Objectives: To study the epidemiological profile and the prognosis of the retro-placental hematoma (HRP) at the maternity ward at Kolda Regional Hospital Center. Materials and methods: This was a retrospective descriptive cross-sectional study conducted over a period of 11 years: from January 1st, 2006 to December 31st, 2016, at Kolda Regional Hospital Center. It included all patients admitted for HRP during this period. The studied parameters concerned sociodemographic characteristics, gynecological obstetrical history; clinical, therapeutic and prognostic data (non-inclusion or exclusion criteria). The data w ere collected from medical records, the delivery room and the surgery room registers using a collection sheet developed for this purpose. The statistical analysis of the variables studied was done with the software Epi-info 3.5. For the qualitative variables, we calculated the frequencies and for the quantitative variables, we studied the distributions. Results: During the study period, 15 , 343 were recorded deliveries and we carried out the diagnosis of HRP in 301 patients (1.97%). The average age of the patients was 24 years with an average parity of 4.8 deliveries. Almost all the patients (87.5%) were evacuated and half had delivered by caesarean section. Maternal and fetal deaths were 7% and 72.1%, respectively. Uterine atony accounted for 21.2% of complications. One third of the cases of uterine atony had resulted in a hysterectomy. The average duration of hospitalization was 6 days. Conclusion: The retro-placental hematoma is a serious medico-obstetric emergency. It is burdened with high maternal and fetal morbidity and mortality in developing countries.
The retroplacental hematoma (HRP) is the premature detachment of the normally inserted placenta while the fetus is still in utero. Its frequency is variously appreciated according to the authors: 0.25% in Europe [
In fact, the obstetrical treatment consists of a rapid uterine evacuation and the delivery route is mainly a function of the labor phase and the foeto-maternal status. The pre and post partum resuscitation is always necessary as well as pediatrician involvement.
The objective of this study is to evaluate the epidemiological profile and the prognosis of the retro-placental hematoma (HRP) at the maternity ward at Kolda Regional Hospital Center.
We conducted a retrospective descriptive cross-sectional study from January 1st, 2006 to December 31st, 2016 at Kolda Regional Hospital Maternity Hospital. It was a Level II maternity hospital, the only Regional Hospital Center in Kolda located on average Casamance (700 km from the capital) and border to the Republic of Guinea Bissau. All health centers in the Kolda region, as well as some in the Sedhiou region and some health posts in Guinea Bissau, evacuated to this structure.
This study included all patients presented clinical signs of HRP in the service regardless of the delivery route during the study period. Patients whose care required evacuation outside the hospital were not included. The parameters studied were as follows: age, parity, mode of admission, existence or absence of uterine scar, term of pregnancy, history of hypertension, mode of entry to work, the mode of delivery, clinical data, maternal-fetal complications and therapeutic aspects.
The severity of the clinical picture was assessed according to the SHER classification, we distinguish: grade 1: seemingly isolated metrorrhagia; grade 2: more complete symptomatology and living child; grade 3: complete symptomatology with fetal death (3A: without coagulation disorders; 3B: with coagulation disorders).
The APGAR score ≤ 6 defined perinatal asphyxia. This data was collected through the patient’s medical records, the birth room and operating room registers. The descriptive statistical analysis was carried out with the Epi-info software. The distributions of the quantitative variables and the proportions of the qualitative variables were calculated.
1) Socio-demographic characteristics
During this period of study, we recorded 15,343 deliveries, comprising 301 cases of retroplacental hematoma representing a frequency of 1.97%.
The average age of the patients was 24 years with extremes of 16 and 43 years. The average parity was 4.8 deliveries with extremes of 1 and 13 deliveries. The majority of patients (85.7%) came from surrounding health structures, particularly from the Kolda region (77.7%), Sédhiou (15.9%) and the Republic of Guinea Bissau (6.3%) (
2) Clinical data
A bit less than one-third of cases (29%) presented chronic arterial hypertension that was not followed or poorly monitored (
Six (6.9%) patients had never had prenatal consultation (ANC) and only 10.4% of our patients completed the 4 ANC recommended by WHO.
Mean gestational age was 36 weeks of amenorrhea (AS) and 3 days with extremes of 24 and 40 weeks of amenorrhea. Prematurity accounted for 43% of cases.
The diagnosis of HRP focused on the clinical database.
Characteristics | Number | Percentage |
---|---|---|
Age | ||
<20 | 41 | 13.6% |
20 to 24 | 69 | 22.9% |
25 to 29 | 92 | 30.6% |
30 to 34 | 48 | 15.6% |
35 to 39 | 44 | 14.6% |
≥40 | 7 | 2.3% |
Parity | ||
Primipare | 42 | 13.9% |
Paucipare | 58 | 19.6% |
Multiparous | 89 | 29.6% |
Grande multiparous | 112 | 37.2% |
Admission criteria | ||
Patients who came on their own | 43 | 14.3% |
Evacuated patients | 258 | 85.7% |
Address | ||
Kolda | 234 | 77.7% |
Sédhiou | 48 | 15.9% |
Guinée Bissau | 19 | 6.3% |
For the majority of patients (87%), the clinical signs at admission were dominated by metrorrhagia (97.7%), uterine hypertonia (77.1%), and absence of fetal heart activity (76%), (1%) and shock (10%) (
Forty percent (40%) of the patients had hypertension on admission, half pre-eclamps. Almost all patients (93.5%) had spontaneously entered work. The most frequent table was grade 3: 226 cases (75.1%). Coagulopathy was observed in 8% of patients (
3) Therapeutic and prognostic aspects
Caesarean section delivery accounted for 51.2% of the sample. The perinatal mortality was high; it concerned 76.1% of the fetuses. Perinatal asphyxia made 19% of births complicated. Maternal morbidity was dominated by anemia (227 cases) followed by renal failure (20%), HELLP syndrome (19%), and uterine atony 32 cases (10%) (
The management of uterine atony consisted of medical treatment in (21.8%) cases, conservative surgery for (40.6%) and hysterectomy in (37.5%). Among the cases of uterine atony, seven received medical treatment with misoprostol, thirteen underwent a conservative surgical technique (arterial ligation and/or B-Lynch compression) and twelve underwent haemostatic hysterectomy.
