Placental abruption: clinico-epidemiological study of risk factors, maternal/ perinatal
outcomes, and histopatholgical finding; does association with chorioaminionitis affect
outcomes?
Dr. Batool Abdulwahid Hashim / MBChB, DGO, FABGO, Lecturer of Obstetrics and
gynecology, medical college, Kufa university.
Abstract
Back ground: the condition of premature separation of the placenta (placental abruption PA)
is defined as separation from the site of uterine implantation before delivery of the fetus,
the complications of accidental hemorrhage include: Maternal, antepartum hemorrhage,
disseminated intravascular coagulation (DIC), acute renal failure, postpartum anemia and
infection, PerinatalPerinatal mortality can be attributed to prematurity. The remaining
perinatal mortality is associated with fetal hypoxia, exsanguinations, and fetal growth
restriction. Despite numerous clinical and epidemiologic studies, the etiology of placental
abruption is yet to be precisely determined, but it is thought to be a disease of the decidua
and uterine blood vessels although, in more than 40% of cases no cause can be identified,
but maternal chronic and acute factors has been blamed as risk factors. Chorioamnionitis
complicating premature rupture of fetal membranes at term or preterm, is said that it is a
major risk for PA with tendency for the latter to occur in up to 50% if PPROM occurs prior to
20 weeks gestation, but the risk of placental abruption with PROM at term is 0.4-1.3%, The
current study is designed to study the association between chorioaminionitis at term and
preterm with PA and to see whether PA is more severe (measured by occurrence of
maternal and perinatal complications) when it occurs in a background of chorioaminionitis.
Patients And Method:153 women with the diagnosis of placental abruption at gestational
age from 24 weeks to term included in this study, history was recorded for each patient
stressing what could be risk factor for PA and possible maternal fetal complications ,
thorough general and obstetric examination for assessment of maternal and fetal conditions
and labour assessment, severity of abruption assessed by degree of shock , development of
maternal complication. After delivery whether by vaginal route or by caesarean section
placenta umbilical cord and placental membrane pieces send for histopathological study,
results were analyzed to prove
the correlation between histopathologically proven-
chorioamnionitis and placental abruption. All analyses were performed using commercially
available software (SPSS version 18).
1
Aim of study
1-to study risk factors, maternal, perinatal outcomes, histological finding in patients with
clinical diagnosis of abruption
2-To confirm the association between histological chorioaminionitis, and placental abruption
3-effects of of chorioamnionitis on severity of abruption measured by maternal and
perinatal complications.
Results: age of patients ranged from 16 to 48 years, the mean age was (27.87±6.8 )years,
placental abruption is more common in multiparity (54.90 %) have 4-8 children, mean
gestational age in weeks
for placental abruption is
(34.64 -+3.69 )weeks, with 57
(37.25%)were preterm and the 96 were term patients (62.75% ), patients who have
ruptured membrane was (39 ) patients about (24.49% ). most common risk factor was
(anemia )which present in (125 )patients (81.7 % ) and the second most common risk factor
was rural unbooked or on substandard antenatal care about (90)patient (58.83 %), patients
with Previous scar accounted for 46 patients (30.0% ) and hypertension was seen in 6
patients (3.92 % ). While studying maternal outcome, it was found that regarding mode of
delivery for abruptio placentae 114 patients about (74.51% ) underwent emmergency
caesarian section(CS) and and that (39 )patient (25.49%) were delivered by vaginal route,
blood transfusion which was done in (42 ) patients (27.45 % ), postpartum hemorrhage was
seen (in 9 )patients(5.88%), renal complication (oliguria) seen in (6 )patients (3.92 %) and
(6 patients ) (3.92 %) needed hysterectomy to control intrapartum or postpartum bleeding.
