Retroplacental hematoma (RPH) is characterized by the accumulation of maternal blood in the space between the maternal surface of the placenta and the adjacent uterine wall, occurring after 20 weeks of gestation and prior to the delivery of the fetus [1] . This condition signifies a loss of maternal vascular integrity, leading to haemorrhage in the retroplacental area. RPH constitutes a serious obstetric complication, representing one of the primary causes of metrorrhagia in the third trimester of pregnancy and frequently contributing to stillbirth and maternal death.

The incidence of RPH affects approximately 0.4% to 1% of pregnancies, with regional variations in its prevalence: it accounts for 0.25% of deliveries in France [2] . while in Morocco, the incidence is reported at 0.8%. At the Maradi mother and child health center in Maradi, RPH frequency is estimated at 5.2% of deliveries [3] . Identified risk factors for RPH include pre-eclampsia, induction of labour with oxytocin, and a history of unfavourable obstetric outcomes [4] .

Fetal mortality is particularly high, reaching 77% in some studies in Mali and 69.76% in Morocco, with a high proportion of deaths in utero [5] [6] . In Burkina Faso, a recent study at the Yalgado Ouédraogo University Hospital showed a maternal case-fatality rate of 5.6% and an alarming perinatal mortality rate of 63.9% [7] . Initiatives have been put in place to improve the management of obstetric emergencies. Free care for pregnant women and children under five, as well as training for medical staff, aim to reduce the number of cases of RPH. The International Federation of Gynaecology and Obstetrics has introduced emergency protocols to aid diagnosis and treatment in health facilities [8] . This study aims to identify prognostic factors for RPH to enhance treatment.

The study was designed as an analytical cross-sectional investigation with retrospective data collection, aiming to analyse the factors that may influence the perinatal prognosis of retroplacental hematoma. The study population comprised women admitted to the obstetrics and gynaecology department at Yalgado Ouédraogo University Hospital for retroplacental hematoma (RPH) from June 1, 2023, to May 31, 2024. Only those women with complete and usable medical records who were hospitalized for RPH were included in this analysis. One woman whose gestational age was unknown and 2 women for whom there was no information on placental examination were excluded from the study. Only cases of retroplacental hematoma confirmed by the presence of a placental cup and/or a blood clot were included in this study. Patients with suspected HPR on ultrasound without placental cup or blood clot were excluded from the study. Multiple pregnancies were excluded from the analysis.

Data collection encompassed various dimensions, including the patients’ socio-demographic characteristics, reasons for admission, medical histories, pregnancy histories, clinical signs, treatment details, and maternal and perinatal outcomes. Information was gathered from admission registers, medical records, and operative reports.

The collected data were checked, coded, and entered into a computer database for analysis using R software. Descriptive statistics were reported as percentages and means. Prognostic factors were initially determined using univariate analysis, which was then complemented by multivariate analysis to compute odds ratios for a deeper assessment of these factors. Any variables that exhibited a two-tailed p-value of less than 0.05 in the bivariate analysis were included in the binary logistic regression model to pinpoint the factors linked to RPH Additionally, adjusted odds ratios (adjusted ORa) along with 95% confidence intervals were calculated.

From an ethical perspective, administrative approval was obtained from the Director General of the hospital and the head of the gynaecology and obstetrics department. Patient confidentiality was ensured, with no identifiable information being included on the data collection forms.

The investigation conducted at the Yalgado Ouédraogo University Hospital provides significant insights into the burden and characteristics of retroplacental haematoma (RPH) within a specific West African tertiary care setting. The reported frequency of RPH at 1% aligns closely with findings from a contemporaneous study at Bouaké University Hospital in neighbouring Côte d’Ivoire, which documented an incidence of 0.96% [9] . This figure sits within the range observed in other African nations, such as the 1.71% prevalence noted in Enugu, Nigeria [10] , although it remains lower than rates reported from certain centres in Senegal, which have reached up to 4.2% or even 6% in specific regional studies, potentially reflecting differences in classification, population characteristics, or referral patterns [11] . However, it is considerably higher than the 0.25% - 0.5% typically cited in high-income countries like France [12] . The observed lethality rate of 3.2% underscores the severe impact of RPH, particularly in resource-constrained environments where access to comprehensive emergency obstetric care, including timely blood transfusions and surgical intervention, may be limited [13] . For clinical practice, these figures emphasise the critical need for high vigilance, rapid diagnostic pathways, and readily available emergency obstetric services in centres managing such high-risk pregnancies, recognising RPH as a life-threatening emergency for both mother and fetus [9] [14] .

The multivariate analysis isolating risk factors for stillbirth revealed crucial associations with significant clinical implications. The substantially increased risk associated with homemaker status (adjusted OR 4.24) likely reflects underlying socioeconomic vulnerabilities. This resonates with findings from Mulago Hospital, Uganda, where low socioeconomic status, indicated by housing quality, was a powerful predictor of severe abruptio placentae (OR 10.5) [15] . Furthermore, studies in Nigeria have highlighted that a majority of women presenting with placental abruption had not received antenatal care (ANC), suggesting barriers related to access or health-seeking behaviour, potentially linked to socioeconomic factors [10] . A systematic review also identified unmarried status and inadequate prenatal care as independent risk factors for placental abruption [16] . The clinical implication is the necessity for targeted antenatal support and health education programmes focusing on socioeconomically disadvantaged groups to improve awareness, encourage timely ANC attendance, and mitigate risks associated with delayed presentation or inadequate care [10] [15] . The association between homemaker status and stillbirth risk in retroplacental hematoma (RPH) cases reflects a multifaceted interplay of socioeconomic and healthcare access factors rather than a direct causal relationship. While the Yalgado Ouédraogo study identified homemaker status as a significant predictor of stillbirth (adjusted OR 4.24), this occupational classification likely serves as a proxy for underlying vulnerabilities.