The specific lethality of HRP was 7%. Eighty-six percent of the deceased patients were discharged and 62% were classified as SHER Stage III. The average duration of hospitalization was 6 days.
Clinical sign | Number | Percentage |
---|---|---|
Metrorrhagia | 294 | 97.7% |
Uterine hypertonia | 232 | 77.1% |
Absence of cardiac activity | 229 | 76.1% |
Shock condition | 30 | 10% |
Stage | Number | Percentage |
---|---|---|
Stage I | 13 | 4.3% |
Stage II | 62 | 20.6% |
Stage III a | 202 | 67.1% |
Stage III b | 24 | 8% |
Morbidity | Number | percentage |
---|---|---|
Anemia | 227 | 75.4% |
Renal failure | 63 | 20.9% |
Hellp syndrome | 57 | 18.9% |
Coagulopaty | 32 | 10.6% |
Uterine atrophy | 32 | 10.6% |
1) Socio-demographic characteristics
In Senegal there is no study evaluating the incidence of retroplacental hematoma at the national level. In our study, the frequency of HRP is 1.97%. This rate is slightly lower than other studies in other regions of Senegal. Thus, Thiam [
These differences are due, on the one hand, to the diversity of classifications used by these authors, a complete picture including anatomopathology, or a simple macroscopic or microscopic finding, or even a purely clinical diagnosis. On the other hand, sociodemographic, economic and environmental characteristics (climatic, seasonal factors, eating habits) noted by these authors, [
2) Clinical data
The average age of HRP was 24 years old and the most represented age group was 25 to 30 years old. This age is slightly lower than that found by studies in Senegal and Africa [
Several studies have shown that multiparity is a risk factor for HRP [
In our series 85% of the patients were evacuees, similar rate to THIEBA (85.9%), OUEDRAOGO (88%), SARR (83%). This mode of admission constitutes a factor of poor maternal and fetal prognosis in Dakar. Indeed the Hospital Center absorbs all the evacuations of the region as well as those of the border structures.
The average age at which HRP occurred was 36 weeks + 3 days, and only 10% of patients completed the 4 prenatal consultations recommended by WHO [
The number of CPNs performed is variously appreciated by the authors; however, all agree that the frequency of HRP is inversely proprotional to the number of ANC [
The occurrence of HRP in a hypertensive context is noted by many authors [
However, our rate is much higher than that of other authors including Ananth et al. [
Clinically, we found metrorrhagia in 97.7% of cases, uterine hypertonicity in 77.1%, absence of fetal heart activity in 76.1% of cases and shock in 10% of cases. Due to the absence of an ultrasound machine in the work room, the ultrasound diagnosis was not done in any of the patients (more discuss the effectiveness of the clinical diagnosis) (there are publications on the clinical diagnosis).
Ouédraogo in Burkina, found a lack of fetal heart activity (82%), uterine hypertonicity (79.8%), metrorrhagia (74.2%) [
3) Therapeutic and prognostic aspects
In our series, 51.1% of patients had delivered by cesarean section. Ouédraogo in Burkina Faso found 64% of normal delivery versus 36% of cesarean section [
Some authors including Krauss et al. [
As in most African studies [
Surveys | Fetal death | Metrorrhagia | Hypertonia |
---|---|---|---|
Our series | 76.1% | 97.7% | 77.1% |
Ouedraougo [ | 82% | 74.2% | 79.8% |
Ananth [ | 16.1% | 71.1% | 27.8% |
Boisrame [ | 12% | 67% | 4% |
In our series we found 32 cases of uterine atony of which 37.5% had a hysterectomy of haemostasis.
We recorded high lethality (7%) compared to other counts (2% - 5%) [
The fetus pays the highest price to the HRP in our African countries [
The retro placental hematoma remains a major medico-obstetric emergency in our practice. Diagnosis and early management improve the prognosis. The prevention of maternal and fetal mortality related to this condition requires an improvement in prenatal consultation, a better organization of the delivery plan, especially in the peripheral maternity ward, and an improvement in evacuation conditions, especially in rural areas where the means are limited.
The authors declare no conflicts of interest regarding the publication of this paper.
Biaye, B., Gassama, O., Gueye, M.D.N., Diallo, M., Niass, A., Cisse, M., Diouf, A. and Moreau, J.C. (2019) Epidemiology and Prognosis of Retroplacental Hematoma in a Maternity Ward at a Regional Hospital Center in Southern Senegal. Open Journal of Obstetrics and Gynecology, 9, 149-157. https://doi.org/10.4236/ojog.2019.92016