Placental abruption and placenta praevia

Antepartum haemorrhage is defined as bleeding from the genital tract from 24 weeks of gestation onwards. The incidence is around 2–5% of all pregnancies progressing beyond 24 weeks. Placenta praevia and placental abruption are of great clinical importance as causes of antepartum haemorrhage. Placenta praevia occurs when the placenta is totally or partly inserted in the lower uterine segment. The aetiology of placenta praevia may merely represent an accident of nature but is associated with advanced maternal age, multiparity and previous uterine damage such as in a previous caesarean section. Usually, the initial bleed is painless and mild, but it may be severe. Screening and diagnosis are normally by ultrasound. A dilemma exists as to whether hospitalisation should be offered to women with an asymptomatic placenta praevia. Caesarean section is the recommended mode of delivery for major placenta praevia. Haemorrhage arising from premature separation of a normally situated placenta is known as abruptio placentae. Risk factors include placental abruption in a previous pregnancy, pre-eclampsia, cigarette smoking, and trauma. The patient typically develops pain over the uterus, and this may not be associated with apparent bleeding at first. The diagnosis is mainly clinical and confirmed by the demonstration of a retroplacental clot after delivery. In the obvious case of abruption, early delivery is of crucial importance. If the baby is still alive and the gestation compatible with survival upon delivery, it is recommended that urgent caesarean section should be performed. However, if the fetus is dead, one should expedite vaginal delivery. Complications of antepartum haemorrhage include maternal shock, especially due to the increased risk of postpartum bleeding. There is a greater risk of premature delivery, fetal hypoxia and sudden fetal death.     

Obstetric history and the risk of placenta previa

OBJECTIVE: To evaluate secular trends in the occurrence of placenta previa and whether placenta previa is associated with the outcome of previous pregnancies, cesarean section, and sociodemographic factors. DESIGN: A cohort study based on the Medical Birth Registry of Norway. Placenta previa in the second pregnancy was investigated for associations with outcomes in the first pregnancy and sociodemographic factors. RESULTS: In birth orders 1 and 2 the occurrence of placenta previa was 1.2 and 2.2 per 1,000, respectively, with no secular trend. The occurrence increased with maternal age and was lowest in women aged 20-29 years. The recurrence rate was 23 per 1,000 (adjusted odds ratio (OR) of recurrence=9.7). In women with prior delivery at < or =25 gestational weeks the risk of placenta previa was 6.7 per 1,000 (adjusted OR=3.0). In women with prior placental abruption the risk was 5.8 per 1,000 (OR=2.6). In women with prior perinatal death the risk was 4.4 per 1,000 (adjusted OR= 1.8). No independent relationship emerged with socio-economic factors, previous birthweight, and a history of pregnancy induced hypertension. Cesarean section was associated with subsequent development of placenta previa (adjusted OR= 1.3). CONCLUSIONS: We found no secular trends in the occurrence of placenta previa. Placenta previa is associated with previously described risk factors for placental abruption. The increased risk of placenta previa subsequent to placental abruption supports the theory of a shared etiologic factor. However, placenta previa and placental abruption do not share a common etiology in relation to a history of pregnancy induced hypertension, fetal growth retardation, and socio-economic factors.     

The risk of unexplained antepartum stillbirth in second pregnancies following caesarean section in the first pregnancy

Objective  To determine if a previous caesarean section increases the risk of unexplained antepartum stillbirth in second pregnancies.
Study design  Retrospective cohort study.
Setting  Large Canadian perinatal database.
Population  158 502 second births.
Methods  Data were obtained from a large perinatal database, which supplied data on demographics, pregnancy complications, maternal medical conditions, previous caesarean section and pregnancy outcomes.
Main outcome measures  Total and unexplained stillbirth.
Results  The antepartum stillbirth rate was 3.0/1000 in the previous caesarean section group compared with 2.7/1000 in the previous vaginal delivery group ( P = 0.46). Multivariate logistic regression modelling, including terms for maternal age (polynomial), weight >91 kg, smoking during pregnancy, pre-pregnancy hypertension and diabetes, did not document an association between previous caesarean section and unexplained antepartum stillbirth (OR 1.27, 95% CI 0.92–1.77).
Conclusion  Caesarean section in the first birth does not increase the risk of unexplained antepartum stillbirth in second pregnancies.     

