Contemporary issues in the management of abnormal placentation during pregnancy in developing nations: An Indian perspective.

The gap between the developed and developing nations with regards to maternal mortality and morbidity may have narrowed but still a lot of dedicated work is required to bridge these differences. Obstetrical haemorrhage is the leading cause of maternal deaths in these developing nations especially in India. The most common causes of this fatal haemorrhage are the placental abnormalities which rarely get detected before delivery. Numerous factors have been incremental in the causation of this abnormal placental implantation with resultant complications. The present article is an attempt to review possible predictors of abnormal placental implantation. Also, a genuine attempt has been made to enumerate possible measures to identify the predictors of abnormal placentation during early pregnancy and their suitable prevention and management.

INTRODUCTION

In spite of numerous advancements in obstetrical health sciences, maternal mortality is still a major cause of concern among the obstetrician throughout the world especially in the developing nations. The painfully gradual decline in the maternal mortality rate in the developing nations like India is perceived as one of the major challenges while formulating the health policies at governmental level.

Abnormal placentation is also one of the major causes of peripartum haemorrhage and higher maternal deaths. This clinical-pathologic entity of abnormal placentation in majority of patients is unanticipated. Though numerous observational studies have been carried out but the impact of these studies in the smooth management of these fatal complications is lacking especially in developing nations like India.[1] The current scenario is quite challenging and the aetiologic factors are numerous leading to a gloomy situation. To enumerate, unhealthy medical termination of pregnancy (MTP) practices, lack of awareness among obstetricians, economic backwardness, socio-cultural values, overzealous treatment of infertility and shortage of specialists’ facilities at peripheral health centers are few of the major factors which contribute ither directly or indirectly to a higher incidence of abnormal placentation.[123]

Abnormal placentation

Invasive placentation refers to abnormal implantation of the placenta where there is absence of the deciduas basilis with incomplete development of nitabuch's layer. Cases of abnormal placenta are usually encountered in the third trimester of pregnancy or during the third stage of labour. Lesser addressed issues include invasive placentation presenting in the first and second trimester of pregnancy and occasionally as an acute abdomen.[45]

Epidemiology

There has been a marked increase in the incidence of invasive placenta. A conservative estimate would be a 10 fold increase with incidences being reported between 0.9% to 1:2500 deliveries.[678] The risk of placenta accrete increases from 25%-40% with subsequent pregnancies after prior lower segment caesarean section in the presence of placenta previa.[910] Abnormal placental implantation like placenta previa can lead to hysterectomy in 5.3% of the patients after caesarean delivery with relative risk of 33 as compared to normal pregnancy.[11] Similarly, such complicated placental conditions can increase the perinatal mortality rates 3-4 times higher in normal pregnancy.[1112]

Aetiopathogenesis

This marked increase in incidence of abnormal implantation of placental tissue is clearly attributable to the increased frequency and number of operative procedures which would disturb the integrity of the deciduas basilis.[13] Studies on histopath specimens following termination of pregnancy or curettage procedure have found myometrial fibres in >34 of the tissues, thus clearly raising the issue of endomyometrial injury being a likely precursor to abnormal placental invasion. The effect of infertility and assisted reproductive technique (ART) on first trimester placentation has not been clearly established.[14] Available studies are at variance, where the role of synthetic exogenous hormones in traumatizing the basilis layer is being considered. Patients of infertility undergo endometrial curettage for diagnosis of endometrial pathology including tuberculosis; for treatment of endometrial polyps which is considered as an endometrial factor causing infertility and also indiscriminate use of energy sources may partially ablate the basilis. Another proposed mechanism in this regards is the reduced differential growth of lower segment of uterus thus allowing only minimal upward shift of the placental tissue with advancing pregnancy.[1516]

Risk factors

With liberalization of abortion practices; easy accessibility and indiscriminate use of medical abortion methods, the incidence of pregnancy related evacuation and curettage have increased and so also the incidence of invasive placentation.[171819202122] The potential aetiologic factors leading to a possible higher incidence of abnormal placentation include but are not limited to-

- Diagnostic modalities

- Lack of awareness among obstetrician and the concerned staff.

- Improper antenatal screening

- In vitro fertilization (IVF) attempts in cases of infertility

- A higher incidence of genital tuberculosis.

- Endometrial samples before invasive procedure

- Ultrasound in infertility patients (for eg. patients with polyp; as they are taken up for hysteroscopic removal)

- Unwanted pregnancies especially in the people who are not sensitized to the practices of contraception.

The number of cases of profuse, life threatening bleeding as a result is on the rise and is being encountered in different settings during the first and second trimesters of pregnancy as well. Often emergency hysterectomy is the only life saving option.

