A study of risk factors and obstetric outcome of antepartum haemorrhage in a tertiary care hospital of eastern India

Background: Antepartum haemorrhage (APH) is haemorrhage in or inside the genital tract after 28th weeks of pregnancy but before the delivery of baby. There are two main types of APH i.e. ‘placenta praevia’, ‘abruptio placentae’ and others are unexplained or extra-placental and local causes. Objective: Aim of our study was to know the different causes of APH along with foeto-maternal outcome. Materials and Methods: This observational study was carried out in a tertiary care hospital during the period of January, 2019 to December, 2019 i.e. the period of one year. Women with more than 28th weeks of gestation and presenting with bleeding per vagina were our study subject. Demographic data, cause of bleeding, mode of delivery and foetomaternal outcomes were tabulated. From the descriptive data, percentages, proportions and significance were calculated by using SPSS software of 24th version. Results: 112 women were studied, which was actually 1.2% of total delivered women in the study period. Study showed placenta praevia and abruptio placentae were 54.5% and 35.7% respectively as a cause of APH. It was seen that incidence of APH increased with age and parity and associated past history of uterine operations. Study showed adverse foetomaternal outcome was more prevalent in APH in the form of postpartum haemorrhage, retained placenta, puerperal infection, coagulation failure and preterm birth, neonatal jaundice, foetal asphyxia, sepsis and increased perinatal and maternal mortality. Conclusion: Women with past history of uterine operation have an increased risk of developing APH. Women with APH has to be considered as high risk pregnancy and needs institutional supervision. © This is an open access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
In India, every year more than 1,00,000 mother die due to pregnancy related causes. Most of these deaths are preventable. Haemorrhage is one of the deadly complications in obstetrics. Haemorrhage accounted for nearly 30% of the maternal mortality of which antepartum Haemorrhage (APH) constitutes 2-5% of the cases. 1,2 The World Health Authority defines antepartum haemorrhage as bleeding after 28 th week of pregnancy i.e. the period of viability. 1,3,4 On an average 0.5 to 5% of all pregnancies are complicated by antepartum and multiparty. Exact cause of placental abruption is unknown but often were associated with preeclampsia, pre-labour rupture of membrane and abdominal trauma, cigarette smoking. 5,8 Local causes such as cervical polyp and cervical carcinoma are rarely found present in APH.
Maternal complication of APH include malpresentation, premature labour, caesarean section, retained placenta postpartum haemorrhage, haemorrhagic shock, rarely disseminated intravascular coagulation and acute renal failure. 5 Foetal complications include prematurity, neonatal jaundice, intrauterine death, still birth and perinatal mortality. 4 The developed world has already reduced maternal mortality from APH by implementing small family norms with increased family planning acceptances, availability of institutional delivery and sophisticated neonatal care units.
Objectives of our study was to evaluate incidences of different types of APH, mode of delivery and foetomaternal outcome of the pregnancy in our study which was complicated by antepartum haemorrhage (APH).

Materials and Methods
The present study was conducted among the women admitted under the department of Obstetrics and Gynaecology of a tertiary care hospital in eastern India within the one-year period of January, 2019 to December, 2019. Women who attended our emergency or outpatient department with a complaint of bleeding at 28 th weeks of gestational age or thereafter but before the delivery of baby, were our study subject. During the study period, a total number of 9334 women were delivered among which 112 were diagnosed as third trimester bleeding per vagina. All booked and unbooked women of third trimester bleeding per vagina were included in this study.
The Institutional Ethics Committee approved the study, and the study was performed in accordance with its recommendations and that of that of Helsinki Declaration of 1975 that was revised in 2000. All women participating in this study gave a written informed consent. Women excluded from the study subject were those having low lying placenta or retro placental haematoma detected on routine antenatal sonography or during caesarean section but remained asymptomatic throughout pregnancy. History of pre-existing coagulation disorder or women with anticoagulants were also excluded from the study subject. Women ++with bleeding before 28 th week of gestation and those with bleeding later due to initiation of labour with excessive show were also excluded from the study. The study was based on history and clinical examination supplemented by ultra-sonogram whenever possible.
History of previous pregnancies and their outcome, whether induced or spontaneous abortion, any surgical procedures undertaken like dilatation and evacuation (D/C), caesarean section, manual removal of placenta or exploration of uterus were recorded. Routine antenatal investigations and along with foetal lie, presentation, maturity was also taken. Diagnosis of APH was done by antenatal sonography. As per standard guide line classifications, diagnosis and mode of delivery of placenta praevia and abruptio placentae was made. Cases, where cause of bleeding was undetermined, were labelled as unexplained variety.
The fundamental areas of concern in this study were as follows-1. To find out the incidence of third trimester bleeding in the study period. 2. Evaluation of the women were done with full medical, surgical and obstetrical history, clinical examination, relevant investigations and obstetrical management. 3. Foetomaternal outcome was recorded within the study group.
The age, parity, socioeconomic status, past gynaecological and obstetrics history and cause of antepartum haemorrhage were recorded in percentages and proportions. Mode of delivery and associated foetomaternal complications were measured by chi-square test and significance of P value at 0.05 and 0.01 level. All of the data were calculated in SPSS 24 th version.

Results
In this study 9334 deliveries were conducted, of which 29 cases were of multiple pregnancy, all of which were twins. During this study period, 112 women were admitted with third trimester bleeding per vagina. Two of the studied subject delivered twin babies. So the number of babies in the studied subject was 114. The incidence of third trimester bleeding per vagina was 1.19% in this study group.
One maternal mortality occurred in a woman of concealed type of placental abruption who was admitted in a condition of severe haemorrhagic shock, coagulation failure and had delivered a stillborn baby vaginally.

