Journal of Reproductive Medicine Gynaecology & Obstetrics Category: Medical Type: Research Article

Epidemiological Therapeutic and Prognosis Aspects of Abruptio Placentae in an Insecure Area of Mali, Case of the Hospital of Timbuktu

Fane Seydou1*, Bocoum Amadou1, Kampo Mamadou2, Kante Ibrahima3, Sissoko Djibril2, Sissoko Abdoulaye4, Traore Soumana Oumar5, Traore Alasane6, Sima Mamadou3, Sanogo Siaka Amara1, Sanogo Abdoulaye1, Kouma Aminata7, Teguete Ibrahima1, Traore Youssouf1*, Thera Tioukani Augustin3 and Mounkoro Niani1
1 Departement De Gynecologie Obstetrique Du Chu, Gabriel Touré Hospital, Bamako, Mali
2 Timbuktu Hospital, Bamako, Mali
3 Teaching Hospital Center Of Point G Of Bamako, Bamako, Mali
4 Mothers Hospital Luxembourg, Bamako, Mali
5 Reference Heath Center Of Commune, Bamako, Mali
6 Mali Hospital, Bamako, Mali
7 Kati Hospital, Koulikoro, Mali

*Corresponding Author(s):
Fane Seydou
Departement De Gynecologie Obstetrique Du Chu, Gabriel Touré Hospital, Bamako, Mali
Email:seydoufane@yahoo.fr
Traore Youssouf
Departement De Gynecologie Obstetrique Du Chu, Gabriel Touré Hospital, Bamako, Mali
Tel:+00223 66710194,
Email:drtraorey@yahoo.fr

Received Date: Nov 19, 2019
Accepted Date: Nov 29, 2019
Published Date: Dec 06, 2019

Abstract

Objectives
Obstetric hemorrhages remain the leading cause of maternal death in the world. In addition, an abruptio placenta is responsible for significant maternal and perinatal mortality in Sub-Saharan Africa. Our objective was to determine the prevalence, the maternal and perinatal prognosis of this pathology at the Timbuktu hospital.

Patients and methods
It’s a cross-sectional descriptive study with retrospective collection over a six - years period from January to December 2018, including all cases of abruptio placentae recorded at the Timbuktu hospital.

Results
We have collected 133 cases of abruptio placentae out of 5999 deliveries, in others words 2.21%. The mean age of the patients was 28 years with a predominance of multiparous patients (32.33%), evacuated (53.38%). No prenatal consultation was performed in 36.09% of cases. Arterial high blood pressure was found in 36.84% of patients and a grade 3 of Sheer in 60.15% (80 cases). The caesarean section rate was 74%. The maternal mortality rate was marked by bleeding disorder in 6.7% anemia requiring blood transfusion in 51.88% of patients. The perinatal mortality rate was 65.22%. The elements of poor perinatal prognosis were represented the severe maternal anemia odds with 95% confidence interval CI at 95% = 15 (3.6-70), the small birth weight ORCI at 95% = 4.8 (2.1-8), non-monitoring of pregnancies ORCI at 95% = 4.7 (2.1-8) and the lack of evacuation.

Conclusion
The maternal and prenatal mortality rate related to abruption placentae is high in our context. Its reduction requires improved prenatal care evaluation conditions and strengthening of the technical platform and qualified personnel.

Keywords

Abruptio placentae; Maternal and prenatal prognosis; Pregnancy; Timbuktu

INTRODUCTION

An abruptio placenta related to maternal mortality is about 1% [1,2] in developing countries. It’s also associated with significant prenatal mortality and morbidity [3,4]. This prenatal mortality is about 7 to 20% [5-8] in developing countries. In Mali abruptio placentae has been responsible for almost all pregnancies stopped in abdominal trauma during pregnancy at Teaching Hospital Gabriel Touré [9]. Management depends on the severity of the clinical presentation and gestational age and required concomitant obstetric management of medical resuscitation [10,11]. The precarious state of technique plateau aggravated by the security crisis that has been raging since 2012 has made it difficult to deal with obstructive emergencies through the reference / evacuation system in this part of the country. Furthermore, the lack of data about abruptio placentae in the Timbuktu region justifies the carrying out of the present study at the Timbuktu hospital. The aim of this study was to study epidemiological, therapeutic and prognosis aspects of abruptio placentae in an insecure area of Mali, case of the hospital of Timbuktu.

