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Abrupt|o p|acentae per|nata| outcome |n normotens|ve and hypertens|ve pat|ents |n 8asra Iraq

volume 4 lssue 2 1998 age 319323

M Sharlef and AA ManLher

1he resulLs lndlcaLe LhaL hyperLenslon and abrupLlo placenLae are closely relaLed 1he lncldence of all
Lypes of hyperLenslon ln paLlenLs wlLh abrupLlo placenLae ln general obsLeLrlcs has been revlewed 7 1he
lncldence ranged from 113 Lo 640 and ls conslsLenL wlLh Lhe 268 hyperLenslve cases reporLed aL Lhe
unlverslLy of Callfornla uSA 8 CLhers clalm LhaL hyperLenslon and abrupLlo placenLae are unrelaLed 19
and several reporLs have dlscounLed Lhe lmporLance of Lhe relaLlon beLween hyperLenslon and abrupLlo
placenLae 31011 lL has been proposed LhaL elevaLlon of blood pressure assoclaLed wlLh abrupLlo
placenLae ls an effecL raLher Lhan a cause of Lhe condlLlon 310 lL ls speculaLed LhaL hyperLenslon ls caused
by vasoconsLrlcLlon secondary Lo haemorrhage or release of vasoacLlve subsLances Powever we belleve LhaL
hyperLenslon ls a predlsposlng or causaLlve facLor ln a slgnlflcanL proporLlon of cases of abrupLlo placenLae

AbrupLlo placenLae ls dlvlded lnLo four groups accordlng Lo cllnlcal presenLaLlon and severlLy 1213
Crade 0 ls a reLrospecLlve dlagnosls of abrupLlo placenLae grade l lncludes paLlenLs wlLh only vaglnal
bleedlng grade ll lncludes paLlenLs wlLh vaglnal bleedlng concealed haemorrhage uLerlne Lenderness and
feLal dlsLress and grade lll lncludes paLlenLs wlLh vaglnal bleedlng concealed haemorrhage uLerlne
Lenderness feLal deaLh and someLlmes coagulopaLhy 1here were slgnlflcanLly more paLlenLs wlLh grade lll
abrupLlo placenLae among Lhose wlLh hyperLenslon compared wlLh normoLenslves ln our sLudy 1hese resulLs
are ln agreemenL wlLh oLhers 813 Lven hyperLenslve women who were dellvered normally were sLlll more
llkely Lo dellver before 37 weeks gesLaLlon 1he hlgh percenLage of normal vaglnal dellvery observed ln boLh
groups was due Lo Lhe hlgh lncldence of grade lll abrupLlo placenLae whlch should be managed by normal
vaglnal dellvery Powever lncreased lncldence of caesarean secLlon wlLh abrupLlo placenLae has been
observed among hyperLenslve paLlenLs 8 lnLeresLlngly normoLenslve women were dellvered of neonaLes
wlLh blrLh welghLs slmllar Lo Lhose of Lhe hyperLenslve group and wlLh a hlgher lncldence of blrLh welghL of
13002300 g

Cur resulLs also lndlcaLe LhaL hyperLenslve women wlLh abrupLlo placenLae had a slgnlflcanLly poorer
perlnaLal ouLcome Lhan Lhe normoLenslve women wlLh abrupLlo placenLae Lhe cause of perlnaLal morLallLy
was asphyxla erlnaLal morLallLy for hyperLenslve women wlLh abrupLlo placenLae has been reporLed Lo be
beLween 38 and 72 and for normoLenslve women beLween 32 and 38 7 1hese flgures dlffer from
Lhose of Morgan eL al who reporLed perlnaLal morLallLy of 172 for hyperLenslve paLlenLs and 131 for
normoLenslve paLlenLs 8 A dlrecL correlaLlon beLween Lhe severlLy of hyperLenslon and perlnaLal morLallLy
has been prevlously reporLed 14 An lncreased raLe of sLlllblrLh wlLh a 3 mmPg lncrease ln arLerlal pressure
over 90 mmPg has been found CLher facLors mlghL lncrease perlnaLal morbldlLy such as low blrLh welghL
low Apgar scores low umblllcal cord pP values lncreased preLerm dellvery and an lncreased caesarean
secLlon raLe

