Original Research ajog.

org

OBSTETRICS

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

BACKGROUND: Placental abruption traditionally is defined as the
premature separation of the implanted placenta before the delivery of the
fetus. The existing clinical criteria of severity rely exclusively on fetal (fetal
distress or fetal death) and maternal complications without consideration
of neonatal or preterm delivery-related complications. However, two-
thirds of abruption cases are accompanied by fetal or neonatal
complications, including preterm delivery. A clinically meaningful
classification for abruption therefore should include not only maternal
complications but also adverse fetal and neonatal outcomes that include
intrauterine growth restriction and preterm delivery.
OBJECTIVES: The purpose of this study was to define
severe placental abruption and to compare serious maternal
morbidity profiles of such cases with all other cases of
abruption (ie, mild abruption) and non-abruption cases.
STUDY DESIGN: We performed a retrospective cohort analysis using the
Premier database of hospitalizations that resulted in singleton births in
the United States between 2006 and 2012 (n ¼ 27,796,465). Severe
abruption was defined as abruption accompanied by at least 1 of the
following events: maternal (disseminated intravascular coagulation,
hypovolemic shock, blood transfusion, hysterectomy, renal failure, or in-
hospital death), fetal (nonreassuring fetal status, intrauterine growth re-
striction, or fetal death), or neonatal (neonatal death, preterm delivery or
small for gestational age) complications. Abruption cases that did not
qualify as being severe were classified as mild abruption cases. The
morbidity profile included amniotic fluid embolism, pulmonary edema,
acute respiratory or heart failure, acute myocardial infarction, cardiomy-
opathy, puerperal cerebrovascular disorders, or coma. Associations were
expressed as rate ratios with 95% confidence intervals that were derived
from fitting log-linear Poisson regression models.
RESULTS: The overall prevalence rate of abruption was 9.6 per
1000, of which two-thirds of cases were classified as being severe
(6.5 per 1000). Serious maternal complications occurred in 15.4,
33.3, and 141.7 per 10,000 among nonabruption cases and mild and
severe abruption cases, respectively. In comparison with no
abruption, the rate ratio for serious maternal complications were 1.52
(95% confidence interval, 1.35e1.72) and 4.29 (95% confidence
interval, 4.11e4.47) in women with mild and severe placental
abruption, respectively. Rate ratios for the individual complications
were 2- to 7-fold higher among severe abruption cases.
Furthermore, the rate ratios for serious maternal complications
among severe abruption cases compared with mild abruption cases
was 3.47 (95% confidence interval, 3.05e3.95). This association was
considerably stronger for virtually all maternal complications among
cases with severe abruption compared with mild abruption. Annual
rates of mild and severe abruption were fairly constant during the
study period. Although the maternal complication rate among non-
abruption births was stable from 2006-2012, the rate of
complications among mild abruption cases dropped from 2006-2008
and then leveled off thereafter. In contrast, the rate of serious
complications among severe abruption cases remained fairly stable
from 2006-2010 and increased sharply thereafter.
CONCLUSIONS: Severe abruption was associated with a
distinctively higher morbidity risk profile compared with the other 2
groups. The clinical characteristics and morbidity profile of mild
abruption were more similar to those of women without an abruption.
These findings suggest that the definition of severe placental
abruption based on the proposed specific criteria is clinically relevant
and may facilitate epidemiologic and genetic research.
Key words: blood transfusion, disseminated intravascular
coagulation, fetal death, intrauterine growth restriction,
maternal complication, placental abruption, preterm delivery

