Journal of Obstetrics and Gynaecology
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Abnormal patterns of blood flow through the uterine arteries: Is it a clue for placental abruption in clinically suspected cases? S. Olgan, M. Ozekinci, E. Cagliyan, R. E. Okyay & S. Altunyurt To cite this article: S. Olgan, M. Ozekinci, E. Cagliyan, R. E. Okyay & S. Altunyurt (2015) Abnormal patterns of blood flow through the uterine arteries: Is it a clue for placental abruption in clinically suspected cases?, Journal of Obstetrics and Gynaecology, 35:8, 869-870, DOI: 10.3109/01443615.2015.1014325 To link to this article: http://dx.doi.org/10.3109/01443615.2015.1014325
Published online: 16 Mar 2015.
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Date: 09 November 2015, At: 01:13
Journal of Obstetrics and Gynaecology, November 2015; 35: 869–870 © 2015 Taylor & Francis Group, LLC ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2015.1014325
OBSTETRIC SHORT COMMUNICATION
Abnormal patterns of blood flow through the uterine arteries: Is it a clue for placental abruption in clinically suspected cases? S. Olgan1, M. Ozekinci1, E. Cagliyan2, R. E. Okyay2 & S. Altunyurt2 1Department of Obstetrics and Gynecology, Akdeniz University Faculty of Medicine, Antalya, Turkey and 2Department of Obstetrics and
Gynecology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
Downloaded by [University of Florida] at 01:13 09 November 2015
Introduction Placental abruption is defined as ‘premature separation of normally implanted placenta from uterus, generally characterised by abdominal/pelvic pain, vaginal bleeding and uterine tenderness’. It complicates approximately 1% of births and is one of the most important causes of maternal morbidity and perinatal mortality (Tikkanen 2011). Therefore, accurate diagnosis of abruption and, possibly, prediction of its worsening are extremely important when considering a conservative treatment. However, as is often the case, the classic triad is present only in minority of cases. Moreover, ultrasonography, despite recent technical advances, is not sensitive in detection of abruption (Glantz and Purnell 2002). Unfortunately, the most sensitive indicator of abruption still seems to be the presence of foetal compromise.
Cases Five patients (30–35 weeks’ gestation) with the obscure symptoms of vaginal bleeding, uterine tenderness and painful uterine contractions were presented to Dokuz Eylul University Hospital between 2008 and 2011 (Table I). Two of the patients reported minor blunt trauma as a reason for their symptoms. Their vital signs were within normal limits at the time of admission. We carried out ultrasound including assessment of foetal growth, any sign of placental abruption and foetal–maternal Doppler evaluation. A Voluson V730 Expert (GE Healthcare, Milwaukee, WI, USA) ultrasound machine was used for the examination. There were no signs of foetal growth retardation in any of the foetuses. The placental abruption was visible in only one case by ultrasonography. Foetal umbilical and middle cerebral artery waveforms were found to be normal. However, high pulsatility indices (PIs) in both uterine arteries were observed in all of the patients (The mean PIs were found to be above 95th percentile according to reference ranges by Gómez et al. 2008). Additionally extensive uterine artery notches were noted in four of the patients at least in one site. Cardiotocography (CTG) monitoring revealed normal foetal heart rate pattern and few foetal movements, but no decelerations. Therefore, expectant management plan with continuous CTG monitoring was instituted. If persistent contractions were present at least an hour after intra-venous hydration, tocolytic therapy (nifedipine)
was started. Maternal corticosteroid was given (intra-muscular betamethasone) for foetal lung maturation. No tocolytics and maternal steroids were used after 34 weeks’ gestation. In the clinical course, emergency caesarean section was performed, 30–360 min after arrival, as a result of recurrent late decelerations. The evidence of abruption was ultimately noted in all of the patients intra-operatively, by the presence of old/fresh blood clots adherent to the placenta.
Discussion Our findings suggest that the high resistance to blood flow in uterine arteries and extensive notches might be related to placental separation in clinically suspected cases even if the abruption is not visible by ultrasonography. In the literature, Morrow and Ritchie (1988), Degani et al. (1990) and Arabin et al. (1998) assessed the flow velocity waveforms in the uterine arteries in the course of evaluation of placental abruption. They advocated expectant management to promote prolongation of the pregnancy in their non-acute cases. Subsequently, they observed similar abnormal patterns of blood flow and high PIs in the uterine artery in response to placental abruption. They postulated that abnormal Doppler findings of uterine arteries might be a result of compression of decidual spiral arteries by increased uterine tone or by the intra-uterine haematoma itself. Therefore, uteroplacental flow velocity waveforms might provide reliable information on which to base the diagnosis of placental abruption (Sekizuka et al. 1994). Interestingly, although most obstetricians would guess that uterine artery Doppler velocimetry is affected with abruption process, none of them use this tool in their routine practice when seldom encountered. In fact, the current literature consists of only a few case reports and scientifically lacks enough evidence for clinicians to lean on. We strongly believe that flow measurement in the uterine artery has been underestimated and might be an important indicator of acute placental conditions. Doppler findings might manifest early before the appearance of morphological findings such as haematoma with conventional ultrasonography. Therefore, the finding of abnormal uterine artery Doppler waveforms should prompt the initiation of closer monitoring of placental abruption in clinically suspected cases.