1he presenL sLudy has conflrmed Lhe assoclaLlon beLween hyperLenslon and abrupLlo placenLae
PyperLenslon affecLed boLh Lhe lncldence and ouLcome of abrupLlo placenLae Also Lhese resulLs glve a
beLLer undersLandlng of Lhe hyperLenslonabrupLlo placenLae relaLlonshlp ln Lhe area
|agnos|s and safe management of p|acenta prev|a
Chi P. Dola, MD, MPH; Sherri A. Longo, MD Journal of Family Practice October 2006 Volume 18

lacenLa prevla ls a leadlng and poLenLlally llfeLhreaLenlng cause of LhlrdLrlmesLer bleedlng1
AlLhough Lhe overall lncldence ls abouL 04 ln pregnancles exceedlng 20 weeks' gesLaLlon2 LhaL flgure rlses
wlLh Lhe number of cesarean secLlons and may reach 10 among women who have undergone 4 or more
cesarean dellverles3 Slnce more women are requesLlng elecLlve and repeaL cesarean dellverles we are
lncreaslngly llkely Lo encounLer Lhls condlLlon
lorLunaLely Lechnologlcal advances have lmproved maLernal and neonaLal ouLcomes afLer placenLa
prevla ulLrasound lmaglng Lechnlques Lo achleve early dlagnosls and safe managemenL of boLh
asympLomaLlc and bleedlng paLlenLs rophylacLlc placemenL of a balloonLlpped caLheLer ln Lhe lnLernal lllac
vessels can subsLanLlally reduce bleedlng aL Lhe Llme of dellveryor ln some cases conLrol lL alLogeLher
neverLheless Lhe condlLlon necesslLaLes cesarean dellvery and can cause serlous maLernal and perlnaLal
morbldlLy lncludlng MaLernal haemorrhage lncreased rlsk of placenLa accreLe reLerm blrLh CongenlLal
malformaLlons leLal growLh resLrlcLlon lL can also occur ln assoclaLlon wlLh vasa prevla whlch Lhough rare
carrles a very hlgh perlnaLal morLallLy raLe
|sk factors
An enlarged placenLa or endomeLrlal dlsrupLlon or scarrlng ln Lhe upper uLerlne segmenL due Lo 1 or more of
Lhe facLors llsLed below may lncrease Lhe llkellhood of abnormal placenLal lmplanLaLlon ln Lhe unscarred
lower uLerlne segmenL Advanced maLernal age lncreased parlLy revlous cesarean dellverles revlous
cureLLage for sponLaneous or elecLlve aborLlon Smoklng and MulLlfeLal gesLaLlon
IIA CI1- 8I- WI1n AI- IAI-A 8I-
1he condlLlon ofLen presenLs as palnless brlghL red vaglnal bleedlng ln Lhe Lhlrd LrlmesLer lL ls usually
dlsLlngulshed from abrupLlo placenLa by Lhe absence of abdomlnal paln and uLerlne conLracLlons3 Powever
approxlmaLely 20 of women have uLerlne acLlvlLy assoclaLed wlLh Lhe flrsL eplsode of vaglnal bleedlng1314
Moreover ln some cases palnful conLracLlons and labor may preclplLaLe vaglnal bleedlng from placenLa
prevla3 1herefore ulLrasound examlnaLlon ls sLrongly recommended for all women wlLh vaglnal bleedlng
durlng pregnancy
U|trasound for other reasons uncovers many cases
WlLh greaLer rouLlne use of ulLrasonography ln obsLeLrlcs a large percenLage of women wlLh placenLa prevla
are dlagnosed prlor Lo Lhe onseL of Lhe characLerlsLlc palnless vaglnal bleedlng ln a 2003 sLudy by uola and
colleagues13 approxlmaLely 43 of placenLa prevla cases were dlagnosed by ulLrasonography performed for
oLher obsLeLrlcal lndlcaLlons prlor Lo Lhe onseL of vaglnal bleedlng
ook for "warn|ng hemorrhage"
1he flrsL eplsode of vaglnal bleedlng ls rarely profuse or llfeLhreaLenlng Lo Lhe moLher or feLus 1he bleedlng
usually subsldes sponLaneously alLhough lL could recur and become more severe wlLh subsequenL eplsodes
regnancy Lyplcally conLlnues afLer Lhe lnlLlal bleedlng eplsode
1he mean gesLaLlonal age aL Lhe Llme of Lhe flrsL bleedlng ls 29 Lo 32 weeks1314 Powever a Lhlrd of cases
have vaglnal bleedlng before Lhe 30Lh week of gesLaLlon a Lhlrd beLween 30 and 36 weeks and a Lhlrd afLer
36 weeks' gesLaLlon1313 1en percenL of women wlLh Lhe condlLlon may be compleLely asympLomaLlc and
progress Lo 38 weeks' gesLaLlon wlLhouL vaglnal bleedlng1314