Placental abruption traditionally is defined

as the premature separation of the implanted
placenta before the
delivery of the fetus. The existing clinical
criteria of severity rely exclusively on
fetal (fetal distress or fetal death)
Cite this article as: Ananth CV, Lavery JA, Vintzileos
AM, et al. Severe placental abruption: clinical definition
and associations with maternal complications. Am J
Obstet Gynecol 2016;214:272.e1-9.
0002-9378/$36.00
ª 2016 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.ajog.2015.09.069
and maternal complications without
consideration of neonatal or preterm
1 coagulation, hypovolemic shock, blood
delivery-related complications. How-
ever, two-thirds of abruption cases are
accompanied by fetal or neonatal com-
plications, which includes preterm
delivery. A clinically meaningful classi-
fication for abruption therefore should
include not only maternal complications
but also adverse fetal and neonatal out-
comes that include intrauterine growth
restriction and preterm delivery.
We hypothesized that the criteria that
were needed to define placental abrup-
tion as “severe” should be clinically
meaningful and should include at least 1
of maternal (disseminated intravascular
transfusion, hysterectomy, renal failure,
or in-hospital death), fetal (non-
reassuring fetal status, intrauterine
growth restriction, or fetal death), or
neonatal (neonatal death, preterm de-
livery, or small for gestational age)
complications. The intrinsic motivation
for this hypothesis was that abruption
cases with 1 of the aforementioned
criteria will identify a distinct subset of
women with very high risks of serious
maternal complications, in comparison

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ajog.org
with women with mild abruption or no
abruption. We tested this hypothesis in
a large cohort of almost 28 million
singleton pregnancies in the United
States.
Methods
Premier data
We performed a retrospective cohort
analysis of data from the Premier data-
base (www.premierinc.com; Premier,
Inc, Charlotte, NC) to obtain all maternal
hospital records for deliveries that
occurred from 2006-2012. The data
include hospitalizations from in-patient,
ambulatory, and emergency admissions
in approximately 500 hospitals each year
in the United States. These hospitals are
chosen to provide a representation of
hospitalizations across the United States.
The Premier data can be purchased from
Premier, Inc. All diagnosis and proce-
dure codes in the Premier data were
coded based on the International Clas-
sification of Disease, 9th version; the
codes used for conditions in this study
are listed in the Supplemental Table. We
sought and obtained approval from the
Institutional Review Board as an exempt
protocol from Columbia University
Medical Center, NY.
Placental abruption
A diagnosis of placental abruption was
based on clinical symptoms that include
vaginal bleeding accompanied with se-vere
abdominal pain, uterine tenderness, or
tetanic contractions. Severe placental
abruption was defined as a delivery with
an abruption accompanied by 1 of the
following maternal, fetal, or neonatal
complications. Maternal complications
included disseminated intravascular
coagulation, hypovolemic shock, blood
transfusion, hysterectomy, renal failure, and
in-hospital death. Fetal complica-tions
included nonreassuring fetal status,
intrauterine growth restriction, or fetal
death. Neonatal complications included
neonatal death, preterm delivery, and small-
for-gestational-age (SGA) births. Although
the risk of some of the severe maternal
morbidities, such as pulmo-nary edema or
cardiomyopathy, are ex-pected to be higher
among pregnancies that are complicated by
abruption, these
OBSTETRICS
conditions are not the typical compli-
cations after abruption; therefore, we do
not consider these variables in the defi-
2-4
nition of severe abruption. Abruption