PATIENTS AND METHODS

The study took place at the Timbuktu hospital in northern Mali, located 1300km from Bamako, the Malian capital. The Timbuktu region is Mali’s seventh administrative region in northern Mali, where armed groups are operating and insecurity is very high. This area is at high risk of attacking terrorism, armed groups and banditry and disruption obstetric evacuations inside the Timbuktu region. In accordance with the sectorial health policy in the reference system / evacuation of Mali, the Timbuktu hospital receives referrals and evacuations of circles from Goundam to 97km, Dire to 135Km, Gourma-Rharous to 160Km, Niafunké to 200Km. The maternity hospital covers 50000 reproductive-age women in the health districts and several rural communities with 46400 births expected each year. Obstetric activities are carried out in basic emergency obstetric care (SOUB) and comprehensive (SONUC). The maternity ward which has only 20 beds and the only regional reference second hospital in the region providing comprehensive emergency obstetric and neonatal care (SONUC) and receiving all references-evacuations of health districts and private structures in the region, available 24 hours a day. The hospital has an operating room with function rooms and a blood bank without medico-surgical unit.

A cross-sectional study with retrospective data collection was carried out. It was conducted from 2013 to 2018. The study population was composed of all pregnant women 28 weeks of age and older who gave birth at the Timbuktu Hospital during the study period. We included in this study all women who had a retro placental hematoma. The variables studied were socio-demographic data, mode of admission, reference structures, reason for admission, medico-surgical history, evolution of previous pregnancies, pathologies associated with pregnancy, parity, number of prenatal consultation, clinical admission data, paraclinical data, length of hospital stay, maternal progress (complications, deaths), newborn status at birth, weight, sex, score Apgar, resuscitation, prematurity, hypotrophy, perinatal death and factors associated with perinatal mortality. Live newborns whose mothers had a retro placental hematoma were followed during the first 7 days of life in order to know the perinatal prognosis. The statistical tests used were the Pearson Chi2 test, the odds ratio and the significance p. The p was significant if the probability is ≤ 0.05. Ethical aspects have been respected guaranteeing confidential medical information.

RESULTS

Abruptio placentae frequency (Figure 1)

The incidence of abruptio placentae varies from year to year. Of a total of 5999 deliveries, 133 cases of abruptio placentae were noted, in others words 2.21%. The minimum incidence was observed in 2014 with 1.75% and maximum in 2015with 3.80%. The epidemiological Characteristics of the patients are summarized in table 1 below.
 
Figure 1: Evolution of the incidence of abruptio placentae in Timbuktu from 2015 to 2018.
 

Characteristics

%

n/n

Age

15-19 years old

11.3

15/133

20-34 years old 

66.1

88/133

35 years old

22.6

30/133

Profession

Housewife

91.0

121/133

Pupils/students

6.0

8/133

Merchant/worker

1.0

1/133

Civil servant

2.0

3/133

Schooling

Non-schooling

89.0

14/133

Educated

11.0

89/133

Admission mode

Evacuated/referred

53.0

70/133

Come from herself

47.0

63:133

Provenance structure

Community health center

35.0

47/133

Reference health center

1.5

22/133

Medical office

1.5

2/133

Home

47.0

62/133

Residence of origin

Timbuktu city

83.5

111/133

Timbuktu city ring road

4.0

5/133

 Gourma-Rharous

8.0

11/133

Goundam

1.5

2/133

Niafunke

1.5

2/133

   Dire

1.5

2/133

Table 1: Epidemiological characteristics of patients.

Clinical characteristics of patients

Our patients had a clinical profile. High blood pressure (20.3%); diabetes (1.5%) and asthma (2.3%) accounted for our medical history. The previous caesarean section was 12% and that of the 1.5% myomectomy. The average parity was 4 with extremes of 1 to 12 abruptio placentae was found in our patients. Multiparous patients predominated with 32.3%. The pathological obstetrical history found in this study was miscarriage (3.8%); abruptio placentae (1.5%); preeclampsia (1.5%); eclampsia (0.8%). Evacuation patterns dominated by isolated menorrhagia and uterine contractions (16.5%); uterine hypertonia (7%) and hypertension (4.5%) of the 133 patients, 10% had at least antenatal visits. Forty-two per cent of the patients had antenatal visits between one and three. However, 59% of the patients had no antenatal visits. The notion of abdominal trauma on pregnancy was found in 3.8% (5/133) patients. About 74% of the patients had labor; the membranes were intact in 80% of patients. The physical examination found a hypertonia in 59% of the cases. Fetal presentation was high for 86% and abnormal for 14% of cases. The urine strip noted more than 2 crosses in 78% of the patients and a trace in 22%. At admission hypertension was diagnosed at 28% and collapse at 13% of patients. The mean gestational age was 36 weeks of amenorrhea with extremes of 22 and 40 weeds of amenorrhea. More than 82% of patients had a pregnancy between 34 and 40 weeks. The other clinical characteristics of the mother and the fetus were dominated by single pregnancies (96%), anemia (83%) and pathologies associated with pregnancy hypertension (28%), lack of fetal activity (66%), shock (6%), Sheer grade3 61%, low birth weight (56%).