Correspondence: Safak Olgan, MD, Department of Obstetrics and Gynecology, Akdeniz University Hospital, 07059, Konyaalti, Antalya, Turkey. E-mail: [email protected], [email protected]
870
S. Olgan et al. Table I. Demographic characteristics, clinical/ultrasonography findings and survey of the patients.
Downloaded by [University of Florida] at 01:13 09 November 2015
Case 1
Case 2
Case 3
Case 4
Case 5
Age 31 32 29 32 40 Gestational age (weeks ⫹ days) 34 ⫹ 2 33 ⫹ 2 31 ⫹ 2 29 ⫹ 5 35 ⫹ 1 Parity 0 1 1 3 2 Systemic disease – – DM – Chronic HT Trauma – – – ⫹ ⫹ PPROM – – – – ⫹ Vaginal bleeding – – ⫹ ⫹ ⫹ Pain (VAS score) 5 2 2 7 6 Contractions on CTG – ⫹ ⫹ ⫹ ⫹ Cervical dilatation (cm)/effacement (%) 2/50 1/0 0/0 2/30 1/0 Transvaginal cervical length (mm) 12 47 39 25 37 Placental localisation Anterior Postero-lateral Postero-lateral Postero-lateral Anterior US findings of abruption – – – † – Uterine artery PI (placental/non-placental) 1.49/1.74 1.99/3.12 1.53/1.97 1.78/4.24 2.05/2.55 Uterine artery notching -/⫹/⫹ ⫹/⫹ ⫹/‡ ⫹/⫹ (placental/non-placental) Tocolysis – – ⫹ ⫹ ⫹ Corticosteroid – – ⫹ ⫹ ⫹ Intra-operative finding of abruption ⫹ ⫹ ⫹ ⫹ ⫹ Uterine atony – – – – ⫹§ Baby/placenta weight (gr) 3100/680 1880/425 2661/690 1670/650 2400/640 Apgar scores (1st/5th min) 7/10 6/9 5/6 1/0 (exitus) 7/9 PPROM, Preterm premature rupture of membranes; VAS, Visual analogue scale; CTG, Cardiotocography; US, Ultrasonography; PI, Pulsatility index; DM, Diabetes mellitus; HT, Hypertension †Complex fluid collection (8 ⫻ 4 cm) was seen along the foetal surface of placenta. The haematoma was adjacent to, but did not compress, the cord insertion site. ‡Absent end-diastolic blood flow. §Hypogastric artery ligation and post-partum hysterectomy performed due to uterine atony.
We intend to draw the researchers’ attention towards this promising correlation and, consequently, evoke them to initiate long-running prospective studies on this issue. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Arabin B, van Eyck J, Laurini RN. 1998. Hemodynamic changes with paradoxical blood flow in expectant management of abruptio placentae. Obstetrics and Gynecology 91:796–798. Degani S, Lewinsky R, Shapiro I, Sharf M. 1990. Fetal and uteroplacental flow velocity waveforms in the expectant management of placental abruption. Gynecologic and Obstetric Investigation 30:59–60.
Glantz C, Purnell L. 2002. Clinical utility of sonography in the diagnosis and treatment of placental abruption. Journal of Ultrasound in Medicine 21:837–840. Gómez O, Figueras F, Fernández S, Bennasar M, Martínez JM, Puerto B, Gratacós E. 2008. Reference ranges for uterine artery mean pulsatility index at 11–41 weeks of gestation. Ultrasound in Obstetrics and Gynecology 32:128–132. Morrow RJ, Ritchie JW. 1988. Uteroplacental and umbilical artery blood velocity waveforms in placental abruption assessed by Doppler ultrasound. Case report. British Journal of Obstetrics Gynaecology 95:723–724. Sekizuka N, Hanaoka J, Takeuchi Y, Tokunaga A. 1994. Fetal and uteroplacental flow velocity waveforms in abruptio placentae: report of two cases. Journal of Perinatal Medicine 22:441–445. Tikkanen M. 2011. Placental abruption: epidemiology, risk factors and consequences. Acta Obstetricia et Gynecologica Scandinavica 90:140–149.
