Re. Co. De.: A Better Classification for Determination of Still Births

Objective

To test the classification system Re. Co. De. to improve our understanding of the main causes associated with fetal deaths.

Method

The study included 348 women who were admitted with intrauterine deaths. After the stillborn babies were examined along with the placenta. The causes were classified according to Re. Co. De. system.

Results

The analysis of the new classification (Re. Co. De.) allowed attributable causes to about 90% of cases of stillbirth explained while 10% where unexplained. The commonest cause was found to be toxaemia of pregnancy, followed by IUGR, rupture uterus, obstructed labour, abruptio placentae etc.

Conclusion

The Re. Co. De. system gives us a better understanding of antecedents of stillbirth and the clinical practices, which need to be addressed to reduce perinatal mortality and have a better obstetric result in the next pregnancy.     

Count every newborn: EN-BIRTH study improving facility-based coverage and quality measurement in routine information systems

Background

An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording.

Methods

The EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017–2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, specificity, percent agreement). We assessed misclassification of stillbirths with neonatal deaths. To examine stillbirth appearance (fresh/macerated) as a proxy for timing of death, we compared appearance to observed timing of intrauterine death based on heart rate at admission.

Results

23,072 births were observed including 550 stillbirths. Register-recorded completeness of birth outcomes was > 90%. The observed study stillbirth rate ranged from 3.8 (95%CI = 2.0,7.0) to 50.3 (95%CI = 43.6,58.0)/1000 total births and was under-estimated in routine registers by 1.1 to 7.3 /1000 total births (register: observed ratio 0.9–0.7). Specificity of register-recorded birth outcomes was > 99% and sensitivity varied between hospitals, ranging from 77.7–86.1%. Percent agreement between observer-assessed birth outcome and register-recorded birth outcome was very high across all hospitals and all modes of birth (> 98%). Fresh or macerated stillbirth appearance was a poor proxy for timing of stillbirth. While there were similar numbers of stillbirths misclassified as neonatal deaths (17/430) and neonatal deaths misclassified as stillbirths (21/36), neonatal deaths were proportionately more likely to be misclassified as stillbirths (58.3% vs 4.0%). Enablers to more accurate register-recording of birth outcome included supervision and data use.

Conclusions

Our results show these routine registers accurately recorded stillbirths. Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, hence more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths.

     

Obstetric antecedents to apparent stillbirth (Apgar score zero at 1 minute only)

OBJECTIVE: To identify antecedent risk factors for the delivery of an infant with an Apgar score of 0 at 1 minute who is subsequently successfully resuscitated. METHODS: Infants born between January 1986 and February 1999 with 1-minute Apgar score of 0 followed by 5-minute Apgar score above 0 were studied. Each eligible infant was randomly matched with two control infants, born in the same year, with 1-minute Apgar score greater than 0. Hospital records of their mothers were reviewed. The variables were compared between the groups by univariate analysis. Those factors demonstrating significant differences were then analyzed by logistic regression. P <.05 was considered statistically significant. RESULTS: Seventy-four of 81,603 infants (0.9:1000 births) born with an Apgar score of 0 at 1 minute only were compared with 148 control babies. Univariate analysis revealed significant differences between study and control group regarding: gestational age, abruptio placentae, preterm premature rupture of membranes, chorioamnionitis, preeclampsia, small-for-gestational age, male gender, bradycardia, and abnormal fetal heart rate (FHR) other than bradycardia, respectively. Logistic regression of these factors found gestational age, bradycardia, and abnormal FHR to be independent risk factors for the delivery of an apparent stillborn infant. After exclusion of FHR criteria, logistic regression found gestational age (odds ratio [OR] 0.8 per week), male gender (OR 2.5), preeclampsia (OR 3.9), and abruptio placentae (OR 13.6) to be independent risk factors for the delivery of an apparent stillborn infant. CONCLUSION: Preterm birth, male gender, preeclampsia, and abruptio placentae are independently associated with an increased risk of apparent stillbirth.     

Value of Cardiotoeography in Women with Antepartum Haemorrhage - Is It Too Late for Caesarean Section When the Cardiotocograph Shows Ominous Features?

