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ORIGINAL ARTICLE
Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 56-59

Placenta praevia at Usmanu Danfodiyo University Teaching Hospital, Sokoto: A 5-year review


Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University, Sokoto, Nigeria

Date of Web Publication19-Jul-2013

Correspondence Address:
C E Shehu
Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University, Sokoto
Nigeria
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DOI: 10.4103/1118-8561.115261

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  Abstract 

Background : Placenta praevia is one of the most acute life-threatening obstetric emergencies. Its prompt management has been advocated to prevent associated morbidity and mortality. This study determines the incidence, risk factors, presentation, and maternal/fetal morbidity and mortality associated with placenta praevia in Usmanu Danfodiyo University Teaching Hospital, Sokoto. Materials and Methods : In this retrospective study, case notes of patients' that had placenta praevia from January 1, 2003 to December 31, 2007 were retrieved. Relevant data were extracted and analyzed using the Epi-info Version 3.5.1 statistical package. Results : The incidence of placenta praevia was 0.84%. Grand multiparous women (50.0%) were more affected than multiparous women (42.7%). Majority (46.9%) presented with vaginal bleeding after 28 weeks of gestation. The Major type of placenta paevia (77.1%) occurred more than the Minor variety (22.9%). The most common risk factor was previous abortion (18.75%) while anemia (7.3%) was the most common complication. Most (83.3%) were delivered by Caesarean section. There was one (1.0%) maternal mortality and 12 (12.5%) perinatal deaths. Conclusions : Placenta praevia has a low incidence in the study population, is mainly of the Major type with identifiable risk factors and occur mainly in the 21-30 years age group and multiparous women. The major modes of presentations are vaginal bleeding and threatened abortion. Though maternal mortality is low perinatal mortality is high.

Keywords: Placenta praevia, morbidity, mortality, risk factors


How to cite this article:
Burodo A T, Shehu C E. Placenta praevia at Usmanu Danfodiyo University Teaching Hospital, Sokoto: A 5-year review. Sahel Med J 2013;16:56-9

How to cite this URL:
Burodo A T, Shehu C E. Placenta praevia at Usmanu Danfodiyo University Teaching Hospital, Sokoto: A 5-year review. Sahel Med J [serial online] 2013 [cited 2017 Mar 29];16:56-9. Available from: http://www.smjonline.org/text.asp?2013/16/2/56/115261


  Introduction Top


Antepartum hemorrhage is defined as bleeding from the genital tract after 28 weeks of gestation until delivery. It is a grave and potentially life-threatening condition which needs immediate evaluation. [1] Bleeding from placenta praevia is a leading cause of antepartum hemorrhage [2] and one of the most acute life-threatening obstetric emergencies. [3] Prompt management of placenta praevia and its associated complications have been advocated. [4]

The incidence of placenta praevia increases with advancing age and higher parity. Most studies in Nigeria report an overall incidence of placenta praevia between 0.89% [5] and 1.65%, [6],[7] Surgical history, especially of previous caesarean section for placenta praevia, is linked to recurrent development of placenta praevia and, more importantly, placenta accreta.

The timing of the diagnosis of placenta praevia has undergone significant changes in recent times following the common practice of early ultrasound scan for the detection of fetal abnormalities and other pregnancy complications. [8] As such, most cases are now detected antenatally prior to the onset of significant bleeding. This practice has also improved the diagnostic accuracy and enhanced intervention strategies and outcome in the management of placenta praevia. [9],[10] However, while ultrasound scan maybe readily available in urban centers in Nigeria, the same cannot be said for most areas of the country where widespread pre-existing anemia, difficulties with transportation and restricted medical facilities ensure that antepartum hemorrhage continues to be responsible for many maternal deaths. [11],[12],[13]

The classic presentation of placenta praevia is painless vaginal bleeding in a previously normal pregnancy, which may be an isolated or recurrent event. The initial event usually does not occur until the second trimester. The risk factors for placenta praevia as seen in Ile-Ife, southern Nigeria included a history of retained placenta, previous caesarean section, previous abortion, grandmultiparity, and maternal age over 35 years. [9] Several studies on incidence and risk factors for placenta praevia in Nigeria have been published. However, data from northern Nigeria remain scanty. Our objective in this study was to determine the incidence and describe the risk factors, clinical presentation, and associated morbidities and mortality of placenta praevia in a tertiary hospital in Sokoto, Nigeria.


  Materials and Methods Top


A list of patients' that had placenta praevia from January 1, 2003 to December 31, 2007 was compiled from the medical records department, labor room and theatre records of the Usmanu Danfodiyo University Teaching Hospital, Sokoto. The case notes were retrieved from the Medical Records Department. Data relating to the age, parity, clinical presentation, risk factors, morbidity, and mortality were extracted. The type of placenta praevia was ascertained from ultrasound scan findings and from findings at surgery.

The information obtained was coded and entered into the computer for analysis using the Epi-info 3.5.1 statistical package.


