Severe abruption: Maternal and Perinatal Outcomes

*Corresponding author: Rachita Garg Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. Severe abruption: Maternal and Perinatal Outcomes Rachita Garg 1, *, Madiha Khan 2, Preeti Singh 3, Latika Sahu 4, Nasrin Fatima 5 and Pallavi Pathak 6 1 Senior Resident, Department of Obstetrics and Gynaecology, MAMC and associated Lok Nayak Hospital, Delhi. 2 Post Graduate, Department of Obstetrics and Gynaecology, MAMC and associated Lok Nayak Hospital, Delhi. 3 Professor, Department of Obstetrics and Gynaecology, MAMC and associated Lok Nayak Hospital, Delhi. 4 Director Professor, Department of Obstetrics and Gynaecology, MAMC and associated Lok Nayak Hospital, Delhi. 5 Senior Resident, Department of Obstetrics and Gynaecology, MAMC and associated Lok Nayak Hospital, Delhi. 6 Senior Resident, Department of Obstetrics and Gynaecology, MAMC and associated Lok Nayak Hospital, Delhi. World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 126-132 Publication history: Received on 25 June 2025; revised on 02 August; accepted on 05 August 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.23.2.0734 Abstract Introduction: Abruption is a common cause of Antepartum Hemorrhage and complicates 0.4-1% pregnancies overall. Severe abruption is defined as evidence of maternal shock or coagulation defects, uterine tetany and intrauterine death of fetus according to the Page classification. Objective: To study maternal and perinatal outcomes in patients with severe abruption Methods: All pregnant women with severe abruption, grade 3 of Page classification were included. Complete evaluation was done with presenting complaints, obstetric history, past history, associated obstetric co-morbidites, obstetrical examination and relevant investigations were done. Maternal and perinatal outcomes were observed and analysed. Results: Among 8600 pregnant women admitted, the incidence of abruption was 1.8% (n=158), with 23 cases being classified as severe. Half of the patients (52%) had abruption at early preterm gestation (<34 weeks). Most common associated risk factor was presence of pre-eclampsia in 65% patients. More than half (56.5%) had vaginal delivery. Major maternal complications observed included PPH in all patients, DIC in 22% patients and AKI in 30.4% patients. Perinatal mortality was 78.2% and 26% required NICU admission. Conclusion: Abruption is one of the major causes of maternal and fetal morbidity and mortality. Early identification and timely termination leads to reduction in maternal complications, but still has a poor perinatal outcome. The aim should be early termination of pregnancy. Keywords: Abruption; AKI; DIC; PPH 1. Introduction Antepartum hemorrhage (APH) is bleeding from or into the genital tract after 24 weeks of gestation till delivery. About 20-25% of cases of APH occur due to placental abruption. It is defined as partial or complete separation of a normally implanted placenta from uterine wall before delivery and accounts for 0.4-1% of total pregnancies.1 Abruption is a major cause for both maternal and fetal morbidity and mortality, depending on the severity. Severe abruption is defined as evidence of maternal shock or coagulation defects, uterine tetany and intrauterine death of fetus according to the Page classification. World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 126-132 127 Maternal complications associated with abruption include risk of shock, need for blood transfusion, risk of DIC, acute kidney injury and need for dialysis, need for hysterectomy. Fetal complications include fetal distress and intrauterine fetal death. 2,3 Disseminated intravascular coagulation (DIC) can be defined as a widespread hypercoagulable state that can lead to microand macrovascular clotting and compromised blood flow, ultimately resulting in multiple organ dysfunction syndrome. Diagnosis is based on a scoring system which includes platelet count, prothrombin time and fibrinogen levels. 4 Acute Kidney Injury is defined as rise in serum creatinine >1.5 times the baseline or > 0.3mg/dl absolute increase within 48 hours or urine volume <0.5 ml/kg/h for 6 hours. 5 Early recognition and prompt management of placental abruption are crucial to minimize maternal and fetal morbidity and mortality. This often involves close monitoring, supportive care, and, eventually, emergency delivery of the baby. Aims and objectives To determine the maternal and perinatal outcomes of severe placental abruption in a tertiary care hospital. 