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Abnormal patterns of blood flow through the uterine arteries: Is it a clue for placental abruption in clinically suspected cases? S. Olgan, M. Ozekinci, E. Cagliyan, R. E. Okyay & S. Altunyurt To cite this article: S. Olgan, M. Ozekinci, E. Cagliyan, R. E. Okyay & S. Altunyurt (2015) Abnormal patterns of blood flow through the uterine arteries: Is it a clue for placental abruption in clinically suspected cases?, Journal of Obstetrics and Gynaecology, 35:8, 869-870, DOI: 10.3109/01443615.2015.1014325 To link to this article: http://dx.doi.org/10.3109/01443615.2015.1014325
Published online: 16 Mar 2015.
Submit your article to this journal
Article views: 30
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [University of Florida]
Date: 09 November 2015, At: 01:13
Journal of Obstetrics and Gynaecology, November 2015; 35: 869–870 © 2015 Taylor & Francis Group, LLC ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2015.1014325
OBSTETRIC SHORT COMMUNICATION
Abnormal patterns of blood flow through the uterine arteries: Is it a clue for placental abruption in clinically suspected cases? S. Olgan1, M. Ozekinci1, E. Cagliyan2, R. E. Okyay2 & S. Altunyurt2 1Department of Obstetrics and Gynecology, Akdeniz University Faculty of Medicine, Antalya, Turkey and 2Department of Obstetrics and
Gynecology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
Downloaded by [University of Florida] at 01:13 09 November 2015
Introduction Placental abruption is defined as ‘premature separation of normally implanted placenta from uterus, generally characterised by abdominal/pelvic pain, vaginal bleeding and uterine tenderness’. It complicates approximately 1% of births and is one of the most important causes of maternal morbidity and perinatal mortality (Tikkanen 2011). Therefore, accurate diagnosis of abruption and, possibly, prediction of its worsening are extremely important when considering a conservative treatment. However, as is often the case, the classic triad is present only in minority of cases. Moreover, ultrasonography, despite recent technical advances, is not sensitive in detection of abruption (Glantz and Purnell 2002). Unfortunately, the most sensitive indicator of abruption still seems to be the presence of foetal compromise.
Cases Five patients (30–35 weeks’ gestation) with the obscure symptoms of vaginal bleeding, uterine tenderness and painful uterine contractions were presented to Dokuz Eylul University Hospital between 2008 and 2011 (Table I). Two of the patients reported minor blunt trauma as a reason for their symptoms. Their vital signs were within normal limits at the time of admission. We carried out ultrasound including assessment of foetal growth, any sign of placental abruption and foetal–maternal Doppler evaluation. A Voluson V730 Expert (GE Healthcare, Milwaukee, WI, USA) ultrasound machine was used for the examination. There were no signs of foetal growth retardation in any of the foetuses. The placental abruption was visible in only one case by ultrasonography. Foetal umbilical and middle cerebral artery waveforms were found to be normal. However, high pulsatility indices (PIs) in both uterine arteries were observed in all of the patients (The mean PIs were found to be above 95th percentile according to reference ranges by Gómez et al. 2008). Additionally extensive uterine artery notches were noted in four of the patients at least in one site. Cardiotocography (CTG) monitoring revealed normal foetal heart rate pattern and few foetal movements, but no decelerations. Therefore, expectant management plan with continuous CTG monitoring was instituted. If persistent contractions were present at least an hour after intra-venous hydration, tocolytic therapy (nifedipine)
was started. Maternal corticosteroid was given (intra-muscular betamethasone) for foetal lung maturation. No tocolytics and maternal steroids were used after 34 weeks’ gestation. In the clinical course, emergency caesarean section was performed, 30–360 min after arrival, as a result of recurrent late decelerations. The evidence of abruption was ultimately noted in all of the patients intra-operatively, by the presence of old/fresh blood clots adherent to the placenta.
Discussion Our findings suggest that the high resistance to blood flow in uterine arteries and extensive notches might be related to placental separation in clinically suspected cases even if the abruption is not visible by ultrasonography. In the literature, Morrow and Ritchie (1988), Degani et al. (1990) and Arabin et al. (1998) assessed the flow velocity waveforms in the uterine arteries in the course of evaluation of placental abruption. They advocated expectant management to promote prolongation of the pregnancy in their non-acute cases. Subsequently, they observed similar abnormal patterns of blood flow and high PIs in the uterine artery in response to placental abruption. They postulated that abnormal Doppler findings of uterine arteries might be a result of compression of decidual spiral arteries by increased uterine tone or by the intra-uterine haematoma itself. Therefore, uteroplacental flow velocity waveforms might provide reliable information on which to base the diagnosis of placental abruption (Sekizuka et al. 1994). Interestingly, although most obstetricians would guess that uterine artery Doppler velocimetry is affected with abruption process, none of them use this tool in their routine practice when seldom encountered. In fact, the current literature consists of only a few case reports and scientifically lacks enough evidence for clinicians to lean on. We strongly believe that flow measurement in the uterine artery has been underestimated and might be an important indicator of acute placental conditions. Doppler findings might manifest early before the appearance of morphological findings such as haematoma with conventional ultrasonography. Therefore, the finding of abnormal uterine artery Doppler waveforms should prompt the initiation of closer monitoring of placental abruption in clinically suspected cases.