  Results Top


There were 11,400 deliveries during the period under review. Of these 96 (0.84) patients had placenta praevia. The age of the patients ranged from 20 to 50 years with a mean age of 37.7 ± 7.5 years. The peak age group was 21-30 years which accounted for 35.4% of cases. Seven (7.3%) of the patients were nulliparous, 41(42.7%) were multiparous, while 48 (50.0%) were grandmultiparous women. Thirty-three (34.4%) patients presented with vaginal bleeding between 28 and 35 weeks of gestation, 30 (31.3%) presented as threatened abortion, while 12 (12.5%) presented with vaginal bleeding after 36 weeks gestation. The rest of the patients, 21 (21.9%), were asymptomatic at presentation [Table 1]. Also, 74 (77.1%) patients had major-degree placenta praevia, while 22 (22.9%) had the minor variety [Table 1].
Table 1: Clinical characteristics of patients

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Of the 96 patients with placenta praevia, 63 (65.6%) had identifiable risk factors. Eighteen (18.75%) had a history of previous miscarriage for which evacuation was carried out; 16 (16.67%) had previous caesarean section for placenta praevia; 16 (16.67%) had previous history of placenta praevia, while 11 (11.46%) had multiple pregnancy. Thirty-five (36.45%) patients had no identifiable risk factor [Figure 1].
Figure 1: Risk factors for placenta praevia

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The gestational age at delivery varied from 30 weeks to 41 weeks. Twenty-five (26.0%) patients carried their pregnancies to term, 60 (62.5%) were delivered close to term (34--37 weeks), while 11(11.5%) were delivered before 34 weeks.

Eighty (83.3%) patients had Caesarean section, while 16 (16.7%) had Vaginal delivery [Table 2].
Table 2: Gestational age and mode of delivery among the study group

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Eighty-six (89.6%) patients did not suffer any morbidity. However, 7 (7.3%) had postoperative anemia, 2 (2.1%) had hysterectomy and there was 1 (1.0%) maternal mortality.

Three (3.1%) neonates suffered birth asphyxia, 10 (10.4%) were still born, and 2 (2.1%) were early neonatal deaths [Table 3].
Table 3: Maternal and fetal morbidity and mortality

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  Discussion Top


The incidence of placenta praevia (0.84%) observed in this study is low compared to 2.6% reported from Havana Specialist Hospital Lagos. [2] However, it is higher than the incidence of 0.38% reported in Israel [14] but similar to that of 0.8% reported by some other workers in Nigeria. [5],[15] This low incidence is probably due to the socio-cultural and economic factors in this environment that do not allow most women to seek medical attention even when in dire need. [16] Grandmultiparous women had the highest incidence of placenta praevia and it agrees with the report of other studies. [9],[17] The peak incidence of placenta praevia was observed in the 20-30 years age group which corresponds to the peak reproductive age group in the setting of the current report where women marry early and as such achieve a high parity at earlier age than usual with its attendant obstetric risks including placenta praevia. [18],[19],[20]

Majority of the patients presented late with bleeding after 28 weeks of gestation probably due to the high level of illiteracy, culture, and poverty which tends to prevent women from coming to the hospital except in life-threatening conditions. [15] Postoperative anemia was the most common maternal morbidity recorded and may be attributed to late presentation. Caesarean hysterectomy was performed on two patients whose placenta praevia were complicated by placenta percreta. A strong association between placenta accreta, placenta praevia, and prior Caesarean birth has been documented. [21] Patients with an antepartum diagnosis of placenta praevia, who have had a previous caesarean section, should be considered at high risk for developing placenta accrete. [22] As there is the potential for significant maternal morbidity the risk of placenta accreta needs to be recognized and women at risk should be considered for delivery at an institution with appropriate expertise and resources in managing the condition.

There was one maternal death from massive hemorrhage at home. The low maternal mortality found in the current study may be due to the improved blood banking services of the hospital as well as the packing system for emergency obstetric surgeries instituted by the hospital management. This scheme offers patients the needed items for emergency interventions on loan to be repaid when the emergency is over. [23]

There were 12 perinatal deaths of which 10 were fresh still births and 2 were early neonatal deaths. The still births were as a result of massive hemorrhage before admission while the neonatal deaths were secondary to severe birth asphyxia.


  Conclusion Top


Most patients presented as obstetric emergencies with vaginal bleeding after the 28th week of gestation and post-operative anemia was the most common complication. There is a need for organizing an enlightenment campaign to encourage pregnant women to report to the hospital as soon as they experience any vaginal bleeding. Routine scan in pregnancy, particularly in women with a previous history of abortion, is recommended for early identification of patients with placenta praevia.