Fortunately therewere (no DIC ) or( maternal death ). Regarding the perinatal outcome:
(114 babies ) about ( 74.51 % ) were born alive and (39) babies (23.53% ) were still born
and of those who were born alive, (30 )babies (19.61% ) admitted to NCU with low APGAR
score. Histological findings of samples taken (placental pieces, amniotic membrane, pieces
of umbilical cord)from patients with placental abruption in this study were that
chorioamnionitis was confirmed histologically in (12 ) preterm patients (21.05 % ) and (3)
term patients about (3.13% ) and ischemic changes and vascular congestion in (14 ) preterm
patients ( 25 % ) and (25)term patients (26.04 % ) chorionic villi with congestion with
decidual reaction (7 ) (12.28 % ) in preterm patients and(30 )about (31.25%) in term
patients and lastlyl normal histology in(24) (42% ) preterm patients and ( 38) term
patients ( 39.58 % ). When outcomes were compared between cases with confirmed
chorioaminionitis and those without chorioaminionitis whether term or preterm the
following results were obtained, (15 ) needed blood transfusion with chorioamionitis (100% )
2
and 27 out of 138 of non aminiontis group (21.09% ) needed blood transfusion, (2 ) patients
(13.33%)underwent hysterectomy for those patients with chorioamionitis for uncotrollable
intra or postpartum haemorrhages and that 4 patient (3.12%) underwent hysterectomy in
those who were with no aminiontis, number of stillborn was 9 (60%) in chorioamionitis
group of patients and 30 (23.44%) in non aminiontis group and low APGAR score NCU –
admission in chorioamionitis was 4 (26.67%)and 26 (20.31%) in non aminiontis.
Discussion: mean maternal age in this study was ( 27.87_+6.85 ) , this is younger age
compared to other Iraqi and non Iraqi studies, agreeing with other studies also, it was found
that placental abruption is more common with multiparity(54.90 % have 4-8 ), In this study
majority of these (58.83%) belonged to rural areas with whom majority of patients remained
unbooked thus result in high incidence of complication rate and this agree with Naila Yousuf,
Fardous Mumtaz study which shows that (60%) cases were unbooked and majority of these
(44%) belonged to rural areas, this confirms that majority of our patients do not avail the
facility of antenatal clinics and they become exposed to multiple risk factors, which could
have been detected and prevented in antenatal care clinics. In this study the major risk
factor was anemia which was found in (125) patients about (81.7% )a finding which was
parallel to Naila Yousuf, Fardous Mumtaz et al, who found that anemia underlies 83% of
cases and they conclude that This is a single most common factor present in majority of
patients and may be considered as a risk factor for abruption. Number of cases diagnosed
with clinical and histopathological chorioaminionitis was 15 in this study (9.8%) of total cases
of PA were distributed as follow, 3 of 96 (3.1%) case of PA at term and 12 of 57 (21%)of PA
at preterm
a figure which was lower than Nath et al. 2007 who's rate of histologically
confirmed chorioamnionitis among women with placental abruption was 30%.
In another study, the rates of abruption among women with or without intrauterine
infection were 4.8% and 0.8% (Ananth et al. 2004), Chorioaminionitis is more common
association in preterm gestations with abruption than cases with PA at term, a finding which
agree with those of Shunji Suzuki et al. Direct bacterial colonization of the decidua with
tissue inflammation may initiate a process that results ultimately in placental abruption.
Regarding to whether the presence or absence of chorioaminionitis would worsen PA
outcome the following results were obtained, more need for blood transfusion 100% vs
21.09%, higher proportion of patients (13.33%) vs 3.12% underwent hysterectomy, higher
proportion of stillborn 60% vs 23.44%, lower APGAR scores and more need for special care
baby unit 26.67% vs 20.31% in aminionitis vs non aminionitis respectively and all these
outcomes were statistically significant. The higher need for blood transfusion in cases of
3
chorioamnionitis may be explained by delayed presentation of those cases of PPROM until
clinical signs and symptoms of chorioamnionitis were superimposed by occurrence of vaginal
bleeding which bring those patients to hospital in majority of rural patients coming from far
places. Poorer perinatal outcome in association with chorioaminionitis was not agreed by
with Shunji Suzuki et al who was stated that the perinatal outcomes of preterm placental
abruption following p-PROM were not different from those without p-PROM at preterm.