Summary: Caesarean section is thought to be indicated by an ominous antepartum cardiotocograph (CTG). However, the fear remains that infants delivered for this indication in the presence of antepartum haemorrhage, especially when premature, are destined to have severe hypoxic neurological damage. We therefore reviewed our experience of cardiotoeography in women with antepartum haemorrhage (APH) from 1989 to 1992. There were 472 women with APH who had a CTG performed. Of them, 68 had abruptio placentae and 317 had an APH of undetermined cause. For the group with abruptio placentae, the perinatal mortality rate (PMR) was 230.7 per 1,000 when the CTG was abnormal, but only 18.2 per 1,000 if the CTG was normal (odds ratio 16.2, 95% confidence interval [CI] 1.53–171.9, p = 0.02). For APH of undetermined cause, the corresponding rates were 90.9 per 1,000 and 9.8 per 1,000 (odds ratio 10.1, 95% CI 0.96–105.8, p = 0.13). There were no perinatal losses in women with APH due to placenta praevia (87 cases).
There were 6 cases of critical fetal reserve identified on a CTG in women with abruptio or APH of undetermined cause. All were delivered by Caesarean section, with 4 surviving infants, 3 with normal neurological outcome and 1 lost to follow-up. There were 3 cases of APH resulting in an infant with cerebral palsy, all of whom had had a normal antepartum CTG. Our data suggest that cardiotoeography allows pregnancy to be safely prolonged in pregnancies complicated by abruptio placentae or APH of undetermined cause, and that Caesarean section is an appropriate form of delivery when the CTG becomes abnormal in these cases.     

National trends in the incidence of abruptio placentae, 1979-1987

Premature separation of the normally implanted placenta is a serious complication of pregnancy and a leading cause of maternal and perinatal morbidity and mortality. Using data from the National Hospital Discharge Survey, we estimated rates of abruptio placentae in the United States for the years 1979-1987 and examined the association of this condition with several demographic risk factors and coexisting obstetric conditions. In 1987, the national rate was 11.5 cases per 1000 deliveries. The rate of abruptio placentae increased significantly between the years 1979-1987 among women of all racial groups. The increase in the rate of placental abruption occurred mainly among women under the age of 25, unmarried women, and women on Medicaid compared with those who had private insurance. Women with placental abruption were 54 times more likely to have coagulopathies and 11 times more likely to have stillbirths than those without placental abruption. Twin gestations, preterm premature rupture of membranes, chorioamnionitis, chronic hypertension, and preeclampsia/eclampsia were also associated with placental abruption. Although the cause for the increase in the incidence of abruptio placentae is not known, most of the increase occurred among women likely to be financially and socially disadvantaged.     

PERINATAL AND MATERNAL OUTCOME FOLLOWING ABRUPTIO PLACENTAE

Objective: To characterize the maternal and fetal presentation of abruptio placentae and associated maternal and fetal morbidity and mortality by mode of delivery and fetal status on admission.

Study Design: Perinatal data (gestational age > 24 weeks) from women with abruptio placentae at a tertiary referral center were analyzed. For the purpose of evaluating fetal morbidity and mortality, group 1 included women with hypertensive disorders of pregnancy (preeclampsia or chronic hypertension), PROM, cocaine abuse, and > 20% abruptio placentae without regard to fetal status on admission (reassuring, nonreassuring, or stillborn). In group 1, either umbilical artery pH < 7.0, Apgar < 3⁵, or base excess > 12 mmol/L represented perinatal hypoxia for this evaluation. Group 2 included women with stillborn fetuses on admission without regard to etiology or size of abruptio placentae. Comparisons between groups were made with one-way analysis of variance, Kruskal–Wallis, or χ² tests; p < 0.05 was considered significant.

Results: Group 1 was comprised of 342 women; 58.4% of fetuses had abnormal fetal heart rate tracings. Overall, the sensitivity of an abnormal fetal heart rate tracing to predict perinatal hypoxia was 87.2%, specificity was 33.9%, positive predictive value was 22.2%, and negative predictive value was 92.5%. Of parameters suggestive for perinatal hypoxia, 17.3% of neonates had Apgar < 3⁵, 13.0% had umbilical artery pH < 7.0, and 9.9% had base excess > 12 mmol/L. Overall, neonatal survival was 84.7%; 12.0% of fetuses were stillborn. For those fetuses alive on admission, cesarean delivery was associated with a significant reduction in neonatal mortality: odds ratio of 0.10 (95% confidence interval: 0.05–0.20) and p = 0.0001. Group 2 was comprised of 61 women. Women presenting with a stillborn infant on admission were more likely to require transfusions and suffer the complications (disseminated intravascular coagulopathy, acute renal failure, and acute respiratory distress syndrome) than women presenting with a live fetus.