CbsLeLrlcs Cynecology
Aprll 1999 volume 93 lssue 4 p 341344
Crlglnal 8esearch
-eonata| Cutcomes W|th |acenta rev|a
C8AnL !CAn M C Mu l8CSC vAn uLn PCl MlCPlLL C Mu l8CSC uCuuS LlnuA hu A8MSCn 8
An1PCn? Mu l8CSC LlS1Cn 8C8L81 M8 l8CSC
Cb[ect|ve 1o ldenLlfy neonaLal compllcaLlons assoclaLed wlLh placenLa prevla
Methods 1hls was a populaLlonbased reLrospecLlve cohorL sLudy lnvolvlng all slngleLon dellverles ln nova
ScoLla from 1988 Lo 1993 1he sLudy group conslsLed of all compleLed slngleLon pregnancles compllcaLed by
placenLa prevla all oLher slngleLon pregnancles were consldered conLrols aLlenL lnformaLlon was collecLed
from Lhe nova ScoLla ALlee perlnaLal daLabase neonaLal compllcaLlons were evaluaLed whlle conLrolllng for
poLenLlal confounders 1he daLa were analyzed uslng 2 llsher exacL LesL and mulLlple loglsLlc regresslon
esu|ts Among 92983 pregnancles dellvered durlng Lhe sLudy perlod 303 cases of placenLa prevla were
ldenLlfled (033) AfLer conLrolllng for poLenLlal confounders neonaLal compllcaLlons slgnlflcanLly assoclaLed
wlLh placenLa prevla lncluded ma[or congenlLal anomalles (odds raLlo C8 248) resplraLory dlsLress
syndrome (C8 494) and anemla (C8 263) 1he perlnaLal morLallLy raLe assoclaLed wlLh placenLa prevla was
230 (compared wlLh 078 ln conLrols) and was explalned by gesLaLlonal age aL dellvery occurrence of
congenlLal anomalles and maLernal age AlLhough Lhere was a hlgher raLe of preLerm blrLhs ln Lhe placenLa
prevla group (4636 versus 727) Lhere was no dlfference ln blrLh welghLs beLween groups afLer
conLrolllng for gesLaLlonal age aL dellvery

Conc|us|on neonaLal compllcaLlons of placenLa prevla lncluded preLerm blrLh congenlLal anomalles
resplraLory dlsLress syndrome and anemla 1here was no lncreased occurrence of feLal growLh resLrlcLlon

lacenLa prevla an lmporLanL cause of anLeparLum hemorrhage ls esLlmaLed Lo occur ln 031 Lo 060 of
pregnancles aL dellvery114 revlous sLudles of compllcaLlons of placenLa prevla mlghL have llmlLed currenL
relevance AlmosL all sLudles were conducLed more Lhan a decade ago19111319 AlLhough expecLanL
obsLeLrlc LreaLmenL has noL changed slnce Lhen Lhere have been lmprovemenLs ln dlagnosls2022 and
neonaLal LreaLmenL2324 1hose reflnemenLs mlghL have changed Lhe raLe of neonaLal compllcaLlons
revlous sLudles examlned women from lndlvldual cenLers lnLroduclng posslble referral blas Some of Lhose
sLudles used blrLh cerLlflcaLe daLa or survey daLa410 llmlLlng Lhe avallable varlables Lven when lmporLanL
varlables were lncluded mosL sLudles dld noL Lake lnLo accounL Lhe poLenLlal effecLs of confoundlng
facLors13381419 1he ob[ecLlve of Lhls sLudy was Lo deLermlne Lhe neonaLal compllcaLlons of placenLa

