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doi:10.1111/jog.12175 J. Obstet. Gynaecol. Res. Vol. 40, No. 2: 369374, February 2014

Prospective risk of abruptio placentae

Mamoru Morikawa1, Takahiro Yamada1, Kazutoshi Cho1, Takashi Yamada1, Shoji Sato2
and Hisanori Minakami1
1
Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, and 2Maternal and Perinatal Care
Center, Oita Prefectural Hospital, Oita, Japan

Abstract
Aim: The aim of this study was to better characterize the nature of abruptio placentae (AP) with regard to the
timing of onset.
Material and Methods: Prevalence and prospective risk of AP according to gestational week (GW) were
determined among 293 899 women who gave birth to singleton infants at and after GW 30. The prospective risk
of AP at gestational week N was defined as the number of all women who experienced an AP at GW N
divided by the number of all women who gave birth at GW N.
Results: AP developed in 2649 (0.90%) women. The prevalence of AP (6.7% among women who gave birth at
GW 3033) sharply decreased with advancing GW at delivery to 0.9% for GW 37 and 0.1% for GW 42. The
highest prospective risk of AP, 9 per 1000 women at GW 30, decreased linearly with advancing gestation to 1
per 1000 women at GW 42. AP accounted for 4.7% (1591/33 725) of all preterm births at GW <37, while
prevalence of AP was 0.41% (1058/260 174) among term births. Preterm AP accounted for 60.1% (1591/2649)
of all AP.
Conclusion: Our figures indicate that AP is more common in preterm births than in term birth and may be
helpful for better understanding the epidemiology of this condition.
Key words: abruptio placentae, gestational week, prospective risk.

Introduction reassuring fetal status at the time of admission to the

Abruptio placentae (AP) is a life-threatening complica-
tion for both mother and infant: AP accounted for 5.0%
of maternal deaths that occurred in Japan between 1991
and 1992;1 perinatal mortality ranges from 9% to
12% in infants born to women with AP;24 AP is one
of the leading causes of infantile cerebral palsy deri-
ved from antepartum and/or intrapartum hypoxic
conditions.510 AP is the single leading causative factor
of infantile cerebral palsy derived from antenatal
and/or intrapartum hypoxic conditions in Japan,
accounting for approximately one-quarter of such cere-
bral palsy cases in this country.10 Approximately 80% of
fetuses with cerebral palsy due to AP exhibited non-
obstetric facility.10 Therefore, prompt access to the
obstetric facility and prompt delivery may be impor-
tant to improve maternal outcome and to avoid neuro-
logical handicap in infants of women with AP.1113
There may be large numbers of women who develop
AP outside obstetric facilities. Such women with some
symptoms suggestive of AP may call on obstetric facili-
ties booked for their delivery regarding whether they
should visit the facility to confirm their status. It is
necessary to estimate the probability of AP in such
situations. However, it has not been extensively
studied how often AP occurs at a given gesta-
tional week and how the prospective risk of AP
changes during the third trimester. This retrospective

Received: February 25 2013.

Accepted: May 3 2013.
Reprint request to: Dr Mamoru Morikawa, Department of Obstetrics and Gynecology, Hokkaido University School of Medicine,
Kita-ku N15 W7, Sapporo 060-8638, Japan. Email: mmamoru@med.hokudai.ac.jp

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Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
M. Morikawa et al.

observational study was conducted to better character-
ize the nature of AP with regard to the timing of onset
in a large Japanese cohort.
Methods
This study was conducted after receiving approval
from the institutional review board of Hokkaido Uni-
versity Hospital. We analyzed data collected from
approximately 120 secondary and tertiary hospitals by
the Japan Society of Obstetrics and Gynaecology Suc-
cessive Pregnancy Birth Registry System. This system
collected information on successive deliveries occur-
ring at gestational week (GW) 22 or more in the partici-
pating hospitals. The available information from this
system included maternal age, parity, GW at delivery,
delivery mode, singleton or multifetal pregnancy,
maternal complications, such as AP, gestational hyper-
tension, pre-eclampsia, birthweight of the neonate, and
outcome of infants, including stillbirth and early neo-
natal death within 7 days of life. A total of 302 795
pregnant women with singleton pregnancies were reg-
istered in this system over a 5-year period between
2005 and 2009, corresponding to approximately 5.6% of
all singleton pregnancies in Japan during this period.
Of these, 293 899 women were included in this study
after excluding 1060 women (0.4%) whose age, GW
at delivery, and/or parity were unknown and 7836
women (2.6%) who delivered at GW less than
30.
We determined the prevalence of AP as well as pro-
spective risk of AP in relation to GW. The prospective
risk of AP at GW N was obtained using the following
equation: number of all women who experienced AP at
GW N/number of all women who gave birth at
GW N.
Statistical analyses were performed using StatView
5.0 for Macintosh (sas Institute) and IBM spss 18.0.
Fishers exact test was used to compare the frequencies.
In all analyses, P < 0.05 was taken to indicate statistical
significance.
Results
Of the 293 899 women, 2649 (0.90%) developed AP
(Table 1). The numbers of women with age 35 years
old, hypertensive disorders, including gestational
hypertension and pre-eclampsia, cesarean deliveries,
preterm birth, low birthweight infants, stillbirth, and
early neonatal deaths, were significantly higher among
the 2649 women with AP than in the 291 250 women
without AP.