Conclusion: Cesarean delivery appeared to reduce neonatal mortality. Whether emergent cesarean delivery resulted in the birth of compromised fetus cannot be evaluated from this study. Composite maternal morbidity is increased when a stillborn fetus is present on admission.     

High prevalence of the prothrombin gene mutation in women with intrauterine growth retardation, abruptio placentae and second trimester loss

BACKGROUND: It has been reported recently that obstetric complications are associated with thrombophilias. Our objective was to investigate the association between pregnancy complications and the guanine 20210 adenine (G20210A) mutation in prothrombin gene. METHODS: Two hundred and twenty-two women (study group) with obstetric complications were tested for the prothrombin mutation. Indications for testing were: severe preeclampsia, mild preeclampsia, intrauterine growth retardation, severe abruptio placentae, unexplained stillbirth, second trimester loss, and three or more consecutive spontaneous abortions. We also tested 156 healthy women who had at least one normal pregnancy and comprised the control group. RESULTS: Demographic data of the study and control groups were similar. Twenty-eight women of the study group (13%) were found to be heterozygous carriers of the 20210 variant of the prothrombin gene compared to five (3.2%) of the control group, p=0.001, odds ratio (OR) 2.9; 95% confidence interval (CI) 1.3-6.5. Compared to the control women, the prothrombin gene mutation was significantly more prevalent in women with IUGR, abruptio placentae, and second trimester loss but not in women with mild or severe preeclampsia, stillbirth and habitual abortion. CONCLUSIONS: Our data demonstrate that the mutation in the prothrombin gene is associated with specific pregnancy complications.     

The changing pattern of fetal death, 1961-1988.

The aim of this study was to assess any changes in cause-specific fetal death rates in the nonreferred population of a tertiary care unit. The fetal death rate (per 1000 births) among 88,651 births diminished from 11.5 in the 1960s to 5.1 in the 1980s. Fetal death due to intrapartum asphyxia and Rh isoimmunization has almost disappeared. Toxemia and diabetes continue to make similar and small contributions to fetal death rates. There has been a significant decline in unexplained antepartum fetal deaths and in those caused by fetal growth retardation, but no significant change in the death rate due to intrauterine infection or abruptio placentae. During the 1960s, the risk of fetal death was increased in women with hypertension, diabetes, or a history of stillbirth; during the 1980s, only women with a history of insulin-dependent diabetes were at risk. Improved application of current knowledge may help decrease the fetal death rate caused by fetal growth retardation. Reduction in deaths due to abruptio placentae, intrauterine infections, or lethal malformations, as well as unexplained antepartum deaths, appears to depend on better understanding of the etiology of these disorders.     

Fetal outcome with oligohydramnios in the second trimester

Thirty-four cases of oligohydramnios in the second trimester were diagnosed by ultrasonography. Nine of these pregnancies were associated with fetal anomalies including Potter syndrome (three), atrioventricular dissociation (two), congenital absence of thyroid (one), and multiple anomalies (three). There were ten unexplained stillbirths, one demise due to abruptio placentae, eight with perinatal morbidity after premature labor or abruptio placentae, and six with live-born term infants. Although oligohydramnios in the second trimester is associated with increased perinatal morbidity, this finding is not associated with a universally poor outcome.     

Challenges in classification and assignment of causes of stillbirths in low- and lower middle-income countries

Stillbirths account for 2.6 million deaths annually. 98% occur in low- and lower middle-income countries. Accurate classification of stillbirths in low-resource settings is challenged by poor pregnancy dating and infrequent access to electronic heart rate monitoring for both the newborn and fetus. In these settings, liveborn infants may be misclassified as stillbirths, and stillbirths may be misclassified as miscarriages. Causation is available for only 3% of stillbirths globally due to the absence of registration systems. In low-resource settings where culture and autopsy are infrequently available, clinical course is used to assign cause of stillbirth. This method may miss rare or subtle causes, as well as those with non-specific clinical presentations. Verbal autopsy is another technique for assigning cause of stillbirth when objective medical data are limited. This method requires family engagement and physician attribution of cause. As interventions to reduce stillbirths in LMICs are increasingly implemented, attention to accurate classification and assignment of causes of stillbirth are critical to charting progress.     

