A study of the location of placenta and its association with type of delivery

R Sujatha

Assistant professor, Department of Obstetrics & Gynaecology, Annapoorana Medical College & Hospital, Salem, Tamil Nadu, INDIA.

Email: sujiguptha60@gmail.com

Abstract         Introduction: While offering a suggesting that the site of placental location could influence the presentation, STEVENSON (1949) stated that the position of the placenta in the near term of term human uterus could indent and alter the ovoid shape of the amniotic sac and thus the polarity of the sac. Aims and Objectives: To Study the Location of Placenta and its association with Breech Delivery Methodology: This prospective study of placental location site in breech and shoulder presentations as compared to the vertex presentations was conducted in the Department of Obstetrics and Gynaecology of Kasturba Medical College, at Govt. Lady Goschen Hospital Mangalore. During the 20 month study period there were 6614 deliveries. Of these 147 number were full term breech deliveries and 19 number were shoulder presentation deliveries. Ultrasound, By inspection and palpation at the time of caesarean section. Result: LGH study march 1990 Majority of the Breech deliveries were having Cornuo-fundal location of placenta i.e. 65% next common location of placenta was Anterior i.e. 11% in Vertex Presentation the most common location of placenta was Anterior -47% in Shoulder Presentation the most common location of placenta was Cornuo- fundal- 44.44%. Stefan fianu Sweden 1978 the Location of Placenta was Cornuo-fundal 72.6% and for the Vertex was Fundal central i.e. 55.4% At Madras 1987most common location of Placenta for Breech wasCornuo fundal- 35.8% and for the Shoulder was Placenta previa 55.6%.atMaulanaazad medical college, at Delhi 1987The most common position for the Breech delivery was Cornuo- fundal -63.5% and for Shoulder was Anterior-43.6%. Conclusion: This study is a reaffirmation the work by the others and serves to emphasize the fact that cornuofundal implantation of the placenta is an established etiology for the breech shoulder presentation. Ultrasound has come to stay as an excellent tool for non-invasive diagnosis of the placental location and has replaced the older methods of placentaography.

Keywords: Location of Placenta, Breech Delivery, Shoulder Delivery.

INTRODUCTION

While offering a suggesting that the site of placental location could influence the presentation, Stevenson (1949)¹ stated that the position of the placenta in the near term of term human uterus could indent and alter the ovoid shape of the amniotic sac and thus the polarity of the sac. The fetus accommodated itself to the shape of the sac, the fetal head seeking its smaller pole, he concluded, that the position of the placement has a definite influencing effect upon the fetal presentation in an appreciable proportion of cases. FFLL (1956)²,³ in a study of placental position in 100 cases with breech presentation noted cornuo-fundal placental implantation more frequently with breech as compared to other presentations, he observed that placental position may not be the principal cause for breech but knowing the position may help in management planning. Subsequently KIAN (1963)⁴analysed the relationship between breech presentation and placement attachment and noted cornuo-fundal attachment of placenta in 66% cases with breech as campared to 3.9% in cases with cephalic presentation. it is possible that a precise localization was lacking in kian’s series as the placental implantation site was determined by manual exploration of the uterus. AnatomyandDevelopment of placenta: Human placenta is discoid, because of its shape; haemochorial because of direct contact of the chorion with the maternal blood and deciduate, because some maternal tissue is shed at parturition. The placenta is attached to the uterine wall and establishes connection between the mother and fetal tissues came In direct contact without rejection suggest immunological acceptance of the foetal graft by the mother. To deduce the position of the placenta by noting the displacement of the presenting part in relation to the pelvic brim. For displacement radiography, the bladder and rectum should be empted before band. Lateral view x-ray is taken with the patients in erect and inclined position (60 degrees). Normally, the gap between the foetal head and the symphysis pubis or the sacral promontory is about 1.5 cms. In placenta praevia,a gap of 3-4 cms. Is noticed either from the symphysis pubis (anterior placenta) or from the sacral promontory (posterior placenta). The combined techniques are quite effective in predicting the diagnosis in about 80% cases. The drawback area: (1) requires perfect radiographic technique (2) applicable only beyond 34 weeks (3) not informative in presentation other than head (4) radiation hazards. The advantages are: (1) Easy availability (2) accidental discovery of foetal bony congenital malformation. ETIOLOGY OF BRECH PRESENTATIONS: The following are the known factors responsible for breech presentation. In a significant number of cases the cause remains obscure. Prematurity –it is the commonest cause of breech presentation. Factors preventing spontaneous version :Breech with extended legs. Twins, Oligohydrammios, Congenital malformation of the uterus such as septate or bicornuate uterus, Short cord, relatives or absolute , Intra uterine death of the foetus, Favourable adaptation: Hydrocephalus- big head can be well accommodated in the wide fundus. Placenta previa, Contracted pelvis, Cornuofundal attachment of the placement- minimises the space of the fundus where the ameller head can be placed comfortably. Undue mobility of the foetus: Hydrammios, Multiparae with lax abdominal wall UNCOMPLICATED BREECH: is defined as one where is no other associated obstetric complications apart from the breech, prematurity being excluded.

MATERIALS AND METHOD

This prospective study of placental location site in breech and shoulder presentations as compared to the vertex presentations was conducted in the department of Obstetrics and Gynaecology of Kasturba Medical College, at Govt. Lady Goschen Hospital Mangalore, During the 20 month study period there were 6614 deliveries. Of these 147 number were full term breech deliveries and 19 number were shoulder presentation deliveries.All mothers with breech presentations who had completed 38 weeks of gestations were included in the study. Shoulder presentations where the gestational age was morethan 38 weeks were included in the study and were compared with vertex presentation who had completed 38 weeks of gestation. Only singleton pregnancies were included in the study. Only those cases. Where there are no other associated complications of pregnancy are included in the study. Placenta previa cases were included in the study.