Diagnostic modalities

With the rising incidence of invasive placenta presenting with life threatening haemorrhage in early gestation, there is an urgent need to attempt to detect this condition with the non-invasive diagnostic modalities. The earliest attempts have been made between 11-14 weeks but the rising incidence of complications presenting much earlier reiterates this need. Potential areas of research would be to identify earlier indications of this abnormal placentation which would be safe in pregnancy. Trans-vaginal sonography (TVS) has been replacing Trans-abdominal sonography as methodology of choice for accurate localization and diagnosis of placenta previa and same is the scenario in our nation.[23242526] TVS is not only safe in placenta previa but also is as good as magnetic resonance imaging (MRI) scan in accurate diagnosis. Moreover, it is easily available in most of the health centers across the nation as compared to limited availability of the costly MRI facility.[272829]

The need to identify patients with clinical risk factors is increasing and will guide who would require ultrasound images, power Doppler and MRI studies to help establish a diagnosis of invasive placentation. The question is how early would imaging modalities be useful? The deciduas basilis has been studied sonographically in early pregnancy loss between 4-10 weeks gestation but the lack of studies on very early diagnosis of invasive placenta pose diagnostic dilemmas and preclude an early management protocol for lack of a definite diagnosis. The physician needs to be aware of the varied presentations in early pregnancy.[3031323334]

Socio-clinical issues

Having identified the ‘at risk’ patient, counseling and consent regarding the rare but real risk of emergency hysterectomy even in a nulliparous patient is warranted. Increased physician awareness about invasive placentation being an unusual aetiologic factor in first and second trimester obstetric emergencies needs to be addressed.

Following medical termination of pregnancy (MTP), the ‘re-do hysterectomy syndrome’ has been described and is attributed to either uterine atony or arterio-venous malformations in the uterus. However, invasive placentation may well be the cause often necessitating hysterectomy.[35] Cases have been described in the literature of placenta increta presenting as delayed post-abortal intraperitoneal bleeding in the first trimester as well as in the second trimester presenting an unusual case of acute abdomen and shock in pregnancy.[3637] Laparoscopy can be safely used in pregnancy to help establish the cause of the acute abdomen and guide further management.[38]

The clinically at risk patient, in whom abdominal pain and/or dysuria is the presenting symptom, it would be prudent to consider the possibility of invasive placenta being the cause.[3940] These cases may often be diagnosed having urinary tract infection (UTI). Haematuria rarely occurs, but the threat of massive life threatening haemorrhage always exists.

The diagnosis of abnormal placenta implantation many a times is accidental during routine antenatal visit. Cases of placenta percreta have been described in non-communicating rudimentary horn of the uterus. In such cases early diagnosis and surgical management can be life saving and laparoscopic intervention can be extremely useful in this regard.[41424344]

Common socio-behavioral Indian scenario

The highly unexplored and minimally looked area is the tendency of young couples to strive for early pregnancy in case of multiple attempts at unsuccessful conception. This socio-behavioral indifference towards healthy contraceptive practices makes them prone to opt for emergency contraception pill or MTP pill which is easily available over the counter.[23] Such a menace cannot be stopped or eliminated without the help of strict governmental policies. There is an urgent need to bring strict legislations into force to stop the indiscriminate and inappropriate use of these pills. The consequences of such misuse include incomplete abortion which necessitates performance of procedures such as suction evacuation and dilatation and curettage. Such an unhealthy and complicated clinical scenario happens mainly because of social stigma attached to premarital sex and/or pregnancy.

Further, these clinical scenarios can acquire a much larger devastating dimension as most of the unmarried sexually active young couples choose to hide their unwanted pregnancy and get termination done in an unauthorized center by dais and quacks in the most unhealthy and unhygienic manner. The fact remains hidden after their marriage and the resulting complication of these past procedures leads to episodes of haemorrhage as a result of abnormal placentation. Occasionally, these patients have to be treated in the intensive care unit for their critical clinical condition.[1]

Impact of modern therapeutic interventions

Another possibility and cause of concern is the higher age of marriage due to delay in professional career building attitude. The advancing age, stressful modern lifestyle, professional competency and many other socio-behavioral factors leads to relative infertility. The desire of a child forces these working couples to opt for early interventions for assisted reproduction techniques like intra-uterine insemination (IUI) and in-vitro fertilization (IVF).[454647] Studies have been performed in establishing a possible association between IVF treatment and abnormal placentation thereafter. In one of the latest studies it has been observed that odds ratio for developing placenta accrete is significantly higher in IVF pregnancies as compared to normal pregnancies.[1345] The conclusions were based on two factors responsible for such an abnormality; biological factor (abnormal response to trophoblast invasion) and mechanical factor (localized trauma to the uterus resulting in deficient deciduas). These factors cause possible alterations in the endometrial environment in women undergoing IVF treatment.[45] Further, there are possibilities that such therapeutic interventions may lead to a disturbed expression of genes in the endometrium.[48] The biological factor may result from the hormonal imbalance especially after the administration of estrogen and progesterone in the first 10 weeks of pregnancy. However, to establish a definite co-relation of abnormal implantation in the uterine wall and hormonal treatment further research is needed.