1999 1he Amerlcan College of CbsLeLrlclans and CynecologlsLs

rev|ous Cesarean e||very and |sks of |acenta rev|a and |acenta| Abrupt|on
CeLahun uarlos Mu MP1 Cyelese ?lnka Mu2 Sallhu Pamlsu M Mu hu1 AnanLh Cande v hu MP1

C8!LC1lvL 1o examlne Lhe assoclaLlon beLween cesarean dellvery and prevla and abrupLlon ln subsequenL

ML1PCuS A reLrospecLlve cohorL sLudy of flrsL 2 (n 136473) and flrsL 3 (n 31102) consecuLlve slngleLon
pregnancles uslng Lhe 19891997 Mlssourl longlLudlnally llnked daLa were performed 8elaLlve rlsk (88) was
used Lo quanLlfy Lhe assoclaLlons beLween cesarean dellvery and rlsks of prevla and abrupLlon ln subsequenL
pregnancles afLer ad[usLlng for several confounders

8LSuL1S 8aLes of prevla and abrupLlon were 44 (n 694) and 79 (n 1243) per 1000 blrLhs respecLlvely
1he pregnancy afLer a cesarean dellvery was assoclaLed wlLh lncreased rlsk of prevla (063) compared wlLh a
vaglnal dellvery (038 88 13 93 confldence lnLerval Cl 1318) Cesarean dellvery ln Lhe flrsL and second
blrLhs conferred a Lwofold lncreased rlsk of prevla ln Lhe Lhlrd pregnancy (88 20 93 Cl 1330) compared
wlLh flrsL Lwo vaglnal dellverles Women wlLh a cesarean flrsL blrLh were more llkely Lo have an abrupLlon ln
Lhe second pregnancy (093) compared wlLh women who had a vaglnal flrsL blrLh (074 88 13 93 Cl 12
13) 1wo consecuLlve cesarean dellverles were assoclaLed wlLh a 30 lncreased rlsk of abrupLlon ln Lhe Lhlrd
pregnancy (88 13 93 Cl 1018) A second pregnancy wlLhln a year afLer a cesarean dellvery was assoclaLed
wlLh lncreased rlsks of prevla (88 17 93 Cl 0931) and abrupLlon (88 13 93 Cl 1123)

CCnCLuSlCn A cesarean flrsL blrLh ls assoclaLed wlLh lncreased rlsks of prevla and abrupLlon ln Lhe second
pregnancy 1here ls a doseresponse paLLern ln Lhe rlsk of prevla wlLh lncreaslng number of prlor cesarean
dellverles A shorL lnLerpregnancy lnLerval ls assoclaLed wlLh lncreased rlsks of prevla and abrupLlon

LLvLL Cl LvluLnCL ll2

2006 1he Amerlcan College of CbsLeLrlclans and CynecologlsLs

Induced abort|on a r|sk factor for p|acenta prev|a
8arreLL !M 8oehm lP klllam A
A Lhreefold lncrease ln Lhe lncldence of placenLa prevla from one ln 318 dellverles (03) ln 19721974 Lo
one ln 109 dellverles (09) ln Lhe LwelvemonLh perlod endlng !une 30 1980 was noLed aL vanderbllL
unlverslLy PosplLal 1wo large groups of paLlenLs noL presenL ln 19721974 were found Lo be responslble for
Lhls lncreased lncldence of placenLa prevla oneway maLernal LransporLs and women who had had lnduced
flrsL LrlmesLer aborLlons 1he frequency of maLernal LransporLs havlng placenLa prevla was 33 (p less Lhan
00001) and Lhe frequency of placenLa prevla ln women afLer an lnduced flrsL LrlmesLer aborLlon was 38 (p
less Lhan 00001) When correcLlon for maLernal LransporLs was made Lhe endogenous lnduced flrsL
LrlmesLer aborLlon populaLlon had a frequency of placenLa prevla of 21 (p less Lhan 0004) whereas Lhe
remalnder of Lhe endogenous populaLlon had an lncldence of placenLa prevla slmllar Lo LhaL found ln Lhe
years 19721974 lnduced flrsL LrlmesLer aborLlon ls seen as a slgnlflcanL facLor predlsposlng Lo placenLa

