Original Paper www.slcog.lk/sljog

A Clinical Study of Maternal and Fetal Outcome in Abruptio Placenta - Couvelaire Uterus a Preventable Obstetric Catastrophe Vijayasree M

postpartum haemorrhage with its Abstract sequelae of acute tubular necrosis and disseminated intravascular Introduction : Hemorrhage is the single most important cause of worldwide. coagulation, low birth weight babies, Obstetrical hemorrhage accounts for almost half of all postpartum deaths in developing increased incidence of Prematurity countries. Among them Abruptio placenta occurs in around 1% of all . Aim of and still birth.9, 10.The purpose of this this study was to determine the maternal and fetal outcome in complicated by study was to determine the risk abruption placenta in relation to the risk factors. factors,clinical presentation and Methods: This was a retrospective study conducted in the Department of and outcome of pregnancies diagnosed Gynecology, Mamata medical college, khammam from January 2010 to December 2014 for with abruptio placenta. The aim of this a period of five years. All pregnant women who were diagnosed with abruptio placenta after study was to determine the maternal 28 weeks of gestation were included in the study. Patients were identified from the admission and fetal outcome in pregnancy and labour room registers. complicated by abruption placenta in Results: Total number of deliveries during the study period were 4000. Patients identified with relation to the risk factors. abruptio placenta were 100, giving a frequency of 2.5%. Majority women were multigravidae Methods and 56% of all the between 26-30 years of age. The mean gestational age at diagnosis was 34 ± 4.21 weeks. Vaginal bleeding was the most common clinical finding seen in 80% of the This was a retrospective study women, followed by blood stained in 16% suggesting concealed abruption conducted in the department of placenta. Fetal heart sounds were absent on admission in 65% of the women. Most common Obstetrics and Gynaecology , Mamata cause of abruption 44% was either patients with past history of pre – or PIH in the medical college, Khammam from present pregnancy. 9 patients with couvelaire uterus were identified and treated effectively. January 2010 to December 2014 for Among them, two patients died due to postpartum hemorrhage. Parity and gestational age a period of five years. All pregnant were found to be significant risk factors for abruptio placentae. women who were diagnosed with abruptio placenta after 28 weeks of Conclusion: Abruptio placenta was associated with poor maternal and fetal outcomes. gestation were included in the study. Early diagnosis and significant treatment of pre eclampsia during the antenatal period would Since ours is a referral centre many prevent abruption and related complications. patients were unbooked without Keywords: Abruption,couvelaire uterus,maternal and fetal outcome. proper antenatal care and are usually admitted with complications. Patients were identified from the admission Introduction and labour room registers. Total the Centers for Disease Control and number of deliveries during the Although medical advances have 1 Prevention . In many developed study period were 4000. Data was dramatically reduced the dangers of countries, hemorrhage is a leading collected on a pre-designed Proforma , death from hemorrhage, reason for admission of pregnant for abruptio placenta. Placental still remains a leading cause of 2, 3,4,5 women to intensive care units . abruption was defined as complete maternal mortality especially in the Indeed, hemorrhage is the single most or partial separation of normally developing countries. Hemorrhage important cause of maternal death located placenta before delivery of is a direct cause of more than 17 worldwide. Obstetrical hemorrhage the . The diagnosis of placental percent of 4200 pregnancy-related accounts for almost half of all abruption was made on clinical signs maternal deaths in the United States postpartum deaths in developing and symptoms of Blood loss per as ascertained from the Pregnancy 6,7 countries .Among them Abruptio vaginam, tense and tender abdomen Mortality Surveillance System of placenta occurs in around 1% of all the 8 and confirmed at delivery by the local pregnancies. Risk factors which have examination of placenta for separation Department of Obstetrics Mamata general been found associated with Abruptio hospital, Khammam.,Andhra pradesh. and presence of retroplacental Placenta include maternal age, blood clots. Demographic variables parity, smoking, hypertension, past Correspondence: which were collected for both group history of Abruption, thrombophilic of women included maternal age, Dr. M. Vijayasree.,MD disorders, abdominal trauma and parity, past history of and E-mail: [email protected] . Abruptio placenta hypertension. Clinical and laboratory has been associated with poor Competing interests: None variables included bleeding per maternal and fetal outcome like

