RETAINED PLACENTA

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RETAINED PLACENTA

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Definition

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

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Causes

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

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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)

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•  Introducing one hand into the vagina along cord

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Supporting the fundus while detaching the
placenta 
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Withdrawing the hand from the uterus
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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.

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Complications of Retained Placenta

• Shock
• Postpartum haemorrhage
• Puerperal Sepsis
• Subinvolution 
• Hysterectomy  
•  

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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
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• The incidence of placenta accreta has increased
  10-fold in 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

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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

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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 is concurrent placenta
  previa previous CS.

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Gray-scale sonographic signs of placenta accreta
normal placenta

• characterized by a hypoechoic boundary between
  the placenta and the urinary bladder that
  represents the myometrium and normal
  retroplacental myometrial vasculature.
• The normal placenta has a homogenous appearance
  as well.

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Gray-scale sonographic signs of placenta accreta

• Loss of the retroplacental hypoechoic zone
• Progressive thinning of the retroplacental
  hypoechoic 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)

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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 pulsatile venous
  flow over cervix.

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Multiple layers of newly formed vessel
Newly formed vessel multiple placental lakes
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Sensitivity Specificity
GRAY SCALE USG 94 79
COLOUR DOPPLER 82 97
MRI 100 72
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MANAGEMENT

• HYSTERECTOMY

• 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

Fertility desired Patient stable No
bleeding Informed written consent
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-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)
Dg uncertain
Avoid TAH Dg certain
Definitive Rx
UAE/Ligation
Do not remove pl
UAE/ligation
TAH
Remove pl
Leave Pl in situ
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Pre/intra op EMBOLISATION
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Haemostatic multiple square suture method
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B-LYNCH SUTURES
2
5
1
6
3
4
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-Placenta Accreta -
Follow-up management 1.- Ultrasound /doppler
Vascularity/involution 2.- HCG titers (If
plateau? consider Mtx) 3. Daily Temp, Other
SS of infection 4.- Bleeding 5.-
Coagulation profile Oxytocics prophylactic
antibiotics Benefit duration not universal
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• Follow-up OUTCOME
• SPONTANEOUS EXPULSION
• RESORPTION
• INTERVAL SURGERY placental removal
• If Intervention necessary for
• - Heavy Bleeding
• - Infection
• - DIC

Proceed directly to TAH
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hysterectomy

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

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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.

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• THANK YOU