Maternal and perinatal outcome in cases of placenta previa- an observational record-based study in a tertiary care hospital in Jharkhand.
Placenta previa is a condition where implantation of Placenta occurs in lower uterine segment partially or completely covering the os. It is caused by low implantation of blastocyst in the uterine cavity, but cause of low implantation is unknown. The aetiology remains controversial.
It is hypothesised to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery or infection.
These factors may reduce differential growth of the lower segment resulting in less upward shift in Placental position as pregnancy advances.  The traditional classification of Placenta previa describes the degree of Placenta encroaches upon the cervix in labour and is divided into low lying, marginal, partial or complete Placenta previa.  In recent years due to increased value of transvaginal ultrasonography in diagnosis of Placenta previa, the traditional classification is obsolete. Diagnosis is made on history, clinical examination and few investigations that include ultrasound (transabdominal/transvaginal) and Magnetic Resonance Imaging (MRI).  The condition is frequently complicated by invasion of Placental villi beyond decidua basalis causing Placenta accreta or increta.
Several risk factors associated with Placenta previa includes advanced maternal age, previous abortion, previous caesarean section and Placenta previa in previous pregnancy.  Myometrial damage due to caesarean section and D and C are main predisposing factors. Previous caesarean section is a known risk factor for placenta previa and risk increases with number of caesarean deliveries and previous history of placenta previa.
Most Obstetricians are concerned about massive haemorrhage not only when complete previa exists, but also when placenta is located in the anterior position of the uterus beneath the caesarean site.
Patients of Placenta previa are at increased risk of spontaneous abortions and congenital malformations. It is also associated with antepartum and postpartum haemorrhage leading to increased blood loss. There is high rate of Caesarean section, peripartum hysterectomy and prolonged hospitalisation. Perinatal outcome is also guarded with increased risk of prematurity and high rate of perinatal mortality and morbidity. As the frequency of primary caesarean section is increasing and cases of Placenta previa are consistently rising, so there is need to assess the demographic profile, risk factors and maternal and perinatal outcome in placenta previa.
Aims and Objectives
This study was conducted to describe epidemiological factors of pregnant mothers who were diagnosed with placenta previa and to find out maternal and perinatal outcome in cases of Placenta previa in a Tertiary Medical Institution of Jharkhand.
MATERIALS AND METHODS
Descriptive study from January 2013 to December 2016 was conducted in the Department of Obstetrics and Gynaecology of Rajendra Institute of Medical Sciences (RIMS), Ranchi. The patients were admitted in labour room and those admitted from OPD with a period of gestation more than 28 weeks with painless vaginal bleeding or diagnosed as having Placenta previa on routine ultrasonography were included in the study. All patients were evaluated with detailed maternal history, clinical examination, laboratory and radiological investigations. Caesarean section was performed at 37 weeks or if there was any obstetrical indications or any acute episode of bleeding per vaginum. Impact of previous surgeries, present method of delivery, maternal and perinatal complications and need for blood transfusion were noted.
All cases of Placenta previa diagnosed by clinical presentation and ultrasonography having gestational age of 28 weeks.
During the study period, a total of 135 patients of Placenta previa were identified.
In our study, 70 patients (58.85%) were found in the age group of 20-25 years followed by 45 patients (33.33%) of age group 26-30 years; 12 (8.89%) of age group > 30 years and 8 patients (5.93%) were belonging to < 20 years' age group. In our study, maximum patients were multigravida (73.33%), only 36 patients (26.67%) were primigravida. Placenta previa was 62.22% in multiparous and 26.67% in nulliparous. Most common type is type 4 with 44 patients (32.59%) followed by type 1 with 39 patients (28.89%), type 2 with 32 patients (23.70%) and type 3 with 20 patients (14.81%).
In this study, 67 patients (49.63%) had history of previous surgeries. In our study 78 patients (57.78%) were with Cephalic presentation, 32 patients (23.70%), transverse lie was in 22 patients (16.29%) and 3 patients (2.22%) were with unstable lie; 68 patients (50.37%) presented with 35 37 weeks of pregnancy, 35 patients (25.92%) were with 38 42 weeks of gestation and 32 patients (23.70%) were with 28 -34 weeks of gestation.
Babies were delivered by caesarean section of 120 patients (88.89%), while 15 patients (11.11%) were delivered vaginally.