Table 1 Demographic characteristics of study subjects

Abruptio placentae P-value
Present Absent
No. of women 2649 (100%) 291 250 (100%)
Primiparous 1312 (49.5%) 154 960 (53.2%) 0.0002
Age (years) 31.7 5.1 31.4 5.1 0.0253
19 23 (0.9%) 3 558 (1.2%) 0.0989
2034 1824 (68.9%) 205 311 (70.5%) 0.0660
35 802 (30.3%) 82 381 (28.3%) 0.0236
Hypertension 351 (13.3%) 12 564 (4.3%) <0.0001
Gestational 132 (5.0%) 6 349 (2.2%) <0.0001
hypertension
Pre-eclampsia 219 (8.3%) 6 215 (2.1%) <0.0001
GW at delivery 35.6 2.8 38.4 1.9 <0.0001
<37 1591 (60.1%) 32 134 (11.0%) <0.0001
<34 656 (24.8%) 9 077 (3.1%) <0.0001
Cesarean delivery 1900 (71.7%) 80 765 (27.7%) <0.0001
Birthweight 2295 610 2 914 497 <0.0001
2499 1633 (61.6%) 46 106 (15.8%) <0.0001
25003499 948 (35.8%) 217 746 (74.8%) <0.0001
3500 62 (2.3%) 27 250 (9.4%) <0.0001
Unknown 6 (0.2%) 148 (0.05%) <0.0001
Stillbirth 328 (12.4%) 1 062 (0.4%) <0.0001
END 28 (1.1%) 620 (0.2%) <0.0001
END, early neonatal death within 7 days of life; GW, gestational week.

370 2013 The Authors

Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
 Prospective risk of abruptio placentae

Table 2 Number of women who gave birth at a given gestational week during the 5-year period between 2005 and 2009
Gestational week 30 31 32 33 34 35 36 37 38 39 40 41 42 Overall
Abruptio 117 113 196 230 281 320 334 329 292 234 159 43 1 2 649
placentae
Hypertension 22 25 33 50 39 41 55 40 24 11 11 0 0 351
Hypertension 341 390 488 590 779 985 1 335 2 004 2 032 1 905 1 509 538 19 12 915
Overall 1684 1904 2679 3466 5109 6863 12 020 38 511 61 100 69 778 63 565 26 234 986 293 899
Number of women diagnosed as having gestational hypertension or pre-eclampsia among women with abruptio placentae at delivery.
Number of women diagnosed as having gestational hypertension or pre-eclampsia among all women at delivery.

Figure 1 Prevalence of abruptio placentae according to

gestational week at delivery during the 5-year period
between 2005 and 2009. , 2005; , 2006; , 2007;
, 2008; , 2009; , Overall.

Figure 2 Cumulative births due to abruptio placentae

according to gestational week. , Overall; , primi-
para; , multipara.

Prevalence of AP in relation to gestational week

at delivery
The prevalence of AP varied according to the GW at
delivery but did not differ markedly according to year
(Fig. 1). Overall, AP accounted for 6.7% of all 9733
preterm births that occurred at GW 3033 (Table 2). The
prevalence of AP then decreased sharply with advanc-
ing GW to 0.1% among women who gave birth at and
after GW 42. Consequently, among women with AP,
cumulative births due to AP exceeded 60% before GW
37 (Fig. 2). These changes in the prevalence of AP did
not differ markedly between primiparous and multipa-
rous women. AP accounted for 4.7% (1591/33 725) of
all preterm births at GW <37, while prevalence of AP
was 0.41% (1058/260 174) among term births. Thus, the
prevalence of AP at preterm was 11.6-fold (95% confi-
dence interval, 10.712.5, P < 0.0001) higher than that
at term.
Prospective risk of developing AP according to
gestational week among women prior to delivery
The prospective risk of AP was 9 per 1000 women who
reached GW 30, implying that 1 per 111 women with
GW 30 would experience AP at unknown GW, but at or
after GW 30 (Fig. 3). This risk decreased linearly with
advancing GW to 1 per 1000 women with GW 42.
Thus, prospective risk of AP was dependent on GW
and differed markedly among women with varied GW
but not among primiparous and multiparous women.

