Abruptio Placentae versus Placenta Previa as a risk factor for ...

163ORIGINAL ARTICLEAbruptio Placentae versus Placenta Previa as a risk factorfor Preterm LabourShazia Shukar-ud-Din, Gulfishan Tariq, Nargis SoomroAbstractObjective: The objective of the study is to identify Abruptio Placentae versus Placenta Previaas a risk factor for Preterm Labour and to compare the fetal outcome.Study design: Cross sectional studySetting: Gynae Unit II Civil Hospital KarachiDuration: 23 May, 2006 to 23, January 2007 (8 months)Patients & methods: 50 consecutive patients of APH due to Abruptio Placentae and PlacentaPrevia were studied.Results: 32 cases of Abruptio Placenta and 20 cases of Placenta Previa were managed. Prematuritywas higher in abruption placenta (46.9%) as compare to placenta previa (40%). Perinatalmortality rate associated with abruption placenta was (59.3%), while (30.0%) in placentaprevia. Increased age, grandmultiparity, hypertension and anemia were most common associatedrisk factors with abruption placenta. Most of the patients presented with bleeding pervaginum. The incidence of placenta previa was (20.0%) in patients with previous Caesareansection and (35%) with previous abortion, D&E and D&C. Placenta previa also has shown anassociation with advancing age and parity.Conclusion: APH is an obstetrical emergency associated with maternal and fetal morbidityand mortality. Prematurity is single most common reason for neonatal mortality.Key words: Preterm labour, Placenta previa, Abruptio placenta.Departmemtof Obstetrics &Gynaecology Unit IIDow University of HealthSciencesKarachiS Shukar-ud-DinG TariqN SoomroCorrespondence:Dr. Shazia Shukar-ud-DinFCPSGulshan Market DoubleStorey # 19, 36/C,Korangi # 5,Karachi #31Phone # 0333-2159246IntroductionThe two most important causes of antepartumhaemorrhage from an obstetric standpoint areplacenta previa and placental abruption. Together,these account for around 50% of thecases of antepartum haemorrhage A significantproportion of antepartum bleeds, however, haveno clear cause evident and are considered unexplainedor unclassified, 1 although often theseare speculatively classified as marginal bleeds orbleeds arising from the placental edge. In addition,bleeding may arise from any site within thelower genital tract. Placental abruption is amongthe most devastating complications of pregnancyfor both the fetus and, to a lesser extent for themother. The condition occurs in approximately1 in 100 pregnancies 2 but is associated with upto one third of all prenatal deaths. 3,4 It is associatedwith 39.6% rate of preterm delivery. 5Some of the bleeding of placental abruptionusually insinuate itself between the membranesand uterus, and then escapes through the cervix,causing external hemorrhage. Less often, theblood does not escape externally but is retainedbetween the detached placenta and the uterus,leading to the concealed hemorrhage.Abruptio Placentae is a major cause of maternaland prenatal morbidity and mortality. Maternalcomplications include hemorrhagic shock, DIC,renal failure, ischemic necrosis of distal organse.g. hepatic, adrenal and pituitary, couvelaireuterus leading to postpartum hemorrhage. Fetalcomplications include hypoxia, anemia, growthrestriction, prematurity, neurodevelopmentPak J Surg. 2010; 26(2):163-168

Abruptio Placentae versus Placenta Previa as a risk factor for Preterm Labourproblems and fetal death. Abruptio Placentae isvery frequently seen in our population; howeverlocal work on this important condition of pregnancyis very sparse.The risk of preterm delivery in placenta previa is41.1%. 6 Although the clinical course of placentaprevia is highly suggestive, the etiology of thiscondition is till remains obscure. The strongestconnection is found between previous history ofcesarean section, high parity, and advanced maternalage. 7 Other potential risk factor includehistory of previous spontaneous and inducedabortion 8,9 , previous uterine operations, previousplacenta previa 10 , smoking or substanceabuse during pregnancy 11 , multiple gestation. 12Diagnosis is made on history, clinical examinationand ultrasonography. Risk of preterm deliveryis increased in women with APH who havesecond trimester vaginal bleeding or the presenceof uterine contraction. These facts highlightthe need for proper maternal care and thediagnosis of condition in all pregnant ladies especiallythose at high risk. So keeping these factsin view such cases must be referred for deliveryat tertiary care hospitals where the trained personalsare available.Preterm birth occurs in 7-12% of all deliveries,but accounts for over 85% of perinatal morbidityand mortality. 