The difference in two conclusions may be explained by that in our study we compared
between chorioamnionitis and non chorioamnionitis group regardless the gestational age.
Conclusion: we conclude from this study that risk factors for abruptio placentae are anemia ,
being rural , previous scar, parity , age(20-29)years and hypertension, while trauma, and
smoking are not recognized risk factors in our studied population, the relation between the
clinical & histological diagnosis of placental abruption remains weak, preterm PA was more
commonly to be associated with chorioamnionitis than PA at term, and that maternal and
perinatal outcome may be poorer in PA cases predisposed by chorioamnionitis than those
without chorioamnionitis.
Introduction
The placenta is a fetomaternal organ, the functional unit of which is the fetal cotyledon. 120
fetal cotyledons grouped into visible lobes(1)The fetal and maternal tissues arranged in such
a way that there are three-dimensional tree- like structures called villous trees of fetal
tissues that float into a lake of maternal blood the fetal tissue repeatedly branch into smaller
villi
(2)
.It has long been recognized that the placenta serves as the fetal lung, due to it is role
in oxygen transfer across fetomaternal barriers in addition to its nutritional and endocrine
functions (3), the condition of premature separation of the placenta (placental abruption PA)
is defined as separation from the site of uterine implantation before delivery of the fetus
(approximately 1 in 77–89 deliveries) in it is severe form (resulting in fetal death) has an
incidence of approximately 1 in 500–750 deliveries. Two principal forms of PA can be
recognized, depending on whether the resulting hemorrhage is external or concealed. In the
concealed form (20%)of cases of PA, the hemorrhage is confined within the uterine cavity,
detachment of the placenta may be complete, and the complications often are severe.
Approximately 10% of abruptions are associated with clinically significant coagulopathies
(disseminated intravascular coagulation [DIC]), but 40% of those severe enough to cause
fetal death are associated with coagulopathy. In the external form (80%), the blood drains
through the cervix, placental detachment is more likely to be incomplete, and the
complications are fewer and less severe. Occasionally, the placental detachment involves
4
only the margin or placental rim. Here, the most important complication is the possibility of
premature labor(4),Other than fetal death the complications of accidental hemorrhage
include: Maternal, antepartum hemorrhage remains a leading cause of maternal mortality.
For pregnancies ending in stillbirth, hemorrhage related to abruptio placentae is the leading
cause of maternal mortality, disseminated intravascular coagulation (DIC) was first reported
to occur in association with placental abruption by De Lee in 1901. The development of DIC
is thought to be due to a release of thromboplastins, as well as consumption of coagulation
factors secondary to an enlarging hematoma. Nearly 30% of patients who present with a
severe (grade 3) abruption develop DIC, acute renal failure is a potential maternal
complication associated with abruption, fortunately the incidence of acute renal failure
appears to be decreasing, possibly due to improved medical management. Postpartum
hemorrhage secondary to uterine atony is associated with abruption, as are postpartum
anemia and infection. PerinatalPerinatal mortality (both fetal and neonatal deaths) varies
from 4 to 12/1000. This high perinatal mortality with abruption is attributable, in part, to its
association with preterm delivery. Of the excess perinatal deaths, about 55% can be
attributed to prematurity. The remaining perinatal mortality is associated with fetal hypoxia,
exsanguinations, and fetal growth restriction (FGR).(5),However clinical outcomes and
occurrence of maternal and perinatal complications is largely dependent on grade of
placental abruption at presentation, within this grade 0 describe an asymptomatic and
incidentally observed retro placental clot, grade 1-3 all are associated with symptoms
although each of this may be revealed or concealed, grade 1 refers to hemorrhage where
there is pain and uterine irritability but no maternal or fetal compromise, grade 2 there is no
maternal compromise but fetal compromise or distress is recognized, grade 3 there is
uterine tetany, maternal compromise and fetal demise (6), (7), Despite numerous clinical and
epidemiologic studies, the etiology of placental abruption is yet to be precisely determined,
but it is thought to be a disease of the decidua and uterine blood vessels. Several conditions
continue to be associated with abruption. However in more than 40% of cases, no cause can
be identified, chronic factors include maternal vascular disease, chronic and pregnancyinduced hypertension (PIH), cigarette smoking, drug ingestion, nutritional deficiency, uterine
anomalies and tumors, supine hypotension syndrome, antiphospholipid syndrome,
congenital thrombophilias (including activated protein C resistance, deficiencies of protein C,
protein S, and antithrombin III), hyperhomocystinemia, and, rarely, congenital
hypofibrinogenemia.
