Accepted Manuscript

Severe Placental Abruption: Clinical Definition and Associations with Maternal

Complications

Cande V. Ananth, PhD, MPH, Jessica A. Lavery, MS, Anthony M. Vintzileos, MD,
Daniel W. Skupski, MD, Michael Varner, MD, George Saade, MD, Joseph Biggio, MD,
Michelle A. Williams, ScD, Ronald J. Wapner, MD, Jason D. Wright, MD
PII: S0002-9378(15)01120-5
DOI: 10.1016/j.ajog.2015.09.069
Reference: YMOB 10657

To appear in: American Journal of Obstetrics and Gynecology

Received Date: 31 August 2015

Accepted Date: 14 September 2015

Please cite this article as: Ananth CV, Lavery JA, Vintzileos AM, Skupski DW, Varner M, Saade G,
Biggio J, Williams MA, Wapner RJ, Wright JD, Severe Placental Abruption: Clinical Definition and
Associations with Maternal Complications, American Journal of Obstetrics and Gynecology (2015), doi:
10.1016/j.ajog.2015.09.069.

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 ACCEPTED MANUSCRIPT

Severe Placental Abruption:

Clinical Definition and Associations with Maternal Complications

Cande V. ANANTH, PhD, MPH,1,2,3 Jessica A. LAVERY, MS,1,2

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Anthony M. VINTZILEOS, MD,4 Daniel W. SKUPSKI, MD,5
Michael VARNER, MD,6 George SAADE, MD,7

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Joseph BIGGIO, MD,8 Michelle A. WILLIAMS, ScD,9
Ronald J. WAPNER, MD,1 Jason D. WRIGHT, MD1

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Author affiliations
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1. Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia
University, New York, NY
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2. Biostatistics Coordinating Center, Department of Obstetrics and Gynecology, College of

Physicians and Surgeons, Columbia University, New York, NY
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3. Department of Epidemiology, Mailman School of Public Health, Columbia University, New

York, NY
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4. Department of Obstetrics and Gynecology, Winthrop-University Hospital, Mineola, NY

5. Department of Obstetrics and Gynecology, Weill Medical College of Cornell University,
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New York, NY
6. Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
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7. Department of Obstetrics and Gynecology, University of Texas, Galveston, TX

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8. Department of Obstetrics and Gynecology, University of Alabama, Birmingham, AL

9. Department of Epidemiology, T.H. Chan School of Public Health, Harvard University,
Boston, MA

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Correspondence
Cande V. Ananth
Department of Obstetrics and Gynecology
College of Physicians and Surgeons
Columbia University

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622 West 168th Street, New York NY 10032
Email: cande.ananth@columbia.edu

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Word count Abstract 499; Text 2,819; Tables 3; Figures 1; Online tables 1
Running head Mild versus severe placental abruption

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Funding None
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Conflicts None declared
Print version Please use figure 1
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Condensation

Severe placental abruption is clinically more homogeneous and is associated with substantially

increased risks of serious maternal complications compared to mild abruptions.

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Abstract

Background: Placental abruption is traditionally defined as the premature separation of the

implanted placenta prior to the delivery of the fetus. The existing clinical criteria of severity rely

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exclusively on fetal (fetal distress or fetal death) and maternal complications without

consideration of neonatal or preterm delivery-related complications. However, two-thirds of

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abruption cases are accompanied by fetal or neonatal complications, including preterm

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delivery. A clinically meaningful classification for abruption should therefore include not only

maternal complications, but also adverse fetal and neonatal outcomes including intrauterine

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growth restriction and preterm delivery.
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Objectives: To define severe placental abruption and to compare serious maternal morbidity
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profiles of such cases to all other cases of abruption (i.e., mild abruption) as well as non-
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abruptions.
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Study design: We performed a retrospective cohort analysis using the Premier database of
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hospitalizations resulting in singleton births in the US between 2006 and 2012 (n=27,796,465).