38 Sri Lanka Journal of Obstetrics and Gynaecology September 2015 www.slcog.lk/sljog Original Paper vaginam, blood stained amniotic study population. Majority 56% of the were absent on admission in 65% of fluid, maternal blood pressure, women were between 26-30 years of the patients. Spontaneous vaginal complete blood picture, serum urea age group. 59% women were either delivery occurred in 70% followed and creatinine, Prothrombin time and second, third or fourth gravida. The by caesarean section in 30% of the partial thromboplastin time. Perinatal mean gestational age was 34 ± 4.21 women. Postpartum hemorrhage outcome which was noted included weeks. 51% delivered preterm before (PPH) was seen in 18%. Though weight and gestational age of the 37 weeks and 49% delivered at or there were 9 patients identified with baby and apgar score.Women with after 37 completed weeks of gestation. couvelaire uterus, there were only 2 multiple pregnancy, fibroid uterus 10% women had history of previous maternal deaths in the patients with and polyhydramnios were excluded. stillbirth and 21% had history of couvelaire uterus in our study and The study was approved by ethical in previous both were due to atonic PPH. The committee of our college. The data pregnancies. Recurrent abruption was mean fetal birth weight was 2400 g. was collected and analyzed by using observed in 9% of the women. The perinatal mortality rate was 66%. appropriate statistical methods. Table-4, 5 shows the clinical Retro placental blood clots, due to placental separation was associated Results characteristics and mode of delivery in the given population. Vaginal with perinatal mortality. Perinatal loss A total of 100 cases were identified bleeding was the most common clinical was associated with a minimum of 200 as abruptio placentae. Total number finding seen in 80% of the women, ml, and with no live birth at loss of of deliveries during the study period blood stained amniotic fluid was seen 1000ml of blood loss since majority of were 4000, giving an overall frequency in 16%. Pre-labour, premature rupture our patients were anemic, even 200ml of 2.5%. of membranes was present in 7 % and of blood loss was also trivial for that women and contributed to significant Table-1, 2 and 3 show the age, parity hypertension in current pregnancy perinatal mortality. and the risk factor distribution of our was seen in 23%. Fetal heart sounds

TABLE-1 :DISTRIBUTION OF PATIENTS ACCORDING TO MATERNAL AGE (N=100)

Maternal age (years) No. of patients percentage 20-25 24 24% 26-30 56 56% 31-35 15 15% >35 5 5%

TABLE-2:DISTRIBUTION OF PATIENTS ACCORDING TO PARITY(N=100)

Parity No of patients percentage Primigravida 27 27% Multigravida(2-4) 59 59% Grandmulti 14 14%

TABLE-3:DISTRIBUTION OF PATIENTS ACCORDING TO THE RISK FACTORS (N=100)

Risk factors No. of patients Percentage H/o previous still birth 10 10% Previous h/o PIH 21 21% Previous h/o abruption 09 09% No h/o recurrent abruption 60 60%

TABLE-4:DISTRIBUTION OF PATIENTS ACCORDING TO THE CLINICAL FEATURES (N=100)

Clinical features No of patients Percentage Blood stained liquor 16 16% Clear /meconium stained liquor 54 54% Hypertention 23 23% PROM 7 7%

September 2015 Sri Lanka Journal of Obstetrics and Gynaecology 39 Original Paper www.slcog.lk/sljog

TABLE-5:DISTRIBUTION OF PATIENTS ACCORDING TO THE MODE OF DELIVERY(N=100)

Mode of delivery No of patients Percentage Vaginal delivery 70 70% Normal delivery 37 37% Instrumental 15 15% Vaginal Breech delivery 18 18% LSCS 30 30% Total 100 100%