13 Although the death rate hasdecreased over the past few decades, this canbe attributed to improvements in the neonatalmanagements rather than a reduction in pretermbirths.The mortality, morbidity and costs of pretermdelivery are higher at lower gestational ages, forexample, mortality rates are 90% at 23 weeksdropping to 2% at 34 weeks. Even in babies thatsurvive, there is a high risk of short and longterm morbidity. 14 Some associated conditionsare acute and amenable to treatment but otherssuch as cerebral palsy, neurodevelopment, andpulmonary disorders can result in long term, severedisability. There are also major implicationsin terms of the psychological and social impactof disability on the individuals and their carers.The devastating consequences of prematurity164have led to attempts to improve outcome by predicting,preventing and treating preterm labour.The study under discussion aims to determinethe frequency of preterm labour in APH andfetal outcome. This study will also identify theclinical risk factor associated with preterm deliveryin women with APH. Such informationwill assist in future management of patient withAPH and women with risk factors of second trimestervaginal bleeding and uterine contractionwill benefit from close surveillance in hospitaland repeated blood transfusion, so it will improvethe fetal outcome.Results:52 consecutive patients of APH due to abruptionplacentae and placenta previa were studiedin a period from May 23, 2006 to Jan 23, 2007in Gynae Unit II, Civil Hospital, Karachi. A predesignedproforma was filled and later on analyzed.32 cases of abruptio placentae and 20 patients ofplacenta previa were observed during the studyperiod. The total number of premature babieswere 15 (46.9%) in abruptio placenta comparedto 08 (40.0%) in placenta previa. Prematuritywas high in abruption placenta when comparedwith placenta previa. Distribution of gestationalages showed that 15 cases (46.9%) were lessthan 37 weeks group and 17 cases (53.1%) weregreater than 37 weeks group, while in patientsFigure 1: Abruptio placenta: distribution of patients accordingto outcome (n-32)50403020100Alive FSB IUD NNDKey: FSB-Fresh Still-birth, IUD-Intrauterine Death,NND-Erarly neonatal deathPak J Surg. 2010; 26(2):163-168

165Figure 2: Placenta Previa: distribution of patients accordingto outcome (n-20)80706050403020100Alive FSB IUDKey: FSB-Fresh Still-birth, IUD-Intrauterine Deathwith placenta previa 08 cases (40.0%) were inless than 37 weeks of gestation and 12 cases(60.0%) were of greater than 37 weeks.The perinatal mortality rate associated withabruption was 59.3%. Mortality with abruptionwas more likely to occur before delivery thanafter. 08 patients (25%) had intrauterine deathand 09 patients (28.1%) had fresh still birth.Neonatal APGAR score at one minute was 0 in17 out of 32 cases. In remaining 15 cases, the AP-GAR score was 5 in 7 cases.Early neonatal death seen in 02 cases. Perinatalmortality was seen in 06 (30.0%) patients in placentaprevia. 04 fresh still birth (20.0%) and 02intrauterine death (10.0%) was seen out of 20patients. APGAR score at one minute was 0 in06 cases. In remaining 14 cases, APGAR scorewas 5 in 08 cases.The age ranged between 25 to 40 years and themean age was 30 years in abruption placenta.However, the maximum numbers of patients09 were 31-35 years old, while 06 patients wereless than 30 years old in patients with placentaprevia.Relation to parity showed that a high proportionof patients with placenta previa were multiparous,while nulliparous were only 01. The paritydistribution showed that 02 were nulliparousand 30 patients were multiparous in abruptionplacenta.S Shukar-ud-Din, G Tariq, N SoomroBleeding per vaginum was the frequent presentingcomplain. In cases of abruption placenta 09patients presented with mild bleeding, 13 patientswith moderate and 10 patients with heavybleeding, while in cases of placenta previa 05patients had mild bleeding, 11 had moderatebleeding while 02 patients presented with heavybleeding.Haemoglobin level of mother ranged from 4.0to 10.5 gm/dl. The haemoglobin distributionshowed 23 cases in the 4.0-9.0 gm/dl groups andonly 9 cases in 9.0-10.5 gm/dl groups in abruptionplacenta. 04 cases of placenta previa had thehistory of previous c/section, 05 patients hadthe history of dilatation and evacuation whileone patient had dilatation and curettage.Recurrence in abruption seen in 03 cases.Discussion:Antepartum haemorrhage is an important obstetricentity. The associated high maternal andfetal morbidity and mortality is very challengingfor the obstetricians.Ananth CV et al reported nearly 12% perinatalmortality in 2001 from United States. 4 High rateof fetal and neonatal mortality have been reportedin some studies, such as from Iraq. 15High frequency of maternal anemia is reflectivenot only of the bleeding of abruption placentabut is aggravated by an underlying chronic maternalnutritional deficit common in this country.The suspicion of pre-exsisting anemia in patientssuffering from abruption placenta is difficult toconfirm because majority of the patients wereadmitted as emergencies and were unbookedand prior haematological investigation is exceptional.The association of anemia to abruptionhas also been reported in other studies. 16Sarwar I et al reported 16.98% frequency of hypertension.17 Ananth CV et al reported the linkof abruption placenta and hypertension. 18Liaquat NF reported the recurrence rate of2-17.3% 19 .Pak J Surg. 2010; 26(2):163-168