cases that did not qualify as being severe
were classified as mild abruptions.
Maternal morbidity profile
The primary endpoint was a composite
morbidity outcome comprised of serious
maternal complications that included
pulmonary edema, acute res-piratory
failure, acute heart failure, acute
myocardial infarction, cardiomyopathy,
puerperal cerebrovascular disorder, coma,
and amniotic fluid embolism. In addition,
we also examined the associa-tions
between abruption and each of these
serious maternal complications.
Clinical characteristics
We examined the rates of mild and se-
vere abruption across patient character-
istics. Maternal sociodemographic and
behavioral characteristics included year
of delivery (2006-2012), maternal age,
single marital status, insurance status,
and tobacco, drug, or alcohol use.
Maternal comorbidities included hy-
pertensive diseases (chronic hyperten-
sion, gestational hypertension, or
preeclampsia/eclampsia), chronic renal
disease, asthma, and congenital cardiac
disease. Intrapartum and labor charac-
teristics included premature rupture of
membranes (at preterm or term gesta-
tions), anemia, intrapartum fever, poly-
hydramnios, oligohydramnios, and
chorioamnionitis. SGA was used as a
proxy for intrauterine growth
restriction.
Statistical analysis
Two sets of log-linear regression models
(with a Poisson distribution and a log-link
function) were fit: the first model was to
evaluate the maternal character-istics that
are associated with mild and severe
placental abruption; the second model
was to estimate the association of
serious maternal complications
(morbidity profile) that are associated
with births with mild and severe
abruptions compared with births with
no abruption and to compare serious
maternal complications between severe
FEBRUARY 2016 American Journal of Obstetrics & Gynecology
Original Research
vs mild (reference) abruptions. For
evaluating risk factors for mild and se-
vere abruptions, we first estimated the
unadjusted rate ratio (RR) and 95%
confidence interval (CI). From this
analysis, we chose risk factors that had
RRs either >1.2 or <0.8 for mild and
severe abruption; risk factors that met
this criterion were entered in the final
multivariable log linear Poisson regres-
sion models from which we evaluated
the associations.
RRs and 95% CIs were calculated
for the composite serious maternal
morbidity profile and for each severe
maternal outcome individually. In this
analysis, we adjusted for all maternal
characteristics as potential
confounding factors. All analyses were
weighted based on the weights
provided in Premier to generate
national estimates.
Cohort composition
From 28,504,661 (weighted) singleton
deliveries that were identified in the
Perspectives database, records identified
as male (n ¼ 1308; unweighted, 236),
twins and higher-order multiple births (n
¼ 530,065; unweighted, 79,594) and
women <15 or >59 years old were
sequentially excluded (n ¼ 32,688; un-
weighted, 5187). We additionally
excluded women who received a diag-
nosis of placenta previa (n ¼ 144,135;
unweighted, 21,241). After all exclu-
sions, the analysis cohort was composed
of 27,796,465 (3,961,031 unweighted)
women.
Results
In this cohort of 27,796,465 singleton
births, the prevalence rates of mild and
severe abruption were 3.1 and 6.5 per
1000, respectively (overall prevalence
rate, 9.6 per 1000). The distribution of
clinical characteristics among the 3
groups of nonabruption, mild abrup-tion,
and severe abruption is shown in Table 1.
Maternal age 35 years old, black race,
cigarette smoking status, and the use of
drugs or alcohol were associ-ated with
increased rates of abruption. Compared
with nonabruption births, the prevalence
rates of hypertensive disorders were
increased among women with mild
abruption but were
272.e2
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Original Research OBSTETRICS ajog.org