5
Acute factors include maternal trauma, decompression of the overdistended uterus, and
perhaps the acute vascular changes secondary to cocaine abuse. Amniocentesis has been a
rare cause of abruption. Other factors such as a short umbilical cord and chorioaminionitis
have been associated with abruptio placentae. Placental abruption also has been reported
after the insertion of catheter tip intrauterine pressure transducers(8)(9)
Chorioamnionitis and risk of abruptio placentae:
Fetal membranes and mechanism of PPROM:
Fetal membranes obtained after delivery comprise the amnion, chorion, and an attached
layer of maternal deciduas. the amnion comprises an epithelial layer, with underlying
collagen- rich connective tissue layer. The chorion consists of a multilayered cytotrophoblast
layer and collagen-rich connective tissue layer. Despite it is lesser relative thickness, the
greatest tensile strength of the fetal membranes lies within the amnion, the chorion
possessing greater extensibility(10), Normally the fetal membranes maintain their integrity
throughout pregnancy and rupture spontaneously in the latter 1st stage or the 2nd stage of
labour at term, PPROM complicates 10% of deliveries, a number of strategies have been
employed to investigate the potential mechanisms involved in PPROM, at molecular,
cellular, histological, biochemical and biophysical levels.
Collagen is the major structural component contributing to the strength of fetal membranes,
however, there is conflicting evidence regarding the level of collagen in fetal membranes
undergo PPROM:some authors report a reduction in total collagen contents, other report no
differences compared to those at term(11), However ; increased levels of matrix
metalloproteinasesMMP-2, MMP-3, MMP-8, MMP-9 and neutrophil elastase within the
amniotic fluid would support an increase in matrix degradation as a potential contributory
factor in PPROM. Breakdown of fetal membranes may also be contributed to by an
increased level of apoptosis in both amnion and chorion, there is no evidence from
biophysical testing that exhibit generalized weakness, however this does not preclude
localized defects in the membranes being an underlying cause. This zone of altered
morphology has been reported in fetal membranes within the lower uterine segment
associated with the rupture site of fetal membranes at term. These structural alteration are
also present prior to labor at term. This region of fetal membranes has recently been
demonstrated to be structurally weak and it has been postulated that premature formation
of the zone of altered morphology may also be a potential mechanism of PPROM (12), Large
number of clinical risk factors have been associated with PPROM like cigarette smoking,
6
previous preterm delivery, vaginal bleeding, nutritional vitaminC deficiency, infection,
cervical damage and genetic predisposition(13). There is no doubt that there is an increased
incidence of abruption when the membranes rupture before term(3)I. e. (PPROM), and it is
said that placental abruption is a major risk occurring in up to 50% if PPROM occurs prior to
20 weeks gestation, the risk of placental abruption with PROM t term is 0.4-1.3%. Hence the
greatest risk factor for placental abruption is midtrimester PPROM(14), the current study is
designed to study the association between chorioaminionitis at term and preterm and to see
whether PA is more severe (measured by occurrence of maternal and perinatal
complications) when it occurs on a background of chorioaminionitis.
