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MATERNAL RISK FACTORS AND FETAL OUTCOME IN PATIENTS OF ABRUPTION PLACENTAE

Abruption placentae are a major cause of maternal and perinatal morbidity and mortality. Placental abruption is due to the rupture of the uterine spiral artery. Bleeding into decidua leads to separation of the placenta. There are many major maternal and fetal complications associated with placental abruption. Objectives: To assess the maternal risk factors, perinatal mortality and morbidity in relation to the severity of placental abruption. Study Design: Descriptive case series. Setting: Department of Obstetrics and Gynecology, Jinnah Hospital, Lahore for one year. Period: From Jan 2016 to Dec 2016. Material & Methods: Hundred females were included with placental abruption and were followed-up till delivery. At the time of delivery maternal and fetal complications were noted. Results: Mean age of females was 29.24 + 3.58years. The mean gestational age at delivery was 32.95+3.12 weeks. About 64% underwent vaginal delivery while 36% underwent cesarean section. Among pre-disposing factors increased risk of anemia i.e. 46%, hypertension was found in 28%, multiple pregnancies with 18% and polyhydromnias were found in 8%. The incidence of fetal mortality was 58% and only 42% were born alive at time of delivery. Fetal morbidity is analyzed, 95.23% were in need of resuscitation, admission to nursery was done in 95.23%, neonatal jaundice was seen in 80.95%, anemia in 71.42% and respiratory problems were found in 85.71%. APGAR score at 5 minutes among 21 alive born fetuses was <8 in 85.71%. Conclusion: Resultantly maternal morbidity and perinatal mortality is significant, and this calls for early detection, regular visits, and special surveillance. There should be timely referral to tertiary care center where antenatal care plays an important role in decreasing the incidence of abruption placenta.


INTRODUCTION
Abruption placenta is defined as detachment of placenta before delivery. Approximately 0.7% to 1.0% singleton pregnancies have abruption placenta. [1][2][3] The incidence increases in twin up to 1% to 2%. 4,5 Even though abruption placenta is not very common; it is still a major cause of fetal and neonatal mortality. This high mortality in abruption placenta can be linked to its association with preterm birth. 6 More than 50% of fetal death in abruption placenta was because of premature delivery. 6 There are many maternal complications as well because of abruption; however the major complications are life threatening blood loss, DIC and sepsis, kidney failure and even maternal death in few cases. 7 While the incidence of placenta abruption is 1%, it is still not well understood. 8 Major risk factors responsible for placental abruption are increase maternal age, smoking and abuse of cocaine, multiparity, woman of poor socio-economic status, multiple births, black woman, male child, hypertensive disease in mother and intrauterine infections. 4,[9][10][11][12][13][14][15] However, the strongest associated factor with placental abruption is history of abruption in previous pregnancy. 16,17,18 Despite being associated with grave maternal and fetal complications, clinical data on abruption, particularly local data is grave. It is important to recognize risk factors and complications associated with abruption, so that appropriate management plan can be made for pregnant women who are at risk of abruption.
In this study, we assess the perinatal mortality and morbidity and risk factors in patients with

MATERIAL AND METHODS
This was a cross-sectional study conducted in department of Obstetrics and Gynecology, Jinnah Hospital Lahore from Jan 2016 to Dec 2016. During this period, total of 100 patients admitted at the time of their delivery with already established diagnosis of placental abruption after 24 weeks of gestation were included. After taking informed consent data was collected for selected cases. Data included age, parity, gestation age, predisposing factors and symptoms of abruption placentae. Mode of delivery, Neonatal Apgar Score at birth and five minute and fetal morbidity was also noted. The morbidity in the form of admission in neonatology unit for more than 48 hours and any complication developed was considered morbid. The data was analyzed using SPSS version 21. Calculating mean and standard deviation for numerical data like age, gestational age and APGAR score. Frequency and percentage were calculated for qualitative variables like parity, maternal and fetal outcome, predisposing factors like hypertension, anaemia, polyhydramnios and multiple pregnancy, symptoms of abruption placentae.

DISCUSSION
Abruption placentae are one of the grave complications of pregnancy. It has very high maternal and perinatal mortality as well as morbidity. These can be avoided by treating shock and conducting early delivery preferably by vaginal route. While this study adds to limited local data available on abruption, because of its crosssectional nature it was not able to establish causal relationship between risk factors and abruption. Large scale multi-centric prospective studies are needed to further establish associations between risk factors and abruption.
Forty six (46%) patients had anaemia, with haemoglobin levels of severe to moderate anaemia. This high prevalence of anemia can be because of bleeding that occurs in abruption.
Another reason for high prevalence of anemia can be nutritional deficit, which is very common in pregnant woman in this country. Another local study supports our finding of high number of patients with anemia; as they reported 34.4% of patients with abruption placentae have anemia. 27 The patients in this study had a frequency of hypertension in 28% cases. This number may be even higher as actual blood pressure at the time of delivery may be masked because of bleeding due to abruption placentae. Various authors have studies role of hypertension. Abdella 28 noted that incidence of abruption was highest in woman who had eclampsia (23.6%), followed by chronic hypertension (10.0%) and then pre-eclampsia (2.3%). Abdella [28] helped established that hypertension is associated with increased incidence of abruption and is associated more with eclampsia than any other hypertensive disorder. Similar findings were seen by Sharief and Manther; 29 In their study they compared hypertensive and normotensives pregnant woman and found that there is increase incidence of abruption in hypertensive group.
In this study, fetal mortality was very high. Fifty eight (58%) patients had intra-uterine fetal mortality. These high fetal mortality can be attributed to either abruption placentae itself or one its complication. Similar high fetal mortality was found in studies from neighboring countries such as India and Iraq. 29 To summarize, abruption placentae is a serious obstetric problem with very high neonatal mortality and morbidity and grave influence on maternal health. It is important that efforts should be made to recognize woman at risk of abruption placentae early and high risk management strategies should be adopted to reduce the risk.