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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RETAINED PLACENTA

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Definition

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


    Definition

    •  Introducing one hand into the vagina along cord

    Dr Mona Shroff www.obgyntoday.info


    Definition

    Supporting the fundus while detaching the placenta


    Definition

    Withdrawing the hand from the uterus


    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


    Definition

    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


    Multiple layers of newly formed vessel

    Newly formed vessel & multiple placental lakes

    Multiple layers of newly formed vessel

    Dr Mona Shroff www.obgyntoday.info


    Definition

    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


    Definition

    -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


    Definition

    Pre/intraop EMBOLISATION


    Definition

    Haemostatic multiple square suture method


    Definition

    B-LYNCH SUTURES

    2

    5

    1

    6

    3

    4


    Definition

    -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


    Definition

    • 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


    Definition

    THANK YOU

    Dr Mona Shroff www.obgyntoday.info


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