Vaginal delivery compared with caesarean section in early preterm breech delivery: a comparison of long term outcome

Objective To determine the optimum mode of delivery of the early preterm fetus in breech presentation.
Design Retrospective comparison of two cohorts of preterm breech fetus.
Setting Two tertiary care centres: at one centre the preferred management for preterm breech presentation was vaginal delivery; at the other centre, the preferred method was caesarean section.
Population All singleton infants delivered after breech presentation from 1984 through 1989, at a gestational age of 26 to 31 weeks. Those with lethal congenital abnormalities, placenta praevia, placental abruption, fetal death or fetal distress before the onset of labour were excluded.
Main outcome measures Survival without disability or handicap documented at two years corrected age. The influence of a number of relevant variables on this outcome was assessed by logistic regression analysis.
Results There was no difference in survival without disability or handicap between the centres (odds ratio 1.5, 95% CI 0.6–3.9 vaginal delivery compared with caesarean section). Survival without disability or handicap was positively influenced by increasing birthweight and corticosteroids > 24 h before birth, and negatively influenced by footling presentation.
Conclusion A policy of caesarean section for early preterm (26–31 weeks) breech delivery is not associated with increased survival without disability or handicap.     

Social disparity affects the incidence of placental abruption among multiparous but not nulliparous women: a register-based analysis of 1,162,126 singleton births

Objectives

To identify risk factors for placental abruption and to evaluate associations between adverse perinatal outcomes and placental abruption stratified by parity among women with singleton births from 1991 to 2010 in Finland.

Study design

A retrospective population-based case–control study of singleton births in Finland from 1991 to 2010 (n = 1,162,126 from the Finnish Medical Birth Register). We modelled the group-specific risk factors for placental abruption in unadjusted and adjusted models.

Results

In total 3.5 and 3.7 per 1000 nulliparous and multiparous women, respectively, were affected by placental abruption. The recurrence rate was 8.6 per 1000 births. The adjusted risk for placental abruption increased in pregnancies characterised by advanced maternal age, low birth weight, smoking, major congenital anomaly, preeclampsia and male foetal sex in both parity groups. In vitro fertilisation increased the risk only in nulliparae whereas anaemia, a prior caesarean section and the lowest socioeconomic status increased the risk in multiparae. Births affected by placental abruption were associated with an increased admission for neonatal intensive care, preterm birth, low birth weight (<2500 g), small for gestational age infants, low Apgar scores, and low newborn umbilical vein pH (<7.15). Placental abruption resulted in increased risks of stillbirth and early neonatal death in both parity groups.

Conclusions

The burden of placental abruption is equal in nulliparae and multiparae, but risk factors vary substantially. Social disparity only affects the incidence of placental abruption among multiparous women, indicating that factors related to lifestyle and health behaviour have different effects on the parity groups.     

Obstetrics and perinatal outcome of pregnancies after the age of 45.

We set out to describe the maternal and perinatal outcome of pregnancies in women >/= 45 years old at the time of delivery. A retrospective review of hospital deliveries after 28 weeks of pregnancy was performed at the Princess Badeea Teaching Hospital (PBTH) in North Jordan for patients delivered between 1 April 1994 and 31 December 1997. During the study period, there were 114 women aged >/= 45 years at delivery at the PBTH. The incidence was 3.3 per 1000 births. The median maternal age was 45 years. The majority of women (81.6%) were 45-46 years old. Maternal ages were 45 (n =64), 46 (n =29), 47 (n =9), 48 (n =8), 49 (n =2) and 50 (n =2) years. Median gravidity was 10, median parity was seven. Forty-four (38.6%) patients had obstetric complications. The most frequent complication was diabetes mellitus (9.6%), followed by hypertension (4.4%). Caesarean section was performed in 32.5%. There were nine stillbirths and four early neonatal deaths, the perinatal mortality rate was 114/1000 births. We conclude that women >/= 45 years old at delivery have high perinatal mortality rate and we also noted a higher incidence of placental abruption, placenta praevia and caesarean delivery, compared with a younger group of women.     

