Research - (2024) Volume 19, Issue 4
Received: 02-Sep-2024, Manuscript No. gpmp-24-148808; Editor assigned: 03-Sep-2024, Pre QC No. P-148808; Reviewed: 14-Sep-2024, QC No. Q-148808; Revised: 21-Sep-2024, Manuscript No. R-148808; Published: 30-Dec-2024
Breech presentation represents a global burden among pregnant women comprising around 4% of pregnancies. Much debated question is whether the incidence of placenta in the cornual-fundal region or placenta praevia can be a causative factor for developing breech presentation. Hence, the current study aims to investigate the incidence of presence of placenta in cornual-fundal region or placenta praevia in patients with breech presentation. The study enrolled 300 women as follows: 100 women with breech presentation and 200 women with cephalic presentation (control). The relationship between site of placental implantation and breech presentation was examined by ultrasonography and by cesarean at or near term. The results of this study showed that placenta was found in cornual-fundal site in a 70% of breech presentation cases as compared with 10% of cephalic presentation cases (control). The findings of this study suggest that site of placental implantation could have an impact on the presentation of fetus.
Breech presentation; Pregnant women; Pregnancies
Breech presentationis defined as an appearance of the fetus in longitudinal position whereboth buttocks and feet enter the pelvis [1]. It is a common concern leading to an increased risk of morbidity and mortality to mother and fetus. Epidemiologically, breech presentationcan be found in a 3% to 4% of the pregnancies representing a meaningful percentage worldwide [2]. There are controversial reports highlighted the location of placenta at cornual-fundal part that could be potential causative factor to develop the breech presentation [3,4]. Hence, this study aims to explore the incidence of cornual-fundal placenta in patients with breech presentation.
The present study was conducted according to strict recommendations of guidelines. It was commenced from January to November (2023) and included three different centres for gynecology and obstetrics in Baghdad, Iraq. Patients were collected from labour wards, antenatal clinics and ultrasonographic clinics, and allocated into two groups as follows: group I was 100 patients with breech presentation and group II was control (200 patients). Gestational ages for both groups were between 36 weeks and 40 weeks.
Different parameters were examined in the present study and included the following
| Category | Cases |
|---|---|
| Frank breech | 60 |
| Full breech | 35 |
| Footling breech | 5 |
Tab. 1. Patients with breech presentation were classified into three categories.
| Positions | Cases |
|---|---|
| Direct sacro anterior | 5 |
| Direct sacro posterior | 2 |
| Right and left sacro anterior | 62 |
| Right and left sacro posterior | 26 |
| Right sacro transverse | 4 |
| Left dacro transverse | 1 |
Tab. 2. The position of breech presentation was classified into eight positions.
| Placenta Praevia | Definition |
|---|---|
| 1st degree | Lower margin of placenta is away from internal os for about 3 to 5 cm |
| 2nd degree | Low margin of placenta is extended down to lower segment and reached the cervix without covering it |
| 3rd degree | Lower margin of placenta reaches the internal os or covers the undilated cervix |
| 4th degree | It is centrally positioned and covers the dilated cervix |
Tab. 3. Placenta praevia which was subdivided into four degrees.
Statistical analysis
Data were presented as percentage unless otherwise stated. Chi square test was used to compare between parameters of the study groups. P value of 0.05 was assigned to be statistically significant.
The relationship between the site of placental implantation and fetal presentation
The site of placental implantation was examined by ultrasonography or by direct examination during cesarean section. Results showed that about 70% of patients in group I (breech presentation were placenta located in cornual-fundal site (Tab. 4.). Furthermore, patients with placenta located in fundal region were 20%, and anterior and posterior locations were represented around 2% and 2% respectively (Tab. 4.). Placenta praevia was found in a 5% of patients with breech presentation (Tab. 4.). In patients with cephalic presentations, the placenta was in fundal site (60% of patients) (Tab. 4.) while the rest of the patients were allocated in comparable percentages including cornual-fundal, anterior, posterior and placenta praevia (Tab. 4.). There has been a significant difference between breech presentation and cephalic presentation in terms of placenta site where 70% of patients in breech group showed that placenta was in cornual -fundal site as compared to cephalic presentation patients (10%) (Tab. 4.).