substantially higher among women

TABLE 1
with severe abruption. Similarly, rates
Distribution of clinical characteristics based on
a of premature rupture of membranes,
mild and severe placental abruption pol-yhydramnios, and oligohydramnios
No abruption, Mild abruption, Severe were also relatively higher among
Variable % % abruption, % severe abruption.
Maternal age, yb The associations between the clinical
<20 9.0 7.1 10.6 characteristics and mild and severe
placental abruption are shown in Table 2.
20-24 23.5 22.5 24.3
Several differences were found between
25-29 28.6 28.1 26.3 mild vs severe abruption. For instance,
30-34 24.3 25.0 22.4 compared with women 25-29 years
35-39 12.9 14.8 14.0 (reference), maternal age 45 years
40-44 1.5 2.3 2.0 showed stronger associations with mild
45 0.1 0.2 0.3 abruption, whereas the risk among
women 45 years old was higher among
Maternal race
women with severe abruption. RRs were
White 51.3 53.0 47.1 higher for severe rather than mild
Black 12.6 13.0 19.7 abruption for black race, single marital
Hispanic 9.9 8.6 8.3 status, and tobacco use. The risk of se-
vere abruption was substantially higher
Other 26.2 25.4 24.8
than mild abruption in relation to chronic
Marital status hypertension (RR, 1.64 vs 1.35), mild
Married 49.7 48.7 41.3 preeclampsia (RR, 2.06 vs 1.69), and
Single 37.6 39.3 46.6 severe preeclampsia (RR, 4.21 vs 2.00).
In contrast, the RRs of mild abruption
Unknown 12.7 12.1 12.1
were higher compared with severe
Tobacco use 4.7 7.6 10.2 abruption among women with gestational
Alcohol use 0.1 0.3 0.4 hypertension (RR, 1.47 vs 1.21). The
Drug use 0.2 0.7 1.0 RRs for severe abruption were higher
Insurance than mild abruption in relation to
premature rupture of membranes, ane-
Commercial 52.1 48.7 43.7
mia, polyhydramnios, oligohydramnios,
Medicare 0.6 0.7 0.8 and chorioamnionitis.
Medicaid 41.2 43.6 47.8 The morbidity profile and the rates of
Uninsured 2.5 3.1 3.4 individual maternal complications in
mild and severe abruption and the
Unknown 3.6 3.9 4.2
adjusted RRs for these complications are
Hypertension status shown in Table 3. Serious maternal
Normotensive 91.4 86.7 82.2 complications occurred in 15.4 per
Chronic hypertension 1.8 2.5 3.2 10,000 for nonabruption and in 33.3 and
141.7 per 10,000 in women for mild and
Gestational hypertension 3.2 4.5 3.5
severe abruption. After adjustment for
Mild preeclampsia 1.8 2.9 3.5 confounders, compared with women
Severe preeclampsia 1.8 3.4 7.6 without abruption, the RRs for maternal
Chronic renal disease 0.2 0.2 0.5 complications were 1.52 (95% CI,
1.35e1.72) in women with mild abrup-
Asthma 2.9 3.5 3.9
tion and 4.29 (95% CI, 4.11e4.47) in
Anemia 9.8 15.1 23.9 women with severe abruption. RRs for
Congenital cardiac disease 0.1 0.0 0.1 many of the individual complications
Premature rupture of membranes 3.5 4.5 8.8 were increased moderately in women
Intrapartum fever 0.1 0.1 0.1 with mild abruption but were 2- to 7-fold
Ananth et al. Severe placental abruption. Am J Obstet Gynecol 2016. (continued)
higher among severe abruptions. In fact,
the RR of the composite serious maternal
complications in relation to severe
abruption was 4.29 (95% CI,
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ajog.org
TABLE 1
Distribution of clinical characteristics based on
a
mild and severe placental abruption (continued)
Variable
Chorioamnionitis
Polyhydramnios
Oligohydramnios
a Number (abruption rate per 1000): no abruption, 27,528,415; mild abruption, 86,917 (3.1); severe abruption, 181,133 (6.5);
b Mean standard deviation: no abruption, 27.7 6.0; mild abruption, 28.3 6.1; severe abruption, 27.7 6.4.
Ananth et al. Severe placental abruption. Am J Obstet Gynecol 2016.
4.11e4.47; Table 3). Similarly, the RRs
for pulmonary edema (RR, 2.97; 95% CI,
2.68e3.29), acute heart failure (RR, 3.05;
95% CI, 2.78e3.36), and acute
respiratory failure (RR, 7.00; 95% CI,
6.62e7.39) were all considerably higher
in women with severe abruptions.
The RRs for serious maternal compli-
cations among severe abruption
compared with mild abruption was 3.47
(95% CI, 3.05e3.95). The associations
were considerably stronger for virtually
all maternal complications for severe
abruption rather than for mild abruption.
Rates of mild and severe abruption
between 2006 and 2012 and the corre-
sponding rates of serious maternal
complications in relations to abruption