Perinatal mortality associated with abruptio placenta in singletons and multiples

OBJECTIVE: This study was undertaken to investigate the association among plurality (number of fetuses per pregnancy), abruptio placenta, and perinatal mortality. STUDY DESIGN: A retrospective cohort study on 15,051,872 singletons, 413,619 twins, and 22,585 triplets delivered in the United States between 1995 and 1998 was conducted. We compared the occurrence of perinatal death between pregnancies complicated by abruptio placenta and those without with the use of adjusted odds ratios. The generalized estimating equations framework was applied to adjust for intracluster correlations among multiples. RESULTS: Placental abruption occurred among 93,968 singletons (6.2 per 1000), 5051 twin (12.2 per 1000), and 353 triplet (15.6 per 1000) gestations ( P for trend<.0001). Placental abruption was associated with significant risk of mortality irrespective of the plurality subtype. Perinatal mortality was greatest among singletons (adjusted odds ratio [95% CI]=14.3[13.2-15.4]), followed by twins (4.4[3.9-4.9]) and least among triplets (3.0[2.0-4.6]) ( P for trend<.0001). CONCLUSION: As plurality increases from 1 to 3, the risk of placental abruption rises, whereas the risk of abruptio-associated perinatal mortality declines.     

Delivery of the term twin

The ever-increasing incidence of twin pregnancies world wide, together with the increasing trend to caesarean delivery, has resulted in intense scrutiny of the most appropriate method of twin delivery. The term twin has an increased risk of twin mortality compared to term singletons and this might be a result of the increase risk of labour and delivery compared to that of singletons. There are three ways to address this from the literature. The first is to compare outcome for the second twin versus the first twin, and to compare these outcomes in those twins delivered vaginally compared to those delivered by lower section caesarean section (LSCS). The second is to compare outcomes for twins delivered vaginally and for those delivered by caesarean section (CS). These data show higher rates of adverse perinatal outcome for the twin at or near term if delivery is vaginal versus CS. The third method is to compare outcomes for twins delivered by planned vaginal birth (VB; actual VB plus emergency CS) versus planned CS. This chapter will review this data thus outline an ongoing randomized controlled trial--the Twin Birth Study.     

Placenta previa: neonatal death after live births in the United States

OBJECTIVE: The purpose of this study was to describe neonatal mortality rates among live births that were complicated by placenta previa in the United States. STUDY DESIGN: This was a population-based retrospective cohort study of 1997 United States singleton live births. Neonatal deaths among pregnancies that were complicated by placenta previa were compared with deaths among pregnancies with no placenta previa. Adjusted and unadjusted hazard ratios were generated from a proportional hazards regression model. RESULTS: Of 3,773,369 live births, 9656 were complicated by placenta previa (2.6 cases per 1000). Among cases of placenta previa, 114 neonatal deaths occurred (11.8 per 1000) versus 14951 (4 per 1000) among non-placenta previa neonates (P <.0001). The adjusted relative risk of death was three times higher among placenta previa neonates (hazard ratio, 3.06; 95% CI, 2.40-3.94). Placenta previa-related death was mediated through preterm delivery rather than small for gestational age. CONCLUSION: Placenta previa triples the rate of neonatal mortality, which is mediated mainly through preterm birth.     

Obstetric outcome in women with subfertility

BACKGROUND: It has been suggested that a history of subfertility is associated with increased obstetric and perinatal risks. It is unclear if the cause is inherent characteristics in the women or the fertility treatment. OBJECTIVES: To compare the obstetric and perinatal risks of singleton pregnancies in women with a history of subfertility in comparison with the general population. DESIGN: Population cohort. SETTING: Aberdeen, Scotland. POPULATION: Cases were women attending the Fertility Clinic between 1989 and 1999 who subsequently went on to have singleton pregnancies. Controls included the general population of women who delivered singletons over the same period. METHODS: We performed a retrospective cohort study to investigate the obstetric outcome of singleton pregnancies in women with subfertility. The general population of women who delivered singletons over the same period served as controls. MAIN OUTCOME MEASURES: Obstetric and perinatal complications in singleton pregnancies. RESULTS: Maternity records were available for a total of 1437 subfertile women and 21,688 controls. Subfertile women were older [mean (SD) age: 31 (4.7) years vs 27 (5.4) years, P < 0.01] and more likely to be primiparous (70% vs 65%, P < 0.001). After adjusting for age and parity, subfertile women were at increased risk of pre-eclampsia (OR 1.9, 95% CI 1.5-2.5), placenta praevia (OR 3.9, 95% CI 2.2-7.0) and placental abruption (OR 1.8, 95% CI 1.1-3.0), and more likely to undergo induction of labour (OR 1.5, 95% CI 1.3-1.6), caesarean section (OR 2.1, 95% CI 1.8-2.4) and instrumental delivery (OR 2.2, 95% CI 1.8-2.6), and deliver low birthweight (OR 1.4, 95% CI 1.3-1.7) and preterm (OR 1.7, 95% CI 1.2-2.2) infants. There were no differences between treatment-related and treatment-independent pregnancies. CONCLUSION: Subfertile women are at higher risk of obstetric complications, which persist after adjusting for age and parity.     

