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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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Dr Mona Shroff

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

Dr Mona Shroff

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

Dr Mona Shroff


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


 Introducing one hand into the vagina along cord

Dr Mona Shroff

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

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

Dr Mona Shroff

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


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

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

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

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

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

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

Dr Mona Shroff


Leave placenta undisturbed +/- METHOTREXATE

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


Fertility desired

Patient stable

No bleeding

Informed written consent

Dr Mona Shroff


-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




Remove pl

Leave Pl in situ

Dr Mona Shroff


-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


Follow-up OUTCOME

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

Proceed directly to TAH

Dr Mona Shroff


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

Dr Mona Shroff

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



Dr Mona Shroff