INTRODUCTION

Placenta praevia is a common obstetrical problem with serious consequences, including a perinatal mortality rate as high as 12.6 to 21.3%, low APGAR score, congenital abnormalities, prematurity and maternal morbidity. It is one the most common causes of   antepartum   haemorrhage which is 3-4% and placenta praevia occurs in 0.8% of pregnancies and accounted for 22% of all antenatal haemorrhage.

Placenta praevia refers to the placenta that is situated wholly or partially in the lower uterine segment at or after 28 weeks of gestation. Prior to 28 weeks, placenta may be situated in or close to the developing lower segment and is described as low lying. Most of the low-lying placenta will not become the placenta praevia.

Smoking and cocaine use at any time during pregnancy increases the relative risk of developing the placenta praevia¹. These findings were confirmed by Handler et al². Their results also found an association between placenta praevia and cocaine use³. Ananth et al found relative risk of praevia in smokers as compared to non-smokers³. The incidence of increased risk of placenta praevia and abruptio placenta was also supported by study of Andres⁴ and Brenner et al⁵.

Placenta praevia was diagnosed by trans-abdominal USG according to Jaunaux and Campbell classification as under:

Type-I: The placenta just encroaches on lower uterine segment.

Type-II: Placenta reaches the margin of the cervical os.

Type-III: Partial placenta, partially covering the internal os.

Type-IV: Total placenta completely covering the internal os.

Classification is very important and useful in the management and decision-making regarding the mode of delivery in patients having placenta praevia.  This study was designed to evaluate the fetaloutcome in major degree placenta praevia and variable in live fetus including weight, apgor score, respiratory distress syndrome, anaemia and jaundice

MATERIALS AND METHODS

This study was conducted in the department of Obstetrics and Gynaecology, Unit-III, Nishtar Hospital, Multan, over one year period extending from July 1998 to June 1999. Total number of deliveries were 1230. A total number of 52 patients were enrolled for the study purpose, which were either received as an emergency or were, booked cases and their fetal outcome was studied. The patient with ante-partum haemorrhage (APH) were admitted and resuscitated in labour rooms, their general condition, vitals and vaginal bleeding were recorded. The possible risk factors for placenta praevia like age, parity, previous caesarean section, previous miscarriages; retained placenta, multiple pregnancies, lie and presentation of the fetus were recorded on a proforma designed for the study. Ultrasound examination was performed for obstetrical reasons as well as for the exact location of placenta.

Inclusion criteria

Major degree placenta praevia type-III and transvaginal diagnosed on USG, both symptomatic and asymptomatic.

Exclusion criteria

Patient having APH due to placenta praevia type-I, II, abruption placenta, incidental causes and major degree placenta praevia with intrauterine death and congenital abnormality were excluded.

RESULTS

Total number of 52 pregnant women having major degree of placenta praevia was enrolled in this study. Analysis of their booking status showed that only 8 (15.38%) cases had booked themselves in the hospital while 44 (84.62%) remained without antenatal care (Table 1).

Table 1: Antenatal booking status 

Regarding the maternal age the maximum number of patients 18 cases (34.61%) were between 36-40 years, while 13 (25%) were of age 31-35 years. The age of 11 patients (21.15%) was between 26-30 years. Only 10 (19.24%) were in the age between 20-25 years (Table 2).

Table 2: Age distribution 

Table 3 shows that the number of fetuses 49 (94.25%) had singleton pregnancies while only 3 (5.8%) patients had twin gestation. Relationship of gestational age at the presentation showed that the maximum number of cases 24 (46.3%) of major degree placenta praevia presented at 33-36 weeks, 16 (30.7%) were at 29-32 weeks, 7 (13.4%) were at 24-28 weeks. Only 5 (9.6%) patients were at 37 weeks and above (Table 4).

Table 3: Number of fetuses 

Table 4: Gestational age at the time of presentation

Regarding the choice of management 37 (71.2%) were actively managed and among them 13 (25%) of the patients having major degree placenta praevia was at 37 weeks or above. Expectant management was given in 15 (28.8%) patients and mean length of management was 15-18 days. In them antenatal Dexamethasone 12.5 mg twice a day was administered intravenously to facilitate lung maturation. The therapy to the mother was repeated after one week if necessary (Table 5). At the time of delivery 33(63.46%) neonates were alive, 19 (36.54%) (Table 6).

Table 5: Active or expectant management 

Table 6: Condition of fetus in utero 

Relationship between weight at different gestational age showed that 6 (11.5%) patients who were at 24-32 weeks gave birth to babies with weight less than 2000 gm.  15 (28.8%) patients at 33-34 weeks gave birth to babies having weight 2100-2500 gm. 18 (34.7%) patients at 35-36 weeks delivered babies having 2600-3000 gm, and 13 (25%) who delivered at 37 weeks or above had babies having weight 3100-3400 g (Table 7).

Table 7: Fetal weight 

Regarding the APGAR score the patients who were managed actively gave birth to babies having APGAR score at 1 minute 4.9, at 5 minutes 6.6 and at 10 minutes 7.9 while the APGAR score was better in neonates of the mother given expectant management. It was 6.8 at 1 minute, 7.7 at 5 minutes and 8.4 at 10 minutes (Table 8).