The effect on the likelihood of further pregnancy of placental abruption and the rate of its recurrence

Objective To assess the effect of having a placental abruption on 1. the probability of having further pregnancies, and 2. the rate of recurrence in such pregnancies.
Design A cohort study based on the Medical Birth Registry of Norway.
Results From 1967 to 1989, placental abruption occurred in 218/4951 subsequent deliveries after a placental abruption index case. After placental abruption with perinatal survival in the first delivery 59% of women had a further delivery, compared with 71% who did not have placental abruption at delivery. After a perinatal loss corresponding rates were 83% and 85%, respectively. Odds ratios of recurrence of abruption, crude and adjusted for maternal age, birth order and time period were 7.1 and 6.4, respectively. No secular trends were found. Caesarean section rates increased and were higher in pregnancies with recurrent placental abruption and in subsequent pregnancies without placental abruption than in the total birth population.
Conclusions Women who have placental abruption are less likely than other women to have another pregnancy. For women who do have subsequent pregnancies placental abruption occurs significantly more frequently.     

Once cesarean section--always cesarean section?

Between 1975 and 1985 from 522 patients, who had undergone caesarean section during their previous delivery or deliveries, per cent 63 have been delivered vaginally and 37 per cent with a caesarean section (52.8% primary, 47.2% secondary). The rate of spontaneous labour was higher, if patient had a spontaneous delivery before caesarean section or the first caesarean section has been performed because of a placenta praevia, a breech presentation or a fetal distress syndrome. Cephalopelvic disproportion went on in 67.2 per cent with a caesarean section. Rupture of the scare occurred in 2.9 per cent. Expectative management of delivery is justified following previous caesarean section. Oxytocin infusions are possible in cases if internal tocography will be done.     

Myasthenia gravis and pregnancy

Three pregnancies in two women with myasthenia gravis (MG), are presented. The first woman expressed no antenatal complications and delivered a full-term 3350 g baby by caesarean section, because of a previous caesarean. The second woman had two preterm births in subsequent pregnancies, which were complicated by hydramnios. Her first pregnancy ended in neonatal death of a 860 g female with multiple congenital anomalies. In her second pregnancy there was an exacerbation of MG and the baby, an 880 g male died soon after birth, due to respiratory failure.     

Vaginal delivery compared with caesarean section in early preterm breech delivery: a comparison of long term outcome.

OBJECTIVE: To determine the optimum mode of delivery of the early preterm fetus in breech presentation. DESIGN: Retrospective comparison of two cohorts of preterm breech fetus. SETTING: Two tertiary care centres: at one centre the preferred management for preterm breech presentation was vaginal delivery; at the other centre, the preferred method was caesarean section. POPULATION: All singleton infants delivered after breech presentation from 1984 through 1989, at a gestational age of 26 to 31 weeks. Those with lethal congenital abnormalities, placenta praevia, placental abruption, fetal death or fetal distress before the onset of labour were excluded. MAIN OUTCOME MEASURES: Survival without disability or handicap documented at two years corrected age. The influence of a number of relevant variables on this outcome was assessed by logistic regression analysis. RESULTS: There was no difference in survival without disability or handicap between the centres (odds ratio 1.5, 95% CI 0.6-3.9 vaginal delivery compared with caesarean section). Survival without disability or handicap was positively influenced by increasing birthweight and corticosteroids > 24 h before birth, and negatively influenced by footling presentation. CONCLUSION: A policy of caesarean section for early preterm (26-31 weeks) breech delivery is not associated with increased survival without disability or handicap.     