 
  References Top

1.Kwawukume EY. Antepartum Haemorrhage. In: Kwawukume EY and Emuveyan EE, Editors. Comprehensive Obstetrics in the Tropics. 1 st ed. Ghana: Asante Hittscher Pub; 2002. p. 140-50.  Back to cited text no. 1
    
2.Ezechi OC, Kalu BK, Nwokoro CA, Njokanma FO, Loto OM, Okeke GC. Placenta praevia: A study of risk factors, maternal and fetal outcome. Trop J Obstet Gynaecol 2004;21:2.  Back to cited text no. 2
    
3.Onwudiegwu U, Ezechi OC. Emergency obstetric admissions: late referrals, misdiagnosis and consequences. J Obstet Gynaecol 2001;21:570-5.  Back to cited text no. 3
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4.Morgan K, Arulkumaran S. Antepartum haemorrhage. Curr Obstet Gynaecol 2003;13:81-7.  Back to cited text no. 4
    
5.Nyango DD, Mutihir JT, Kigbu JH. Risk factors for placenta praevia in Jos, North central Nigeria. Niger J Med 2010;19:46-9.   Back to cited text no. 5
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6.Loto O, Onile TG. Placenta praevia at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. A ten year analysis. Niger J Clin Pract 2008;11:130-3.   Back to cited text no. 6
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7.Ikechebelu JI, Onwusulu DN. Placenta praevia: Review of clinical presentation and management in a Nigerian teaching hospital. Niger J Med 2007;16:61-4.   Back to cited text no. 7
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8.Chama C, Wanonyi I, Usman J. The Natural History of placenta praevia in a Nigerian population. Trop J Obstet Gynaecol 2004;21:2.  Back to cited text no. 8
    
9.Eniola AO, Bako AU, Selo-Ojema OO. Risk factors for placenta praevia in Southern Nigeria. East Afr Med J 2002;79:535-8.  Back to cited text no. 9
    
10.Sheriar NK. Ultrasonography of the placenta. In: Kumar P, Rawal MY, Dasgupta S, Rajan R, Malhatra N, Editors. Imaging in Obstetrics and Gynaecology. New Delhi: Jappee Brothers Medical Publishers Ltd.; 1998. p. 94-9.  Back to cited text no. 10
    
11.Audu LR, Ekele BA. A ten year review of maternal mortality in Sokoto, northern Nigeria. West Afr J Med 2002;21:74-6.  Back to cited text no. 11
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12.Airede LR, Ekele BA. Adolescent maternal mortality in Sokoto, Nigeria. J Obstet Gynaecol 2003;23:163-5.  Back to cited text no. 12
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13.Chukwudebelu WO. Preventing maternal mortality in developing countries. In: Okonofua A, Odunsi K, Editors. Contemporary Obstetrics and Gynaecology for Developing Countries. Women's Health and Action Research Centre; 2003. p. 644-57.  Back to cited text no. 13
    
14.Sheiner E, Shoham Vardi I, Hallak M, Hershkowitz R, Katz M, Mazor M. Placenta previa: Obstetric risk factors and pregnancy outcome. J Matern Fetal Med 2001;10:414-9.  Back to cited text no. 14
    
15.Adinma JI. Aetiology and management of obstetric haemorrhage. In: Okonofua A, Odunsi K, Editors. Contemporary Obstetrics and Gynaecology for Developing countries. Women's Health and Action Research Centre; 2003. p. 620-43.  Back to cited text no. 15
    
16.Nwobodo EI. Obstetric emergencies as seen in a tertiary health institution in North-Western Nigeria: Maternal and fetal outcome. Niger Med Practit 2006;49:54-5.  Back to cited text no. 16
    
17.Faiz AS, Ananth CV. Aetiology and risk factors for placenta praevia: An overview and metal-analysis of observational studies. J Maternal Fetal Neonatal Med 2003;13:175-90.  Back to cited text no. 17
    
18.Abu Heija AT, EI Jallad F, Ziadeh S. Placenta praevia: Effect of age, gravity, parity and previous caesarean section. Gynaecol Obstet Invest 1999;47:6-8.  Back to cited text no. 18
    
19.Getahun D, Oyelesa Y, Salihu HM, Anantha CV. Previous caesarean section delivery and risk for placenta praevia and placenta abruption. Obstet Gynaecol 2006;107:721-78.  Back to cited text no. 19
    
20.Archibong EI, Ahmed EM. Risk factors maternal and neonatal outcome in major placenta praevia: A prospective study, Ann Saudi Med 1999;16:12-6.  Back to cited text no. 20
    
21.Armstrong CA, Harding S, Matthews T, Dickinson JE. Is placenta accreta catching up with us? Aust N Z J Obstet Gynaecol 2004;44:210-3  Back to cited text no. 21
    
22.Cieminski A, Dlugoliecki F. Placenta Praevia accreta. Ginekol Pol 2004;75:919-25.  Back to cited text no. 22
    
23.Ahmed Y, Shehu CE, Nwobodo EI, Ekele BA. Reducing maternal mortality from ruptured uterus. The Sokoto Initiative. Afr J Med Sci 2004;33:135-8.  Back to cited text no. 23
    


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