Genetic hypofibrinolysis in complicated pregnancies

OBJECTIVE: To assess the hypofibrinolytic 4G/4G mutation of the plasminogen activator inhibitor (PAI-1) gene as a possible factor contributing to severe preeclampsia, abruptio placentae, fetal growth restriction, and stillbirth. METHODS: We compared 94 women from a previous report who had obstetric complications to 95 controls with normal pregnancies matched for ethnic background and age. We collected blood and extracted DNA after delivery. All subjects had been tested for thrombophilic mutations factor V Leiden, C677T mutation in the methylenetetrahydrofolate reductase gene, and the G20210A mutation in the prothrombin gene. In the present study we tested for the hypofibrinolytic 4G/4G mutation in the PAI-1 gene. RESULTS: Women who had obstetric complications were more likely than controls to be 4G/4G homozygotes, 32% (30 of 94) women versus 19% (18 of 95) controls, odds ratio (OR) and 95% confidence intervals (CI) 2.0 (1.02, 3.9). Mutations in the PAI-1 gene were independently associated with obstetric complications (OR 1.56, 95% CI 1.005, 2.43). Heterozygosity for the factor V Leiden mutation was more common in the 30 women who had PAI-1 4G/4G than in the 18 4G/4G controls (33% versus 0%, Fisher P =.008). Seventy-six percent of women had some form of thrombophilia or hypofibrinolysis compared with 37% of controls (Fisher P <.001). CONCLUSIONS: Women with severe preeclampsia, abruptio placentae, fetal growth restriction, and stillbirth had increased incidence of the hypofibrinolytic 4G/4G mutation of the PAI-1 gene that is frequently associated with the thrombophilic factor V Leiden mutation, further predisposing them to thrombosis.     

The effect of smoking and hypertensive disorders on abruptio placentae in Norway 1999-2002

OBJECTIVE: To assess the effects of smoking and hypertension on abruptio placentae and whether the effect of hypertension is modified by smoking and vice versa. To quantify the proportion of abruptio placentae cases attributable to hypertension and smoking. DESIGN: Registry based national cohort study. MATERIALS AND METHODS: 814 cases of abruptio placentae among a total of 211,868 births in Norway during the period 1999-2002. Logistic regression analysis was used to assess whether the risk of abruptio placentae is influenced by maternal smoking habits and hypertensive disorders and to evaluate interactions in the effects on abruptio placentae of smoking and hypertension. RESULTS: In occasionally and daily smokers at the onset of pregnancy, abruptio placentae occurred in 5.4 and 5.7 per 1000, respectively, against 3.4 per 1000 in non-smokers (adjusted odds ratios (ORs) for maternal age and birth order 1.6-1.7). No significant dose-response effect was found. Adjusted ORs for abruptio placentae in women with pre-eclampsia superimposed on chronic hypertension, transient hypertension, mild and severe pre-eclampsia, and pre-eclampsia with onset before 34th weeks of gestation were significantly increased (ORs 1.6-4.1). The combined effects of smoking and hypertensive disorder were additive. Hypertension explained 3.3% of abruptio placentae, while smoking explained 6.9% of abruptio placentae cases. CONCLUSIONS: The effects on abruptio placentae of hypertensive pregnancy disorders and smoking are independent and additive, indicating that smoking and hypertension have their effects though separate mechanisms. If smoking were eliminated in pregnant women, the number of abruptio placentae cases would be reduced by 7%.     

Perinatal mortality and late sequelae in children born after abruptio placentae

Of 40 children born after abruptio placentae in the third trimester of pregnancy, 18 were stillbirths, 4 died within two days of preterm birth and 18 reached school age. All children alive at the age of 5–9 yr underwent neurological examination: 3 were abnormal (severe motor retardation, spastic hemiplegia) and 8 suspect. The 3 abnormal children had been severely premature at birth, whereas all 5 born at term were normal. The findings suggest that prematurity plays a major role in both neonatal mortality and in cerebral damage after abruptio placentae.     