Severe abruption was defined as abruption accompanied by at least one of the following:
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maternal (DIC, hypovolemic shock, blood transfusion, hysterectomy, renal failure or in-hospital
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death), fetal (non-reassuring fetal status, intrauterine growth restriction or fetal death) or

neonatal (preterm delivery or small for gestational age) complications. Abruption cases that did

not qualify as being severe were classified as mild abruptions. Morbidity profile included

amniotic fluid embolism, pulmonary edema, acute respiratory or heart failure, acute myocardial

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infarction, cardiomyopathy, puerperal cerebrovascular disorders or coma. Associations were

expressed as rate ratio (RR) with 95% confidence interval (CI) derived from fitting log-linear

Poisson regression models.

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Results: The overall prevalence rate of abruption was 9.6 per 1000, of which two-thirds were

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classified as being severe (6.5 per 1000). Serious maternal complications occurred in 15.4, 33.3

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and 141.7 per 10,000 among non-abruption, and mild and severe abruption, respectively. In

comparison to no abruptions, the RR for serious maternal complications were 1.51 (95% CI

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1.34, 1.71) and 3.93 (95% CI 3.77, 4.10) in women with mild and severe placental abruption,
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respectively. RRs for the individual complications were 2 to 7-fold higher among severe

abruptions. Furthermore, the RR’s for serious maternal complications among severe abruption
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compared to mild abruption was 3.47 (95% CI 3.05, 3.95). This association was considerably
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stronger for virtually all maternal complications among severe abruption compared to mild
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abruption.
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Annual rates of mild and severe abruption were fairly constant during the study period (figure).

While the maternal complication rate among non-abruption births was stable between 2006
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and 2012, the rate of complications among mild abruption dropped between 2006 and 2008
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and then leveled off thereafter. In contrast, the rate of serious complications among severe

abruption remained fairly stable between 2006 and 2010, and increased sharply thereafter.

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Conclusions: Severe abruption was associated with a distinctively higher morbidity risk profile

as compared to the other two groups. The clinical characteristics and morbidity profile of mild

abruption was more similar to those of women without an abruption. These findings suggest

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that the definition of severe placental abruption based on the proposed specific criteria is

clinically relevant and may facilitate epidemiological and genetic research.

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Key words

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Placental abruption; maternal complications; ischemic placental disease; IUGR; preterm
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delivery; fetal death; DIC; blood transfusion
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Introduction

Placental abruption is traditionally defined as the premature separation of the implanted

placenta prior to the delivery of the fetus. The existing clinical criteria of severity rely

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exclusively on fetal (fetal distress or fetal death) and maternal complications without

consideration of neonatal or preterm delivery-related complications.1 However, two-thirds of

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abruption cases are accompanied by fetal or neonatal complications, including preterm

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delivery. A clinically meaningful classification for abruption should therefore include not only

maternal complications, but also adverse fetal and neonatal outcomes including intrauterine

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growth restriction and preterm delivery.
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We hypothesized that the criteria to define placental abruption as “severe” should be clinically
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meaningful and should include at least one of maternal (disseminated intravascular

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coagulation, hypovolemic shock, blood transfusion, hysterectomy, renal failure or in-hospital

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death), fetal (non-reassuring fetal status, intrauterine growth restriction or fetal death) or

neonatal (preterm delivery or fetal growth restriction [FGR]) complications. The intrinsic
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motivation for this hypothesis was that abruption cases with one or more of the above criteria

will identify a distinct subset of women with very high risks of serious maternal complications,
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in comparison to women with mild abruption or no abruption. We test this hypothesis in a large
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cohort of almost 28 million singleton pregnancies in the United States.

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Methods

Premier data

We performed a retrospective cohort analysis of data from the Premier database

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(www.premierinc.com) to obtain all maternal hospital records for deliveries that occurred from

2006 to 2012. The data includes hospitalizations from in-patient, ambulatory and emergency

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admissions in about 500 hospitals each year in the US. These hospitals are chosen to provide

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representation of hospitalizations across the US. The Premier data can be purchased from

Premier, Inc. All diagnosis and procedure codes in the Premier data were coded based on the

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International Classification of Disease, 9th version (ICD-9), and the codes used for conditions in
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this study are listed in the supplemental table 1. We sought and obtained approval from the

Institutional Review Board as an exempt protocol from Columbia University Medical Center, NY.
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Placental abruption
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A diagnosis of placental abruption was based on clinical symptoms that include vaginal bleeding

accompanied with severe abdominal pain, uterine tenderness, or tetanic contractions. Severe
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placental abruption was defined as a delivery with an abruption accompanied by one or more

of the following maternal, fetal or neonatal complications. Maternal complications included