Maternal and perinatal outcome of pregnancies after the age of 45

OBJECTIVE: To describe the maternal and perinatal outcome of pregnancies in women aged 45 years or more at the time of delivery and to compare them with pregnancies in women aged between 20 and 29 years. METHODS: A retrospective review of hospital deliveries after 28 weeks gestation was performed at the Princess Badeea Teaching Hospital in North Jordan for patients delivered between 1st April 1994 and 31st December 1997. We compared the maternal and perinatal outcome of pregnancies in women aged of 45 years or more (study group, n = 114) with women aged between 20-29 years (control group, n = 121) delivered at the same hospital during the same period. RESULTS: The incidence of pregnant women aged 45 years or more was 3.3 per 1,000 births. The median maternal age was 45 years. The majority of women (81.6%) were 45 to 46 years old. Gravidity and parity was significantly higher in the study group (p < 0.0001), also antenatal and medical complications as pre-eclampsia and diabetes mellitus were higher in the study group. Caesarean section rate, incidences of placental abruption and placenta previa were more common in older patients compared with young patients (32.4 vs 10.7%, 6.1 vs 0.8% and 4.4 vs 1.6%, respectively). There were no differences in the incidences of neonatal deaths, lethal malformations and fetal weight between the 2 groups. CONCLUSION: Women aged 45 years or more at delivery may expect a good pregnancy outcome but should expect a higher incidences of placental abruption, placenta previa, preeclampsia and caesarean delivery.     

Conservative management of a case of placenta praevia percreta

Pregnancies complicated by placenta praevia and a history of caesarean section are associated with increased risk of placenta percreta (1). Placenta praevia percreta sometimes involves the bladder or other pelvic organ, invasion leading to genital bleeding or haematuria (2, 3). Bladder injury or uncontrollable profuse haemorrhage occasionally occurs in such patients during surgery. Examination of placental invasion is necessary as this clinical condition is severe. Treatment of placental myometrium invasion is required to prevent uncontrollable profuse haemorrhage during surgery. We present a multiparous patient who was diagnosed prenatally with placenta praevia percreta using magnetic resonance imaging (MRI) and who was treated conservatively with a good prognosis.     

Reproductive risk factors,Doppler findings,and outcome of affected births in placental abruption: a population-based analysis

Placental abruption complicates about 1% of all singleton pregnancies and the aim of this study is to assess the reproductive maternal risk factors associated with placental abruption, and the outcome of affected births. We analyze 170 women with singleton pregnancies complicated by placental abruption who gave birth at Kuopio University Hospital from March 1989 to December 1999. The general obstetric population ( n = 22,905) was selected as the reference group and logistic regression analysis was used to identify independent reproductive risk factors. Furthermore, Doppler ultrasonographic results and pregnancy outcome measures in the two groups were also recorded. The incidence of placental abruption was 0.57% in the referral area. Preeclampsia, grand multiparity, velamentous umbilical cord insertion, cigarette smoking, prior fetal demise, advanced maternal age (>35 years), and previous miscarriage were independent risk factors of placental abruption, with adjusted relative risks of 4.39, 3.60, 2.53, 2.46, 2.02, 1.62, and 1.55, respectively. Most cases of placental abruption occur before the onset of labor in low-risk pregnancies and are not predictable with regard to maternal reproductive risk factors. Current antepartum methods of detecting uteroplacental problems, including Doppler ultrasonography, are not effective in prenatal prediction of placental abruption. The outcome of affected births is still poor.     

Evidence of placental abruption as a chronic process: associations with vaginal bleeding early in pregnancy and placental lesions

BACKGROUND: Clinicians widely regard placental abruption as an acute event, though accumulating data point towards abruption being the end-result of chronic processes early in pregnancy, and perhaps even extending to conception. The Collaborative Perinatal Project was a prospective cohort study performed from 1959 to 1966 in the United States. Since enrolled pregnancies were managed without the biases created by modern perinatal surveillance and interventions, the natural history of disease in these data is ideal to study obstetrical complications such as placental abruption. OBJECTIVE: We assessed the associations versus contributions of the clinical feature of early gestational vaginal bleeding and histologic lesions (chronic and acute) with placental abruption. STUDY DESIGN: Women enrolled in the Collaborative Perinatal Project (1959-1966) were used, restricting the analysis to those that delivered singleton births (n=46,364). Risks of placental abruption were compared between women with and without vaginal bleeding at <20 weeks gestation. We also examined the relationships between placental abruption and chronic and acute histologic lesions, including infarcts, decidual necrosis, presence of macrophages in the decidua, amnion or chorion, and neutrophil infiltration in the amnion, chorion, placental surface, and umbilical vein. RESULTS: Any episode of vaginal bleeding at <20 weeks in pregnancy conferred an increased risk of placental abruption (adjusted relative risk (RR) 1.6, 95% confidence interval (CI) 1.3, 1.8). The greatest risk occurred with bleeding in both the first two trimesters (RR 3.1, 95% CI 2.3, 4.1). The presence of histologic lesions in the placenta, cord and membranes similarly carried an increased risk of placental abruption, even in the absence of vaginal bleeding. The risk of abruption was, however, highest in the presence of both histologic lesions and vaginal bleeding early in pregnancy. CONCLUSION: Vaginal bleeding early in pregnancy and histologic lesions of the placenta, umbilical cord, and membranes are associated with increased risk of placental abruption in later pregnancy. However, the increased risk associated with placental lesions, especially chronic inflammatory lesions, even in the absence of early vaginal bleeding, suggests that prolonged inflammation may be implicated in placental abruption.     

