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RETAINED PLACENTA

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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  1. RETAINED PLACENTA Dr Mona Shroff www.obgyntoday.info

  2. Definition • Failure of placental delivery within 30 minutes after delivery of the fetus. Dr Mona Shroff www.obgyntoday.info

  3. 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

  4. 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

  5.  Introducing one hand into the vagina along cord Dr Mona Shroff www.obgyntoday.info

  6. Supporting the fundus while detaching the placenta

  7. Withdrawing the hand from the uterus

  8. 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

  9. Complications of Retained Placenta • Shock • Postpartum haemorrhage • Puerperal Sepsis • Subinvolution  • Hysterectomy   Dr Mona Shroff www.obgyntoday.info

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. Newly formed vessel & multiple placental lakes Multiple layers of newly formed vessel Dr Mona Shroff www.obgyntoday.info

  18. Dr Mona Shroff www.obgyntoday.info

  19. 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

  20. -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

  21. Pre/intraop EMBOLISATION

  22. Haemostatic multiple square suture method

  23. B-LYNCH SUTURES 2 5 1 6 3 4

  24. -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

  25. 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

  26. 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

  27. 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

  28. THANK YOU Dr Mona Shroff www.obgyntoday.info

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