RETAINED PLACENTA 1 Dr Mona Shroff

RETAINED PLACENTA

1Dr Mona Shroff www.obgyntoday.info

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


Morbid Adherence of the placenta Placenta Acreta Placenta Increta Placenta Percreta

Uterine Abnormality Constriction Ring - reforming

cervix Full bladder


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)


• Introducing one hand into the vagina along cord


Supporting the fundus while detaching the placenta

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Withdrawing the hand from the uterus

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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.


Shock Postpartum haemorrhage Puerperal Sepsis Subinvolution Hysterectomy


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-fold10-fold

in the past 50 yearsin the past 50 years, to a current frequency of 1 per 1 per

2,500 deliveries2,500 deliveries. largely as a result of the increase in the number increase in the number of cesarean sectionsof cesarean sections


Risk factors for placenta accreta include :1. placenta previa with or without previous

uterine surgery.2. previous myomectomy.3. previous cesarean delivery. 4. Asherman's syndrome.5. submucous leiomyomata. 6. maternal age of 36 years and older.

The ACOG committee


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 & concurrent placenta previa &

previous CS.previous CS.14Dr Mona Shroff www.obgyntoday.info

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

The normal placenta has a homogenous The normal placenta has a homogenous appearance as well.appearance as well.

normal placenta


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LossLoss ofof the retroplacental hypoechoic zone

Progressive thinningProgressive thinning of the retroplacental hypoechoic zone

Presence of multiple placental lakesmultiple placental lakes ("Swiss cheese" appearance)

Thinning of the uterine serosa-bladder uterine serosa-bladder wall complexwall complex (percreta)

ElevationElevation of tissue beyond the uterine serosa (percreta)


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.


Newly formed vessel & multiple placental lakes


SensitivitySensitivity SpecificitySpecificity

GRAY SCALE GRAY SCALE USGUSG

9494 7979

COLOUR COLOUR DOPPLERDOPPLER

82 82 9797

MRIMRI 100100 7272

Dr Mona Shroff www.obgyntoday.info

CONSERVATIVECONSERVATIVE Leave placenta Leave placenta

undisturbed +/- undisturbed +/- METHOTREXATEMETHOTREXATE

Uterine artery ligation UAE Internal iliac ligation Oversewing of placental

bed Condom temponade B-Lynch/square sutures Argon beam coagulation

HYSTERECTOMYHYSTERECTOMY

Fertility desired

Patient stable

No bleeding

Informed written consent


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)

TAH

Dg uncertain

Avoid TAH & Dg certain

Definitive Rx

UAE/Ligation

Remove pl

Leave Pl in situ

UAE/ligationDo not remove pl

--Placenta AccretaPlacenta Accreta - -

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Dr Mona Shroff www.obgyntoday.info

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Pre/intra op EMBOLISATION

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Haemostatic multiple square suture method

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1

2

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5

6

B-LYNCH SUTURES

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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

--Placenta AccretaPlacenta Accreta - -


Follow-up OUTCOME

•SPONTANEOUS EXPULSION

•RESORPTION

•INTERVAL SURGERY –placental removal

If Intervention necessary for

- Heavy Bleeding

- Infection

- DIC

Proceed directly to TAH


Resort to hysterectomy

SOONER RATHER SOONER RATHER THAN LATERTHAN LATER

(especially in cases of placenta accreta when future fertility is out of concern)


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.


THANK YOUTHANK YOU


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RETAINED PLACENTA 1 Dr Mona Shroff