Abruptio Placentae versus Placenta Previa as a risk factor for Preterm LabourTuzovic Lea et al reported that 41% of womenwith placenta previa delivered prematurely. 6This finding is consistent with another studyconducted by Ananth CV et al. 3 Another studyagain conducted by Ananth CV and colleague in2001 was not coinciding with above and the incidenceof preterm delivery was 12% 20The placenta previa was associated with 30.0%perinatal mortality rate and was explained bygestational age at delivery. Ananth et al & Salihuobserved that the major causes of fetal death inplacenta previa were prematurity, severe haemorrhageand congenital abnormality. 21This study clearly demonsterated that womenolder than 30 years had higher risk of placentaprevia development. Frederiksen and his colleaguereported a similar observation, 22 althoughthe study of Abu-Heija et al, could notprove this association. 8 The mechanism bywhich advanced maternal age impaires normalplacental development is not well understood.One of the possible explanations could be thatthe percentage of sclerotic changes on intramyometrialartries increases with increasing age,thereby reducing the blood supply to placenta.In the study of Abu Heija et al, the gravidity becameimportant after 5 or more previous pregnancies.Some earlier studies showed that paritybecame significant after 4 or more previouspregnancies. 8Women presented with vaginal spotting were atlower risk of being delivered prematurely, whencompared to women who had heavy bleeding.Lam CM et al reported similar results. 23Women with major placenta previa were foundto have higher number of previous c/section,which is in accordance with the study of Dolaet al, in 2003. 24 Study conducted by Ashraf Rand his colleague at Lahore General Hospital in2005 found 65% frequency. 25166It can be concluded that APH is an obstetricemergency associated with maternal and fetalmorbidity and mortality. Prematurity is thesingle most common reason for neonatal mortality.The fetal survival is much lower in developingcountries than in developed world due tothe lack of properly equipped neonatal intensivecare facilities. The blood transfusion services,which are mainly available at tertiary care centresare unable to meet the demand of massivetransfusion which is required in APH. The etiologyof abruption may remain unknown so it willremain unavoidable cause of poor fetomaternaloutcome. More research is needed to explorethe insight of abruption to achieve a better outcome.The majority of patients of perinatal mortalitypresented with intrauterine death so that anymanagement protocol directed at abruptionplacenta and its consequences is of little help inpreventing perinatal mortality.Any patient who is at risk of abruption placentaand has vaginal bleeding during the last trimesterof pregnancy should be hospitalized until thedelivery and blood transfusion. Obstetric outcomefor women with the history of abruptionplacenta can be improved if good antenatal careis provided at a center with the expertise to identifythe risk factors and to intervene timely.Women with risk factors should be carefullyevaluated during pregnancy for detection of placentaprevia. The condition can be diagnosed onultrasonography. Early detection should encouragea careful and exact evaluation with timelydelivery in order to prevent or reduce the occurrenceof maternal and perinatal complicationsassociated with placenta previa. The results ofstudy indicate that knowledge about the obstetricfactors predisposing the women for placentaprevia development is important for choosingadequate preventive measures for these women.Awareness of clinical risk factors can aid in carefulpreoperative preparation and in counselingwomen with placenta previa regarding the likelihoodof encountering placenta accreta.Advanced maternal age, a risk factor for placentaprevia is important for women who contemplatedelayed child bearing and for clinicians whoprovide antenatal care and counseling to them.Pak J Surg. 2010; 26(2):163-168