are shown in the Figure. Rates of mild
and severe abruption were fairly constant
during the study period. Although the
maternal complication rate among births
with no abruption was stable be-tween
2006 and 2012, the rate of com-plications
for mild abruption dropped between 2006
and 2008 and then leveled off thereafter.
In contrast, the rate of serious
complications for severe abrup-tion
remained fairly stable between 2006 and
2010, and increased sharply thereafter.
Comment
Placental abruption is a serious and often
a life-threatening condition to the fetus
5-13
and, to a lesser extent, to the woman.
We show that the clinical characteristics
for abruption differ substantially be-
tween mild and severe forms of the
condition and with varying strengths of
associations. The choices of maternal
No abruption, Mild abruption, Severe
% % abruption, %
1.4 2.2
0.8 1.0
2.6 2.5
conditions that constitute a diagnosis of
severe abruption were not different than
those previously reported in the obstet-
rics literature. The maternal morbidity
profile that we chose includes extreme
maternal conditions that typically are not
seen with abruption and typically are not
included in the definition of abrup-tion.
Under maternal morbidity profile, we
included cardiomyopathy, myocar-dial
infarction, and respiratory failure, which
are conditions that are associated with
severe, prolonged hypoxia. Amni-otic
fluid embolism was also included in the
maternal morbidity profile because it is
not typical for the diagnosis, but its
association with abruption has been well-
2-4,14
documented. These conditions are
extremely serious but not typical of
abruption; for this reason, we included
them in the maternal morbidity profile
rather than in the definition of severe
abruption.
The morbidity profile and rates of
serious maternal complications are pro-
foundly different between mild and se-
vere abruptions, with the rates being
substantially higher between severe
(141.7 per 10,000) rather than mild (33.3
per 10,000) abruptions. Importantly,
severe abruptions comprise two-thirds of
all abruptions mainly because pre-term
delivery and SGA were included in the
definition of severe abruption even in the
absence of severe maternal symp-toms.
Taken together, these findings suggest
that severe abruptions are the distinct
group of really ill patients and that
combining mild and severe forms of the
disease may introduce substantial
heterogeneity in clinical research.
FEBRUARY 2016 American Journal of Obstetrics & Gynecology
OBSTETRICS Original Research
In this study, the diagnosis of
placental abruption was based on clinical
criteria rather than placental pathology
reports (which were unavailable).
However, in our view, pathology reports
may not be necessary for 3 reasons: (1)
4.1 epidemio-logic databases very rarely, if
1.2
ever, have data regarding pathology
reports;
3.9
(2) there are very few experts in placental
diseases, so any definition that use reli-able
placental pathology information may affect
generalizability; and (3) the prevalence rate
of abruption of 9.6 per 1000 in this study is
within the range that
has been reported in other population-
5,15-17
based studies. This suggests that
we have not missed a significant
number of cases because of a 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.
Limitations of the data
Despite the interesting observations, the
findings must be interpreted with some
caution. Primarily, the Premier data in-
cludes data on a large number of de-
liveries, but data on few 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 being affected by
unmeasured confounders remain. There
is also some possibility of misclassifica-
tion 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 the really ill
patients with >1 serious complication,
and it is very unlikely that abruption
status would be misclassified in this
group.
Strengths of the study
The strengths of the study include the
large study size with data from hospi-
talizations that are associated with over
27 million singleton deliveries from 441
hospitals over a 7-year period (2006-
2012) in the United States. All analyses
were weighted by the sampling weights
of deliveries, which permitted general-
izability of the findings. The associations
272.e4
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Original Research OBSTETRICS ajog.org