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disseminated intravascular coagulation, hypovolemic shock, blood transfusion, hysterectomy,

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and renal failure and in-hospital death. Fetal complications included non-reassuring fetal status,

fetal growth restriction or fetal death, and neonatal complications included neonatal death,

preterm delivery and small for gestational age (SGA) births. Although the risk of some of the

severe maternal morbidity, such as pulmonary edema or cardiomyopathy, are expected to be

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higher among pregnancies complicated by abruption, these conditions are not the typical

complications following abruption; therefore we do not consider these variables in the

definition of severe abruption.2-4 Abruption cases that did not qualify as being severe were

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classified as mild abruptions.

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Maternal morbidity profile

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The primary endpoint was a composite morbidity outcome comprised of serious maternal

complications including pulmonary edema, acute respiratory failure, acute heart failure, acute

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myocardial infarction, cardiomyopathy, puerperal cerebrovascular disorder, and coma and
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amniotic fluid embolism. In addition, we also examined the associations between abruption and

each of these serious maternal complications.

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Clinical characteristics
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We examined the rates of mild and severe abruption across patient characteristics. Maternal

sociodemographic and behavioral characteristics included year of delivery (2006-2012),

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maternal age, single marital status, and insurance status, as well as tobacco, drug or alcohol

use. Maternal comorbidities included hypertensive diseases (chronic hypertension, gestational

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hypertension, or preeclampsia/eclampsia), pregestational diabetes, gestational diabetes,

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chronic renal disease, asthma, and congenital cardiac disease. Intrapartum and labor

characteristics included premature rupture of membranes (at preterm or term gestations),

anemia, intrapartum fever, polyhydramnios, oligohydramnios, and chorioamnionitis. SGA was

used as a proxy for intrauterine growth restriction.

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Statistical analysis

Two sets of log-linear regression models (with a Poisson distribution and a log-link function)

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were fit: the first was to evaluate the maternal characteristics associated with mild and severe

placental abruption; and second, to estimate the association of serious maternal complications

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(morbidity profile) associated with mild and severe abruptions compared to non-abruption

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births, as well as a comparison of serious maternal complications between severe versus mild

(reference) abruptions. For evaluating risk factors for mild and severe abruptions, we first

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estimated the unadjusted rate ratio (RR) and 95% confidence interval (CI). From this analysis,
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we chose risk factors that had RRs either above 1.2 or below 0.8 for mild and severe abruption;

risk factors that met this criterion were entered in the final multivariable log linear Poisson
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regression models from which we evaluated the associations.

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Rate ratios (RR) and 95% confidence intervals (CI) were calculated for the composite serious

maternal morbidity profile, as well as for each severe maternal outcome individually. In this
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analysis, we adjusted for all maternal characteristics as potential confounding factors. All

analyses were weighted based on the weights provided in Premier in order to generate national
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estimates.
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Cohort composition

From 28,504,661 (weighted) singleton deliveries identified in the Perspectives database, twins

and higher-order multiple births (n=530,091; unweighted 79,594) and women younger than 15

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or older than 59 years were excluded (n=30,940; unweighted 5,187). We additionally excluded

women diagnosed with placenta previa (n=141,135; unweighted 22,241). After all exclusions,

the analysis cohort was composed of 27,796,465 (3,961,031 unweighted) women.

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Results

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In this cohort of 27,796,465 singleton births, the prevalence rates of mild and severe abruption

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were 3.1 and 6.5 per 1000, respectively (overall prevalence rate of 9.6 per 1000). The

distribution of clinical characteristics among the three groups of non-abruption, mild abruption

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and severe abruption is shown in table 1. Maternal age 40 years or older, black race, cigarette
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smoking status and use of drugs or alcohol were associated with increased rates of abruption,

with a stark contrast in rates observed for mild versus severe abruption cases. Compared to
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non-abruption births, the prevalence rates of hypertensive disorders were increased among
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women with mild abruption but were substantially higher among women with severe
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abruption. Similarly, rates of premature rupture of membranes, polyhydramnios and

oligohydramnios were also relatively higher among severe abruption.