Discussion: 0.5 percent17respectively. Both these managed with oxytocics after initial factors are found to be significantly resuscitation followed by laparotomy This study was conducted in a associated with Abruption. In our .B- lynch procedure was applied ,since tertiary care referral centre with many study, 9% of women gave past both the patients were unstable ,we patients referred from the peripheral history of Abruption. Past history attempted peripartum hysterectomy hospitals. Review of literature showed of abruptio placenta was found to .In spite of our best efforts we lost that abruptio placenta complicates be associated with poor perinatal these two patients .Both of these 1% of all the pregnancies. The outcome18 .Toivonen et al, reported patients had gone into DIC which frequency of Abruptio Placenta in a recurrent abruption rate of 11.9%, is usually seen in severe degree of our study group was 2.5%. Sarwar et in women with previous history of concealed haemorrhage. al, reported a prevalence of 4.4% in Abruption19 .Thus, it is recommended their population.11 Similar, high rates Perinatal mortality has been strongly that in women with past history have been observed in studies from associated with Abruptio Placenta of Abruption, delivery should be Abu-Heija A et al and Leunen K et al in both national and international considered between 34-37weeks of from Middle East.12, 13. Studies from literature. Many studies from our gestation, once the lung maturity Ananth CV et al have taken maternal Nation, found the perinatal mortality has been documented. Bleeding per age > 35 years as a significant risk around 59%. The high perinatal vaginum was present 80% of them factor for Abruptio Placenta. The mortality rate was not due solely to and it was found to be the most incidence of abruption increases , but also to the common clinical manifestation of with maternal age. In the First and associated increased incidence of Abruption followed by blood stained Second Trimester Evaluation of Risk preterm delivery and fetal-growth amniotic fluid in 16%. Similar results (FASTER) trial, women older than 40 restriction. Nath and co-workers , were also seen in a study by Tikkanen years were 2.3 times more likely to however, reported that et al. Hurd and co-workers reported experience abruption compared with was the overriding association with vaginal bleeding in 78 percent, uterine those 35 years or younger 14.Our study these low-birthweight babies. tenderness or back pain in 66 percent, did not show significant association and in 60 percent of their In the above study, there were a total of Abruption with maternal age. patients20. The mean haemoglobin of 54 (65%) fetal deaths. Statistical Grand multiparity has been found concentration was 7gm/dl, in our analysis in our study showed to be significantly associated with study population. This reflects poor significant association of fetal deaths Abruption in a study done by Pritchard nutritional status in our patients with gestational age. Increased and co workers15, though we found it with iron and folic acid deficiency perinatal mortality was seen with more commonly in third gravida. The which is also a high risk factor for preterm gestation. In our study, the study by Sarwar et al also had 49% of abruption. In another study from association was found much stronger their population with parity between Asia, decreased body mass index, for moderately preterm gestation in 1 and 4. History of previous stillbirth again reflecting poor nutritional status conflict with Ananth study, where and gestational hypertension was seen was found as an etiologic factor for association was far stronger with in 10% and 21% in our population. Abruption21 .Majority of our women, very preterm gestation. This may be Ananth and associates reported a 2.4- 70% had vaginal delivery followed attributed to sample size as well as fold increased incidence of abruption by Caesarean section in 30%. In different limits in salvaging the babies with chronic hypertension, and this study by Tikkanen et al, Caesarean in our setup. The mean birth weight was increased further if there was section rate was as high as 91%.We was found to be 2400g. In a study by superimposed preeclampsia or fetal- had two maternal deaths in our study Nath et al, among abruption cases, growth restriction16. Zetterstrom and group, both due to uncontrolled 60.3% (n = 94) were low birth weight colleagues also reported a two fold haemorrhage. They were referred late in comparison with 11.2% (n = 19) of increased incidence of abruption in to the unit in shock .Both the patients controls. This was attributed to the women with chronic hypertension had severe degree of couvelaire gestational age, and ruled out other compared with normotensive uterus followed by PPH,they were confounders like thrombophilia. women—an incidence of 1.1 versus