that we report were adjusted for a

TABLE 2
variety of confounding factors.
Association between clinical characteristics and
a
risks of mild and severe placental abruption Interpretation of findings
Adjusted rate ratio (95% confidence More than 4 decades ago, Pritchard et
interval)b 18
al proposed that severe abruptions
Risk factors Mild abruption Severe abruption are those that are accompanied by 1 of
Maternal age, y short umbilical cord, external trauma,
<20 0.70 (0.68, 0.72) 0.97 (0.95, 0.99) sudden uterine decomposition, uterine
anomaly or tumor, occlusion of the
20-24 0.89 (0.87, 0.91) 0.95 (0.94, 0.97)
inferior vena cava, maternal folate
25-29 1.00 (Reference) 1.00 (Reference) deficiency, maternal vascular disease,
30-34 1.10 (1.08, 1.13) 1.11 (1.09, 1.12) high parity, and previous abruption. A
35-39 1.23 (1.21, 1.26) 1.28 (1.26, 1.30) second classification was based on a
system that assigns a score that ranges
40-44 1.58 (1.51, 1.65) 1.47 (1.42, 1.52)
from 0-3, with 0 indicating asymp-
45 0.70 (0.68, 0.72) 0.97 (0.95, 0.99) tomatic women with evidence of small
Maternal race retroplacental clots on the placental
White 1.00 (Reference) 1.00 (Reference) surface on pathologic examination
after delivery, 1 denoting those women
Black 0.92 (0.90, 0.94) 1.31 (1.29, 1.33)
with bleeding and uterine tenderness or
Hispanic 0.83 (0.81, 0.86) 0.89 (0.88, 0.91) tetanic contractions, 2 denoting
Other 0.94 (0.92, 0.96) 1.01 (1.00, 1.02) bleeding with fetal distress (but no
Single marital status 1.06 (1.04, 1.08) 1.20 (1.19, 1.22) signs of maternal shock), and 3 denot-
ing bleeding with uterine tetany,
Tobacco use 1.49 (1.45, 1.53) 1.90 (1.87, 1.93) persistent abdominal pain, maternal
Alcohol use 1.86 (1.63, 2.13) 1.78 (1.65, 1.92) 19
shock, and fetal death.
Drug use 2.08 (1.91, 2.26) 2.32 (2.21, 2.44) The classification for severe placental
Insurance abruption that we propose is broad and
encompasses more objective criteria of
Commercial 1.00 (Reference) 1.00 (Reference)
clinically meaningful abruption. In fact,
Medicare 1.14 (1.05, 1.24) 1.10 (1.04, 1.16) the conditions that were used to define
Medicaid 1.21 (1.19, 1.23) 1.19 (1.18, 1.21) severe abruption were based on serious
Uninsured 1.43 (1.37, 1.49) 1.56 (1.52, 1.60) co-occurring maternal, fetal, and
neonatal clinical complications. The
Hypertension status grading system to classify abrup-tion
Normotensive 1.00 (Reference) 1.00 (Reference) 19
severity is restrictive, because even the
Chronic hypertension 1.35 (1.29, 1.41) 1.64 (1.60, 1.69) grade 0 abruption that results in preterm
Gestational hypertension 1.47 (1.42, 1.52) 1.21 (1.18, 1.24) delivery will be deemed as being “severe”
Mild preeclampsia 1.69 (1.63, 1.77) 2.06 (2.01, 2.12) based on this classifica-tion system.
Based on this definition, two-thirds of all
Severe preeclampsia 2.00 (1.92, 2.08) 4.21 (4.13, 4.29) clinically diagnosed abruption cases were
Chronic renal disease 0.73 (0.62, 0.86) 1.35 (1.26, 1.45) classified as being severe. Furthermore,
Asthma 1.13 (1.09, 1.17) 1.04 (1.02, 1.07) fetal growth re-striction and abruption
are both largely a chronic process that
Anemia 1.59 (1.56, 1.63) 2.45 (2.42, 2.47)
share strong similarities and are driven
Premature rupture of membranes 1.27 (1.23, 1.32) 2.52 (2.48, 2.56) 20,21
by uteropla-cental ischemia, which
Intrapartum fever 2.13 (1.76, 2.57) 1.34 (1.16, 1.55) provides further support that both
Polyhydramnios 1.15 (1.07, 1.23) 1.39 (1.33, 1.45) preterm de-livery and fetal growth
Oligohydramnios 0.96 (0.91, 1.00) 1.45 (1.42, 1.49) restriction should be considered in the
definition of severe abruptions. This
Chorioamnionitis 1.50 (1.43, 1.58) 2.42 (2.36, 2.48) classification not only identifies women
a Associations for all factors listed in the Table 1 were adjusted with the use of the log-linear Poisson regression with severe abruption with substantially
model; b Rate ratios for mild and severe abruption are each compared with the nonabruption group.
Ananth et al. Severe placental abruption. Am J Obstet Gynecol 2016.
higher risk of serious morbidity but also
ac-knowledges that women with severe

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ajog.org OBSTETRICS Original Research