Treatment and prognosis

In table 2, we have described the management of abruptio placentae cases and the early perinatal prognosis.
 

Characteristics

%

n/n

Vascular filling

Yes

31

41/133

No

69

92/133

Delivery route

Caesarean

26

35/133

Vaginal

74

98/133

Anesthesia

General anesthesia

26

35/133

Locoregional

4

5/133

None

70

93/133

Clot weight (grams)

< 500

15

20/133

≥500

15

20/133

Unspecified

70

93/133

Delay between admission and expulsion (hours)

≤ 2

74

99/133

> 2

26

34/133

Apgar at the first minute

Still dead

66

91/138

1 to 3

0.7

1/138

4 to 7

14

19/138

≥8

19.3

27/138

Transfusion

Yes

52

69/133

No

48

64/133

State of the newborn

Living

91

43/47

Perinatal deaths

 

4/47

Transfer pattern in neonatology

Prematurity

7.5

10/133

Respiratory distress

4

5/133

Hypotrophy

3

4/133

Table 2: Therapeutic management and prognosis.

Factors associated with perinatal deaths

Factors associated with perinatal death have been studied in table 3.
 

Factors

Perinatal deaths

Khi²

Odds ratio CI 95

P

Yes

No

     

Home

Timbuktu

71

37

0.4

1,1 (0.4-3.8)

0.8

Other

14

8

 

Anemia (g/dl)

? 7

36

2

20

 

0.000

≥ 7

44

39

Fetal weight (gram)

< 2500

56

16

16

4.8 (2.2-10.6

0.000

≥ 2500

21

23

Antenatal visits

No

49

10

14

4.7 (2.1-10.8)

0.000

Yes

36

35

Terms
(week of amenorrhea)

< 37

40

16

1.6

1.6 (0.7-3.3)

0.2

≥ 37

50

32

Admission mode

Reference evacuation

58

13

18

5.3 (2.3-11.6)

0.000

Self - reference

27

32

High blood pressure

Yes

23

20

2.3

0.6 (0.2-1.2)

0.1

No

52

25

Table 3: Factors associated with perinatal deaths in Timbuktu.

Maternal and perinatal prognosis

Maternal morbidity was dominated by anemia secondary to hemorrhage in 77/133 cases, 77% of which 29% was severe. A table of acute renal failure was observed in 2 cases (1.5%). A shock state associated with abruptio placentae in 8 cases is 6% of cases and finally a combination of coagulopathy and abruptio placentae in 9 cases representing 7% of cases. The elements of poor maternal prognosis were represented by the severity of the clinical picture from which sheer grade 3 contributed to (63%), women evacuated (53%), laps (13%), severe anemia (83%), delay between admission and delivery 26%. However, the delivery route was caesarean section in 74% of cases and the vaginal route in 26%. These deaths occurred after uterine evacuation and coagulopathy was responsible for death in one patient. For perinatal prognosis, we recorded 91 stillbirths and 4 deaths in the first week of life. Perinatal mortality was 69%. The average birth weight was 2250 ranges with extremes of 500 ranges and 4500 ranges. Low birth weight was observed in 74 patients, or 56% of cases. The factors of poor fetal prognosis were represented by the severity of the clinical picture with anemia p = 0.000; low birth weight OR = 4.8 (2.2-10.6), no antenatal visits OR = 4.7 (2.1-10.8) and health assessment OR = 5.3 (2.3-11.6). The leading causes of maternal death were clotting disorders 66% and renal failure 33% (1/3). The perinatal mortality was 69% (95/138) whose main causes were the prematurity, respiratory distress.

DISCUSSION

Rate (Frequency)

Abruptio placentae complicated 2.21% of births our study. This frequency is similar with those of the authors in Africa notably that of Sandjo [12] at teaching hospital Gabriel Touré of Bamako, which found 2.05% and Nayama [8] in Niger found 3.6%. On the other hand, those found by Tieba [9] in Ouagadougou and Mian DB et al., [13] attaching Cocody hospital were lower than ours, a frequency of 0.96% and 1.55% respectively (10.38). Western studies reported frequencies around 0.5 to 1%. The incidence of abruptio placentae in Strasbourg in 2013 was 6.6% [10,14]. Indeed, these differences in the incidence of abruptio placentae in African countries can be explained by the study population and the diagnostic criteria used by the Authors clinical and \ or pathological.