8lsk facLors assoclaLed wlLh Lhe developmenL of placenLa prevla a slgnlflcanL compllcaLlon of pregnancy are
mulLlparlLy advanclng age mulLlfeLal gesLaLlon clgareLLe smoklng and a hlsLory of prevlous aborLlon
vanderbllL unlverslLy PosplLal experlenced a 3fold lncrease ln Lhe prevalence of placenLa prevla from 1 ouL
of 318 dellverles (03) ln 19721974 Lo 1 ouL of 109 dellverles (o9) ln Lhe 12monLh perlod endlng !une 30
1981 1hls sLudy reLrospecLlvely evaluaLed Lhe causes for Lhls lncrease ln Lhe frequency of placenLa prevla
1oLal number of dellverles prevalence of placenLa prevla maLernal age parlLy race and aborLlon hlsLory
were evaluaLed durlng Lhe perlods 19721974 and !uly 1 1979 Lo !une 30 1980 ln all cases of placenLa
prevla Lhe dlagnosls was conflrmed aL Lhe Llme of Cesarlan secLlon olsson dlsLrlbuLlon was used Lo
deLermlne Lhe probablllLy of placenLa prevla occurlng ln Lhe varlous rlsk groups durlng 19791980 whlle Chl
square analysls was used Lo compare frequencles of placenLa prevla sponLaneous aborLlon and lnduced
aborLlon durlng Lhe 2 perlods 1he lncreased lncldence of placenLa prevla was aLLrlbuLed Lo 2 large groups of
paLlenLs noL presenL ln 19721974 1way maLernal LransporLs and women who had had lnduced flrsL
LrlmesLer aborLlons Cf 332 maLernal LransporLs 11 (33) had placenLa prevla (p0001) Cf 210 paLlenLs wlLh
a hlsLory of lnduced flrsL LrlmesLer aborLlons 8 (38) had placenLa prevla (p00001) 130 were ln Lhelr flrsL
pregnancy slnce Lhe lnduced flrsL LrlmesLer aborLlon wlLh 7 (46) havlng placenLa prevla (p0001) 4 (21)
of 193 nonLransporL paLlenLs who had undergone lnduced flrsL LrlmesLer aborLlon had placenLa prevla
(p00004) SucLlon cureLLage was Lhe aborLlon meLhod performed ln 6 of 8 women wlLh placenLa prevla
Mean Llme lnLerval beLween lnduced flrsL LrlmesLer aborLlon and LermlnaLlon of pregnancy compllcaLed by
placenLa prevla was 4223 monLhs Average age and parlLy of paLlenLs was 286 years and 193 respecLlvely
slgnlflcanLly hlgher Lhan LhaL of Lhe general populaLlon (p0001) LndomeLrlal cureLLage may play a role ln Lhe
lncreased lncldence of placenLa prevla subsequenL Lo lnduced flrsL LrlmesLer aborLlon LlmlLaLlon of Lhls sLudy
ls Lhe relaLlvely small sample slze lurLher research should be done Lo elucldaLe Lhe poLenLlal rlsks of lnduced
flrsL LrlmesLer aborLlon

Inc|dence of |acenta| Abrupt|on |n e|at|on 1o C|garette mok|ng and nypertens|ve |sorders ur|ng
regnancy A MetaAna|ys|s of Cbservat|ona| tud|es
AnanLh Cande v hu MP Smullan !ohn C Mu MP vlnLzlleos AnLhony M Mu
Cb[ecLlve 1o sysLemaLlcally revlew Lhe llLeraLure and summarlze Lhe relaLlonshlp beLween clgareLLe smoklng
and placenLal abrupLlon and Lo evaluaLe Lhe [olnL lnfluences of smoklng and hyperLenslve dlsorders (chronlc
hyperLenslon and preeclampsla) on Lhe subsequenL developmenL of abrupLlon