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The associations between the clinical characteristics and mild and severe placental abruption
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are shown in Table 2. Several differences were found between mild versus severe abruption.
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For instance, compared to women 25-29 years (reference), maternal age up to 45 years showed

stronger associations with mild abruption, whereas the risk among women ≥45 years higher

among severe abruption. Rate ratios were higher for severe than mild abruption for black race,

single marital status, tobacco use. The risk of severe abruption was substantially higher than

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mild abruption in relation to chronic hypertension (RRs 1.64 versus 1.35), mild preeclampsia

(2.06 versus 1.69) and severe preeclampsia (4.21 versus 2.00). In contrast, the RRs of mild

abruption were higher compared to severe abruption among gestational hypertensive women

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(1.47 versus 1.21). The RRs for severe abruption were higher than mild abruption in relation to

premature rupture of membranes, anemia, polyhydramnios, oligohydramnios, and

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chorioamnionitis.

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The morbidity profile and the rates of individual maternal complications in mild and severe

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abruption, as well as the adjusted RR for these complications are shown in Table 3. Serious
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maternal complications occurred in 15.4 per 10,000 among non-abruption births, and in 33.3

and 141.7 per 10,000 in women with mild and severe abruption. After adjusting for
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confounders, compared to women without abruption, the RR for maternal complications was
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2.14 (95% CI 1.89, 2.41) in women with mild abruption and 4.29 (95% CI 4.11, 4.47) in women
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with severe abruption. RRs for many of the individual complications were moderately increased

in women with mild abruption, but were 2 to 7-fold higher among severe abruptions. In fact,
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the RR of the composite serious maternal complications in relation to severe abruption was

3.47 (95% CI 3.05, 3.95) (Table 3). Similarly, the RRs for pulmonary edema (RR 2.40, 95% CI 1.82,
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3.17), acute heart failure (RR 4.20, 95% CI 3.08, 5.74), and acute respiratory failure (RR 5.47,
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95% CI 4.48, 6.68) were all considerably higher in women with severe abruptions.

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The rate ratio for serious maternal complications among severe abruption compared to mild

abruption was 3.47 (95% CI 3.05, 3.95). The associations were considerably stronger for

virtually all maternal complications among severe abruption than among mild abruption.

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Rates of mild and severe abruption between 2006 and 2012 and the corresponding rates of

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serious maternal complications in relations to abruption are shown in Figure 1. Rates of mild

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and severe abruption were fairly constant during the study period. While the maternal

complication rate among non-abruption births was stable between 2006 and 2012, the rate of

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complications among mild abruption dropped between 2006 and 2008 and then leveled off
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thereafter. In contrast, the rate of serious complications among severe abruption remained

fairly stable between 2006 and 2010, and increased sharply thereafter.
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Comment
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Placental abruption is a serious and often a life threatening condition to the fetus and, to a

lesser extent, to the woman.5-13 We show that the clinical characteristics for abruption differ
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substantially between mild and severe forms of the condition and with varying strengths of

associations. The choices of maternal conditions that constitute a diagnosis of severe abruption
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were not different than those previously reported in the obstetrical literature. The maternal
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morbidity profile that we chose includes extreme maternal conditions that are not typically

seen with abruption and are not typically included in the definition of abruption. Under

maternal morbidity profile we included cardiomyopathy, myocardial infarction and respiratory

failure, which are conditions, associated with severe, prolonged hypoxia. Amniotic fluid

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embolism was also included in the maternal morbidity profile since it is not typical for the

diagnosis but its association with abruption has been well documented.2-4, 14 These conditions

are extremely serious but not typical of abruption and this was the reason that we included

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them in the maternal morbidity profile rather than in the definition of severe abruption.

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The morbidity profile and rates of serious maternal complications are profoundly different

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between mild and severe abruptions, with the rates being substantially higher among severe

(141.7 per 10,000) than mild (33.3 per 10,000) abruptions. Importantly, severe abruptions

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comprise two-thirds of all abruptions mainly because preterm delivery and SGA were included
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in the definition of severe abruption even in the absence of severe maternal symptomatology.

Taken together, these findings suggest that severe abruptions are the distinct group of really
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sick patients and that combining mild and severe forms of the disease may introduce
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substantial heterogeneity in clinical research.

