AFJOG

African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 3 | 2024 | 22 ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 3 | 2024 | High risk of major placenta praevia presents deleterious effects on Maternal and foetal outcomes. underpinned by damage and scarring of the uterus during caesarean section which predispose to low implantation of the placenta. The study has shown that frequent antenatal visits (≥5) added a clinical benefit of early identification of PP and hence minimization of associated complications. In this study half of patients delivered at term while 3.2% delivered at early pre-termbetween 28 and 33weeks. Present findings are consistent with those of earlier studies 15,35,47 . Chidimma and colleagues 40 reported that 77.1% of their patients were more than 37 weeks of gestation while Maiti et al48reported 63.3%. These outcomes were larger than in the current study. These findings are in line with the Royal College of Obstetricians and Gynaecologists guideline that advocate delivery at 38 weeks for asymptomatic patients to prevent prematurity complications. The department of Obstetricians and Gynaecology at SMU advocates for admission of patients diagnosed with major PP for foetal lung maturation and delivery at 36 weeks of gestation. There was a significant number of late referrals from feeder hospitals which contributed to delays in diagnosis of PP and resulted in delivery at term. This is in contrast to Rao et al who found that patients with major PP were delivered significantly earlier at 35.1 weeks of gestation. Chung et al reported the same findings in their study. This was the result of higher percentage (72%) of patients in their study who experienced massive APH. In the current study a large percentage of patients underwent elective CS delivery which represented 74.4%, of which one quarter had emergency CS. This correlated positively with the outcomes of research conducted by Crane et al 2. The likely explanation of this result is due to early admission of all patients with major PP before delivery for close monitoring as well as for steroid administration to encourage foetal lung maturation. A study conducted in Pakistan by Baloch et al resulted in 80% of their subjects delivered by emergency CS; elective CS was conducted in 20% of the patients. This outcome was attributed to increased incidence of APH (92%). A total 17 (26.1%) patients had APH in this study. These findings are comparable to the study by Kindolo et al (24.7%) 38 . A systematic review and meta-analysis by Dazhi et al 49 showed prevalence of APH of 51.6%. Chung and co-workers 46 reported that APH occurred in 72.7% of the population studied. The result showed higher level of APH compared to the current study. This may have resulted from their small sample size. A study by Mohamed and colleagues14 found that 71% of their patients had intraoperative blood loss of more than 1000 ml. It is almost similar to those of Rao et al (77.9%). Their findings are almost double those of the current study (41.5%). The study by Shakuntala and colleagues30 showed prevalence of intrapartum haemorrhage in patients with PP to be higher than in patients with no PP. The contributing factors were found to be placental location which was praevia, adhesion formation as well as skill of the surgeons. In the current study, PPH occurred in nearly 32.3% of patients, similar to the work conducted by Shuruth et al (27.9%) 37 . Chidimma et al 40 identified that only 17.5% of their patients with PP had complication of PPH. In contrast, Chung et al 43 highlighted increased incidence of PPH in 45% of patients. The contributing factor was a result of non- usage of carbetocin and tranexamic acid for prevention and management of PPH. Blood transfusion products were administered to 72.5% of patients in this study; it is common in clinical background of PP. This is a resuscitative measure for blood loss during CS for PP. Salim et al 39 reported that blood products were used in less than 40% of patients while Shuruth and colleagues found that 92.7% of patients were transfused. Grönvall et al 32 stated that patients with major PP had a higher incidence of post-partum haemorrhage and subsequently required transfusion. Findings by Baha et al 3 have shown that there was increasing rate of blood transfusion. The finding was due to increased rate of hysterectomy and not to PP. The conclusion was drawn following removal of confounding factors. Obstetric haemorrhage in the current study was 57%. This was lower than the study by Maiti et al 48 (23.3%). Obstetric haemorrhage is an anticipated obstetric complication in PP. This is confirmed by Saving Mother’s report (2021-2022) which highlighted association of anaemia and obstetric haemorrhage as leading causes of maternal mortality. Balock et al 17 reported a prevalence of 8% in their study. This can be explained by a small sample size. The current study established that 22% of patients underwent intrapartum hysterectomy for life threatening haemorrhage. This is similar to the study of Salim et al (21.15%).39 Studies by Chidimma and colleagues showed the incidence of 10.2% whereas Kassenet al 12 (3.1%) and Shu-Yu Lung et al (1.3%). Asicioglu et al 19 had high rate (80%) which they attributed to poor surgical skills and underutilization of uterine balloon tamponade due to the cost. In this study, late referral from peripheral hospitals, undiagnosed placenta accreta as well as unskilled surgeons contributed to intrapartum hysterectomy. Bahar et al 3 established that pregnant patients with major PP were five times more at risk of undergoing hysterectomy. This high rate contributed to increased incidence of intraoperative and postoperative complications. This study showed that 8.1% of patients sustained iatrogenic bladder injury. This finding is in agreement with report by Ascioglu et al 19 . Alsamani and colleagues reported a greater percentage (28.7%) of intraoperative bladder injury, while Phillip et al 43 observed only it in 0.5% of their patients. These injuries mostly occurred in patients who underwent intrapartum hysterectomy and repeated caesarean sections. Excessive adhesions were a major factor in these cases. Maternal mortality in this study was 4.7% - it is considered high when compared against studies conducted by Baloh et al (2%). Mohammed et al50 on the other hand had mortality rate of 6.9% among patients with major PP. The high maternal mortality rate was due to late referral of haemodynamically unstable patients from peripheral hospitals. The second reason was finding of morbidly adherent placenta which contributed to severe intrapartum haemorrhage and delay in decision making to proceed to hysterectomy in those patients. ICU admission accounted for 11.2% of the population studied which is much lower than 48.2% revealed by Varlas et al 42 in their retrospective study. According to DGMAH’s Department of Obstetrics protocol all patients are further managed and monitored in the labour ward high care area post CS for PP. The patients were admitted in ICU for haemodynamic stability. Iatrogenic pre-term delivery has been frequently associated with PP. In this study nearly half of the neonate had birth weight ranging between 1500 to 2499 grams. These results are largely supported by Gronvall et al 32 . Crane et al 20 reported an incidence of 85% low birth weight which