Concluslon Cur meLaanalyses showed an lncreased rlsk for placenLal abrupLlon ln relaLlon Lo boLh clgareLLe
smoklng and hyperLenslve dlsorders durlng pregnancy 8ecause clgareLLe smoklng ls a modlflable rlsk facLor
and hyperLenslve dlsorders are poLenLlally LreaLable lf dlagnosed early ln pregnancy paLlenL educaLlon
smoklng cessaLlon programs and early prenaLal care may be lmporLanL facLors ln Lhe prevenLlon of placenLal

lacenLal abrupLlon ls deflned as Lhe premaLure separaLlon of a normally lmplanLed placenLa before
dellvery1 lL occurs ln 0810 of all pregnancles2 wlLh much hlgher lncldences among women wlLh sudden
uLerlne decompresslon uLerlne Lumors shorL umblllcal cord pregnancles compllcaLed by hyperLenslve
dlsorders (lncludlng chronlc hyperLenslon pregnancylnduced hyperLenslon and preeclampsla) premaLure
rupLure of membranes ollgohydramnlos and uLerlne lnfecLlons such as chorloamnlonlLls AfLer an lnlLlal
pregnancy compllcaLed by abrupLlon Lhe recurrence of Lhls condlLlon ls almosL 20 Lo 30 Llmes greaLer ln
subsequenL pregnancles2 llnally obsLeLrlc and llfesLyle facLors LhaL slgnlflcanLly conLrlbuLe Lo Lhe lncreased
lncldence of placenLal abrupLlons lnclude advanced maLernal age grand mulLlparlLy clgareLLe smoklng and
cocalne use

1obacco use durlng pregnancy has been assoclaLed wlLh many adverse reproducLlve ouLcomes lncludlng
lnferLlllLy sponLaneous aborLlon low blrLh welghL preLerm dellvery and longLerm physlcal and
developmenLal dlsorders ln lnfanLs AlLhough Lhe deleLerlous effecLs of smoklng on pregnancy ouLcomes are
well descrlbed evldence llnklng Lobacco smoke Lo placenLal dlsorders especlally placenLal abrupLlon has
been lnconslsLenL among sLudles and Lhe relaLlonshlp has noL been compleLely lnvesLlgaLed 1hls
shorLcomlng ls parLly because of weaknesses ln sLudy deslgn lnadequaLe sample slzes and lnconslsLenL
deflnlLlons of placenLal abrupLlon2 lnformaLlon on clgareLLe smoklng ln publlshed sLudles ls based excluslvely
on selfreporLed smoklng behavlor 8ecause Lhere ls a soclal sLlgma assoclaLed wlLh smoklng Lhese sLudles
may have been hampered by slgnlflcanL underreporLlng of smoklng behavlor

1he ob[ecLlve of our sLudy was Lo perform a sysLemaLlc overvlew and meLaanalysls of publlshed sLudles on
clgareLLe smoklng and hyperLenslve dlsorders durlng pregnancy and Lhe subsequenL developmenL of
placenLal abrupLlon We also revlewed Lhe llLeraLure Lo assess Lhe dosedependence relaLlonshlp beLween
Lhe number of clgareLLes smoked and Lhe subsequenL developmenL of placenLal abrupLlon AnanLh eL al2
recenLly reporLed Lhe resulLs of a meLaanalysls on Lhe relaLlonshlp beLween hyperLenslve dlsorders (chronlc
hyperLenslon and mlld and severe preeclampsla) and placenLal abrupLlon 1he presenL meLaanalysls
aLLempLs Lo summarlze Lhe relaLlonshlp beLween smoklng and abrupLlon and Lhe [olnL lnfluences of smoklng
and hyperLenslve dlsorders on Lhe subsequenL developmenL of placenLal abrupLlon

1999 1he Amerlcan College of CbsLeLrlclans and CynecologlsLs

1he |sk of ctop|c regnancy after 1uba| ter|||zat|on
PerberL 8 eLerson Mu Zhlsen xla hu !oyce M Pughes Lynne S Wllcox Mu Llsa 8aLllff 1ylor 8S
and !ames 1russell hu for Lhe uS CollaboraLlve 8evlew of SLerlllzaLlon Worklng Croup
n Lngl ! Med 1997 336762767March 13 1997