2. Materials and methods This was a prospective observational study done over a period of 15 months: June 2023-September 2024 in a tertiary care hospital in Delhi, India. All pregnant women with severe abruption, grade 3 of Page classification were included. The women’s demographic details such as age, obstetric index, gestational age, menstrual history, past, family, and personal history were recorded. Detailed obstetric history was obtained and maternal high-risk factors like gestational hypertension, pre-eclampsia, gestational diabetes mellitus and polyhydramnios were noted. All the women underwent a complete obstetrical examination and clinical workup including general physical examination, abdominal and pelvic examination, and relevant blood investigations such as complete blood count, coagulation profile and certain biochemical markers. After initial resuscitation, the mode of delivery was decided depending upon the condition of the mother and fetus. Fetal well-being was assessed with ultrasonography and cardiotocography. Maternal complications were noted down which included postpartum hemorrhage, disseminated intravascular coagulation, acute renal failure, shock, pulmonary edema and infections. Fetal outcome such as NICU admission, complications of prematurity and perinatal mortality were noted down. All information was gathered and results were entered in Microsoft Excel sheet. Results were stastically analysed using SPSS-25 version. 3. Results A total of 8600 pregnant females were admitted during the study period. The incidence of abruption in the present study was 1.8% (N=158), out of which 23 patients were classified as having severe grade 3 abruption. 3.1. Demography Maximum frequency, 61% (N=14) was observed in the age group 21-29 years. Fourteen patients (61%) were multigravida. Only 17% (N=4) patients had multiple pregnancy and the rest 83% (N=19) had singleton pregnancy. Gestational age at presentation varied with most patients with most patients, 74% (N=17), presenting preterm (<36 weeks). (Table 1) Table 1 Demographic Details Demographic Parameter Frequency (N=23) Percentage (%) Age <21 years 21-29 years 1 14 4.3 61 World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 126-132 128 30-39 years >40 years 6 2 26 8.7 Parity Primigravida Multigravida 9 14 39 61 Period of gestation 28-34 weeks 34-36 weeks >36 weeks 12 5 6 52 22 26 Number of Fetus Singleton Multiple 19 4 83 17 Clinical Presentation Bleeding PV Pain abdomen Both 2 4 17 8.7 17.3 74 Time duration to reach hospital after bleeding <4 hours 4-6 hours > 6 hours 9 7 7 39 30.5 30.5 3.2. Clinical Presentation Pain abdomen and bleeding per vaginum were the presenting complaints in most patients, however 4 patients (17%) did not have bleeding as their chief complaint. One third of the patients, 39% (N=9) presented early to the hospital within 4 hours of their symptoms. (Table 1) 3.3. Obstetric Comorbidities Presence of other obstetric disorders like polyhydramnios, hypertension, anemia and others were identified. Preeclampsia was the most frequent comorbidity associated with abruption in 65% (N=15) patients with anemia being the second most common association in 52% (N=12) patients. (Figure 1) Two patients had subchorionic hematoma in the first trimester and were on conservative management. On follow up, they developed abruption in the third trimester. Both patients had hematoma of <2cm size. World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 126-132 129 Figure 1 Obstetric Comorbidities 3.4. Maternal Outcomes Maximum patients, 56.5% (N=13) underwent vaginal delivery (spontaneous/induced) while the rest 43.5% (N=10) had to undergo an emergency lower segment cesarean section. One-third of cesarean section patients (3/10) had Couvelaire uterus intra-operatively. (Table 2) All patients with Couvelaire uterus developed post-partum hemorrhage with blood loss of >1.5L and required transfusion of blood and blood products. All 3 required ICU admission. One of the patients developed AKI, requiring 6 cycles of dialysis. Two of the three had IUD, while the remaining one was preterm and was in NICU for 20 days. In almost all patients, 82.6% (N=19) delivery was expedited within 6 hours of diagnosis. Four patients took longer than 6 hours to deliver, however all of them had uncomplicated vaginal delivery. Presence of retroplacental clots (RPCs) just after delivery was noted irrespective of mode of delivery and it was found out that 4 patients (17.4%) had RPC of > 1000ml, 6 patients (26%) had RPC of 500-1000ml, 12 patients (52.2%) had RPC of < 500ml while one did not have any RPC. However, presence of massive RPC (>1000ml) did not corelate with maternal complications like DIC or AKI. (Table 2) Maternal complications observed included Post Partum Hemorrhage (PPH), Acute Kidney Injury (AKI), Disseminated Intravascular Coagulopathy (DIC), need for dialysis, ICU admission, transfusion of blood and blood products. All of the patients had PPH requiring transfusion of blood and blood products. Six patients had severe PPH (blood loss of >1.5L), 14 patients had moderate PPH (blood loss of 1-1.5L) while 3 patients had mild PPH (blood loss of <1L). Five patients went into DIC (21.7%) and needed correction in the form of platelet and FFP transfusion. All 5 patients had transfusion of 4 units FFPs each. ICU care was required for 10 (43.5%) patients which led to increased hospital stay of >15 days in 9/10. (Tabe 2) AKI was noted in 7 patients (30.4%) and all of them needed dialysis for treatment. One patient was transferred to a dialysis center while the rest 6 improved on dialysis and had normal KFT after stopping dialysis on discharge. Table 2 Maternal Outcomes Maternal Outcomes Frequency (N=23) Percentage (%) Mode of delivery Vaginal 13 56.5 World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 126-132 130 LSCS 10 43.5 PPH Mild Moderate Severe 3 14 6 13 61 26 Blood Transfusion PCV FFPs Platelets 61 74 47 DIC 5 22 ICU admission 10 43.5 AKI 7 30.4 Duration of hospital Stay 1-2 weeks 2-3 weeks 3-4 weeks >4 weeks 9 6 1 7 39 26 4.5 30.5 3.5. Perinatal Outcomes Perinatal outcomes observed included Intrauterine death, prematurity, poor APGAR and need for NICU admission. Intrauterine death occurred in 17 of 23 (74%) cases due to fetal hypoxia secondary to blood loss. Out of the surviving 6 fetuses, 2 had preterm delivery while rest 4 delivered at >36 weeks. However, all 6 required NICU admission and there was one early neonatal death. Four of the 6 babies had poor APGAR of <7 at 1 minute of life. (Table 3) Table 3 Perinatal Outcomes Perinatal Outcomes Frequency (N) Percentage (%) IUD 17 74 Preterm delivery 2 8.7 NICU admission 6 26 Poor APGAR (<7) 4 17.4 4. Discussion Abruption is a major cause of maternal and fetal morbidity and mortality. It needs to be identified and managed promptly to prevent complications. The incidence of abruption in the present study was 1.8%. Similar rates have been reported in other studies with incidence ranging from 0.4% - 2.7%. 4, 6-12 Predisposing risk factors for abruption includes age of the mother (extremes of age), multiparity, twin gestation, polyhydramnios, prior history of abruption, history of first trimester bleeding in current pregnancy, chronic hypertensive disorders, preeclampsia, premature rupture of membranes, abdominal trauma, smoking, drug abuse like with cocaine and amphetamines, maternal thrombophilia like factor V Laiden mutation etc. 4 In the present study, maximum cases (61%) were in the age group 21-29 years and 61% were multigravida. Other studies have also reported abruption to be more common in similar age group and in multigravida. 4, 6-12 World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 126-132 131 Pre-eclampsia was the most common risk factor identified in 65% patients along with the presence of pre-existing anemia in 52% subjects. Association of Hypertensive disorders of pregnancy with abruption is a common finding in other studies, ranging from 48-67%. Hypertension leads to premature separation of placenta by causing bleeding due to rupture of spiral arteries and hematoma formation in the decidua basalis. 4, 6-8, 13 Two patients (8.6%) in the present study had history of subchorionic bleed in the first trimester, another risk factor associated with hypertension. Khan et al8 and Kanavi et al10 also reported presence of subchorionic hematoma as an identifiable risk factor for abruption in 9.4% and 9.3% subjects respectively. Sixteen patients (69.5%) had mixed type of abruption; one had only revealed abruption while remaining 6 had only concealed abruption in the present study. Kapadia et al13 also found mixed type of abruption to be the most common presentation (69%). Pain abdomen and bleeding are the most common presenting complaints. In the current study, 17% patients did not have any bleeding as presentation. In the studies done by Khan et al8 and Devi et al11, bleeding was not a chief complaint in 18% and 14% respectively. Thus, there needs to be a high suspicion for the