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In this study the diagnosis of placental abruption was based on clinical criteria rather than
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placental pathology reports (which were unavailable). However, in our view, pathology reports

may not be necessary for three reasons: (i) epidemiologic database very rarely, if ever, have
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data regarding pathology reports; (ii) there are very few experts in placental pathology, so any
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definition using reliable placental pathology information may affect generalizability; and (iii) the

prevalence rate of abruption of 9.6 per 1000 in this study is within the range reported in other

population-based studies.5, 15-17 This suggests that we have not missed a significant number of

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cases due to lack of placental pathology data. However, the data allowed for distinguishing

preterm from term births despite the lack of data on the individual gestational age.

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Limitations of the data

Despite the interesting observations, the findings must be interpreted with some caution.

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Primarily, the Premier data includes data on large number of deliveries, but data on few

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socioeconomic and behavioral characteristics (such as maternal education, prepregnancy body-

mass index, and weight gain during pregnancy) are lacking, so the possibility of the associations

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being affected by unmeasured confounders remain. There is also some possibility of
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misclassification of abruption cases. However, we believe that such misclassification, if present,

is likely more common for the milder forms of the condition. Women with severe abruption are
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the really sick patients with more than one serious complication and it is very unlikely that
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abruption status will be misclassified in this group.

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Strengths of the study

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The strengths of the study include the large study size with data from hospitalizations

associated with over 27 million singleton deliveries from 441 hospitals over a seven-year period
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(2006-2012) in the US. All analyses were weighted by the sampling weights of deliveries
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permitting generalizability of the findings. The associations we report are adjusted for a variety

of confounding factors.

Interpretation of findings

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Over four decades ago, Pritchard and colleagues18 proposed that severe abruptions are those

that are accompanied by one or more of short umbilical cord, external trauma, sudden uterine

decomposition, uterine anomaly or tumor, occlusion of the inferior vena cava, maternal folate

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deficiency, maternal vascular disease, high parity, and previous abruption. A second

classification was based on a system that assigns a score ranging from 0 to 3, with 0 indicating

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asymptomatic women with evidence of small retroplacental clots on the placental surface on

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pathologic examination after delivery, 1 denoting those with bleeding and uterine tenderness

or tetanic contractions, 2 denoting bleeding with fetal distress (but no signs of maternal shock)

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and 3 denoting bleeding with uterine tetany, persistent abdominal pain, and maternal shock
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and fetal demise.19
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The classification for severe placental abruption that we propose is broad and encompasses
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more objective criteria of clinically meaningful abruption. In fact, the conditions used to define
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severe abruption are based on serious co-occurring maternal, fetal and neonatal clinical

complications. The grading system to classify abruption severity19 is restrictive since even the
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grade 0 abruption that results in preterm delivery will be deemed as being “severe” based on

this classification system. Based on this definition, two-thirds of all clinically diagnosed
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abruption cases were classified as being severe. Furthermore, fetal growth restriction and
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abruption are both largely a chronic process that share strong similarities and are driven by

uteroplacental ischemia,20, 21 and this provides further support that both preterm delivery and

fetal growth restriction should be considered in the definition of severe abruptions. This

classification not only identifies women with severe abruption with substantially higher risk of

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serious morbidity, but also acknowledges that women with severe abruption are distinctly

different than those with milder forms of the complication.

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Virtually all studies on placental abruption have focused exclusively on assessing risks in the

perinatal period and during infancy,22-26 and evaluation of maternal risks associated with this

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condition are sparse. Furthermore, we are unaware of any study that has attempted to

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separate mild from severe forms of abruption. In fact, the inclusion of neonatal complications

(preterm delivery and SGA) in the definition of severe abruption results in two-thirds of all

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abruptions being classified as being severe.
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Risk factors for severe abruption appear largely driven by inflammation and, to a lesser extent,
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infection-related pathways.27 That tobacco and drug use are stronger risk factors for severe
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than mild abruptions suggest that chronic hypoxia leading to uteroplacental underperfusion as
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a result of tobacco smoke11, 28-30 appears to shape the risk of severe abruption. Other

pathological chronic conditions including chronic hypertension,12, 31-33 preeclampsia,34, 35

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premature rupture of membranes,36 anemia,37 oligohydramnios38 and infection-related

conditions such as chorioamnionitis38, 39 are stronger risk factors for severe than mild
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abruptions. Interestingly, asthma and intrapartum fever showed stronger associations with mild
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than with severe abruptions.

