Ischemic placental disease and risks of perinatal mortality and morbidity and neurodevelopmental outcomes

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Abstract

Preeclampsia, intrauterine growth restriction, and placental abruption are serious obstetrical complications that constitute the syndrome of ischemic placental disease and account for a disproportionate degree of perinatal morbidity and mortality. We review the risks of stillbirth and neonatal and infant mortality in relation to ischemic placental disease, focusing on population-based studies. We also review the risks of neonatal morbidity and neurodevelopmental outcomes in relation to ischemic placental disease. A synthesis of the findings of the relevant studies relating ischemic placental disease to adverse perinatal outcomes underscores two important observations. First, despite the low prevalence of each of the three obstetrical complications, all are associated with increased risks of adverse perinatal and infant outcomes, as well as neurodevelopmental deficits. Second, the burden of increased perinatal risks appears strongest during the preterm period. Efforts to reduce the risks of ischemic placental disease remain critically important and developing effective clinical interventions will be a target worthy for consideration.

Introduction

Ischemic placental disease is defined as a constellation of obstetrical complications that include preeclampsia, intrauterine growth restriction (IUGR), and placental abruption.1 Although the prevalence of each of these conditions is fairly low, they confer significant burden to overall maternal morbidity and mortality. In addition, these complications are associated with disproportionately increased risks of perinatal morbidity and mortality. In fact, preeclampsia, IUGR, and abruption are implicated in well over half of all indicated preterm deliveries,1, 2 which in turn, is associated with increased perinatal mortality and morbidity. While the rate of obstetrical interventions (labor induction or prelabor cesarean) at preterm gestations in the US has increased,3, 4 such increases are associated with a reduction in the risk of stillbirth.4, 5, 6 However, whether the increase in obstetrical interventions has resulted in a concurrent decline in the neonatal and infant mortality rates remains poorly understood.

This review is organized in two parts. We first discuss the risks of adverse perinatal outcomes, including preterm delivery and IUGR as well as risks of stillbirth and neonatal and infant mortality in relation to ischemic placental disease, focusing on studies that are population-based. In the second part, we review the risks of neonatal morbidity and adverse neurodevelopmental outcomes in relation to ischemic placental disease.

Section snippets

Preeclampsia

Preeclampsia is associated with increased risks of stillbirth and neonatal and infant mortality. Population-based studies in the Scandinavian countries and the United States have shown perinatal mortality rates in pregnancies exposed to preeclampsia to be about two-fold higher compared to normotensive pregnancies. Preeclampsia remains one of the most important indications for either a labor induction or a prelabor cesarean or both.1, 7 Therefore, if preeclampsia occurs early in pregnancy

Preeclampsia

Preeclampsia is associated with adverse neonatal outcomes (Table 4),25 particularly in the setting of iatrogenic preterm delivery when delivery occurs to reduce risk for maternal severe morbidity and mortality.26 Risk for major neonatal morbidity and/or mortality is highest when delivery occurs during the periviable or early preterm period (≤28 weeks).27, 28 Neonatal risk from preeclampsia may be reduced when severe preeclampsia at less than 34 weeks is managed expectantly.29 A Cochrane review

Preeclampsia

Delivery in the setting of preeclampsia may be an independent risk factor for adverse neonatal neurologic outcomes. A cohort study of infants delivered before 32 weeks demonstrated increased risk for SGA and intraventricular hemorrhage when preeclampsia was present; at two years of age, birth in the setting of preeclampsia was associated with a significantly lower score on the mental development index of the Bayley Scales of Infant Development.53 Another cohort study evaluated SGA neonates born

Conclusions

While the strengths of association amongst preeclampsia, IUGR, and placental abruption on adverse perinatal mortality and morbidity vary, it is apparent that all three conditions are associated with a substantial burden of increased perinatal risks. Furthermore, the perinatal risks associated with ischemic placental disease are stronger at preterm than term gestational ages, suggesting that ischemic placental disease that manifest at preterm gestations may be different from those that manifests

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