Patients and method
This study is prospective cross sectional case observation study carried out at the labor ward
of AL-Zahraa teaching hospital in An-Najaf city attachment to Kufa University department of
gynecology and obstetrics from 1st March to the end of November 2013. 153 women with
the diagnosis of placental abruption at gestational age from 24 weeks to term included in
this study . Consent for participation were taken from all of them .History was recorded for
each patient including age, rural or urban, blood group, gestational age ,parity, previous
obstetrical history, (hyper tension (chronic hyper tension, pregnancy induced hyper tension,
preeclampsia), diabetes
,previous abruption, intrauterine growth restriction ,preterm
labor, intrauterine death, thromboembolic disease ,family history of thromboembolic
disease , Polyhydramnios , smoker, history of drug abuse , anemia ,trauma , previous scar),
membrane was intact or rupture and time of fetal membranes rupture in hours with or
without
presence of symptoms of chorioamnionitis, thorough general and obstetric
examination for assessment of maternal and fetal conditions and labour assessment mode
of delivery if by vaginal delivery or by caesarean section , and neonatal outcome assessed
by APGAR score calculation at one and five minute and need for admission to neonatal care
unit, severity of abruption assessed by
degree of shock , development of maternal
complication( blood transfusion postpartum hemorrhage , renal shut down, disseminated
intravascular coagulation , need for caesarean
hysterectomy ,and death) ,fetal
complication(complications of prematurity, FGR, and PA). Blood sample taken together
while assessing and providing initial management and sent for full blood count, coagulation
profile , biochemistry study, cross match and saving. After delivery whether by vaginally or
by caesarean section placenta umbilical cord and placental membrane pieces send for
histopathological study which was done at Al Sader medical city and sample analyzed by
number of national board certified histopathologists . Data collected were fixed on pre7
designed Performa from the patients records and results were analyzed to prove the
correlation between histopathologically proven- chorioamnionitis and placental abruption .
Inclusion criteria All patient
more than 24 week
presented with vaginal bleeding
,abdominal pain or blood stained liquor with intact or rupture fetal aminiotic membranes
with bloody amniotic fluid .
Exclusion criteria
vaginal bleeding due to placenta praevia, cervicitis show of labor or other coincidental cause
of antepartum hemorrhage where excluded in this study .
Statistical analysis
All analyses were performed using commercially available software (SPSS version 18).
Descriptive statistics was used to determine mean, standard deviation(SD) and percentage.
Significant differences were assessed by chi squared test(X2-tests, P ≤ 0.01).. A P-value ≤0.01
was considered as statistically highly significant at 1%. Continuous (measurable) variables
represented as mean±SD and ranked (unmeasurable) variables were represented as no(%) in
tables
RESULTS
(Table 1 ) study of age group
Age group(years )
NO
%
Less than 20
14
9.1
20—29
72
47.1
30—39
64
41.8
40 and more
3
1.9
8
Study patient Characteristics
Table (2)Study patient Characteristics.
Variable
Mean±SD
Age(Yrs)
27.87±6.848
G.A.(wks)
34.64±3.694
Multi parity
84
54.90
Preterm
57
37.25
Term
96
62.75
Intact
114
74.51
Rupture,
39
25.49
Chorioaminionitis
15
9.8
Anemia
125
81.70
Pscar
46
30.07
Hypertension
6
3.92
Polyhydraminios
3
1.96
Trauma
3
1.96
Rural
90
58.83
Urban
63
41.17
DM
0
0
Thrombo
0
0
Smoker
0
0
Membrane status
Risk factors
9
Maternal outcome
Table (3) Maternal outcome.
Variable
No
(%)
114
74.51
39
25.49
Blood transfusion
42
27.45
Renal complications
6
3.92
PPH
9
5.88
Hysterectomy
6
3.92
DIC
0
0
Death
0
0
Mode of delivery
C/S
V.D
Maternal complications
Perinatal outcome.
Table ( 4) Perinatal outcome.
Outcome
No.
%
A live
114
74.51%
Still born
39
23.53%
Admitted to NCU- low Apgar
30
19.61%
Scor
10
Histological finding
Table (5)Classification of histological finding in patients with clinical diagnosis of abruption.