Mathematic modeling to predict abruptio placentae

OBJECTIVE: This study was undertaken to identify correlates of abruptio placentae and to develop a mathematic model for the prediction of abruptio placentae. STUDY DESIGN: A total of 170,258 singleton birth records from 1991 to 1996 contained in the Schleswig-Holstein perinatal database were analyzed. Fifty-two recognized obstetric risk factors were subjected to univariate analysis. Correlates of abruptio placentae then underwent stepwise forward binary logistic regression. A constant value B(0), coefficients B(1) through B(p), an odds ratio, and a 95% confidence interval were calculated for individual correlates. RESULTS: Abruptio placentae occurred in 874 of 170,258 singleton gestations (0.5%). Of the 52 risk factors 31 proved to be correlates of abruptio placentae, with 16 among primiparous women and 25 among multiparous women. Ten correlates for primiparous, women and 13 for multiparous women emerged from the linear regression, with 7 correlates being shared by both primiparous and multiparous women. CONCLUSION: The probability that abruptio placentae will occur (p) can be calculated according to the following expression: p = e (z)/(1 + e (z)), where z = B(0) + B(1), em leaderB(p). For example, for a primiparous woman who smokes with bleeding at >28 weeks' gestation and a male fetus in the breech position, the following calculation would yield the chance of abruptio placentae:z = -2.25 + 2.51 + 0.41 + 0.24 + 0.60 = 1.51; p = e (1.51)/ (1 + e (1.51)) = 4. 53/5.53 = 0.82, or 82%.     

Combined heterozygosity for methylenetetrahydrofolate reductase (MTHFR) mutations C677T and A1298C is associated with abruptio placentae but not with intrauterine growth restriction.

OBJECTIVE: This study was undertaken to investigate the involvement of MTHFR gene mutations C677T and A1298C implicated in vascular disease, in patients with abruptio placentae and intrauterine growth restriction (IUGR). STUDY DESIGN: DNA was extracted from blood samples of 54 patients with placental vasculopathy (18 patients with abruptio placentae and 36 with IUGR) and 114 control patients and amplified by the polymerase chain reaction (PCR). The resulting fragments were subjected to restriction enzyme analysis and resolved by gel electrophoresis. RESULTS: A significant association could be demonstrated between mutation A1298C and both abruptio placentae and IUGR. Combined heterozygosity for mutations C677T and A1298C was detected in 22.2% of abruptio placentae cases. CONCLUSIONS: Combined heterozygosity for MTHFR mutations C677T and A1298C may represent a genetic marker for abruptio placentae.     

Pre-pregnancy weight and the risk of stillbirth and neonatal death

OBJECTIVE: To evaluate the association between maternal pre-pregnancy body mass index (BMI) and the risk of stillbirth and neonatal death and to study the causes of death among the children. DESIGN: Cohort study of pregnant women receiving routine antenatal care in Aarhus, Denmark. SETTING: Aarhus University Hospital, Denmark, 1989-1996. POPULATION: A total of 24,505 singleton pregnancies (112 stillbirths, 75 neonatal deaths) were included in the analyses. METHODS: Information on maternal pre-pregnancy weight, height, lifestyle factors and obstetric risk factors were obtained from self-administered questionnaires and hospital files. We classified the population according to pre-pregnancy BMI as underweight (BMI <18.5 kg/m(2)), normal weight (BMI 18.5-24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)) and obese (BMI 30.0 kg/m(2) or more). MAIN OUTCOME MEASURES: Stillbirth and neonatal death and causes of death. RESULTS: Maternal obesity was associated with a more than doubled risk of stillbirth (odds ratio = 2.8, 95% confidence interval [CI]: 1.5-5.3) and neonatal death (odds ratio = 2.6, 95% CI: 1.2-5.8) compared with women of normal weight. No statistically significantly increased risk of stillbirth or neonatal death was found among underweight or overweight women. Adjustment for maternal cigarette smoking, alcohol and caffeine intake, maternal age, height, parity, gender of the child, years of schooling, working status and cohabitation with partner did not change the conclusions, nor did exclusion of women with hypertensive disorders or diabetes mellitus. No single cause of death explained the higher mortality in children of obese women, but more stillbirths were caused by unexplained intrauterine death and fetoplacental dysfunction among obese women compared with normal weight women. CONCLUSION: Maternal obesity more than doubled the risk of stillbirth and neonatal death in our study. The present and other studies linking maternal obesity to an increased risk of severe adverse pregnancy outcomes emphasise the need for public interventions to prevent obesity in young women.     