The methods by which placental implantation site was located are: Ultrasound, By inspection and palpation at the time of caesarean section. The placental site is classified bases on the segment of the uterus in which a major portion of the placenta is situated. Following are the main groups:-Anterior, Posterior, Fundal central Cornuo-fundal ,Placenta frevia. There were 6614 deliveries in lady coschen hospital manalore during the period from march 1990 to October 1991. Of these 147 number were full term breech deliveriesand19 number were shoulder presentation deliveries.

RESULT

Table 1: LGH study march 1990 to October 1991

 From Above Table it is clear that Majority of the Breech deliveries were having Cornuo-fundal location of placenta i.e. 65% next common location of placenta was Anterior i.e. 11% in Vertex Presentation the most common location of placenta was Anterior -47% in Shoulder Presentation the most common location of placenta was Cornuo- fundal- 44.44%.

Table 2: Stefan fianu Sweden 1978

In the studies of Sweden1978 also the Location of Placenta was Cornuo-fundal72.6% and for the Vertex was Fundal central i.e. 55.4%

Table 3: At Madras 1987

At Madras the studies in 1987 the most common location of Placenta for Breech wasCornuo fundal- 35.8% and for the Shoulder was Placenta previa55.6%.

Table 4: At Maulanaazad medical college,at Delhi 1987

From the studies of Maulana Azad Medical College, at Delhi 1987 the most common position for the Breech delivery was Cornuo fundal -63.5% and for Shoulder was Anterior-43.6%.

DISCUSSION

Breech presentation and breech deliveries have always evoked interest among obstetricians.⁵ The optimum mode of delivery for breech fetuses is controversial.⁶ Breech is the most common mal presentation in pregnancy, occurring in 3–4% of the pregnancies at term.^7-9 However, incidences as low as 1.4%⁶ and as high as 5.7%⁶ have been documented in Calabar and Ibadan, respectively. The incidence of breech presentation rises with a reduction in gestational age.3-5 At 34 weeks, the incidence is 6.8%, and up to 40% of the fetuses present by the breech at 20 weeks.⁷ In Zaria, the preterm breeches constituted about 31% of all breech presentations. ¹¹ The options on the mode of delivery include external cephalic version (ECV) and cephalic delivery at term, assisted vaginal breech delivery (VBD), breech extraction (BE) and caesarean section (CS).⁷ The controversies surrounding the best mode of delivery for breech fetuses were thought to have been resolved by the Term Breech Trial, ¹² which concluded that CS was the best mode of delivery for a breech. However, subsequent studies have highlighted that most cases of neonatal death and morbidity in the Term Breech Trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies.^13-15 Besides, CS may not be applicable in all settings. ¹⁵ Why 3% of all fetuses at term present as breech still remains an unanswered question. Tomkins (1943) estimated that in only 15% of cases could a causative factor be shown. It is conceivable, by pajots law of accommodation, that my alteration in the shape of the uttering cavity may change the fetal lie. Apart from congenital anatomical deformities and uterine tumours amniotic cavity. The placenta is implanted in one of the corneal regions of the fundus, proportions of this ovoid will be reversed so that the wider portion is nor below. In such a cavity the fetus will accommodate itself in to the largest dimension, i.e., the breech supplemented by the thigh and legs. Below and the smaller dimension of the head above. This concept has prompted an investigation of the possible role of the placental location in the etiology of breech presentation. Some works have determined the placental position after delivery by manual palpations, recording it is done gently with all aseptic precautions. Recording of fundal implantation might be due to improper orientation of the site at times because the examining hands tend to rotate the uterus, or due to particular detachment of the placenta. The study done by Stefan fianu. Here the incidence of cournuo- fundal implantation is found to be 72.6% in breech and 4.6% in vertex. In his study ultrasound was used for localizing placenta. In the 124 breech cases studied. There was no cases of placenta previa. The results of the study conducted at institute of obstetrics and gynaecology, madras 1987, showing the incidence of cornuo-fundal implantation in breech to be 35.8%, in vertex as 7% and in shoulder as 44.4% the incidence of central fundal implantation to be 32.2% in breech and 58% in vertex. The incidence of placenta previa in breech presentations was found to be 21% in vertex to be 2% and in shoulder presentation to be 55.6% Ultrasound examinations palpations at the time of caesrean sections and gentle intra uterine palpation at the time of vaginal deliveries were the methods used in this study at madras for localization of placenta site. Table -9 shows the study done at Maulana Azad Medical College, Delhi 1987 which shows the incidence of cornuo fundal implantation to be 63.5% in breech as compared to 13.25% in vertex. The incidence of placenta previa in breech presentation was found to be 9.5% and in vertex to be 1.65% So the study done at lady goschen hospital is in agreement with the other studies that cornuo fundal implantation site is more common in breech presentation and shoulder presentations, it is of the etiological for breech and the shoulder presentation

CONCLUSION

This study is a reaffirmation the work by the others and serves to emphasize the fact that cornuofundal implantation of the placenta is an established etiology for the breech shoulder presentation. Ultrasound has come to stay as an excellent tool for non-invasive diagnosis of the placental location and has replaced the older methods of placentaography.

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