We found LhaL Lhe 10year cumulaLlve probablllLy of ecLoplc pregnancy afLer Lubal sLerlllzaLlon varled
accordlng Lo Lhe meLhod of sLerlllzaLlon and age aL Lhe Llme of Lhe procedure Among women who
underwenL sLerlllzaLlon before Lhe age of 30 years Lhe greaLly lncreased probablllLy of ecLoplc pregnancy
afLer blpolar coagulaLlon (27 Llmes as hlgh as Lhe probablllLy wlLh posLparLum parLlal salplngecLomy) ls
noLable because Lhls ls Lhe mosL popular sLerlllzaLlon Lechnlque for women who have noL [usL dellvered a
Cur flndlng LhaL women who underwenL lnLerval parLlal salplngecLomy had a slgnlflcanLly greaLer rlsk of
ecLoplc pregnancy Lhan Lhose who underwenL posLparLum parLlal salplngecLomy ls probably due Lo chance or
blas 1he relaLlvely few women who underwenL lnLerval parLlal salplngecLomy were generally Lhose for whom
laparoscopy was consldered Lo pose unaccepLable rlsks ofLen because of rlsk facLors LhaL were Lhemselves
llkely Lo reduce Lhe effecLlveness of Lhe sLerlllzaLlon procedure
We prevlously reporLed LhaL a womans age aL Lhe Llme of Lubal sLerlllzaLlon affecLed Lhe llkellhood of fallure
of Lhe procedure8 whlch ln Lurn affecLs Lhe llkellhood of ecLoplc pregnancy ln Lhe currenL sLudy we found
LhaL women who were under 30 aL Lhe Llme of sLerlllzaLlon were nearly Lwlce as llkely as older women Lo
have a subsequenL ecLoplc pregnancy We suspecL LhaL Lhe prlmary effecL of age on Lhe rlsk of ecLoplc
pregnancy ls lLs effecL on fecundlLy11
AlLhough our sLudy ls based on Lhe experlence of Lhousands of women who underwenL sLerlllzaLlon ln
medlcal cenLers across Lhe unlLed SLaLes our flndlngs may noL be generallzable Lo Lhe uS populaLlon as a
whole 1he women were noL randomly selecLed from among all Lhe women undergolng sLerlllzaLlon ln Lhe
unlLed SLaLes mosL were enrolled aL Leachlng cenLers and Lhelr rlsk of pregnancy afLer sLerlllzaLlon may
dlffer from LhaL of women sLerlllzed ln oLher seLLlngs
rocedural Lechnlque ls probably a crlLlcal deLermlnanL of Lhe rlsk of sLerlllzaLlon fallure1213 lor example
one experlmenL suggesLs LhaL sysLems deslgned for blpolar coagulaLlon can be hlghly effecLlve produclng a
degree of coagulaLlon slmllar Lo LhaL produced by unlpolar sysLems lf speclflc Lechnlques are
used13 Slmllarly prellmlnary analyses from our sLudy suggesL LhaL Lhe probablllLy of pregnancy afLer blpolar
coagulaLlon ls low when Lhe falloplan Lube ls coagulaLed sufflclenLly lf Lhe use of proper Lechnlques for Lubal
sLerlllzaLlon became more wldespread afLer enrollmenL ln Lhls sLudy was compleLed our resulLs may
overesLlmaLe currenL rlsks
8oLh slllcone rubberband appllcaLlon (ln whlch a band ls placed over a loop of falloplan Lube) and sprlngcllp
appllcaLlon (ln whlch a small plasLlc cllp ls placed over Lhe Lube) were assoclaLed wlLh hlgher raLes of ecLoplc
pregnancy Lhan unlpolar coagulaLlon buL Lhey are more llkely Lhan unlpolar coagulaLlon Lo be successfully
reversed by Lubal anasLomosls13 osLparLum parLlal salplngecLomy was assoclaLed wlLh Lhe lowesL
probablllLy of ecLoplc pregnancy buL women undergolng Lhls procedure were found ln an earller reporL on
Lhls cohorL Lo be 40 percenL more llkely Lhan women havlng procedures aL a Llme separaLe from pregnancy Lo
regreL havlng been sLerlllzed16
LcLoplc pregnancy afLer Lubal sLerlllzaLlon ls noL rare parLlcularly among women sLerlllzed before Lhe age of
30 and all women undergolng Lhls procedure should be lnformed LhaL ecLoplc pregnancy may occur long
afLer sLerlllzaLlon ln addlLlon Lhose who provlde care Lo women of chlldbearlng age should noL assume LhaL
a hlsLory of Lubal sLerlllzaLlon rules ouL Lhe posslblllLy of an ecLoplc pregnancy ln a woman who has sympLoms
or slgns of pregnancy especlally of ecLoplc pregnancy