Gestational
Choroaminitis
Age
Ischemic
changes
Chorionic villi with Normal
and congestion
Total
P value
and
vascular
decidual
congestion,
reaction(deciduitis)
haemorrhage
No
%
No
%
No
%
No
%
No
%
0.000**
Preterm
12
21
14
25
7
12
24
42
57
100
Chi=39.187
Term
3
3.13
25
26.04
30
31.25
38
39.58
96
100
df=7
Severity of abruption in cases of chorioaminionitis
Table (6) Severity of abruption in case of chorioamnionitis
Chorioamionitis
No aminiontis
(15)
(128)
No(%)
No(%)
Blood transfusion
15(100%)
27(21.09%)
0.000**
Hysterectomy
2(13.33%)
4(3.12%)
0.000**
Maternal Death
0(0%)
0(0%)
-
Still born
9(60%)
30(23.44%)
0.000**
Severity of Abruption
Maternal
Fetal
Low
APGAR-
4(26.67%)
26(20.31%)
P value
0.049*
Admitted to NCU
11
Figure(1)Severity of abruption in case of chorioamionitis measured by maternal outcome
12
Figure (2) Severity of abruption in case of chorioamionitis measured by perinatal outcome.
DISCUSSION
In Iraq as a part of whole of the developing countries, and due to comparatively lower
individual income, lower health resources, substandard health care provided for people
living in places far from major cities , lower population medical educational levels added to
the lack of political stability and internal conflicts this all have adversely affected both
maternal and perinatal outcome, and because antepartum hemorrhage is one of the major
obstetric complications that are faced in the 3rd trimester we plan for this study to elucidate
the risk factors for placental abruption and how it can be related to other common obstetric
complication seen in our obstetric practice that is the preterm premature rupture of fetal
membranes (PPROM) and when abruption occurs in background picture of chorioamnionitis
will it worsen the outcome for both mother and fetus or not.
Table 1 show that the peak age group of incidence of placental abruption was from 20-29
years (47%) and (41.8%)of patients were between 30—39 years of age and The age of
patients ranged from 16 to 48 years with mean age in this study was( 27.87_+6.85 ) , this is
younger age compared to other Iraqi study done by Miami A. Ali andThaeer Jawad15in
Baghdad the capital whose figure was 30.1 ±6.38 and outer world studies like Naila Yousuf,
13
Fardous Mumtaz study16done in Pakistan whose figure was 30(47%), years and, as well
Cande V. Ananth 17whose study done on US population show that 37 percent increase
incidence was apparent for the 35–49 years age group in comparison with women aged 25–
29 years.
Table 2 studies patient characteristics and it shows that placental abruption is more
common in multiparity (54.90 % have 4-8 ) Therefore this study corresponds to Maiami
study which show mean parity for the patients was 1.7 ±2.16 & for the control was 1.54 ±
2.03 and Naila Yousuf, Fardous Mumtaz study which show 54% have 4 - 12 children and
similar to Cande V. Ananth et al which conclude that analysis of singleton births indicated
that abruption risk increased steadily with increasing gravidity for all age group .
In this study majority of these (92%) belonged to rural areas with majority of patients
remain unbooked thus result in high incidence of complications rate and this agree with
Nailayousuf, FardousMumtaz study which shows that (60%) cases were unbooked and
majority of these (44%) belonged to rural areas. Whereas Cande V. Ananth study shows only
22% unbooked. This confirms that majority of our patients do not avail the facility of
antenatal clinics and they become exposed to multiple risk factors, which could have been
detected and prevented in antenatal care clinics.
Trauma could not be confirmed as a risk factor leading to abruptio in this study, as there
was no patient (0%) with history of trauma. This disagree with other literatures correlate
abruptio placentae with physical violence in pregnancy18. And pregnant women involved in
severe accidents, for example in one study, (Pearlman et al. 1990)19,Placental abruption is
attributable to any trauma inapproximately 6% of all cases and to major trauma in 20-25%
of cases(Vaizey et al. 1994)20This could not be confirmed in this study, the reason may be
explained by the small sample size, the short duration of study and also that domestic
violence is not a common phenomenon in our society.