Table 8: Live birth/dead fetus fresh stillbirth

As regards the need for resuscitative measures, 19 (57.58%) neonates required no resuscitation while 14 (42.42%) neonates were shifted to neonatology intensive care unit. Of those shifted to the neonatology intensive care unit, 5 915.15%) expired within 24 hours while 9 (27.27%) recovered and were shifted back to the ward in a satisfactory condition. The perinatal mortality from my study was 46.15% (Table 9).

Table 9: Mean aogar score of live born fetuses (n-33*) 

 Fetuses who had already intrauterine death were excluded for this table. 

Out of 33 live born neonates, 14 (42.42%) babies were shifted to neonatology intensive care unit where they were diagnosed having respiratory distress syndrome on clinical grounds, 3 99%) babies were diagnosed as having anaemia (haemoglobin level <13.5 g/dl) in first 12 hours of life, 2 (6%) babies developed jaundice within first 24 hours. All these babies had preterm delivery(gestational age <37 weeks)(Table 10).

Table 10: Neonatal outcome in live-born fetuses (n-33)

DISCUSSION

Placenta praevia is a common obstetrical problem associated with considerable maternal and fetal morbidity and mortality. It is frequently associated with antepartum haemorrhage and is a precipitating factor for preterm labour.

Exact etiology is unknown but the risk factors are advancing maternal age, multiparity, previous pregnancy with placenta praevia, previous caesarean sections, post-abortal pregnancies or pregnancy with multiple gestation. Painless bleeding in the second half of pregnancy is the cardinal sign of placenta praevia in 70-80% of patients.

The study reveals that APH due to placenta praevia was more common in mothers who had no antenatal visits as compared to those availed effective antenatal care and had prenatal diagnosis of placenta praevia before it manifested as APH, thus showing the importance of antenatal care. Most of the patients with major degree placenta praevia were multiparous with advancing age and these results are consistent with studies done by Cunningham and Leveno⁶.

The percentage of asymptomatic patients was 38.8%, which is quiet high as compared to study results of Cotton⁷, which was of 10%. The choice for the management of major degree placenta praevia was at that discretion of the obstetrician in charge. Those patients with severe antepartum haemorrhage were actively managed with blood transfusion and immediate delivery with caesarean section irrespective of the period of gestation.

In other patient in whom the period of gestation was less than 36 weeks and were asymptomatic or had mild vaginal bleeding were given expectant management. It was seen the outcome variables of neonates (APGAR score, anaemia, respiratory distress syndrome, jaundice) were better as compared to those patients managed actively.

The majority of the patients in this study had preterm deliveries and these preterm infants tended to suffer from lower APGAR score which is consistent with of other reports^3,5. It was also noted that preterm infants of the mother with placenta praevia were associated with higher incidence of respiratory distress syndrome and it was possibly worst in severity as has reported similar findings by Silver⁸.

CONCLUSION

It is concluded from the study results that neonatal complications of major degree placenta praevia include preterm birth, low APGAR score, respiratory distress syndrome, anaemia and congenital anomalies.

Antenatal care should be improved and placenta praevia should be pre-diagnosed and patients with major degree placenta praevia should be referred to hospitals with good anaesthetic, surgical and neonatal facilities to improve the maternal and fetal outcome.

The study results showed that babies delivered after expectant management had better APGAR score, lower prevalence of RDS and anaemia as compared to the neonates of actively managed patients. So we should prolong the pregnancy in the patients having major degree placenta praevia to 36 weeks gestational or longer if no contra-indication is present. Prenatal Dexamethasone should be administered to facilitate fetal lung maturation. Neonatal unit should be well equipped to cope with problem associated with prematurity.

REFERENCES

William MA, Mittendrof R, Leiberman. Cigarette smoking during pregnancy in relation to placenta praevia. Am Obstet Gynecol 1991; 165: 28.

Handler AS, Mason ED, Rosenberg DL. The relationship between exposures during pregnancy to cigarette smoking and cocaine use and placenta praevia. Am J Obstet Gynecol 1994; 170: 884.

Ananth CV, Savitz DA, Luther ER. Department of epidemiology, School of Public Health, University of North Carolina at Chapel hill USA. Am J Epidemiol 1996; 144(9): 881-89.

Andres. Division of maternal and fetal medicine, University of Texas, Houston Health Science Centre, USA. Senin perinatal 1996. The association of cigarette smoking with placenta Praevia and abruptio placenta.

Brenner W, Edelman D, Hendrick C. Characteristics of patient with placenta praevia and results of expectant management. Am J Obstet Gynecol 1978; 132: 180-9.

Cunningham FG, MacDonald PC. Leveno KJ. William’s obstetrics. 18^th edition. (suppl-2). East Norvalk: Applenton and Lange, 1989.

Cotton D, Read J, Paul R, Quillign E. the conservative aggressive management of placenta praevia. Am J Obstet Gynecol 1980; 137: 687-95.

Silver R, Depp R, Salbagha RE, Dooley SI, Socolni Turma RK. Placenta praevia aggressive expectant management. Obstet Gynecol 1984; 150: 15-22.