Abruptio placenta: an obstetrician’s nightmare

ISSN Print – 2454-2334; ISSN Online – 2454-2342 DOI -10.21276/obgyn.2023.10.1.26 RESEARCH ARTICLE Abruptio placenta: an obstetrician’s nightmare Abhirami GR, Sathyavani C, Maria Cecilia Alexander, Shiny Varghese, Ravi N Patil, Rajnish Samal, Nalini Arun Kumar Corresponding author: Dr Anusha Kamath, Assistant Professor, Department of Obstetrics and Gynaecology, AIIMS, Nagpur, India; Email – Distributed under Attribution-Non Commercial – Share Alike 4.0 International (CC BY-NC-SA 4.0) ABSTRACT Background: Abruptio placenta is as an important cause of antepartum hemorrhage (APH) and accounts for 20 – 25% of all cases of APH. It is defined as premature separation of a normally situated placenta before the delivery of the fetus. Abruptio placenta is a serious obstetric condition that increases maternal and neonatal morbidity and mortality. Objectives: This study was undertaken to determine the incidence, etiology, risk factors, clinical presentation and feto-maternal outcome of abruptio placenta. Method: This was a prospective observational study done in Bangalore Baptist Hospital from 2017-2020. The primary outcomes were included the occurrence and frequency of various maternal complications and evaluation of fetal and neonatal outcomes in patients with abruptio placenta. All the pregnant women fulfilling the inclusion criteria were considered for the study. Results: We had a total of 37 women with abruptio placenta during this period with an incidence of 0.4%. The incidence was higher in the age group above 30 years (40.5%) and among primiparous women (54.1%). Pre-eclampsia was identified as the most common risk factor among these women (59.5%). There were 13 women (35.1%) who had an intra-uterine fetal demise at the time of admission. The main mode of delivery among live births was caesarean section (61.5%) and that for intra-uterine fetal demise was vaginal delivery (83.3%). The maternal complications included requirement of blood transfusion (67.6%), disseminated intravascular coagulation (DIC) (3%), hypovolemic shock (11%) and ICU admission (16.2%). There was no maternal mortality among the study population. The perinatal mortality was 48.6 % comprising of 13 intra-uterine fetal demise and 5 early neonatal deaths. Conclusion: Abruptio placenta is associated with poor maternal and fetal outcome. Hence early detection and active management is necessary to reduce maternal and fetal morbidity. Educating the pregnant mother about the importance of antenatal care and easy accessibility to quality antenatal services would go a long way in bringing down the maternal and perinatal morbidity and mortality related with abruptio placenta. Keywords: Abruptio placenta, pre-eclampsia, live births, maternal complications. The Royal College of Obstetricians and Gynaecologist defines antepartum hemorrhage (APH) as bleeding from or into the genital tract after 24+0 weeks till the birth of the baby. Abruptio placenta (AP) is as an important cause of APH and accounts for 20 – 25% of all cases of APH 1, 2. It is defined as premature separation of a normally situated placenta before the delivery of the fetus. AP complicates approximately 0.4- 1% of all pregnan cies 3. It is classified into concealed and revealed types, where the blood collects behind the placenta and there is no evidence of vaginal bleed in concealed type and the blood tracks down between the membranes and the uterine wall to present through the vagina in a revealed abruptio placenta. The primary cause of AP in majority of the cases remains unknown but the main predisposing and precipitating factors are pregnancy induced hypertension, pre-eclampsia, advanced maternal age, multiparity, premature rupture of membranes, smoking, polyhydramnios, abdominal trauma, fetal growth restriction, intrauterine infections and past history of abruption 1, 4. There is a tenfold increased risk in subsequent pregnancies with the diagnosis of abruptio placenta 5. Received: 3rd November 2021, Peer review completed: 22nd March 2022, Accepted: 6th April 2022. Abhirami GR, Sathyavani C, Alexander MC, Varghese S, Patil RN, Samal R, et al. Abruptio placenta: an obstetrician’s nightmare. The New Indian Journal of OBGYN. 2023; 10(1): 149-53. The New Indian Journal of OBGYN. 2023 (July-December);10(1) The clinical hallmarks of AP are abdominal pain and vaginal bleed with which most patients usually present 6. The RCOG recommends that the process of triage essentially include history of pain and extent of vaginal bleed followed by an assessment of maternal cardiovascular condition. Only then should assessment of foetal well-being be attempted 1. AP is a major cause of maternal and perinatal morbidity and mortality 7. It is associated with maternal complications like, disseminated intravascular coagulopathy (DIC), maternal shock, acute renal failure (ARF), postpartum hemorrhage (PPH) and anemia 1, 8. It is also associated with undesirable fetal outcomes due to hypoxia, prematurity, growth restriction and fetal death 1, 9. Most of the perinatal mortality is attributable to death within the uterus 10. Abruptio placenta is a serious obstetric condition that increases maternal and neonatal morbidity and mortality. Accurate knowledge is essential for prompt diagnosis and timely intervention. Hence this study was undertaken to determine the incidence and to evaluate the risk factors that predispose to placental abruption. The primary outcomes also included the occurrence and frequency of various maternal complications and evaluation of fetal and neonatal outcomes in patients with abruptio placenta. Methodology This was a prospective observational study done over a period of 3 years from 2017-2020 in Bangalore Baptist hospital, a tertiary hospital in Bangalore, South India. The study population included all the pregnant women who presented with abruptio placenta and excluded pregnant women who presented with antepartum hemorrhage due to other causes. Institutional review board and ethical committee approval was obtained. All the pregnant women booked at Bangalore Baptist Hospital and fulfilling the inclusion criteria were considered for the study. The women’s demographic details such as age, gravida status, gestational age, menstrual history, past, family, and personal history were recorded. Detailed obstetric history was obtained and maternal high-risk factors like gestational hypertension, pre-eclampsia, gestational diabetes mellitus and polyhydramnios were noted. All the women underwent a complete obstetrical examination and clinical workup including general physical examination, abdominal and pelvic examination, and relevant blood investigations such as complete blood count, coagulation profile and certain biochemical markers. Since 95% of the women presented in the emergency department, placental abruption was suspected depending on clinical features of vaginal bleeding, uterine tenderness, hypertonic uterus, and diagnosis was confirmed by retro (...truncated)