Profile and Prognosis of Retro Placental Hematoma Victims at the Regional University Associated Hospital of Borgou (CUAB) in Republic of Benin

Patients and Methods

This is a descriptive retrospective study that took place in the Obstetric and Gynecology Service of the CUAB, wich is a level 3 Maternity in northern Benin. It focused on all complete medical records of the patients admitted for RPH between January 1 and December 31, 2019. Were included pregnant women in the third trimester, in whom the diagnosis was made either by clinical examination accordingly to the HURS’s criteria (presence of two of the following four signs : hemorrhage, pain, abnormal uterine contraction or fetal heart rate) [6] and/or by ultrasound and confirmed by the presence of placental cups. The studied variables were related to the maternal profile (socio-demographic, clinical characteristics, paraclinical data, data relating to drug, obstetrical and surgical management) and the maternal and perinatal prognosis. The sample was non-probabilistic. The files were collected and then analyzed using a previously validated form.

Data entry and analysis were carried out by EPI Data and EPI Data software. Strict compliance with ethical rules and standards has been observed.

Frequency

During the study period, 1,740 deliveries were performed. The diagnosis of RPH was made in forty seven (47) patients, i.e a frequency of 2,7%.

Socio-demographics data (Table1)

The mean age of the patients was 29,57+/- 5 years with extremes of 18 to 40 years. The 25 to 34 age group was the most affected with 51% of cases (n=30). The Bariba and Dendi ethnic groups were the most represented with 48,9 % (n=23). The majority (72%) of the victims (n=31) came from the city of Parakou and lived as a couple in 89,4% (n=42).

The most common histories in the RPH patient population are listed in the table below. Table 1: Socio-professional characteristics of patients with RPH.

Clinical data (Table 2)

Most of the victims (89%) (n=39) were referred from the outlying peripheral centers of the city of Parakou. Pregnancy was not at term (<37 AW) in 74,5% of pregnancies and mean prematurity (32-34 AW) was observed in 46,8% (n=22). The main reasons for referral were uterine bleeding (metrorrhagia) in 97,8% (n=45), lumbo-pelvic pain in 72,3% (n=34), suspicion of RPH in 48,9% (n=23) and in utero death in 46,8% (n=22), Preeclampsia in 38,3% (n=18), high blood pressure in 14,9% (n=7), the diabetes (n=2) and sickle cell disease (n=1) were the most common past mediacal history. antecedents,The nulliparous and multiparous were the most affected in the same proportion of 34% (n=16). The systolic blood pressure was abnormal (SBP≥ 16mmHg) in

51% of the cases, the diastolic blood pressure was abnormal (90≤DBP≥110 mmHg) in 93,6% (n=44). Urine dipstick albumineria was significant (≥ 2+) in 72% of cases (n=34) and negative (negative or 1+) in 28% (n= 13).

Uterine hypertonia, one of the pathognomonic signs of RHP after bleeding, was found in 74,5% of pregnant women (n=35).

Therapeutic data

Pregnant women benefited from the blood transfusion (68.3%) of the cesarean section for fetal rescue in 32% (n=15) and maternal rescue in 14.9% (n=7). Magnesium sulfate was used only in 2 patients against 34 indications, ie a rate of use of 5.9%. Obstetrical treatment consisted of rupture of membranes in 74.5% (n=35) followed by the injection of pethidine by intramuscular route and of the infusion of Syntocinon.

Prognosis (Tables 3 & 4)

Maternal: Maternal morbidity was represented by anemia and bleeding disorders (25,5%). Three maternal deaths were recorded in our series, i.e a mortality rate of 6%.

Fœtal: The APGAR score at 5 min was inferior to 7 in 17% of patients (n=8) and required resuscitation procedures.

Deaths were registered in ante partum period in 46.8% (n=22), in perinatal periode in 12.8% (n=6) and neonatal period in 8.5% (n=4). The perinatal mortality rate of RPH was 68%.

Death was observed in 83% for cups weighing between 501 and 1000g and 100% for cups weighing over 1000 grams (Table 4).

Epidemiologic and Clinical Characteristics

This study found that RPH represented 2.7% of deliveries. The high frequency in our series may be due to the fact that DUHC/B is the single referral university associated hospital in the northern region of Benin. This frequency is comparable to those found by many authors in Sub-Saharan Africa. Nayama and Coll in Niger in 2007 [7] found in their series a frequency in a hospital comparable to the UHC of North Benin in terms of admission of referrals. In general, the frequency of RPH in sub-Saharan Africa remains higher than that observed in developed countries. Milan DD and coll in their series at Cocody University Hospital in Ivory Coast in 2014 [8] found 1.55%. According to Anca D. this frequency varies from 0,13 to 1,38% [9]. According to Guennec and coll in 2016 the frequency of RHP was 0.78% [10]. This can be explained by the higher socio- economic level, the adequate follow-up of pregnancies and the much higher technical platform in European countries. However, the level of development does not seem to be the only one explanatory factor given the high frequencies recorded also in some Asian countries whose socio-economic level is comparable to that of Europe. This is what Ayser H. and coll study showed in 2018 in India with a frequency of 3.1% [11]. According to several authors, preeclampsia, arterial hypertension, premature rupture of membranes, malnutrition were incriminated [7, 12]. In our series, the mean age of  onset of RPH was 29,57 ± 5,4 years old with extremes of 18 to 40 years old. RPH occurs at all ages especially in young women our series. The predominance of young age can be explained by the lack of pregnancy follow- up and the anxiety generated by pregnancy.