Fetal growth restriction and other risk factors for stillbirth in a New Zealand setting

BACKGROUND: Stillbirth affects almost 1% of pregnant women in the Western world but is still not a research priority. AIMS: To assess in a cohort of stillbirths: the demographic risk factors, the prevalence of small for gestational age (SGA) by customised and population centiles, and the classification of death using the Perinatal Society of Australia and New Zealand Perinatal Death Classification (PSANZ-PDC). METHODS: The study population comprised 437 stillborn babies (born from 1993 to 2000 at National Women's Hospital, Auckland, New Zealand) and their mothers. The referent population for demographic factors was live births n=69 173. RESULTS: After multivariable analysis, risk factors for stillbirths were: Indian (odds ratio (OR) 1.85, 95%CI (1.18, 2.91)), or Pacific Islander (OR 1.65, 95%CI (1.27, 2.14)); smoking (OR 1.33, 95%CI (0.99, 1.79)) or unknown smoking status (OR 2.87, 95%CI (2.30, 3.58)); nulliparity (OR 1.42, 95%CI (1.10, 1.83)), and para 2 (OR 1.36, 95%CI (1.01, 1.83)). One hundred and twenty-nine (46%) stillbirths born>or=24 weeks (n=278) were SGA by customised, and 94 (34%) by population centiles. Customised SGA was more common in preterm versus term stillbirths (101 of 198 (51%) vs 28 of 80 (35%), respectively, P=0.02) but rates of population SGA did not differ (72 of 198 (36%) vs 22 of 80 (28%) P=0.16). 'Spontaneous preterm' was the most common cause of stillbirth at <28 weeks and 'unexplained' at >or=28 weeks using PSANZ-PDC classification. CONCLUSIONS: This study again emphasises the importance of suboptimal fetal growth as an important risk factor for stillbirth. Customised centiles identified more stillborn babies as SGA than population centiles especially preterm.     

Mild gestational hypertension: differences in ethnicity are associated with altered outcomes in women who undergo outpatient treatment

OBJECTIVE: The purpose of this study was to evaluate the impact of ethnicity on outcome in women with mild gestational hypertension that is remote from term. STUDY DESIGN: Nulliparous women with mild gestational hypertension who participated in an outpatient monitoring program between January 1995 and December 1999 were candidates. Patients had a singleton pregnancy at <37 weeks of gestation and were followed up for a minimum of 2 days as an outpatient. Maternal and perinatal outcomes were compared between groups by the Student t test, Mann-Whitney U test, and Pearson chi2 analyses. RESULTS: One thousand one hundred eight-two women were included in the analysis. No clinically remarkable differences in gestational age or incidence of proteinuria at the start of observation were noted. Newborn infants of Hispanic and African American women had significantly smaller birth weights compared with those of white women. African American women had a higher incidence of abruptio placentae (n = 5), stillbirths (n = 3), and neonatal deaths (n = 2) versus the other groups (n = 0 for all). The frequency of progression to thrombocytopenia/HELLP (hemolysis, elevated liver enzymes, and low platelet count syndrome) and cesarean delivery rates were similar between groups. CONCLUSION: Differences in outcomes are observed between ethnic groups even when the women undergo the same intensive outpatient monitoring for mild gestational hypertension.     

Abruptio placentae following nipple stimulation

A case of severe abruptio placentae evolved during the course of prepartum electronic fetal heart rate (FHR) monitoring which was associated with nipple stimulation. The fetal monitor tracing and clinical course are discussed. The unpredictability of abruptio placentae is underscored by the normal appearance of the FHR tracing immediately preceding the event. The association of nipple stimulation with abruptio placentae in this case raises concerns about the potential dangers of this surveillance technique.