Although not conclusive enough evidence is available, but the need for the hour is to find out whether IUI can also have significant problems related to disturbed endometrial milieu. The research should be targeted on biochemical assay, newer non-invasive diagnostic modalities as well as search for possible predictors during early pregnancy so as to identify the patients with these probable risk factors both in the developing and developed nations.

Numerous health schemes are active now at grass root level in the country and massive training programs of the paramedical staff and health workers have enabled a larger number of deliveries taking place at higher health centers where all the resuscitative facilities are available.[4950] Even the frequency of antenatal check-up has picked up in the last 3-4 years. This provides an ample opportunity to screen the high risk patients for abnormal placentation. On the flip side, many deliveries are conducted by partially trained workers who are ignorant about the implications and complications of abnormal placentation. This has not helped at all in decreasing the incidence of post-partum haemorrhage and maternal mortality and morbidity.[51]

Role of conservative approach

Conservative management has been practiced from time to time by various researches but the results and observations of these practices are not conclusive enough to make these strategies a popular choice worldwide.[52] The various uterus preserving strategies like uterine artery embolization, expectant management, methotrexate therapy and uterus preserving surgery have been practiced from time to time either alone or in combination.[535455] However, a slightly better success rate with these modalities does not mandate the routine practice of such techniques in developing nations like India. The limited resources, shortage of specialists like obstetricians, anaesthesiologists and interventional radiologists at peripheral health centers, lack of uniform availability of intensive care back-up facilities and multitude of other socio-cultural factors warrant a more definite treatment in the form of hysterectomy rather than adopting a conservative approach. The complications resulting from conservative approach may become more difficult to handle in set-ups with limited resources which are a common scenario in India.

Prevention and management strategies

In a country with limited resources as well as socio-cultural diversity, it is not easy to develop clear cut policies and guidelines for management of such clinically challenging situations. The approach has to be multidisciplinary among various quarters including the health administrators, social organizations, the media and above all the general public of the country. Based on these perspectives following measures are suggested to reduce the incidence of maternal mortality and morbidity due to haemorrhagic disorders arising out of placental abnormalities.

Patient education

As the patients are the ultimate sufferers, their awareness and education is one of the most important initiatives whenever such patients present for the diagnostic and other abortion related procedures, they should be made to understand about the possible hazards and complications during future pregnancy. The similar educational programs should be an essential component of antenatal care during the antenatal visits.

Educating health care providers

In such a massive country with huge population, patient to doctor ratio is dismally high and gloomier is the patient to specialist ratio. Therefore, there is an urgent need to educate the local health care providers about various clinical aspects and measures to be adopted while managing potentially high risk patients. The reporting system should be made stronger at peripheral health level to possibly identify the high risk patients during early pregnancy or during the conduction of abortion procedures.

Identifying at risk patients

This requires a lot of dedicated efforts on the part of the attending obstetrician and physician. Identification can be done at initial antenatal visit as well as counseling those patients who are going to plan conception in the near future and are presently undergoing abortion related or diagnostic procedures for infertility.

Enrolling patients in on at risk clinic

After identification of potential at risk patient, they should be enrolled on institutional record register along with their complete details. A regular communication with those at risk patients can be maintained either directly or services of local health care social workers can be utilized. Such a task ensures a possible early detection of abnormal placentation and its timely management.

Protocols from conception to delivery

The protocols of developed nations cannot be applied uniformly on the developing nations as there are numerous limitations and factors prevalent in developing nations which hinders their successful execution. However, after some modifications, these protocols and guidelines can be applied to a large extent which can then help in thorough management of such high risk patients right from the conception stage to delivery.

Ensuring blood bank services

A fully functional blood bank is the lifeline of a hospital and is the most vital component of emergency services. After identification of high risk patients, these deliveries, both operative and non-operative, should be planned in a hospital which has got ample transfusion facilities. Even for managing the patients in later pregnancy with abnormal placentation, blood banks are essential. The risk of torrential haemorrhage always looms large during management of the patients with placental abnormalities.