Correspondence: Safak Olgan, MD, Department of Obstetrics and Gynecology, Akdeniz University Hospital, 07059, Konyaalti, Antalya, Turkey. E-mail: [email protected], [email protected]
870
S. Olgan et al. Table I. Demographic characteristics, clinical/ultrasonography findings and survey of the patients.
Downloaded by [University of Florida] at 01:13 09 November 2015
Case 1
Case 2
Case 3
Case 4
Case 5
Age 31 32 29 32 40 Gestational age (weeks ⫹ days) 34 ⫹ 2 33 ⫹ 2 31 ⫹ 2 29 ⫹ 5 35 ⫹ 1 Parity 0 1 1 3 2 Systemic disease – – DM – Chronic HT Trauma – – – ⫹ ⫹ PPROM – – – – ⫹ Vaginal bleeding – – ⫹ ⫹ ⫹ Pain (VAS score) 5 2 2 7 6 Contractions on CTG – ⫹ ⫹ ⫹ ⫹ Cervical dilatation (cm)/effacement (%) 2/50 1/0 0/0 2/30 1/0 Transvaginal cervical length (mm) 12 47 39 25 37 Placental localisation Anterior Postero-lateral Postero-lateral Postero-lateral Anterior US findings of abruption – – – † – Uterine artery PI (placental/non-placental) 1.49/1.74 1.99/3.12 1.53/1.97 1.78/4.24 2.05/2.55 Uterine artery notching -/⫹/⫹ ⫹/⫹ ⫹/‡ ⫹/⫹ (placental/non-placental) Tocolysis – – ⫹ ⫹ ⫹ Corticosteroid – – ⫹ ⫹ ⫹ Intra-operative finding of abruption ⫹ ⫹ ⫹ ⫹ ⫹ Uterine atony – – – – ⫹§ Baby/placenta weight (gr) 3100/680 1880/425 2661/690 1670/650 2400/640 Apgar scores (1st/5th min) 7/10 6/9 5/6 1/0 (exitus) 7/9 PPROM, Preterm premature rupture of membranes; VAS, Visual analogue scale; CTG, Cardiotocography; US, Ultrasonography; PI, Pulsatility index; DM, Diabetes mellitus; HT, Hypertension †Complex fluid collection (8 ⫻ 4 cm) was seen along the foetal surface of placenta. The haematoma was adjacent to, but did not compress, the cord insertion site. ‡Absent end-diastolic blood flow. §Hypogastric artery ligation and post-partum hysterectomy performed due to uterine atony.
We intend to draw the researchers’ attention towards this promising correlation and, consequently, evoke them to initiate long-running prospective studies on this issue. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Arabin B, van Eyck J, Laurini RN. 1998. Hemodynamic changes with paradoxical blood flow in expectant management of abruptio placentae. Obstetrics and Gynecology 91:796–798. Degani S, Lewinsky R, Shapiro I, Sharf M. 1990. Fetal and uteroplacental flow velocity waveforms in the expectant management of placental abruption. Gynecologic and Obstetric Investigation 30:59–60.
Glantz C, Purnell L. 2002. Clinical utility of sonography in the diagnosis and treatment of placental abruption. Journal of Ultrasound in Medicine 21:837–840. Gómez O, Figueras F, Fernández S, Bennasar M, Martínez JM, Puerto B, Gratacós E. 2008. Reference ranges for uterine artery mean pulsatility index at 11–41 weeks of gestation. Ultrasound in Obstetrics and Gynecology 32:128–132. Morrow RJ, Ritchie JW. 1988. Uteroplacental and umbilical artery blood velocity waveforms in placental abruption assessed by Doppler ultrasound. Case report. British Journal of Obstetrics Gynaecology 95:723–724. Sekizuka N, Hanaoka J, Takeuchi Y, Tokunaga A. 1994. Fetal and uteroplacental flow velocity waveforms in abruptio placentae: report of two cases. Journal of Perinatal Medicine 22:441–445. Tikkanen M. 2011. Placental abruption: epidemiology, risk factors and consequences. Acta Obstetricia et Gynecologica Scandinavica 90:140–149.