167Older mother especially after the age of 35 yearsshould be carefully evaluated for placenta previa.Women should be encouraged to completetheir families relatively earlier in their reproductiveage.Women of higher gravidity and parity also needspecial attention with regard to the placentallocalization. Public awareness should be thereabout the risk of multiparity especially grandmultiparity.Couples should be advised to limitthe family size and practice contraception.Caesarean delivery is an important milestone inthe history of obstetrics, though has considerablydecreased the maternal and perinatal morbiditybut at the sametime has resulted in certain adverse consequences.The frequency of placenta previa is very highin previous caesarean section. One should anticipateit in all patients with previous caesareansection. One should also anticipate adherentplacenta and the chances of performing caesareanhysterectomy should also be kept in mind.Always counsel and take prior consent fromthe patient and her husband about the possibilityof undergoing caesarean hysterectomy. Thestudy thus provides the reason for reducing theprimary c/ section rate and advocating vaginalbirth for women with prior caesarean delivery.ECV should be promoted for breech presentation.Obstetrician should be sufficiently trainedto conduct instrumental vaginal deliveries andbreech delivery of a woman who comes at fullcervical dilation.The association of placenta previa with previousmiscarriage is important. Woman with suchhistory especially evacuated by D&E should becarefully screened for placenta previa. Peopleshould be informed of the dire consequences ofinduced abortion and advised to practice othermethods of family planning rather than gettingrid of conception in this way. In Pakistan manywomen fall a pray in the hands of quacks to getrid of unwanted pregnancy, who carry out abortionin an unsafe manner without asepsis, whichresult in serious morbidity and some times mortality.Delay or fault from the part of patient, her relativeor traditional and religious barrier, poortransport facilities and bad roads may lead tomany deaths at home or on the way. The complicationsare life threatening and can be preventedby adequate health care infrastructure by usingavailable resources.The poor fetal outcome is more common inabruption than in placenta previa. Howeverboth condition compromise maternal outcome.PPH, renal complications, caesarean hysterectomyrequiring massive blood transfusion are themajor maternal complications observed.References:S Shukar-ud-Din, G Tariq, N Soomro1. Chan CC, To WW. Antepartum haemorrhage of unknownorigin- what is its clinical significance? Acta Obstet GynaecolScand 1999; 78:186-1902. Ananth CV, Smulian JC, Demissie K, Vintzileos AM, KnuppelRA. Placental abruption in singletone and twin births inUnited States: risk factors profiles. Am J Epidemiol 2001;153: 771-83. Ananth CV, Berkowitz GS, Savitz DA, Lapinski RH. Placentalabruption and adverse perinatal outcomes. JAMA 1999;282:1646-514. Ananth CV, Wilcox AJ. Placental abruption and perinatal mortalityin the United States. Am J Epidemiol 2001; 153: 332-75. Sheiner E, Shoham-Vardi I, Hardar A, Hallak M, Hackmon R,Mazor M. Incidence, obstetric risk factors and pregnancy outcomeof preterm placental abruption: a retrospective analysis.J Metern Fetal Neonatal Med 2002; 11: 34-96. Tuzovic L, Djelmis J, Llijic M. Obstetric risk factors associatedwith placenta previa development; case control study. CroatMed J. 2003; 44: 728-33.7. Gilliam M, Rosenberg D, Davis F. The likelihood of placentaprevia with greater number of cesarean deliveries and highparity. J Obstet Gynaecol 2002; 99: 976-808. Abu-Heija A, EL-Jallad F, Ziadeh S. Placenta previa: effect ofage, gravidity, parity and previous cesarean section. ObstetGynaecol Inv 1999; 47: 6-89. Ananth CV, Smulian JC, Vintzielos A. The association of placentaprevia with history of cesarean delivery and abortion: ameta analysis. Am J Obstet Gynaecol 1997; 177:1071-810. Weerasekera DS. Placenta previa and scard uterus – an obstetrician’sdilemma. J Obstet Gynaecol 2000; 20: 484-8511. Macones GA, Sehdev HM, Parry S, Morgan MA et al. The associationbetween maternal cocaine use and placenta previa.Am J Obstet Gynecol 1997; 177:1097-10012. Francois K, Johnson JM, Harris C. Is placenta previa morecommon in multiple gestation? Am J Obstet Gynecol 2003;188:1226-713. Goswami K, Thornton S. The prevention and treatment of pretermlabour. Studd J. Progress in obstetrics and gynaecology.2007; 17: 217-30.14. Hack M, Flannery DJ, Schluchter M, Cartar L, Borawski E etal. Outcomes in young adulthood of very low birth weight infants.N Engle J Med 2002; 346: 149-5715. Sharief M, Manther AA. Abruptio placentae: perinatal outcomein normotensive and hypertensive patients in Basra,Iraq. East Mediterr Health J.1998; emhj; 4: 319-23. AvailablePak J Surg. 2010; 26(2):163-168

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