The long-term risk of mortality and morbidity from premature cardiovascular disease are about

2 to 6-fold higher among women with abruption compared to otherwise normal pregnancies.40-

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In addition, this study suggests that the risks of serious maternal cardiovascular complications

also remain substantially higher among women with severe than mild abruptions. Acute

complications such as myocardial infarction and respiratory failure are about 7-fold higher

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among women with severe abruption. These findings provide support to available data showing

that ischemic conditions during pregnancy such as preeclampsia,44, 45 fetal growth restriction,46,

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preterm delivery48, 49 and placental abruption40, 41, 43 may be linked to future cardiovascular

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disease in women later in life. One of the intriguing and unexpected finding is the temporal

increase in the rate of serious maternal complications among women with severe abruption

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since 2010 (Figure 1), but this increase remains clinically insignificant.
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Conclusions
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This large population-based study suggests that the frequency of maternal clinical risk factors is
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different between mild versus severe abruptions. Furthermore, the associated serious
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morbidity profile of women diagnosed with severe abruption is considerably worse than in

those with mild abruption. These findings underscore a substantial heterogeneity in both risk
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factor profile and serious adverse maternal complications. Importantly, the definition of severe

that we propose is based on objective data that includes maternal, fetal and neonatal
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complications. Although this proposed definition is not one that can be used prospectively
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because it includes outcome data in the definition of severe abruption, these observations

underscore that future studies on placental abruption should attempt to separate mild from

severe forms, when feasible. This recommendation will be particularly helpful for studies that

seek to understand the genetic imprints and gene-environment interactions on abruption risk.

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Research to unravel the etiology may also benefit from separating mild from severe placental

abruption.

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Table 1
Distribution of clinical characteristics based on mild and severe placental abruption

Non Mild Severe

Abruption Abruption Abruption
% % %

PT
Number (abruption rate per 1000) 27,528,415 86,917 (3.1) 181,133 (6.5)

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Maternal age (years)

SC
<20 9.0 7.1 10.6
20-24 23.5 22.5 24.3

U
25-29 28.6 28.1 26.3
30-34 24.3 25.0 22.4
AN
35-39 12.9 14.8 14.0
40-44 1.5 2.3 2.0
M

≥45 0.1 0.2 0.3

Mean (standard deviation) 27.7 (6.0) 28.3 (6.1) 27.7 (6.4)
D

Maternal race
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White 51.3 53.0 47.1

Black 12.6 13.0 19.7
EP

Hispanic 9.9 8.6 8.3

Other 26.2 25.4 24.8
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Marital status
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Married 49.7 48.7 41.3

Single 37.6 39.3 46.6
Unknown 12.7 12.1 12.1

Tobacco use 4.7 7.6 10.2

Alcohol use 0.1 0.3 0.4

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Non Mild Severe

Abruption Abruption Abruption
% % %
Drug use 0.2 0.7 1.0

PT
Insurance
Commercial 52.1 48.7 43.7

RI
Medicare 0.6 0.7 0.8
Medicaid 41.2 43.6 47.8

SC
Uninsured 2.5 3.1 3.4
Unknown 3.6 3.9 4.2

Hypertension status
U
AN
Normotensive 91.4 86.7 82.2
Chronic hypertension 1.8 2.5 3.2
M

Gestational hypertension 3.2 4.5 3.5

Mild preeclampsia 1.8 2.9 3.5
D

Severe preeclampsia 1.8 3.4 7.6

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Pregestational diabetes 0.8 0.7 1.2

Gestational diabetes 5.5 5.3 5.1
EP

Chronic renal disease 0.2 0.2 0.5

Asthma 2.9 3.5 3.9
C

Anemia 9.8 15.1 23.9

AC

Congenital cardiac disease 0.1 0.0 0.1

Premature rupture of membranes 3.5 4.5 8.8

Intrapartum fever 0.1 0.1 0.1
Chorioamnionitis 1.4 2.2 4.1
Polyhydramnios 0.8 1.0 1.2

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Non Mild Severe

Abruption Abruption Abruption
% % %
Oligohydramnios 2.6 2.5 3.9

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RI
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Table 2
Association between clinical characteristics and risks of mild and severe placental abruption