| Placental Location | Breech Presentation | Cephalic Presentation | ||
|---|---|---|---|---|
| No | % | No | % | |
| Fundal | 20 | 20% | 120 | 60% |
| Cornual-Fundal | 70 * | 70%* | 20 | 10% |
| Anterior | 3 | 3% | 18 | 9% |
| Posterior | 2 | 2% | 22 | 11% |
| Placenta Praevia | 5 * | 5% * | 20 | 10% |
| Total | 100 | 100% | 200 | 100% |
Tab. 4. Relationship between site of placental implantation and fetal presentation.
The relationship between location of placenta and types of breech presentation
Results revealed that 27.60% of patients presented with frank breech presentation had placenta implanted in cornual-fundal site. Furthermore, 8.40% of patients with full breech presentation had placenta located in cornual-fundal region (Tab. 5.). Rest of patients were allocated as indicated in Tab. 5.
| Placental Location | Full Breech | Frank Breech | Footling Breech | |||
|---|---|---|---|---|---|---|
| No | % | No | % | No | % | |
| Fundal | 8 | 22.80% | 9 | 15% | 3 | 60% |
| Cornual fundal | 24 | 68.57% | 46 | 76.66% | - | - |
| Anterior | 1 | 2.85% | 2 | 3.33% | - | - |
| Posterior | 1 | 2.85% | - | - | 1 | 20% |
| Placenta praevia | 1 | 2.85% | 3 | 5% | 1 | 20% |
| Total | 35 | 100% | 60 | 100% | 5 | 100% |
Tab. 5. The relationship between location of placenta and types of breech presentation.
Relationship between the degree of placenta praevia and fetal presentation
There have been no marked differences between breech and cephalic presentations in terms of degree of placenta praevia (Tab. 6.). The percentages of patients were similar or closer among the degree of placenta praevia in breech and cephalic presentations (Tab. 6.).
| Degree of placenta Praevia | Breech Presentation | Cephalic Presentation | ||
|---|---|---|---|---|
| No | % | No | % | |
| First degree | 1 | 20% | 7 | 35% |
| Second degree | 1 | 20% | 6 | 30% |
| Third degree | 1 | 20% | 4 | 20% |
| Fourth degree | 2 | 40% | 3 | 15% |
| Total | 5 | 100% | 20 | 100% |
Tab. 6. Relationship between the degree of placenta praevia and fetal presentation.
Relationship between the site of placental implantation and position of fetal sacrum
The present study explored that patients with cornual-fundal placenta comprised 70% of breech presentation group while the rest were distributed among other sites (fundal, anterior, posterior and placenta praevia). Results showed that incidence of right and left- sacro-anterior and -sacro-posterior positions were 61.42% and 30% of cornual-fundal placenta cases respectively (Tab. 7.). Furthermore, out of 20 of fundal cases, 15 and 3 patients were laid in right and left-sacro-anterior and sacro-posterior respectively (Tab. 7.).
| Position of the Sacrum | Fundal | Cornual-Fundal | Anterior | Posterior | Placenta Praevia | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| No | % | No | % | No | % | No | % | No | % | |
| Sacro-anterior | 1 | 5% | 3 | 4.28% | 1 | 33.3% | - | - | - | - |
| Sacro-posterior | - | - | 1 | 1.42% | - | - | - | - | 1 | 20% |
| Right and left sacro-anterior | 15 | 75% | 43 | 61.42% | 1 | 33.3% | 2 | 100% | 1 | 20% |
| Right and left sacro-postrior | 3 | 15% | 21 | 30% | - | - | - | - | 2 | 40% |
| Right sacro- transverse | 1 | 5% | 2 | 2.85% | 1 | 33.3% | - | - | - | |
| Left sacro- transverse | - | - | - | - | - | - | - | - | 1 | 20% |
| Total | 20 | 100% | 70 | 100% | 3 | 100% | 2 | 100% | 5 | 100% |
Tab. 7. Relationship between the position of fetal sacrum and site of implanted placenta.