40 Sri Lanka Journal of Obstetrics and Gynaecology September 2015 www.slcog.lk/sljog Original Paper

Abruptio placenta is a catastrophic MMWR 52:1, 2003 . perinatal outcome. J Obstet Gynaecol Res obstetrical condition, commonly 2. Gilbert TT, Smulian JC, Martin AA, et al: 1998; 24: 141-4. seen in our hospital. Prevalence of Obstetric admission to the intensive care 13. Leunen K, Hall DR, Odendaal HJ, Grove this disease is higher in our set-up, unit: Outcomes and severity of illness. D. The profile and complications of women since ours is a referral centre and Obstet Gynecol 102:897, 2003. with placental abruption and intrauterine lot of patients with high risk factors 3. Hazelgrove JF, Price C, Pappachan death. J Trop Pediatr 2003; 49: 231-4. do get admitted in our labour room. VJ, et al: Multicenter study of obstetric 14. Cleary-Goldman J, Malone FD, Vidaver J, This condition can be prevented with admissions to 14 intensive care units in et al: Impact of maternal age on obstetric good antenatal care, early diagnosis southern England. Crit Care Med 29:770, outcome. Obstet Gynecol 105:983, 2005. and treatment of risk conditions that 2001 . 15. Pritchard JA, Cunningham FG, Pritchard can cause abruption. No definite 4. Zeeman GG, Wendel Jr GD, Cunningham SA, et al: On reducing the frequency of etiological factor has been identified; FG: A blueprint for obstetric critical care. severe abruptio placentae. Am J Obstet neither the disease can be predicted Am J Obstet Gynecol 188:532, 2003 . Gynecol 165:1345, 1991 . with good sensitivity and specificity. 5. Zwart JJ, Richters JM, Öry F, et al: 16. Ananth CV, Peltier MR, Kinzler WL, et al: The rate of recurrence in subsequent Severe maternal morbidity during Chronic hypertension and risk of placental pregnancies is higher and is also pregnancy, delivery and puerperium in abruption: Is the association modified by associated with poor prognosis. the Netherlands: A nationwide population- ischemic ? Am J Obstet Recently, use of low molecular weight based study of 371,000 pregnancies. Gynecol 197:273.e1, 2007 . heparin has been found to improve BJOG 115:842, 2008. 17. Zetterstrom K, Lindeberg SN, Haglund B, pregnancy outcome in women who 6. Lalonde A, Daviss BA, Acosta A, et al: et al: Maternal complications in women are at risk for recurrent abruption, Postpartum hemorrhage today: ICM/FIGO with chronic hypertension: A population- irrespective of thrombophilia status.22 initiative 2004-2006. Int J Obstet Gynaecol based cohort study. Acta Obstet Gynecol There may be a role of heparin in 94:243, 2006. Scand 84:419, 2005 . improving pregnancy outcome in 7. McCormick ML, Sanghvi HC, McIntosh N: 18. Matsaseng T, Bagratee JS, Moodley J. diseases involving the utero-placental Preventing postpartum hemorrhage in low- Pregnancy outcomes in patients with interface.23 Though, this needs to be resource settings. Int J Gynaecol Obstet previous history of abruptio placentae. Int tested in large randomized trials. 77:267, 2002. J Gynaecol Obstet 2006; 92: 253-4. 8. Ananth CV, Savitz DA, Williams MA. 19. Toivonen S, Heinonen S, Anttila M, Kosma Conclusion Placental abruption and its association VM, Saarikoski S. Obstetric prognosis Abruptio placenta is associated with with hypertension and prolonged rupture after placental abruption. Fetal Diagn Ther poor maternal and fetal outcome. It of membranes: a methodologic review and 2004; 19: 336-41. may recur in subsequent pregnancy. meta-analysis. Obstet Gynecol 1996; 88: 20. Hurd WW, Miodovnik M, Hertzberg V, Improved nutritional status, antenatal 309-18. et al: Selective management of abruptio care and delivery between 34- 9. Nath CA, Ananth CV, DeMarco C, placentae: A prospective study. Obstet 37 weeks of gestation, once lung Vintzileos AM, New Jersey-Placental Gynecol 61:467, 1983. maturity is established, may improve Abruption Study Investigators. Low 21. Hung TH, Hsieh CC, Hsu JJ, Lo LM, Chiu outcome in subsequent pregnancies. birthweight in relation to placental TH, Hsieh TT. Risk factors for placental couvelaire uterus and subsequent abruption and maternal thrombophilia abruption in an Asian population. Reprod PPH can be prevented by termination status. Am J Obstet Gynecol 2008; 198: Sci 2007; 14: 59-65. of pregnancy as soon as abruption 293 e1-5. 22. Rey E, Garneau P, David M, Gauthier R, is diagnosed especially concealed 10. Ananth CV, Berkowitz GS, Savitz DA, Leduc L, Michon N, et al. Dalteparin for variety. ■ Lapinski RH. Placental abruption and the prevention of recurrence of placental- adverse perinatal outcomes. JAMA 1999; mediated complications of pregnancy 282: 1646-51. in women without thrombophilia: a pilot 11. Sarwar I, Abbasi AN, Islam A. Abruptio randomized controlled trial. J Thromb References placentae and its complications at Ayub Haemost 2009; 7: 58-64. 1. Gerberding JL: Centers for Disease Teaching Hospital Abbottabad. J Ayub 23. Hossain N, Paidas MJ. Adverse pregnancy Control and Prevention: Update: Med Coll Abbottabad 2006; 18: 27-31. outcome, the uteroplacental interface, and Pregnancy-related mortality ratios, by 12. Abu-Heija A, al-Chalabi H, el-Iloubani preventive strategies. Semin Perinatol year of death—United States, 1991-1999. N. Abruptio placentae: risk factors and 2007; 31: 208-12.

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