Diabetes and smoker also could not be fined as risk factors in this study as there is no
patients (0% ) who were diabetic or smoker, however; Smoking is a well known risk factor
for placental abruption and also for many other adverse pregnancy outcomes, including
infertility, spontaneous abortion, low birth weight, preterm delivery, and long term physical
and developmental disorders in infants (Ananth et al. 1999a)21. It was found that
approximately 5% of all perinatal deaths are attributable to maternal smoking largely due to
placental abruption (Andres and Day. 2000)22. Smoking is also associated with a 2.5fold
increase in severe abruption resulting in fetal death (Raymond and Mills. 1993)23, regarding
diabetes, although it was not found to be a risk factor(0%), some reported that diabetes
14
mellitus (all types) has odd ratio of 0.8-2.8 Minna et al 24, This can be explained probably by
underdiagnosis of gestational diabetes in our pregnant population due to lack of effective
antenatal screening.
In this study the major risk factor was anemia which was diagnosed in (125) patients about
(81.7% )a finding which was parallel to Naila Yousuf, FardousMumtaz et al, who found that
anemia underlies 83% of cases and they conclude that this is a single most common factor
present in majority of patients and may be considered as a risk factor for abruption.
Hypertension which was only (6)patients (3.9%) while Naila Yousuf, FardousMumtaz ) study
38 patients (38%) had hypertension. This factor is an important factor present in many
patients and has been much discussed in the literature. Some studies have shown only
chronic hypertension as a definite risk factor. Whereas other studies include both i.e,
pregnancy induced (PIH) as well as chronic .16
Number of cases diagnosed with clinical or histopathological chorioaminionitis was 15 in our
study (9.8%), a figure which was lower than Nath et al. 2007 who's rate of histologically
confirmed chorioamnionitis among women with placental abruption was 30%.25
In another study, the rates of abruption among women with or without intrauterine
infection were 4.8% and 0.8% (Ananth et al. 2004)26, Chorioaminionitis is more common
association in preterm gestations with abruption than cases with PA at term, a finding which
agree with those of Shunji Suzuki et al 27.Direct bacterial colonization of the decidua with
tissue inflammation may initiate a process that results ultimately in placental abruption.
Sometimes a subclinical decidual thrombosis may initiate an inflammatory process.
Nevertheless, infection activates cytokines such as IL and TNF. These cytokines upregulate
the production and activity of MMPs in the trophoblast. This may result in destruction of the
extracellular matrix and cell to cell interactions which then may lead to disruption of the
placental attachment and finally to placental abruption (Nath et al. 2007).25
No reported cases of thrombophilias in the current study in spite of it's well known
association with PA, Thrombophilias associated with abruption include MTHFR deficiency,
factor V Leiden mutation, prothrombin gene mutation, protein S and protein Cdeficiency,
antithrombin deficiency, lupus anticoagulant, and anticardiolipin antibodies (Oyeleseand
Ananth. 2006)28.
Table 3 show the frequecy of occurence of maternal complications in cases of PA:
The mode of delivery for abruptio placentae was by Caesarian Section (CS) in 114 patients
about (74.51% ) and about (39 )patient (25.49%) by vaginal route. The most common
maternal complication was blood transfusion which was done in (42 ) patients (27.45 % ),
15
next to it was postpartum hemorrhage which was seen (in 9 )patients (5.88%), renal
complication (oliguria) seen in (6 )patients (3.92 %) and (6 patients ) (3.92 %) needed
hysterectomy to control intractable intrapartum or postpartum bleeding. Fortunately there
were (no DIC ) or( maternal death ).
table 4 shows the frequency of occurance of perinatal complications as follow: (114 babies
) about ( 74.51 % ) were born alive and (39) babies (23.53% ) were still born and of those
who were born alive, (30 )babies (19.61% ) admitted to NCU with low APGAR score.