Multiparity is a factor in RPH incriminated in the littérature. In addition, age is a factor when it is associated with parity according to TIKKANEN and coll in 2011 who found a higher frequency of RPH after 35 years old with a relative risk of 1.3 [13]. According to Thieba B. and coll, RPH at young age is due to a defect or insufficiency of prenatal follow up and not to a vascular cause [14]. The nulliparous and multiparous were the most affected in our series, whereas in most of the studies in the literature multiparity was incriminated [15]. Nayama and coll had shown through their series that RPH did not spare any parity, thus confirming the data of our study [7].

RPH victims in our series were refered patients in 97.8%. This could be explained by the fact that Borgou University associated Hospital is the single referral hospital in the department where all cases from outlying hospitals were sent. Thieba B and coll in 2003 at Ouagadougou had found 85.9% of RPH coming from medical evacuations [14]. The referrence reasons were  : bleeding in 97.8% (n=45), lumbopelvic pain in 72.3% (n=34), suspicion of RPH in 48,9% (n=23) and death in utero in 46.8% (n=22). Severe forms were the most frequent and could be due to delayed diagnosis and/or referral.

These severe forms can also explain the high rates of ante partum deaths in our series (46.8%). Belinga and coll in 2017 in Yaounde found death after neonatal asphyxia as one of the main obstetrical complications associated with the referral. All cases of RPH cases in our series occured after 32 AW. This finding confirms the thesis that RPH is an entity of the third trimester of pregnancy. Niyama had reaches the same conclusion in his series [7]. The significant blood loss before admission in 97.8% could justify the coagulation disorders 25.5% in a context of severe preeclampsia in 72.8% of cases. According to Offer Erez in 2015, hemorrhages and preeclampsia are the big providers of coagulopathy [16].

Treatment

Bohec C and coll recommended in 2010 a quick correction of blood volume lost in the event of significant hemorrhgagic shock by infusing 1500 to 3000 ml of crystalloids and then gelatins [17]. In our study, treatment consisted of preoperative resuscitation with vascular filling in all of our patients. The state of vascular collapse observed in most cases of RPH justified this approach.

Magnesium sulphate was used in only 2 patients whilw prescribed for 34 patients (severe preeclampsia complicated by RPH) ie a use rate of 5.9%. Tonato Bagnan JA and coll in 2017, found a magnesium sulphate use rate of 87.18% at Cotonou’s University Associated Hospital of Mother and Child Lagune in the management of preeclampsia and eclampsia. Our result shows insufficient use of magnesium sulphate in severe preeclampsia complicated by RPH. The absence of an emergency kit and the shortages of magnesium sulphate among suppliers could explain this performance.

Obstetrical treatment consisted of rupture of membranes in 74.5% (n=35) followed by intramuscular injection of pethidine and infusion of syntocinon. This protocol is used in case of delivery by natural routes is chosen . The high frequency of the choice of vaginal route for the uterine evacuation in our series is related to the frequency of deaths in utero. The same management was observed in Niamey and Burkina Faso in 2003 in the same indications [7, 14].

The caesarean has been carried out in 46.8% of cases of wich 31.9% for fetal rescue. Thieba B abd coll had found 35.6% caesarean for fetal rescue in their series [14].

Prognosis

Maternal morbidity was related to hemorrhages in 97.8% (n=45), source of anemia in 80%, hypovolemic shock and coagulation disorders in 25.5%. Maternal lethality from RPH was 6% in our series. This rate is comparable to that observed by Nayama in Niger in 2003 (5,1%). But it far higher than in developed countries where maternal mortality remains exceptional with a rate of less than 1% [7, 18].

Prematurity after 32 WA was observed in 74.5% in our series versus 67% in the Boisramé T series in 2014 in strasbourg and 59% in the Tikkanen series in 2011 [7, 14]. Perinatal mortality was dominated by death in utero in 46.8% (n=22), followed by fresh born deaths in 12.8% (n=6) and neonatal deaths 8,5% (n=4). The perinatal case-fatality ratio from RPH was 68%. In Tikkanen’s series, perinatal mortality was also dominated by in utero deaths [19, 20].

The death of children was observed, in a proportion of 83% for cups’s weight between 501 to 1000g and 100% for cups of more than 1000g. Nayama in Niger had made the same conclusion. Perinatal mortality was proportional to the weight of the cup [7].