diagnosis of abruption with presence of other symptoms even in the absence of bleeding. In this study, 56.5% patients had vaginal delivery, either spontaneous or augmented. Termination by cesarean section required ICU care in most patients (7/10), including 3 patients with Couvelaire uterus. However, no association was seen with development of AKI or DIC and cesarean section in the current study. Mode of delivery varied considerably in studies conducted, with caesarean section rates ranging from 26-83%.4,6-13 Couvelaire uterus was reported in 13% (N=3) patients in the present study. Kanavi et al10 and Devi et al11 reported Couvelaire uterus in 8.6% and 5% patients respectively. Maximum patients, 86.9% (N=20) had blood loss of >1L and transfusion of blood and blood products {packed red blood cells (PRBC), fresh frozen plasma, platelets} were required for all patients. Total of 61 PRBC, 74 FFP, 47 platelets were transfused. There was no association between the amount of blood loss and development of DIC, AKI or IUD. Need for blood transfusion is almost always needed in abruption patients as there is blood loss due to revealed bleeding or concealed in the form of retroplacental clots. Coleman et al4 observed a mean blood loss of 2300 ml with an average 3.5 units PRBCs transfusion per patient and it was a separate indicator for maternal (death) and fetal (stillbirth) outcome. Other studies have also reported need of transfusion in 47%-67% patients.8-12 Maternal outcomes in the current study included PPH in all patients, DIC in 22%, AKI in 30.4% with need for dialysis in all and 43.5% requiring ICU admission. Other studies have reported PPH in 11-37%, DIC in 7-20%, AKI in 1.4-21% and ICU admission in 1.5-16%.4,6-13 Few studies have also reported maternal mortality of 1.6-4%.4,8,9,13 However, there was no mortality in the current study. Patients who presented late to the hospital (>6hrs) needed ICU admission (5/7). Interval between diagnosis and delivery was not a determinant factor for ICU admission or development of AKI and DIC. Similar observation has been reported by Kanavi et al.10 Fetal outcomes included IUD in 74% patients at presentation to the hospital and 1 early neonatal death making perinatal mortality of 78.2%. Four of the six live babies had poor APGAR (<7) at birth. All patients with live births presented early to the hospital within 6 hours. Amount of blood loss did not corelate with fetal outcomes. Other studies also report stillbirth rate of 30-69%.4,6-13 Limitations The current study has been done over a period of one year. A bigger study with longer study period and a greater number of participants and longer follow up is needed to establish the findings of this study. 5. Conclusion Abruption is one of the major causes of maternal and fetal morbidity and mortality. Early identification and timely termination leads to reduction in maternal complications like AKI, need for dialysis and ICU stay. However, it is one of the major causes leading to stillbirth even after timely intervention as even a small amount of blood loss leads to IUD. The aim should be early termination of pregnancy once diagnosis has been made to prevent complications. The clinician should be aware of the complication like AKI and ensure proper monitoring to detect them and manage timely to decrease maternal morbidity. World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 126-132 132 Compliance with ethical standards Disclosure of conflict of interest No conflict of interest to be disclosed. Statement of ethical approval Ethical approval was obtained. Statement of informed consent Informed consent was obtained from all individual participants included in the study. References [1] Brandt JS, Ananth CV. Placental abruption at near-term and term gestations: pathophysiology, epidemiology, diagnosis, and management. Am J Obstet Gynecol. 2023 May;228(5S):S1313-S1329. [2] Ananth, C. V., Lavery, J. A., Vintzileos, A. M., Skupski, D. W., Varner, M., Saade, G.,Wright, J. D. (2016). Severe placental abruption: clinical definition and associations with maternal complications. American Journal of Obstetrics and Gynecology, 214(2), 272.e1–272.e9. [3] Coleman J, Srofenyo EK, Ofori EK, Brakohiapa EK, Antwi WK. Maternal and fetal prognosis in abruptio placentae at Korle-Bu Teaching Hospital, Ghana. Afr J Reprod Health. 2014 Dec;18(4):115-22. [4] Pereira M, Rodrigues N, Godinho I, Gameiro J, Neves M, Gouveia J, Costa E Silva Z, Lopes JA. 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