Table 5 shows the results of histological study of samples taken (placental pieces, amniotic
membrane, pieces of umbilical cord)from patients with placental abruption in this study,
normal histology was seen in(24) (42% ) preterm patients and ( 38) term patients ( 39.58
%), chorioamnionitis was confirmed histologically in (12 ) preterm patients (21.05 % ) and
(3) term patients about (3.13% ), ischemic changes and vascular congestion in (14 ) preterm
patients ( 25 % ) and (25)term patients (26.04 % ), chorionic villi with congestion and
decidual reaction was (7 ) (12.28 % ) in preterm patients and(30 )about (31.25%) in term
patients. This result agree with that of Denise A. Elsasser et al who concluded that The
concordance between clinical and pathologic criteria for abruption diagnosis is poor.30This
histopathological confirmation of chorioamnionitis in 15 cases of abruption with 12(23.13%)
cases 0f them were preterm and 3(3.13%) were term pregnancies.This show clinically
significant higher incidence of chorioamnionitis in preterm than term cases of PA, this agrees
with
Shunji Suzuki et al ,who is The major findings was that the preterm singleton
pregnancies complicated by placental abruption following p-PROM was strongly associated
with the presence of histological more than those without p-PROM,27while Nathen et al in
2006 who stated that severe histological chorioamnionitis is associated with abruption in
both preterm and term gestations, implicating inflammation as a potential contributor
causal pathway15.
Regarding ischemic changes and vascular congestion accounted for 39 case (51.04%) it was
significantly more common in term 25 (26.04%) than preterm 14(25%) .
Since trophoblastic invasion in the spiral arteries and consequent early vascularization may
be defective, and there is the incomplete remodeling of maternal arteries causes high
resistance to uterine artery blood flow which may predispose to vascular rupture in the
placental bed leading to placental abruption31-Signore et al, and when occur its seems to be
more in term than preterm cases of abruption due to may be longer time for vascular
changes needed to exhibit themselves .
16
For congestive chorionic villi and deciduitis which was positive in 37(43.25%) case
30(31.25%) of these term and 7(12%) preterm , in Nihon Sanka et al this can be explained
by tissue injury cause a rapid release of various bioactive mediators at the maternal fetal
interface
24
.
Table(6) compares the maternal and perinatal outcome in cases of PA in those with
chorioamnionitis and those without chorioamnionitis and explains the severity of abruption
measured by the occurrence of both maternal and fetal complications: (15) chorioamionitis
and ( 138 )no aminiontis of them (15 ) need blood transfusion with chorioamionitis (100% )
and 27 about of non aminiontis group (21.09% ) needed blood transfusion
(2 ) patients (13.33%)underwent hysterectomy for those patients
with
chorioamionitisand patient 4 (3.12%)underwent hysterectomy in those who are with no
aminiontis. And the number of stillborn was 9(60%) in Chorioamionitis group of patients
and
30(23.44%) in non aminiontis group, low APGAR
score NCU –admission in
chorioamionitis was 4(26.67%)and 26(20.31%) in nonaminiontis . All complications were
statistically clinically significant for aminionitis group, fortunately there was no maternal
death in both group .For perinatal outcome the neonates who born with low Apgar score
and needed admission clinically significant to those which were without chorioamnionitis,
this disagree with Shunji Suzuki et al who was stated that the perinatal outcomes of preterm
placental abruption following p-PROM were not different from those without p-PROM at
preterm
27
. The difference in two conclusion may be explained by that in our study we
compared between chorioamnionitis and non chorioamnionitis group regardless the
gestational age and since chorioamnionitis in our study was higher in preterm PA this can be
explained by that the lower perinatal outcome obtained in our study was due to prematurity
complications added to the adverse consequence of PA.
The higher need for blood transfusion in cases of chorioamnionitis may be explained by
delayed presentation of those cases of PPROM until clinical signs and symptoms of
chorioamnionitis were superimposed by occurrence of vaginal bleeding which bring those
patients to hospital in majority of rural patients coming from far places.
Conclusion
17
1-The risk factors for abruptio placentae in our study are anemia ,rural , previous scar, parity
, age(20-29)years and hypertension .
2- The relation between the clinical & histological diagnosis of placental abruption remains
weak.
3-preterm PA was more commonly associated with chorioamnionitisthan PA at term.
4-in our study the maternal and perinatal outcome was poorer in PA cases predisposed by
chorioamnionitis than those without chorioamnionitis.
Recommendation
All cases with PPROM require to be managed inpatient and those patients need to
be especially educated for signs and symptoms of PPROM (chorioamnionitis) and even of
possible abruption and probably the worse outcome if both conditions occur concomitantly.
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