RETAINED PLACENTA - management and pptx

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1. Beyond Delivery: Addressing Retained Placenta DR AMRITA JENA DR SHREYA GUPTA MODERATOR- DR KAVITHA

2. DEFINITION Retained placenta can be defined as lack of expulsion of the placenta within 30 minutes of birth of the neonate National Institute for Health and Care Excellence (NICE) guidance is clearer and suggests making the diagnosis 30 minutes after active management . Usually placenta delivers within 30 minutes of birth of the neonate but active management of third stage of labour (AMTSL) enables placenta to deliver within 5–12 min.

3. Natural history of retained placentas with active and physiological management. Predicted rate of retained placenta by gestational age The retained placenta. Best Pract Res Clin Obstet Gynaecol 2008; 22:1103. Dombrowski MP, Bottoms SF, Saleh AA, et al. Third stage of labor: analysis of duration and clinical practice. Am J Obstet Gynecol 1995; 172:1279.

4. PREVALANCE P revalence of retained placenta varies across settings and over time. Retained placenta occurs in around 1–3% of deliveries Risk of recurrence- Following a retained placenta in any previous pregnancy, the odds of recurrence were 12.6 (95% CI 3.6-44.1) in one study . In other studies, the absolute risk of recurrent retained placenta was 6.25 percent and the absolute risk of recurrent manual placental extraction was 17 percent.

5. PHASES OF PLACENTAL SEPARATION There are Four phases in the third stage of labor. An abnormality in one or more of these phases may result in a retained placenta: The initial " latent phase " occurs immediately after birth. All of the myometrium contracts except for the portion beneath the placenta. The " contraction phase " begins when the retroplacental myometrium also starts to contract. Failure leads to Placenta adherans. The " detachment phase " begins when contraction of the retroplacental myometrium produces horizontal (shear) stress on the maternal surface of the placenta, causing it to detach. the " expulsion phase " occurs when myometrial contractions expel the detached placenta from the uterus. Failure leads to Trapped Placenta. The pathogenesis of placenta accreta spectrum is completely different, as it is a histopathological rather than a functional abnormality.

6. (a) Placenta not separated at the beginning of third stage. (b) Placenta begins separating and a blood clot forms behind it. (c) Placenta descending through the cervix. (d) Placenta completely expelled marks the end of third stage; the uterus contracts powerfully . 

7. Separation in the center and folds in on itself as it descends into the lower part of the uterus. The fetal surface appears at the vulva with membranes trailing behind. Minimal visible blood loss as Retroplacental clot contained within membranes. Separation starts at the lower edge of the placenta lateral border separates. The maternal surface appears first at the vulva. More bleeding from the placental site due to slower separation and no retro placental clot.

8. CLASSICAL SIGNS OF PLACENTAL SEPARATION Sudden G ush of blood into the vagina. A globular and firmer fundus. Outward movement of the umbilical cord as the placenta descends into the vagina- Apparent Lengthening of the umbilical cord. E levation of the fundal height.

9. ACTIVE MANAGEMENT OF THIRD STAGE Uterotonic (10 Units of Oxytocin IM) administered with the birth of the anterior shoulder or within 1 minute of delivery. Delayed cord clamping. Controlled Cord Traction with the first contraction.

10. TYPES OF RETAINED PLACENTA Trapped or incarcerated placenta – A separated placenta that has detached completely from the uterus, but has not delivered spontaneously or with light cord traction because the cervix has begun to close or due to constriction ring formation. Placenta adherens – A placenta that adheres to the uterine wall but is easily separated manually. Arrows indicate the lack of subplacental - myometrial contraction. Placenta accreta spectrum – A placenta that is pathologically attached to the myometrium. It cannot be cleanly separated manually, although the placenta may still be removed transvaginally if the abnormal area of attachment is small.

11. RISK FACTORS Retained placenta after vaginal delivery: risk factors and management; International Journal of Women's Health 2019:11 527–534

12. DIAGNOSIS Trapped placenta- classic clinical signs of placental separation are present and the edge of the placenta is palpable through a small but patent cervical os . USG - With a trapped placenta, the myometrium is thickened all around the uterus and the placenta is seen within but largely separate from the uterine body in the lower segment.

13. Placenta adherens – Absence of signs and symptoms of placental separation. But a clean plane of separation can be created between the entire placenta and decidua at the time of attempted manual removal. USG - myometrium will be thickened in all areas except where the placenta is attached, where it will be very thin or even invisible and no area of the placenta will be separate from the uterine body. HPE- Adherens-type retained placentas had a significantly smaller surface area, were more oblong in shape, and had more signs of maternal under-perfusion. 