Clinical aspects

Risk factors for abruptio placentae are known [1,2,14]. The abdominal trauma during pregnancy was found in 3.8% (5/133) of the patients in the study on clinical examination. This was a public accident during transport with two-wheeled vehicles or ambush attack by armed groups or armed bandits frequent in this locality of the country. The classical risk factors of abruptio placentae were found in our study (see clinical characteristics of patients). The existence of hypertension, the antecedent miscarriages and antecedent of fetal death in utero were found in this study. Three main reasons for consultation were isolated menorrhagia (42%), uterine contractions (18%) and menorrhagia + uterine contractions (16.5%). Pregnancy was no longer followed in 59% of cases against 41% of pregnancies followed. Proteinuria was significantly greater than two crosses in the strip in 78% of cases. The pregnancy had a term greater than 34 weeks in 81% of cases, of which 61% of cases in the future. Hypertension was the main pathology (28%) associated with pregnancy and patients were received in sheer class 3 including 7% coagulopathy. We had recourse to vascular filling, blood transfusion, caesarean section and general anesthesia respectively in 31%, 52%, 26% and 26% of cases.

Maternal and perinatal prognosis

Regarding the path of entry, there seems to be consensus showing the superiority of caesarean section in the case of live fetuses [4,9]. These results corroborate those of Boisramé et al., [14] and Sananes et al., [7]. In France who reported respectively 68% (28) and 88% (12) cesarean section. On the other hand, our result is lower than that of Thieba [9] which found 35.9% in the majority of cases, our patients were admitted during the labor latency phase and the severity of the clinical presentation at admission may explain our high caesarean section rate compared to that of Thieba [9]. As in several African studies [8,9], anemia is the major maternal complication of HRP. In our series, anemia was present in 83% of cases, 35% of cases of severe. However, 3 cases of maternal death were noted in our series; 2.26%. This rate corroborates that of Coleman et al., [6] in Ghana who found 2%. On the other hand, it is lower than those of some authors in Africa [2,5,9,15] who found rates ranging from 5.1% to 11.5%.

While it is higher than those in developed countries which remains below 1% [16-18]. This thanks to a fast and adapted support in the middle of resuscitation. Our cases of death can be explained on the other hand, by the low health coverage in the peripheral area, the delay of patients to resort to health centers, evacuation conditions and on the one hand, by the insufficiency of effective resuscitation measures in the region. As for the fetal prognosis, it remains dark in our developing countries. In our series, fetal morbidity as dominated by a low birth weight in 55.80% of cases with an average weight of 2250 ranges against 2680 ranges for Thieba in Ouagadougou [9] and 4142 ranges for Thiam in Senegal [1]. Our rate of low birth weight is lower than that of Boisramé T [14] 68.2% in France against higher than that of Madagascar 43.7%. This difference could be explained by an unspecified estimate of this gestational age in our (date of the last imprecise, late ultrasound). The perinatal mortality rate was % (95 cases/ 138); this perinatal mortality rate is close to Coleman J et al., [6] in Nigeria, which found 63.9%. As for stillbirth it was 91 cases/ 138 or 66%; this is lower than that of Nayama [8] which found 71%. This significant proportion is explained by: the low rate of rough forms with live child, the patients often presenting on admission a severe clinical picture (more than 60% of grade 3 of Sheer). Some African authors [5,18-21]. Found as factors of bad perinatal prognosis: the gravity of the clinical picture, the medical evacuation, the importance of the blood clot, the low birth weight, and the way low as a mode of delivery. Factors that were statically associated with perinatal mortality in our setting were: severe maternal anemia, small birth, missed pregnancies and referral/evacuation (Table 3). The perinatal mortality in our study was estimated at 72% comparable to that of Thiam in Senegal 60% (1).

CONCLUSION

This study conducted at Timbuktu hospital aimed to improve its management. Indeed, the frequency of abruptio placentae remains high in our context. It identified severe maternal anemia, low birth weight, unregulated pregnancies and sanitation as factors that were relation with increased perinatal mortality. Patients presenting abrupt placentae were mostly evacuated in a context of insecurity with attack of the medical ambulance. The clinical picture was severe, imposing a huge transfusion requirement in a remote and insecure area and not having the blood donation culture. This attitude is taken into account in the indications of Cesareans. The development of a coherent and cost-effective care strategy should help to reduce the maternal and perinatal mortality rates of still high obstetric emergencies.

PUBLIC DECLARATION OF INTEREST

I, the undersigned, Dr. Fane Seydou, declare that I have no direct or indirect financial or in-kind interest with a private, industrial or commercial organization in relation to the subject presented.

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Citation: Seydou F, Amadou B, Mamadou K, Ibrahima K, Djibril S, et al. (2019) Epidemiological, Therapeutic and Prognosis Aspects of Abruptio Placentae in an Insecure Area of Mali, Case of the Hospital of Timbuktu. J Reprod Med Gynecol Obstet 4: 031.

Copyright: © 2019  Fane Seydou, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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