Back-up facilities of Anaesthesia/ Intensive Care Services

The choice of anaesthesia lies clearly with attending anaesthesiologist and does depend upon his experience in handling such cases.[56] Regional anaesthesia seems to be a popular choice and has been supported by literary evidence.[5758] In our daily routine practice, we administer graded epidural anaesthesia with ropivacaine and fentanyl or dexmedetomidine as adjuvant. The main advantage of such technique is not only just avoidance of airway instrumentation but also, a stable haemodynamic state is achieved and maintained with accurate titration of dose of local anaesthetic.[5960] In case of any failure or anticipated complication, the procedure can be converted to general anaesthesia as warranted.[57]

Few of these patients may undergo operative procedures and some of them probably can have substantial haemorrhage during parturition. Occasionally haemorrhagic shock can develop which may require the active services of anaesthesiologist and/or intensivist. Further ensuring a smooth anaesthesia during the operative procedures in such cases and the availability of a complete intensive care facilities are a big boon for managing such cases. The resulting haemorrhage not only leads to shock but can cause cardiac, pulmonary, renal, and metabolic and various other problems. Therefore, the assistance of an anaesthesiologist and intensivist during such situations is immensely helpful in the management of haemorrhage due to abnormal placentation.

Counseling future fertility

The patients who have either undergone some traumatic mini-procedures like dilatation and curettage, suction evacuation or even IVF or have been managed successfully with abnormal placentation during previous pregnancy should be counseled thoroughly about the potential possible risks of abnormal placentations and resulting haemorrhage in future pregnancies. The risks and benefits of future pregnancy should be fully explained to them by the attending obstetrician.

Training of birth attendants

In a country where more than half of the births occur outside the hospital setting, there is an acute need for awareness among the health care providers about the possible complications of abnormal placentations. These birth attendants should be trained in managing episodes of torrential haemorrhage as well as prevention of uterine inversion while managing third stage of labour.

Training of junior doctors

Peripheral health centers in many parts of the country are being managed by junior doctors who have limited exposure in managing such complications. The training to these young doctors includes practicing avoidance of vigorous curettage during the diagnostic and therapeutic procedures. The training schedule should be intensive for such doctors which should not only cover the management of complications but should enable them to proceed with peri-partum hysterectomy and/or internal iliac ligation if a need arises.

Legislations

Strict legislations should be enacted to stop the indiscriminate practice of medical abortions. This will definitely go a long way in decreasing the incidence of incomplete abortion. Also, the incidence of various procedures like dilatation and curettage will go down thus possibly decreasing the incidence of unnecessary trauma to the endometrium and subsequent chances of abnormal implantation of placenta. Strict legislations are also needed to curb the incidence of foeticide as it is highly prevalent in the Indian society. The main reason for such a crime is the desire of male child and illegal female foeticide on detection of the gender of foetus by ultrasonography. These practices are probably predisposes to a higher incidence of abnormal placentation. Along with legislations a socio-behavioral change in the society is the need of the hour.

Motivation for contraception

There is a need for motivating the safe contraception practices among the sexually active young couples. More and more stress should be given to the judicious use of Intra-uterine contraceptive devices, oral contraceptive pills.[2] The awareness regarding contraceptive practices can be brought with launching more of educational programs aiming at contraception.

Decreasing operative interventions

During antenatal visits, the pregnant females should be counseled to avoid repeated caesarean section and to discourage the operative intervention on demand. Vaginal birth after caesarean section should be encouraged and such deliveries should preferably be carried out in higher centers, thus decreasing the overall incidence of operative interventions. This will definitely help in decreasing the incidence of placental abnormalities. This mimics the practice of nipping the evil in the bud only.

CONCLUSIONS

The need of the hour is to identify early in pregnancy, patients at risk for invasive placentation. This would include those who have undergone investigations for infertility, conceived after IVF, give history of medical or surgical abortions, have unexplained dysuria and/or unexplained acute pain abdomen in early pregnancy. The altered endometrial environment, the breached junctional zone and other as yet unrecognized factors both before pregnancy and very early in pregnancy, are possibly responsible for the invasive placentation. More intensive and early surveillance would go a long way in preventing unexpected life threatening haemorrhage.

In spite of the advancements, it is not possible to bring down the maternal haemorrhagic complications unless and until there are widespread socio-behavioral changes in the society of developing nations like India. These changes require co-ordinated efforts and a multi-disciplinary approach from various quarters to achieve a safe environment for motherhood. The governmental health policies and strict legislations are equally essential in enforcing these changes. The health infrastructure has to be strengthened at peripheral health sector and to recruit more and more of specialists for various clinical streams. There should be a proper budg et al. location to bring about reforms in improving maternal health.