Similarly, the finding that transfer from another healthcare facility significantly increased the odds of stillbirth (adjusted OR 3.49) points towards the dangers of delayed definitive management. Tertiary centres like the one in this study, as well as those in Enugu and Kolda, often receive complex referred cases, potentially contributing to higher observed complication rates [10] [11] . Delays inherent in the referral process can worsen outcomes, particularly for a time-sensitive condition like RPH [13] . Clinically, this highlights the urgent need for streamlined referral protocols, improved inter-facility communication and transport, and potentially decentralising aspects of emergency obstetric care to minimise delays and ensure women receive timely, life-saving interventions [11] [13] .

The association identified between male fetal sex and stillbirth (adjusted OR 3.56) adds to a complex body of evidence. While some large systematic reviews have not consistently identified male sex as an independent risk factor across all populations [16] , the finding in this study warrants attention. However, this corroborates with findings from previously published studies indicating that male fetuses are consistently at greater risk for stillbirth and other adverse outcomes. For instance, McClure et al. (2007) conducted a meta-analysis that revealed significant disparities in risks associated with fetal sex, emphasizing a higher vulnerability among male fetuses [17] . Pathophysiological differences related to fetal sex in response to hypoxic stress or placental function could underlie this observation, though mechanisms remain incompletely understood. Clinicians managing pregnancies complicated by RPH might consider fetal sex as one component within a broader risk assessment, although further research is needed to clarify its predictive value and clinical utility.

A particularly noteworthy finding is the strong association between RPH not related to pre-eclampsia and severe maternal anaemia (haemoglobin < 8 g/dl), with an adjusted OR of 3.18. This underscores that significant RPH can occur and lead to substantial blood loss even in the absence of hypertensive disorders. Anaemia itself (defined as Hb < 11 g/dL) is recognised as an independent baseline risk factor for placental abruption [16] . Furthermore, severe haemorrhage is a hallmark complication of RPH, frequently necessitating blood transfusion, as observed in the Bagalkot study where 21% of abruption cases required transfusion for severe anaemia [9] [13] [14] . The clinical imperative arising from this finding is twofold: firstly, rigorous screening for and management of anaemia throughout pregnancy is essential, as anaemia can worsen maternal tolerance to haemorrhage; secondly, clinicians should maintain a high index of suspicion for RPH in severely anaemic pregnant women presenting with relevant symptoms, even if normotensive, ensuring prompt investigation and management to prevent catastrophic blood loss [13] [16] .

The management of RPH fundamentally relies on prompt diagnosis, resuscitation, and delivery [14] . Traditional principles emphasise early delivery, often via caesarean section if the fetus is alive and viable, adequate blood product replacement guided by clinical status and coagulation parameters, pain relief, and intensive maternal-fetal monitoring [14] . Even if the fetus has demised, prompt delivery, typically vaginal induction if feasible, is pursued to control haemorrhage and prevent further maternal complications like coagulopathy or postpartum haemorrhage [14] . Multidisciplinary care involving obstetricians, anaesthetists, haematologists, and neonatologists is often required, particularly in severe cases [11] . Ensuring the availability of blood products and access to surgical facilities are critical components of preparedness in any unit managing obstetric emergencies [13] .

Beyond the immediate clinical event, the pathophysiology of placental abruption is increasingly understood to involve complex molecular and immunological processes at the maternal-fetal interface [18] . Research highlights disruption of immunological balance, features of chronic inflammation, and potentially the role of inflammasomes like NLRP7 in the decidua and trophoblast cells, processes which may be influenced by factors like hypoxia [18] . While numerous clinical risk factors are known, including previous abruption (a major risk factor for recurrence), maternal age, multiparity, smoking, hypertension, pre-eclampsia, previous caesarean section, trauma, and substance use, RPH can still occur unpredictably [9] [15] [16] [19] . This complex pathophysiology implies that predicting RPH remains challenging [13] , and clinicians must remain vigilant. Furthermore, distinguishing between retroplacental and intraplacental haematomas may be clinically relevant, as some evidence suggests differing risk profiles, with intraplacental haematomas potentially associated more with placental insufficiency and growth restriction, while retroplacental haematomas are strongly linked to fetal death [20] .

This study of retroplacental haematoma (RPH) at the Yalgado Ouédraogo University Hospital highlights the serious implications of this obstetric complication, particularly in resource-limited settings. The results show that the incidence of RPH is high, with very high maternal and stillbirth rates. Identifying prognostic factors such as the mother’s professional status, obstetric history and foetal sex is crucial to optimising outcomes for both mother and foetus. The study highlights the urgent need to improve diagnostic procedures, ensure timely referral and improve maternal emergency care services. Recognition of RPH as a critical emergency may facilitate better preparation and ultimately save lives, underlining the importance of ongoing research and clinician vigilance in the management of these high-risk pregnancies.