Frequency of incidence among the types of the breech presentation in relation to gestational age
The results of current study demonstrated that about 34%, 31% and 60% of patients with full breech, frank breech and footling breech respectively were in 36 week of gestation (Tab. 8.). At 37 weeks, incidence of full breech and frank breech was about 22% and 21% respectively (Tab. 8.). Furthermore, incidence of full breech and frank breech were around 18% and 14% respectively at 38 weeks while 17% and 13% respectively at 39 weeks (Tab. 8.). Patients with cephalic presentations showed gestational ages at 36, 37, 38, 39 weeks with similar incidences (Tab. 8.). There has been a significant difference in the incidence of breech presentations at 36 weeks as compared to gestation age at 40 weeks (Tab. 8.).
| Gestational Age (week) |
Full Breech | Frank Breech | Footling Breech | Cephalic Presentation | ||||
|---|---|---|---|---|---|---|---|---|
| No | % | No | % | No | % | No | % | |
| 36 | 12 | 34.28% | 19 | 31.66% | 3 | 60% | 44 | 22% |
| 37 | 8 | 22.85% | 13 | 21.66% | 46 | 23% | ||
| 38 | 5 | 14.28% | 11 | 18.33% | 1 | 20% | 47 | 23.50% |
| 39 | 6 | 17.14% | 8 | 13.33% | 1 | 20% | 34 | 17% |
| 40 | 4 | 11.42% | 9 | 15% | 29 | 14.50% | ||
| Total | 35 | 100% | 60 | 100% | 5 | 100% | 200 | 100% |
Tab. 8. Frequency of incidence among the types of the breech presentation according to gestational age.
Breech presentation remains clinical issue worldwide and thus researchers in this field have been paying attention to the role played of placental implantation and risk of breech presentation [5]. Little is known about why more than 4% of fetuses at term are diagnosed with breech presentation although advances in the management guidelines [6]. It has been reported that the shape of the uterine cavity could have a role in fetus position [7]. Preterm delivery, low birth weight, oligohydramnios, primigravidae and congenital malformations are potential risk factors for breech presentation although mechanical factors may be key in the mechanism of development of this condition [8]. The present study demonstrated that placenta was in cornual-fundal site in about 70% of breech presentations whereas only 10% cephalic presentations where the placenta was found in cornual-fundal region. These finding are in agreement with earlier studies which showed that between 50% and 70% of breech presentation patients in which the placenta was located in cornual-fundal site [9,10]. It has been reported that site of fetus could be critical in shaping the uterine cavity that would consequently lead to changes in the location of placenta [4]. Although previous concept pointed to the role of placenta praevia in the development of breech presentation, the current study showed only 5% of breech presentation cases had placenta praevia which was consistent with previous studies [7,11]. The relationship between age and breech presentation was investigated in the present study and reveled that ~ 34% of cases with breech presentation were at age of 36 weeks as compared with cephalic presentation cases that comprised only 22%. These results are in line with those of previous studies [4,12]. The present study shows that incidence of frank breech (60%) greater than those with full breech (35%) suggesting that splinting influences of extended legs can interfere with cephalic position of frank breech [13,14].
This study has identified implantation of placenta at cornual-fundal region has a role played in breech presentation and considered a causative factor for developing breech presentation. Further work is needed to fully understand the clinical consequences of the presence of placenta in cornual-fundal region.
(A) Study Design · (B) Data Collection . (C) Statistical Analysis · (D) Data Interpretation · (E) Manuscript Preparation · (F) Literature Search · (G) No Fund Collection
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