Thirty-eight babies (28.15%) were admitted in NICU, out of which 10 babies died due to prematurity and its complications. Fifteen babies (11.11%) were still born.
There were 2 maternal mortality in our study group (1.48%); 115 patients (85.18%) needed blood transfusion in our study group.
The present study was undertaken to access foetomaternal outcome in patients of Placenta previa from January 2013 to December 2016. Our Institute is a Tertiary Referral Centre, so we get referred cases from all areas of Jharkhand. In our study, 104 patients were unbooked (77.03%) which was responsible for late detection of cases. In our study, maximum number of patients belonged to age group 20-25 years (51.85%) and 26-30 years (33.33%). It denotes that maximum number of patients were below 30 years of age, which is comparable to study by Kaur B,  Zhang J, Savitz D, in 1993 shows that incidence of Placenta previa increases with maternal age.  Placenta previa was found more commonly in multiparous women than nulliparous women. The results of our study are comparable to the study by Faiz et al.  Previous surgeries like caesarean section, D and E are proven risk factors as reported in different studies and it is also found in the present study. [7,8] In our study, 67 patients (49.63%) had history of previous surgeries and 12 cases (8.89%) had Caesarean Hysterectomy usually due to decreased contractility of scarred lower segment leading to postpartum haemorrhage in 4 cases (2.96%) and morbidly adherent Placenta (5.92%).  In our study 78 patients had cephalic presentation (57.78%), while others were noncephalic (Breech, Transverse lie and Unstable lie).  Out of 135 patients, 120 patients (88.89%) were delivered by Caesarean section and rest delivered vaginally.
Babies born between 28-34 weeks is 32 babies (23.70%), 68 babies (50.37%) were born between 35-37 weeks of gestation and 35 (25.92%) babies were born between 38-42 weeks of gestation. Thirty-eight babies were admitted in NICU with body weight less than 2 kg. Out of them, 10 babies (7.40%) died in NICU due to prematurity and its complications.
In our study 82 patients (60.74%) presented with antepartum haemorrhage, 42 patients (31.11%) had postpartum haemorrhage, 70 patients (51.85%) had anaemia, 12 patients (8.89%) had emergency Obstetric Hysterectomy which were due to morbidly adherent placenta (8 patients) and due to intractable haemorrhage (4 patients). There was one case of bladder injury in case of Placenta accreta intraoperatively. Haemorrhage was more in scarred cases with anterior placenta previa. In our study 115 patients (85.18%) received blood transfusion, in which 20 patients (14.81%) received more than 4 units of blood transfusion. In our study, atonic PPH was found in significant number of patients (31.11%) and they were treated vigorously with oxytocin and other uterotonics, balloon tamponade and additional sutures like B-Lynch and cervicoisthmic sutures. In our study 2 patients died due to irreversible haemorrhagic shock due to compromised status at time of admission.
Placenta previa is a great challenge to every Obstetrician due to high risk of maternal and perinatal complications. Thus, good antenatal check-up, correction of anaemia and timely diagnosis by ultrasonography and referral to tertiary care centre with blood bank facility and good NICU setup, skilled Obstetrician and efficient team of anaesthetist are the key factors for successful maternal and foetal outcome. As previous surgery is a proven risk factor for Placenta previa, so liberalisation of caesarean section should be stopped. Unintended pregnancy can be prevented by contraceptive use, as multiparity and D and E are also known risk factors for Placenta previa.
 Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies. J Matern Fetal Neonatal Med 2003;13(3):175-90.
 Oppenheimer L. Society of obstetrician and gynaecologist of Canada. Diagnosis and management of placenta previa. J Obstet Gynaecol Can 2007;29(3):261-73.
 Razia A, Aliya B, Ashma G, et al. Frequency of placenta previa with previous caesarean section. Ann King Edward Med Coll 2005;1:299-300.
 Hung TH, Hsieh CC, Hsu JJ, et al. Risk factors for placenta previa in an Asian population. Int J Gynaecol Obst 2007;97(1):26-30.
 Kaur B, Dhar T, Sohi I. Incidence risk factor and neonatal outcomes of placenta previa presenting as antepartum haemorrhage in tertiary care centre of North India. International Journal of Basic and Applied Medical Sciences 2015;5(3):58-61.