Adjusted Risk Ratio (95% Confidence Interval)

Risk Factors
Mild abruption Severe abruption

PT
Maternal age (years)
<20 0.70 (0.68, 0.72) 0.97 (0.95, 0.99)

RI
20-24 0.89 (0.87, 0.91) 0.95 (0.94, 0.97)
25-29 1.00 (Reference) 1.00 (Reference)

SC
30-34 1.10 (1.08, 1.13) 1.11 (1.09, 1.12)
35-39 1.23 (1.21, 1.26) 1.28 (1.26, 1.30)

U
40-44 1.58 (1.51, 1.65) 1.47 (1.42, 1.52)
AN
≥45 0.70 (0.68, 0.72) 0.97 (0.95, 0.99)

Maternal race
M

White 1.00 (Reference) 1.00 (Reference)

Black 0.92 (0.90, 0.94) 1.31 (1.29, 1.33)
D

Hispanic 0.83 (0.81, 0.86) 0.89 (0.88, 0.91)

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Other 0.94 (0.92, 0.96) 1.01 (1.00, 1.02)

Single marital status 1.06 (1.04, 1.08) 1.20 (1.19, 1.22)

EP

Tobacco use 1.49 (1.45, 1.53) 1.90 (1.87, 1.93)

Alcohol use 1.86 (1.63, 2.13) 1.78 (1.65, 1.92)
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Drug use 2.08 (1.91, 2.26) 2.32 (2.21, 2.44)

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Insurance
Commercial 1.00 (Reference) 1.00 (Reference)
Medicare 1.14 (1.05, 1.24) 1.10 (1.04, 1.16)
Medicaid 1.21 (1.19, 1.23) 1.19 (1.18, 1.21)
Uninsured 1.43 (1.37, 1.49) 1.56 (1.52, 1.60)

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Hypertension status
Normotensive
Chronic hypertension
Gestational hypertension
1.00 (Reference) 1.00 (Reference)
1.35 (1.29, 1.41) 1.64 (1.60, 1.69)
1.47 (1.42, 1.52) 1.21 (1.18, 1.24)
1.69 (1.63, 1.77) 2.06 (2.01, 2.12)

PT
Mild preeclampsia
Severe preeclampsia 2.00 (1.92, 2.08) 4.21 (4.13, 4.29)

RI
Chronic renal disease 0.73 (0.62, 0.86) 1.35 (1.26, 1.45)
Anemia 1.59 (1.56, 1.63) 2.45 (2.42, 2.47)

SC
Premature rupture of 1.27 (1.23, 1.32) 2.52 (2.48, 2.56)
membranes
Intrapartum fever 2.13 (1.76, 2.57) 1.34 (1.16, 1.55)
Polyhydramnios
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1.15 (1.07, 1.23) 1.39 (1.33, 1.45)
AN
Oligohydramnios 0.96 (0.91, 1.00) 1.45 (1.42, 1.49)
Chorioamnionitis 1.50 (1.43, 1.58) 2.42 (2.36, 2.48)
M

Rate ratios for mild and severe abruption are each compared to the non-abruption group
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Associations were adjusted for all factors listed in the table 1 through log-linear Poisson
regression model
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Table 3
Rate and rate ratio (95% confidence interval) of serious maternal complications
in relation to mild and severe placental abruption

PT
Non-abruption Mild placental abruption Severe placental Severe versus mild

RI
(n=27,528,415) (n=86,917) abruption (n=181,133) abruption
Adjusted Rate Adjusted Rate Adjusted Rate
Rate Rate Rate

SC
Ratio (95% CI) Ratio (95% CI) Ratio (95% CI)

Composite maternal outcome 15.4 33.3 1.52 (1.35, 1.72) 141.7 4.29 (4.11, 4.47) 3.47 (3.05, 3.95)

U
Pulmonary edema 2.8 7.2 1.60 (1.24, 2.08) 23.4 2.97 (2.68, 3.29) 2.40 (1.82, 3.17)

AN
Puerperal cerebrovascular 2.46 (1.97, 3.08) 2.72 (2.41, 3.07)
2.9 9.8 16.5 1.20 (0.92, 1.55)
disorders
Acute heart failure 4.1 5.7 0.93 (0.69, 1.25) 27.5 3.05 (2.78, 3.36) 4.20 (3.08, 5.74)

