Materno-Fetal Prognosis of Retro-Placental Hematoma at the Centre Hospitalier Universitaire Communautaire ()
1. Introduction
The majority of pregnancies and births go off without incident even though they all present risks [1]. Among these risks there is retro-placental hematoma (RPH), an extreme obstetric emergency. RPH, and placental insertion anomalies, are the two main etiologies of bleeding in the third trimester of pregnancy [2] [3]. RPH is a major cause of perinatal mortality and morbidity [4].
In general, 30% of HRP cases can be iatrogenic origin [2]. The proportion of RPH in the population is estimated at 0.8%, 0.7% and 1.0%, respectively in all races, white and black [5]. But its frequency is variously appreciated. Globally, some authors estimate it to be 0.25% to 0.50% of cases on average [2]. In the USA, its incidence is estimated between 0.6% and 1.2% of all pregnancies [6]. In 80,000 deliveries, 181 cases (0.23%) of RPH were observed by Merger [7]. In Africa, the Akpadza study in Togo estimated its frequency at 0.47% [8]. Other African authors have reported higher RPH frequencies ranging from 1.97% to 3.6% [9] [10] [11].
In the Central African Republic (CAR), no specific study has been carried out on the subject. In the studies by Sépou and Coll on bleeding in the third trimester of pregnancy, 0.23% of RPH cases (17 cases/7164 deliveries) were observed [12]. In another Central African study, these bleedings are due to RPH in 0.16% of cases [13]. The proportions of maternal and neonatal deaths from RPH were 5.3% and 71.4%, respectively [14]. Other studies report 1.2% and 6.2% respectively of maternal deaths from RPH [14] [15]. The purpose of our study was to assess the maternal-fetal prognosis of this pathology in our patients.
2. Patients and Methods
This is a retrospective descriptive and analytical study over 5 years ranging from the period from January 1st, 2015 to December 31st, 2019. The study population consisted of pregnant women, in the 3rd trimester who presented with the retro-placental hematoma during the pregnancy or childbirth and taken care in the maternity ward of the Centre Hospitalier Universitaire Communautaire. The RPH diagnosis was clinically done and confirmed after the childbirth. Our sample was comprehensive, including all retro-placental hematoma cases. The variables studied on each patient were: Age, parity, gestational age, history of toxemia of pregnancy, clinical signs, association with placenta previa, route of delivery and maternal-fetal complications.
The data were collected on a pre-established form, tested and validated during the pre-survey phase. After the analysis and coding of the survey forms, data entry and analysis were done with Epi Info software version 3.5.3. We received the ethical clearance before realizing the study.
3. Results
During our study period, we recorded 87 cases of retro-placental hematoma, and 40,763 deliveries. The frequency of retro-placental hematoma was 0.21% at delivery. The average maternal age was 26.4 years with extremes of 16 and 40 years. The average parity was 3.8 with extremes of 1 and 13 (Table 1).
The mean gestational age at the time of the onset of the accident was 35.9 amenorrhea weeks (AW) with extremes of 28 and 40 AW. The majority of patients, 63 cases (72.4%), were seen after 37 AW while in 27.6% (24 cases) the gestational age ranged from 28 to 36 AW. The high blood pressure history on the pregnancy was found in 43% of the patients. Clinically 17.3% had altered consciousness, and 81.6% had conjunctival pallor (Table 2).
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Table 1. Distribution according to the age and the parity of patients.
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Table 2. Distribution according to the general signs.
SBP = Systolic Blood Pressure and DBP = Diastolic Blood Pressure.
The combination of retro-placental hematoma and placenta previa was found in 5 patients (5.7%). The diagnosis of retro-placental hematoma was clinical in 84 patients (96.5%) compared to 3 cases (3.5%) diagnosed after emergency ultrasound.
The proportion of vaginal deliveries was 45 cases (51.7%), and caesarean section 42 cases (48.3%). We performed 4 cases of hysterectomy (4.5%). We recorded 8 maternal deaths (9.2%) (Table 3) and 60 newborn deaths (69%).
The causes of maternal death were dominated by afibrinogenemia 62.5%, followed by renal failure in 25%. Factors influencing maternal death were referred parturients and those who developed afibrinogenemia with a statistically significant difference (Table 4).
4. Discussion
We did a hospital study that cannot be extrapolated to the whole country. This is the limit of the study. The frequency of cases of retro-placental hematoma in our series was 0.21% of delivery. This frequency is similar to that of several authors who respectively reported 0.47%, 0.34%, 0.65%, and 0.23% [8] [12] [16] [17].
This frequency follows the trend of high blood pressure during pregnancy. Patients in the 20 to 24 age group were found in 31% of cases in our study. This proportion is identical to that reported by Akpadza in Togo and Mezane in Morocco, with respectively 29.86% and 29.8% of cases [8] [18].
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Table 3. Distribution according to the types of maternal complications.
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Table 4. Distribution according to the admission mode and the causes of death.
Then, teenage girls had also occupied a significant place with 13.8% of cases. In Chad, Foumsou found 10.9% of HRP cases in obstetric complications in adolescent girls during labor [19]. The proportion of teenage girls found by Akpadza and Mezane is lower than that of our study, respectively 5.22% and 8.5% [8].
This is explained by the fact that girls enter sex life in Bangui at an early age, as Sépou has pointed out [20]. Even if multiparity is incriminated as a factor in the onset of retro-placental hematoma due to vascular fragility due to microangiopathy, as is also found in twin pregnancy and hydramnios [3].
In our series; it occurs regardless of the parity. Retro-placental hematoma most often occurs after high blood pressure in pregnancy [3]. If it is diagnosed and managed correctly, during pregnancy the chance of having RPH decreases. The mean gestational age reported by our study (35.9 AW) was close to those found by Diouf and Hossain, respectively 36 WA and 34 AW [21] [22]. Conjunctival pallor was found in 81.6% of cases (71/87) in our study. In Togo, Akpadza had a similar result with 76.3% of cases of paleness of the conjunctiva [8].
In addition, Konaté observed a rate of conjunctival pallor close to the half to the one of our study (43.1% of cases) [17]. The high rate of conjunctival pallor is thought to be linked to the late diagnosis of retro-placental hematoma. The association of retro-placental hematoma and placenta previa was identified by Akpadza and Konaté in 4.74% and 17.24% respectively [8] [17].
We found this association in 5.5% of cases. This combination often worsens the risk of bleeding. RPH is a life-threatening emergency for both the mother and the fetus if it is still alive. The management depends on the severity of the RPH, the gestational age, the immediate risks (maternal and fetal) and the anticipation of these risks [23]. It should always be remembered that the care must not delay. Vaginal delivery, after direction of labor (in the absence of contraindication), was performed in 51.7% of cases.
Caesarean section was performed in 48.3% of cases in our series. Her decision had been made straight away whether the child was alive and whether the vaginal birth had maternal and fetal risks or after a failure of the labor management. The caesarean section rate in our study is within the range of those in the literature [17] [22]. Maternal morbidity was marked by acute anemia of hemorrhagic origin in 81.6%, hypovolemic shock in 44.8%, coagulation disorders which were found in 12 patients (13.8%), acute renal disease in 5.7% (our results are consistent with the one of Akpadza [8].
The parameters of poor maternal prognosis were afibrinogenemia and the baseline with a statistically significant difference (p < 0.00). Several authors have reported high perinatal mortality rates [6] [8] [21]. In our series, we recorded 69% of deaths among newborns.
5. Conclusion
At the end of this 5-year study on the retro-placental hematoma, in the Department of Gynecology and Obstetrics, it appears that this pathology has a high maternal and fetal mortality.