There is an increased need for blood transfusions among patients with stillbirth from suspected placental abruption, according to a recent study published in the American Journal of Obstetrics & Gynecology.
Takeaways
- The study highlights an elevated requirement for blood transfusions in cases of stillbirth attributed to suspected placental abruption.
- Placental abruption was identified as the primary cause in 12% of stillbirths, underscoring its significance in fetal outcomes. Additionally, 55.2% of these cases required blood transfusion, indicating a substantial impact on maternal health.
- The study analyzed various demographic factors such as maternal age, race, and underlying comorbidities associated with placental abruption. Preeclampsia was notably prevalent in cases requiring blood transfusion.
- Patients receiving blood transfusions demonstrated distinct hematologic indices, including lower fibrinogen levels, platelet counts, and hematocrit compared to those not requiring transfusion.
- The study revealed that 71% of patients received their first blood transfusion before delivery. The types of blood products administered varied, with packed red blood cells and whole blood being the most common.
Placental abruption, defined as premature separation of the placenta, is seen in 0.6% to 1% of births. Symptoms include contractions, abdominal pain, and vaginal bleeding. Placental abruption increases the risks of postpartum hemorrhage, disseminated intravascular coagulation (DIC), cesarean delivery, and blood transfusion.
Data has indicated an association between stillbirth and placental malfunction, with a 2005 study determining abruption as one of the top 3 causes for stillbirth. Additionally, cases of abruption severe enough to cause fetal demise are associated with increased DIC risk.
There is currently little data evaluating clinical outcomes and hematologic indices in patients with stillbirth. To describe the clinical presentation, course, and hematologic indices in patients with stillbirth caused by abruption, investigators conducted a retrospective cohort study.
Participants included patients who delivered stillbirth infants with a weight above 500 g or gestational age of 24 weeks or more. A multidisciplinary stillbirth review committee was consulted to determine abruption in patients. Members discussed clinical parameters and notes from antepartum, intrapartum, and postpartum care, as well as genetic testing, autopsy reports, and other pathology studies.
An obstetrical quality database was evaluated to obtain data on maternal demographic characteristics, visit data, and perinatal outcomes. Additional data collected included specific labor characteristics, type and number of blood products received, and hematologic indices.
Maternal conditions associated with abruption, such as age, race and ethnicity, and underlying comorbidities were assessed. Two cohorts were developed, with patients placed based on whether they required blood transfusion. Presenting symptoms, including vaginal bleeding and abdominal pain, were assessed separately across cohorts.
Other factors compared between cohorts included rates of DIC development, time of hospitalization, average blood loss, rates of postpartum hemorrhage, and percentage of placental surface affected by abruption.
There were 128,252 deliveries with data obtained, of which 0.48% were a stillbirth. Abruption was the primary cause of 12% of stillbirths, with 55.2% of these cases requiring transfusion of blood products. Of patients, 61.8% were non-Hispanic White and 29% non-Hispanic Black. A median gestational age of 34 weeks at delivery was reported.
At the time of presentation, abdominal pain was reported in 47.4% of patients and vaginal bleeding in 39.5%. Of cases with abruption stillbirth, 61.8% presented with preeclampsia with severe features, 63.1% with labor inductions requiring an oxytocin, and 80% with vaginal delivery.
Necessary blood transfusion was less common among Hispanic patients compared to non-Hispanic patients, but this difference was not significant after logistic regression, and no other associations were found based on age, race, or gestational age. A preeclampsia diagnosis was more common in patients receiving preeclampsia than not, at 0.76 vs 0.44.
A median EBL of 1000 mL was reported among patients receiving blood transfusion, compared to 500 mL among patients not receiving blood transfusion. A greater median percentage of placental surface area impacted by abruption was also reported among patients receiving blood transfusion.
Patients receiving blood products had a median hospital stay of 4 days, compared to 3 days among those not receiving blood products. The odds of a blood transfusion were increased 3-fold among patients with vaginal bleeding on admission. Patients needing a blood transfusion were also more likely to present with preeclampsia.
Seventy-one percent of patients received their first blood transfusion before delivery, with all patients undergoing a transfusion receiving either packed red blood cells or whole blood. Fresh frozen plasma was necessary in 52.4% of patients, platelets in 16.7%, cryoprecipitate in 19%, and tranexamic acid in 2.4%
Different hematologic indices were reported based on blood transfusion status. In patients requiring a blood transfusion, fibrinogen levels were 355 mg/dL, platelets 191,000/µL, and hematocrit 32%. In patients not requiring a blood transfusion, these levels were 522 mg/DL, 244,000/µL, and 35.9%, respectively.
Of patients with total abruption demise, 17% had DIC. DIC was also reported in 28% of patients receiving blood products, vs 0% of patients not receiving blood products.
These results indicated an increased need for blood products among patients with stillbirth because of abruption. Investigators concluded blood transfusions should be prioritized in patients with stillbirth from suspected placental abruption.
Reference
White A, Pruszynski J, Williams R, et al. Transfusion and hematologic indices in cases of stillbirth due to placental abruption. Am J Obstet Gynecol. 2023;229:677.e1-10. doi:10.1016/j.ajog.2023.06.042
