2.05, 1.49-2.83) (Table). CONCLUSION: Deliveries of SGA infants are associated with an increased risk for intrapartum CD compared to those of non-SGA mainly due to fetal distress. Moreover, in deliveries with SGA the risk for CD is inversely related to BW-centile. Factors such as nulliparity, prematurity, induction of labor and meconium further increase the risk for CD.

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This a preprint and has not been peer reviewed. Data may be preliminary.