Discussion
Incidence of antepartum haemorrhage (APH) varied widely with demographic profiles and different geographical areas.
From the literature review, Yadav et al 4 reported in their study that 25-29 years' age were commonest age group in their study which was quite similar to our study. In their study, placenta praevia, abruptio placentae and unclassified     variety were 76.8%, 20.5% and 2.7% respectively. In their study, incidences of placenta praevia was slightly more than finding of our study. In another study, conducted by Majumder et al 3 it was also found that 26-30 years' age group was most commonly affected age group of APH in their study.
A study conducted by Patvekar et al 10 found placenta praevia, abruptio placentae and indeterminate type were 29%, 66% and 5% respectively. In their study, incidences were differing from our study, which may be due to different geographical locations of study.
A study reported by Majumder et al 3 found 66% APH were placenta praevia, of which 12% were primigravida, 48% were 2-4 th gravida and 6% were from 5 th gravida onwards. In the same study, it was also found that 34% of APH were from abruption placentae and within these 6% were primigravida, 23% were 2-4 th gravida and 5% were from 5 th gravida or more. In their study, there were increased preponderance of APH of both categories towards higher parity. Their findings were consistent with our study findings.
In our study, according to updated Kuppuswamy scale for 2007, 9 socio-economic status of the women was classified into five groups. Highest number 43 (38.4%) of women were from lower socio economic status.
On literature review, it was seen that there was paucity of data on socio economic status of women with APH. A study conducted by Mukherjee S et al 11 found two-third of women with abruptio placentae were more in upper lower (112/318) and lower (102/318) socioeconomic status.
A study conducted by Ayushma J et al 12 found 21% of women with APH had prior history of caesarean section in their study group. In another study reported by Patvekar M et al, 10 17.3% and 34.7% of women with placenta praevia had a past history of caesarean section and abortion with curettage respectively. Their study findings were quite similar to our study finding.
In the present study, two women of twin pregnancy were associated with placenta praevia, so there was 63 new-born present among the 61 women of placenta praevia. Twin gestation is associated with larger placental site for which there was more chances of placenta encroaching the lower uterine segments easily and leading to increased incidence of placenta praevia said by Strong TH and Brar HS. 13 In their study, majority of placenta praevia (86.9%) were terminated by caesarean section and abruption placentae was mostly delivered vaginally of which spontaneous vaginal delivery 9 (22.5%) and labour induction by ARM followed by oxytocin drip were 13 (32.5%). Most of the women of the undetermined origin were also delivered vaginally.
The study conducted by Wasnik SK et al 2 found, rate of caesarean section was 90% in their APH group. In a similar study, reported by Lankoande M et al, 14 it was found rate of caesarean section in placenta praevia and abruptio placentae (i.e. retro placental hematoma) were 56.9%, 43.1% and vaginal birth in placenta praevia and abruptio placentae were 66.6%, 33.4% respectively. Their finding was very similar to finding of our study. Another study reported by Senkoro EES et al 15 found that women with placenta praevia had tenfold higher odds of caesarean delivery. These findings were also consistent with our study findings.
In another study, Patil Y et al 16 reported that emergency caesarean section, elective caesarean section and vaginal delivery of placenta praevia were 55%, 30%,15% respectively, in abruption placentae it was 50%, 40%, 10% and undetermined type it was 58%, 35% and 7% respectively. The mode of delivery in their study was found significant (<0.05).
Another study, conducted by Singhal S et al 6 reported that caesarean section, postpartum haemorrhage, coagulation failure and maternal mortality were 43.8%, 21.8%, 3.8% and 2.2% respectively in their similar study.
In another study, conducted by Majumder S et al 3 it was found that caesarean section, postpartum haemorrhage, retained placenta, coagulation failure due to DIC were 66%, 2%, 1%, 2% respectively but without any maternal death. Most of the figures were similar to our study.
Outcome of pregnancy with APH were considered as increased foetomaternal complications. In our study, mild asphyxia and severe asphyxia of new-born distinguished by Apgar score of 4-6 and 0-3 respectively. Among the women of APH, mild asphyxia was present in 20 (17.5%) of which 14 (12.3%) was from abruptio placentae and severe asphyxia was present in 9 (7.9%) women of APH in which 6 (5.3%) were from placental abruption. Total 03 (2.6%) still birth was present in our study. Distribution of babies according to Apgar score were highly significant (p<0.01).
A study conducted by Wasnik SK et al 2 found birth asphyxia was 16% in their similar study, though their figure was a little lower than that of our study figure. Birth asphyxia was more common in our study, may be due to our adoption of stringent diagnostic criteria to select asphyxia in new-born.
A study conducted by Yadav MC et al 4 found neonatal jaundice was present in 26.8% of APH but among the women of placenta praevia it was present in each (30/30) new-born. Their findings were contradictory with the finding of our study, that may be due to study conducted in different geographical locations, or may be due to there was small sample size.
In another study reported by Sharmila G et al 1 it was found that still birth and neonatal death were 31.37% and 5.8% respectively. Their neonatal death rate was almost similar to our study but still birth rate of our study was relatively lower, that may be due to availability of better obstetrical care.

Conclusion
Vaginal bleeding during third trimester of pregnancy may lead to grave consequences of women's life. From our study, we found that risk of APH increased with past history of uterine operations and rate of caesarean delivery with adverse foetomaternal outcomes was also increased in the women with APH. But it may be concluded that regular antenatal care, identifying the major degree of APH to provide care in tertiary care hospital and also availability of neonatal intensive care is required for better outcome.

Authors' contributions
All author exclusively contributed in this work and read and approved the final manuscript.

Source of Funding
No financial support was received for the work within this manuscript.

Conflict of Interest
The authors declare they have no conflict of interest.