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

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A Clinical Study of Maternal and Fetal Outcome in Abruptio Placenta - Couvelaire Uterus a Preventable Obstetric Catastrophe Vijayasree M 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 maternal death 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 pregnancies. Aim of and still birth.9, 10.The purpose of this this study was to determine the maternal and fetal outcome in pregnancy 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 Obstetrics 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 amniotic fluid 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 – eclampsia 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 childbirth, 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 fetus. 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 stillbirth and E-mail: [email protected] polyhydramnios. 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 gestational hypertension 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.
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