Learning from adverse clinical outcomes: major obstetric haemorrhage in Scotland, 2003-05

Objective  To describe a system for learning from cases of major obstetric haemorrhage.
Design  Prospective critical incident audit.
Setting  All consultant-led maternity units in Scotland, between 1 January 2003 and 31 December 2005.
Population  Women suffering from major obstetric haemorrhage (estimated blood loss ≥2500 ml or transfused ≥5 units of blood or received treatment for coagulopathy during the acute event).
Methods  Hospital clinical risk management teams reviewed local cases using a standard, national assessment pro forma.
Main outcome measures  Standard of care provided and learning points identified.
Results  Rate of major haemorrhage was 3.7 (3.4–4.0) per 1000 births. Pro formas returned for 517 of 581 reported cases (89%); 41% were delivered by emergency caesarean section (compared with 15% of all Scottish births). Uterine atony was the most common cause (250 women, 48%); 32% had multiple causes. A consultant obstetrician gave hands-on care to 368 (71%) and a consultant anaesthetist to 262 (50%). Placenta praevia as a cause was independently associated with consultant presence. Central venous pressure monitoring was used in 164 (31%) women, and 108 (21%) women were admitted to intensive care. Parity, blood loss, and placenta praevia as a cause were independently associated with peripartum hysterectomy (performed in 62 women, 12%). Balloon tamponade and haemostatic uterine suturing were successful in 92 of 116 women (79%). Most cases were assessed as well managed, with 'major suboptimal' care identified in only 14 cases (3%).
Conclusions  It is feasible to identify and assess cases of major obstetric haemorrhage prospectively on a national basis. Most women received appropriate care, but many learning points and action plans were identified.     

Costs of NHS maternity care for women with multiple pregnancy compared with high-risk and low-risk singleton pregnancy

Objective  To compare antenatal and obstetric costs for multiple pregnancy versus singleton pregnancy risk groups and to identify factors driving cost differentials.
Design  Observational study over 15 months (2001–02).
Setting  Four district hospitals in southeast England.
Population  Consecutive women with multiple pregnancy and singleton women with risk factors for fetal congenital heart disease (CHD) (pregestational diabetes, epilepsy, or family history of CHD) or Down syndrome, and a sample of low-risk singleton women.
Methods  Clinical care was audited from the second trimester anomaly scan until postnatal discharge, and the resource items were costed. Multiple regression analysis determined predictors of costs.
Main outcome measures  NHS mean costs of antenatal and obstetric care for different types of pregnancy.
Results  A total of 959 pregnancies were studied. Three percent of 243 women with multiple pregnancy reached 40 weeks of gestation compared with 54–55% of 163 low-risk and 322 Down syndrome risk women and 36% of 231 cardiac risk women. Antenatal costs for cardiac risk (£1,153) and multiple pregnancy (£1,048) were nearly double the costs for other two groups ( P < 0.001). As 63% of multiple births were delivered by caesarean section, the obstetric cost for multiple pregnancy (£3,393) was £1,000 greater overall. Pregestational diabetes was the most influential factor driving singleton costs, resulting in similar total costs for multiple pregnancy women (£4,442) and for women with diabetes (£4,877).
Conclusions  Our analyses confirm that multiple pregnancies are substantially more costly than most singleton pregnancies. Identifying women with diabetes as equally costly is pertinent because of the findings of the Confidential Enquiry into Maternal and Child Health that standards of maternal care for diabetics often are inadequate.