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Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
M. Morikawa et al.
Figure 3 Prospective risk of developing abruptio placen-
tae among women who reached a given gestational
week. , Overall; , primipara; , multipara.
Effects of hypertensive disorders on the
prevalence and prospective risk of AP
A total of 351 (2.7%) of 12 915 women with hyperten-
sive disorders developed AP, while 2298 (0.8%) of
280 984 women without hypertensive disorders devel-
oped AP (Table 1). The presence of hypertensive disor-
ders did not seem to markedly affect the prevalence of
AP according to GW at delivery (Fig. 4a). However, the
prospective risk of developing AP differed markedly
between women who later did and did not develop
hypertensive disorders (Fig. 4b), although it was not
clear when hypertension actually developed in women
with hypertensive disorders.
Discussion
The results of the present study emphasized that the
prevalence of AP differed markedly according to GW at
delivery and decreased with advancing GW. Further-
more, we provided data on the prospective risk of AP
among women who reached certain GW. This novel
viewpoint regarding AP may be helpful to gain a better
understanding of the epidemiology of AP.
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Journal of Obstetrics and Gynaecology Research 2013 Japan Society of Obstetrics and Gynecology
The prevalence rates of AP were 6.8% (426/6267),
6.3% (937/14 842), and 4.7% (1591/33 725) for women
with GW at delivery <33, <35, and <37, respectively, in
this study. These prevalence rates may appear some-
what high. However, AP has been reported to account
for 7.7% of all of 5737 births at GW 2831 in Finland,14
5.8% of all of 31 238 births at GW <35 in Missouri,
USA,15 and 5.1% of all of 5934 births at GW <37
in Israel,16 consistent with the results of the present
study. The prevalence of term AP in this study, 0.41%
(1058/260 174), was somewhat higher than the values
of 0.3% among 72 995 term deliveries in Israel17 and
0.21% among 1 079 399 term deliveries in Finland.16
However, these results clearly demonstrated that the
prevalence of AP decreased with advancing gestation.
The prevalence of AP may be dependent on GW at birth
and decreases from approximately 1 in 15 women with
GW 30 at delivery to one in approximately 1000 women
with GW 42 at delivery, irrespective of ethnicity.
As the prevalence of AP among women who gave
birth at a certain GW is based on the retrospective
viewpoint, this may not be helpful for women prior to
delivery. The prospective risk of AP presented here
may provide an adequate answer regarding the risk of
developing AP. For example, the present study sug-
gested that women who reached GW 30, 34, 37, and 40
would have absolute risks of developing AP of 0.90%,
0.70%, 0.41%, and 0.22%, respectively. These figures
may be helpful for physicians in counseling women
about their risk of AP.
Figure 4 shows the prospective risk of AP among
women who later developed hypertensive disorders.
However, as length of pregnancy after onset of hyper-
tension until delivery is approximately 2 weeks,18 it
does not imply that all of the women who developed
AP at certain GW had hypertension during the several
weeks prior to the onset of AP. For example, most
women who developed AP at GW 36 were reasonably
speculated not to be hypertensive at GW 30. Thus, pro-
spective risks of AP shown in Figure 4 were diluted by
the considerable number of women who were actually
not hypertensive. Thus, it should be noted that women
who actually had hypertension at a given GW had a
higher prospective risk of AP than the risk shown in
Figure 4.
The speed of response may influence the outcome of
infants born to women with complications, such as AP;
AP has accounted for 6.3% of 126 emergent (crash)
cesarean deliveries in a hospital in the USA, and such
patients with emergent (crash) cesarean deliveries
indeed showed increased risks of low 5-min Apgar
2013 The Authors
 Prospective risk of abruptio placentae

(a) (b)

Figure 4 Effects of hypertensive disorders on (a) the prevalence and (b) the prospective risk of abruptio placentae (AP).
Figure 4b shows prospective risk of developing AP among women who had hypertensive disorders at the onset of AP.
Most women who developed AP at gestational week (GW) N were speculated not to be hypertensive several weeks prior
to GW N. Thus, as prospective risks of AP shown here were diluted by the considerable number of women who were
actually not hypertensive, it should be noted that women who actually had hypertension at a given GW had a higher
prospective risk of AP than the risk shown in this figure. , Hypertension (+); , hypertension (-).

score and infant intubation,12 likely attesting to the
need for expedited delivery. As AP occurs in women in
the absence of hypertension, as shown in this study as
well as previous studies,1517 there may be a large
number of preterm women who develop AP outside
obstetric facilities. A better understanding of the likeli-
hood of AP according to GW may facilitate prompt
admission of preterm patients with AP to hospital.
Disclosure
All authors declare that they have no financial relation-
ships with biotechnology manufacturers, pharmaceu-
tical companies, or other commercial entities with an
interest in the subject matter or materials discussed in
this manuscript.
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2013 The Authors