TABLE 3
a b
Rate and rate ratio of serious maternal complications in relation to mild and severe placental abruption
Severe placental
Nonabruption Mild placental abruption abruption Severe vs mild
(n ¼ 27,528,415) (n ¼ 86,917) (n ¼ 181,133) abruption
Adjusted rate ratio Adjusted rate ratio Adjusted rate ratio
(95% confidence (95% confidence (95% confidence
Variable Rate Rate interval) Rate interval) interval)
Composite maternal 15.4 33.3 1.52 (1.35e1.72) 141.7 4.29 (4.11e4.47) 3.47 (3.05e3.95)
outcome
Pulmonary edema 2.8 7.2 1.60 (1.24e2.08) 23.4 2.97 (2.68e3.29) 2.40 (1.82e3.17)
Puerperal cerebrovascular 2.9 9.8 2.46 (1.97e3.08) 16.5 2.72 (2.41e3.07) 1.20 (0.92e1.55)
disorders
Acute heart failure 4.1 5.7 0.93 (0.69e1.25) 27.5 3.05 (2.78e3.36) 4.20 (3.08e5.74)
Acute myocardial infarction 0.2 — — 2.7 7.56 (5.51e10.38) —
Cardiomyopathy 3.4 7.4 1.48 (1.13e1.92) 15.2 2.12 (1.87e2.41) 1.68 (1.26e2.26)
Acute respiratory failure 5.7 13.0 1.62 (1.33e1.96) 88.9 7.00 (6.62e7.39) 5.47 (4.48e6.68)
Amniotic fluid embolism 0.4 — — 5.1 10.56(8.42e13.24) —
Coma 0.1 — — 1.9 7.04 (4.83e10.25) —
b
a Rates are expressed per 10,000; Associations were adjusted for the factors listed in Table 1 with the use of the log-
linear Poisson regression model. Ananth et al. Severe placental abruption. Am J Obstet Gynecol 2016.

abruption are distinctly different than

those with milder forms of the
FIGURE complication.
Changes in the rates of mild and severe placental abruption
Virtually all studies on placental
between 2006 and 2012 and that of composite outcome among
abruption have focused exclusively on
women with mild and severe abruption
assessing risks in the perinatal period and
22-26
during infancy, and evaluations of
maternal risks that are associated with
this condition are sparse. Furthermore,
we are unaware of any study that has
attempted to separate mild from severe
forms of abruption. In fact, the inclusion
of neonatal complications (preterm de-
livery and SGA) in the definition of se-
vere abruption results in two-thirds of all
abruptions being classified as severe.
Risk factors for severe abruption
appear driven largely by inflammation
and, to a lesser extent, infection-related
27
pathways. That tobacco and drug use
are stronger risk factors for severe,
rather than mild, abruptions suggest
that chronic hypoxia that leads to
uteroplacental under-perfusion as a result
Although the maternal complication rate among births with no abruption was stable between 11,28-30
of tobacco smoke appears
2006 and 2012, the rate of complications for mild abruption dropped between 2006 and 2008
to shape the risk of severe abruption.
and then leveled off thereafter. In contrast, the rate of serious complications for severe
Other pathologic chronic conditions that
abruption remained fairly stable between 2006 and 2010, and increased sharply thereafter. 12,31-33
include chronic hypertension,
Ananth et al. Severe placental abruption. Am J Obstet Gynecol 2016.
34,35
preeclampsia, premature rupture