M
Acute myocardial infarction 0.2 ̶ ̶ 2.7 7.56 (5.51, 10.38) ̶
Cardiomyopathy 3.4 7.4 1.48 (1.13, 1.92) 15.2 2.12 (1.87, 2.41) 1.68 (1.26, 2.26)

D
Acute respiratory failure 5.7 13.0 1.62 (1.33, 1.96) 88.9 7.00 (6.62, 7.39) 5.47 (4.48, 6.68)
10.31 (8.21,

TE
Amniotic fluid embolism 0.4 ̶ ̶ 5.1 ̶
12.94)
Coma 0.1 ̶ ̶ 1.9 7.04 (4.83, 10.25) ̶
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Rates are expressed per 10,000
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Associations were adjusted for factors listed in table 1 through log-linear Poisson regression model
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Figure 1

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Supplemental Table 1
ICD-9 clinical modification codes for variables in this study

Condition ICD-9-CM code

PT
Delivery V27.0-V27.9

RI
Singleton birth Multiple births (V272-V277, 654.x) were excluded

SC
Placental abruption 641.2

Infant outcomes

U
Stillbirth 656.4x, V27.1x
Neonatal death 768.x, 798.x

AN
Preterm delivery 644.2x
Fetal growth restriction 656.5x, 764x

M
Nonreassuring fetal status 656.3x, 659.7x

D
Covariates
Hypertensive disorders

TE
Chronic hypertension 642.00-642.24
Gestational hypertension 642.30-642.34
Mild preeclampsia 642.40-642.49
EP
Severe preeclampsia 642.50-642.54
Superimposed preeclampsia 642.70-642.74
C

Tobacco use 305.1.x, 649.0x

AC

Alcohol use 291.xx, 303.xx, 305.0x

Drug abuse 304.x, 305.2x-305.9x, 648.3x

Chronic renal disease 646.2x, 581.x, 582.x, 583.x, 585.x, 587, 588.x
Asthma 493, 493.0, 493.00, 493.02, 493.1, 493.10, 493.12, 493.2, 493.20, 493.22, 493.81, 493.82,

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493.9, 493.90, 493.92

Preexisting diabetes 250.x, 648.0x
Gestational diabetes 648.8x (without pre-existing diabetes)

PT
Outcomes/procedures
Maternal death 761.6

RI
671.5, 671.50, 671.51, 671.52, 671.53, 671.54, 674.0, 674.00, 674.01, 674.02, 674.03,
Puerperal cerebrovascular 674.04, 430, 431, 432, 432.0, 432.1, 432.9, 436, 997.01, 997.02, 433.01, 433.11, 433.21,

SC
disorders 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, 325, 348.1, 348.3, 348.30, 348.31, 348.39,
348.5, 437.1, 437.2, 437.6, 346.6, 346.60, 346.61, 346.62, 346.63
Pulmonary edema 514, 518.4, 428.1

U
Amniotic fluid embolism 673.1x
DIC 666.3x, 286.6, 286.7, 286.9, 287.4, 287.41, 287.49

AN
Acute renal failure 584, 584.5, 584.6, 584.7, 584.8, 584.9, 669.3, 669.30, 669.32, 669.34
Acute heart failure 415, 415.0, 427.5, 428.0, 428.1, 428.21, 428.31, 428.41, 997.1, 428.23, 428.33, 428.43, 428.9

M
Acute myocardial infarction 410.x
Cardiomyopathy 674.5x, 425x
Acute liver failure 570, 646.7, 646.70, 646.71, 646.73

D
Acute respiratory failure 518.81, 518.82, 518.84, 518.5, 518.51, 518.52, 518.53, 799.1, 518.7

TE
Blood transfusion V58.2, 99.0, 99.01-99.07
Hysterectomy 68.3, 68.31, 68.39, 68.4, 68.41, 68.49, 68.6, 68.69, 68.9
Coma 780.01, 780.03, 572.2, 250.2x, 250.3x, 251.0x
EP
Shock 669.1x, 785.5x, 998.0x, 995.4, 995.0, 995.94, 99.4x
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