 Zhang J, Savitz DA. Maternal age and placenta previa: a population-based, case-control study. Am J Obstet Gynaecol 1993;168(2):641-5.
 Lavender T, Hofmeyr GJ, Neilson JP, et al. Caesarean section for non-medical reasons at term. Cochrane Database Syst Rev 2012;3:CD004660.
 Karlstrom A, Nystedt A, Hildingsson I. A comparative study of the experience of childbirth between women who preferred and had a caesarean section and women who preferred and had a vaginal birth. Sex Reprod Healthc 2011;2(3):93-9.
 Wolf EJ, Mallozzi A, Rodis JF, et al. Placenta previa is not an independent risk factor for a small for gestational age infant. Obstet Gynecol 1991;77(5): 707-9.
 Zaki ZM, Bahar AM, Ali ME, et al. Risk factors and morbidity in patients with placenta previa accreta compared to placenta previa non-accreta. Acta Obstect Gynaecol Scand 1998;77(4):391-4.
Kiran Trivedi (1), Shashi Bala Singh (2), Megha Bhagat (3), Rashmi Kumari (4)
(1) Associate Professor, Department of Obstetrics and Gynaecology, Rajendra Institute of Medical Sciences.
(2) Associate Professor, Department of Obstetrics and Gynaecology, Rajendra Institute of Medical Sciences.
(3) Senior Resident, Department of Obstetrics and Gynaecology, Rajendra Institute of Medical Sciences.
(4) 2nd Year Junior Resident, Department of Obstetrics and Gynaecology, Rajendra Institute of Medical Sciences.
Financial or Other, Competing Interest: None.
Submission 10-05-2017, Peer Review 23-05-2017, Acceptance 25-05-2017, Published 01-06-2017.
Corresponding Author: Dr. Kiran Trivedi, Rama Nursing Home, Opposite GEL Church Main Road, Ranchi-834001, Jharkhand.
Table 1. Occurrence of Placenta Previa among Patients in Relation to Baseline Characteristics (n = 135) Characteristics Frequency Percentage Registration Status Booked 31 22.96% Unbooked 104 77.03% Age of Pregnant Female < 20 years 8 5.9% 20-25 years 70 51.85% 26-30 years 45 33.33% > 30 years 12 8.88% Gravida Status Primigravida 36 26.66% Multigravida 99 73.33% Parity Para 0 51 37.77% Para 1 55 40.74% Para 2 18 13.33% Para >= 3 11 8.14% History of any Previous 1 CS 40 29.62% Previous Surgeries Previous 2 CS 12 8.88% D and E 15 11.11% Period of Gestation 28-34 wks 32 23.70% at Time of Admission 35-37 wks 68 50.37% 38-42 wks 35 25.92% Type of Placenta Previa Low Lying 39 28.89% Marginal 32 23.70% Incomplete 20 14.81% Central Previa Complete 44 32.59% Central Previa Presentation of Foetus Cephalic 78 57.78% Breach 32 23.7% Transverse Lie 22 16.29% Unstable Lie 3 2.22% Table 2. Perinatal Outcome of Patient associated with Placenta Previa (n = 135) Mode of Delivery Vaginal Delivery 15 11.11% LSCS 120 88.89% Perinatal Outcome Still Birth 15 11.11% Live Birth 120 88.89% Weight of Baby < 2 kg 42 31.11% 2-2.5 kg 52 38.52% 2.6-3 kg 34 25.18% > 3 kg 7 5.18% Table 3. Maternal Complication associated with Placenta Previa among Patient (n = 135) Maternal Antepartum Haemorrhage 82 60.74% Complications Postpartum Haemorrhage 42 31.11% Maternal Anaemia 70 51.85% Cervicoisthmic Sutures 8 5.92% B-Lynch Sutures 2 1.48% Balloon Tamponade/ Vaginal 8 5.92% Packing Obstetric Hysterectomy 12 8.89% Febrile Illness 15 11.11% Wound Infection 10 7.40% Bladder Injury 1 0.74% Prolonged Hospital Stay 32 23.70% Need Blood Transfusion 115 85.18%
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|Title Annotation:||Original Research Article|
|Author:||Trivedi, Kiran; Singh, Shashi Bala; Bhagat, Megha; Kumari, Rashmi|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Jun 1, 2017|
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