FEBRUARY 2016 American Journal of Obstetrics & Gynecology

272.e6
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Original Research
36 37
of membranes, anemia, oligohy-
38
dramnios, and infection-related con-
ditions such as chorioamnionitis
38,39
are stronger risk factors for severe,
rather than mild, abruptions.
Interestingly, asthma and intrapartum
fever showed stronger associations
with mild than with severe abruptions.
The long-term risk of death and
morbidity from premature cardiovascular
disease are approximately 2- to 6-fold
higher among women with abruption
compared with otherwise normal preg-
40-43
nancies. In addition, this study sug-
gests that the risks of serious maternal
cardiovascular complications also remain
substantially higher among women with
severe, rather than mild, abruptions. Acute
complications such as myocardial infarction
and respiratory failure are approximately 7-
fold higher among women with severe
abruption. These findings provide support
to available data that show that ischemic
conditions during pregnancy such as
preeclampsia,44,45 fetal
growth restriction,46,47 preterm de-
livery48,49 and placental abruption40,41,43
may be linked to future cardiovascular
disease in women later in life. One of
the intriguing and unexpected findings
is the temporal increase in the rate of
serious maternal complications among
women with severe abruption since
2010 (Figure), but this increase
remains clinically insignificant.
Conclusion
This large population-based study sug-
gests that the frequency of maternal
clinical risk factors is different with mild
vs severe abruptions. Furthermore, the
associated serious morbidity profile of
women who receive a diagnosis of severe
abruption is considerably worse than in
those with mild abruption. These find-
ings underscore a substantial heteroge-
neity in both risk factor profile and
serious adverse maternal complications.
Importantly, the definition of severe that
we propose is based on objective data
that include maternal, fetal, and neonatal
complications. Although this proposed
definition is not one that can be used
prospectively, because it includes
outcome data in the definition of severe
abruption, these observations
272.e7 American Journal of Obstetrics & Gynecology FEBRUARY 2016
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OBSTETRICS
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. Research to unravel the
causes may also benefit from separating
mild from severe placental abruption. n
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Author and article information
From the Department of Obstetrics and Gynecology (Drs Ananth,
Wapner, and Wright and Ms Lavery) and the Biostatistics
Coordinating Center (Dr Ananth and Ms Lavery), College of
Physicians and Surgeons, and the Department of Epidemiology,
a Joseph L. Mailman School of Public Health (Dr Ananth),
Columbia University, New York, NY; the Department of
Obstetrics and Gynecology, Winthrop-University Hospital,
Mineola, NY (Dr Vintzileos); the Department of Obstetrics and
Gynecology, Weill Medical College of Cornell University, New
York, NY (Dr Skupski); the Department of Obstetrics and
Gynecology, University of Utah, Salt Lake City, UT (Dr Varner);
the Department of Obstetrics and Gynecology, University of
Texas, Galveston, TX (Dr Saade); the Department of Obstetrics
and Gynecology, University of Alabama, Bir-mingham, AL (Dr
Biggio); the Department of Epidemi-ology, T.H. Chan School of
Public Health, Harvard University, Boston, MA (Dr Williams).
Received Aug. 31, 2015; accepted Sept. 14, 2015.
The authors report no conflict of interest.
Corresponding author: Cande V. Ananth, PhD, MPH.
cande.ananth@columbia.edu
272.e8
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Original Research OBSTETRICS ajog.org

SUPPLEMENTAL TABLE
International Classification of Diseases, 9th edition, clinical modification codes for variables in this study
Condition International Classification of Diseases, 9th edition, clinical modification code
Delivery V27.0-V27.9
Singleton birth Multiple births (V272-V277, 654.x) excluded
Placental abruption 641.2
Infant outcomes
Stillbirth 656.4x, V27.1x
Neonatal death 768.x, 798.x
Preterm delivery 644.2x
Fetal growth restriction 656.5x, 764x
Nonreassuring fetal status 656.3x, 659.7x
Covariates
Hypertensive disorders
Chronic hypertension 642.00-642.24
Gestational hypertension 642.30-642.34
Mild preeclampsia 642.40-642.49
Severe preeclampsia 642.50-642.54
Superimposed preeclampsia 642.70-642.74
Tobacco use 305.1.x, 649.0x
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, 493.9, 493.90, 493.92
Outcomes/procedures
Maternal death 761.6
Puerperal cerebrovascular disorders 671.5, 671.50, 671.51, 671.52, 671.53, 671.54, 674.0, 674.00, 674.01, 674.02, 674.03,
674.04, 430, 431, 432, 432.0, 432.1, 432.9, 436, 997.01, 997.02, 433.01, 433.11, 433.21,
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
Amniotic fluid embolism 673.1x
Disseminated intravascular coagulation 666.3x, 286.6, 286.7, 286.9, 287.4, 287.41, 287.49
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
Acute myocardial infarction 410.x
Cardiomyopathy 674.5x, 425x
Acute liver failure 570, 646.7, 646.70, 646.71, 646.73
Acute respiratory failure 518.81, 518.82, 518.84, 518.5, 518.51, 518.52, 518.53, 799.1, 518.7
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
Shock 669.1x, 785.5x, 998.0x, 995.4, 995.0, 995.94, 99.4x
Ananth et al. Severe placental abruption. Am J Obstet Gynecol 2016.

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