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RETAINED PLACENTA

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RETAINED PLACENTA. Definition. Failure of placental delivery within 30 minutes after delivery of the fetus. Causes. Morbid Adherence of the placenta Placenta Acreta Placenta Increta Placenta Percreta Uterine Abnormality Constriction Ring - reforming cervix Full bladder .

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slide1

RETAINED PLACENTA

Dr Mona Shroff www.obgyntoday.info

definition
Definition
  • Failure of placental delivery within 30 minutes after delivery of the fetus.

Dr Mona Shroff www.obgyntoday.info

causes
Causes
  • Morbid Adherence of the placenta
    • Placenta Acreta
    • Placenta Increta
    • Placenta Percreta
  • Uterine Abnormality
  • Constriction Ring - reforming cervix
  • Full bladder

Dr Mona Shroff www.obgyntoday.info

management
Management

If the placenta is undelivered after 30 minutes consider:

    • Emptying bladder
    • Breastfeeding or nipple stimulation
    • Change of position - encourage an upright position

If bleeding: immediately

  • Inform Anaesthetist
  • Insertion of large bore IV (18g) cannula
  • Insert urinary catheter
  • Commence/continue oxytocin infusion 20 units in 1 litre / rate – 60drops per min
  • Measure and accurately record blood loss
  • Prepare and transfer patient to theatre for manual removal of placenta (MROP)

Dr Mona Shroff www.obgyntoday.info

slide5

 Introducing one hand into the vagina along cord

Dr Mona Shroff www.obgyntoday.info

post procedure care
POST-PROCEDURE CARE
  • Observe the woman closely until the effect of IV sedation has worn off.
  • Monitor the vital signs (pulse, blood pressure, respiration) every 30 minutes for the next 6 hours or until stable. 
  • Palpate the uterine fundus to ensure that the uterus remains contracted.
  • Check for excessive lochia.
  • Continue infusion of IV fluids.
  • Transfuse as necessary.

Dr Mona Shroff www.obgyntoday.info

complications of retained placenta
Complications of Retained Placenta
  • Shock
  • Postpartum haemorrhage
  • Puerperal Sepsis
  • Subinvolution 
  • Hysterectomy  

Dr Mona Shroff www.obgyntoday.info

umbilical vein injection for management of retained placenta
Umbilical vein injection for management of retained placenta
  • Umbilical vein injection of saline solution plus oxytocin appears to be effective in the management of retained placenta. Saline solution alone does not appear be more effective than expectant management. The difficulties in implementing this intervention are related to the training of personnel in the technique of giving injections into the umbilical vein.

The WHO Reproductive Health Library, No 8, Oxford, 2005.

The Cochrane Database of Systematic Reviews 2006 Issue 4

Dr Mona Shroff www.obgyntoday.info

slide12

The incidence of placenta accreta has increased 10-foldin the past 50 years, to a current frequency of 1 per 2,500 deliveries.

largely as a result of the increase in the number of cesarean sections

Dr Mona Shroff www.obgyntoday.info

risk factors
Risk factors

Risk factors for placenta accreta include :

  • placenta previa with or without previous uterine surgery.
  • previous myomectomy.
  • previous cesarean delivery.
  • Asherman\'s syndrome.
  • submucous leiomyomata.
  • maternal age of 36 years and older.

The ACOG committee

Dr Mona Shroff www.obgyntoday.info

prenatal risk probability
Prenatal risk probability

Because of the fact that many of these cases become evident only at the first attempt to separate the placenta at delivery, it is essential to attempt to identify antenatally both placenta accreta and its attendant risk factors, the most common of which isconcurrent placenta previa & previous CS.

Dr Mona Shroff www.obgyntoday.info

gray scale sonographic signs of placenta accreta
Gray-scale sonographic signs of placenta accreta

characterized by a hypoechoic boundary between the placenta and the urinary bladder that represents the myometrium and normal retroplacentalmyometrial vasculature.

The normal placenta has a homogenous appearance as well.

normal placenta

Dr Mona Shroff www.obgyntoday.info

gray scale sonographic signs of placenta accreta1
Gray-scale sonographic signs of placenta accreta
  • Lossof the retroplacentalhypoechoic zone
  • Progressive thinningof the retroplacentalhypoechoic zone
  • Presence of multiple placental lakes("Swiss cheese" appearance)
  • Thinning of the uterine serosa-bladder wall complex(percreta)
  • Elevation of tissue beyond the uterine serosa (percreta)

Dr Mona Shroff www.obgyntoday.info

color doppler signs suggestive of placenta accreta
Color Doppler signs suggestive of placenta accreta
  • Dilated vascular channels with diffuse lacunar flow.
  • Irregular vascular lakes with focal lacunar flow.
  • Hypervascularity linking placenta to bladder.
  • Dilated vascular channels with pulsatilevenous flow over cervix.

Dr Mona Shroff www.obgyntoday.info

slide20
Dr Mona Shroff www.obgyntoday.info
management1
MANAGEMENT

CONSERVATIVE

Leave placenta undisturbed +/- METHOTREXATE

  • Uterine artery ligation
  • UAE
  • Internal iliac ligation
  • Oversewing of placental bed
  • Condom temponade
  • B-Lynch/square sutures
  • Argon beam coagulation

HYSTERECTOMY

Fertility desired

Patient stable

No bleeding

Informed written consent

Dr Mona Shroff www.obgyntoday.info

slide22

-Placenta Accreta -

Intraoperative management

1.-Map exact position of placenta  Make high transverse uterine incision to avoid cutting through placenta

2.- Deliver fetus  Rapid hemostasis of uterine incision (clamps, sutures)

Definitive Rx

Dg uncertain

Avoid TAH & Dg certain

Do not remove pl

UAE/Ligation

UAE/ligation

TAH

Remove pl

Leave Pl in situ

Dr Mona Shroff www.obgyntoday.info

slide28

-Placenta Accreta -

Follow-up management

1.- Ultrasound /doppler :Vascularity/involution

2.- HCG titers (If plateau consider Mtx)

3. Daily Temp, Other S&S of infection

4.- Bleeding

5.- Coagulation profile

Oxytocics & prophylactic antibiotics : Benefit & duration not universal

Dr Mona Shroff www.obgyntoday.info

slide29

Follow-up OUTCOME

  • SPONTANEOUS EXPULSION
  • RESORPTION
  • INTERVAL SURGERY –placental removal
  • If Intervention necessary for
  • - Heavy Bleeding
  • - Infection
  • - DIC

Proceed directly to TAH

Dr Mona Shroff www.obgyntoday.info

hysterectomy
hysterectomy

Resort to hysterectomy SOONER RATHER THAN LATER(especially in cases of placenta accreta when future fertility is out of concern)

Dr Mona Shroff www.obgyntoday.info

take home message
Take home message
  • Active Mx of third stage can prevent & reduce the incidence of retained placenta.
  • In case of risk factors,always consider placenta accreta & L/f usg/doppler features in antenatal period & plan accordingly.

Dr Mona Shroff www.obgyntoday.info

slide32

THANK YOU

Dr Mona Shroff www.obgyntoday.info

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