14. Placenta accreta spectrum- Absence of signs and symptoms of placental separation. No clean plane of separation between placenta and decidua. Variants of PAS are classified by depth of trophoblastic growth 1 Placenta accreta indicates that villi are attached to the myometrium 2 Placenta increta villi invade the myometrium 3 Placenta percreta defines villi that penetrate through the myometrium and to or through the serosa

15. USG Findings - Multiple large, irregular intra-placental sonolucent spaces or placental lacunae(moth-eaten" appearance). Disruption of the bladder line  Loss of the clear zone Myometrial thinning Abnormal vascularity Abnormal uterine contour  Exophytic mass

16. C olor Doppler ultrasonography- Turbulent lacunar blood flow (>15 cm/sec) Bridging vessels Diffuse or focal intraparenchymal flow Hypervascularity of serosa-bladder interface Prominent sub-placental venous complex HPE- Placental villi anchored directly on, or invading into or through the myometrium, without an intervening decidual plate.  (A)T hin myometrium (arrows) in the region of prior cesarean delivery scar. (B) and (C) Grey scale and color Doppler show enlarged vascular spaces within the placenta and a focal mass invading the myometrium (dashed arrow) . (D) no crossing of vessels , no evidence of a "bulge" into the bladder wall

17. Cessation of blood flow between the basal placenta and myometrium following delivery of the baby is the sonographic hallmark of normal placental separation. In all cases of normal placental separation there was decreased blood flow during the latent period and complete cessation coinciding with the onset of the first contraction. In contrast, cases with placenta accreta had persistent blood flow between the myometrium and placenta beyond the latent period.

18. COMPLICATIONS OF RETAINED PLACENTA Postpartum hemorrhage Shock (hypovolemic) Uterine inversion Puerperal Sepsis Postpartum endometritis Subinvolution Hysterectomy

19. WHEN TO INTERVENE ? Retained placenta with postpartum hemorrhage is an obstetric emergency that requires prompt intervention. Patients without severe bleeding  —  In a actively managed ( ie , administration of a uterotonic agent, controlled cord traction) we can wait up to 30 minutes. A physical examination (and sometimes ultrasound) is performed to determine whether the placenta is merely trapped or still adherent. Patients with severe bleeding  —  The retained placenta should be manually removed as soon as possible. Expulsion of the placenta promotes global uterine contraction and will likely reduce bleeding.

20. MANAGING TRAPPED PLACENTA Excessive uterine/ cervical contraction- If the cervix/lower uterus is contracted, preventing expulsion of the placenta ("trapped placenta"), administering  Nitroglycerine  may relax smooth muscle in the myometrium and cervix and facilitate manual placental delivery Glyceryl trinitrate two sprays (400 micrograms/spray) onto or under the tongue. Administration of sequential bolus IV injections: 50 micrograms, may repeat at one-minute intervals (maximum cumulative dose of 250 micrograms) until sufficient uterine relaxation is achieved to allow manual removal of the placenta. S ublingual tablets 0.6 to 1 milligrams. Uterine relaxation occurs within 60 seconds after the dose and lasts for one to two minutes . Blood pressure should be monitored continuously .

21. UTERINE ATONY- Intravenous Oxytocin may facilitate placental delivery – 10 to 40 Units in 500ml saline. Prostaglandin F2-alpha ( C arboprost tromethamine ) may be of benefit if bleeding is severe and not controlled with oxytocin. Ergometrine should be avoided, if possible, as it constricts the cervix, making manual removal very difficult.

22. MANAGEMENT Control cord Traction Manual removal of Placenta Instrumental extraction Managing unexpected Placenta Accreta Post Partum Hemorrhage management Management of Underlying cause

23. Call for help. Alert the senior obstetrician. 2 wide bore IV cannulas are placed and blood samples are sent for crossmatching, urgent hemogram, coagulation profile and arrangement of blood products. Adequate fluid resuscitation should be done by crystalloids followed by colloids. The bladder is emptied and catheterized If placenta is retained despite AMTSL performed, an attempt to deliver the placenta by controlled cord traction (CCT) can be made. Repeat above step after administering IM/IV of an additional dose of 10 units of oxytocin. Alternatively, oxytocin with saline can be injected in the intra-umbilical vein to facilitate expulsion of placenta. If still the placenta couldn’t be delivered and the patient is bleeding excessively or her clinical signs and symptoms are deteriorating, a senior obstetrician should intervene and without any undue delay proceed with manual removal of placenta.

24. CONTROLLED CORD TRACTION Gentle controlled cord traction alone may result in successful delivery of a trapped or incarcerated placenta or promote separation of placenta adherens  . CCT adds partly to the beneficial effect of the AMTSL. Reduces the risk of PPH and Manual removal of placenta. However, CCT requires training to acquire this manual skill, and it may lead to maternal complications such as cord rupture or, even more severe, uterine inversion.

25. MODIFIED BRANDT-ANDREW MANEUVER One hand is placed on the abdomen to secure the uterine fundus pushing the uterus upwards and backwards to prevent uterine inversion The other hand exerts gentle sustained downward traction on the umbilical cord in a direction parallel to the birth canal. Initially applying downwards and backwards then downwards till placenta and membranes are completely expelled. In modified technique cord is held with forceps, instead of hand. If first attempt is unsuccessful , maneuver can be repeated after 1-2minutes. Care should be taken to avoid avulsing the cord.

26. UMBILICAL VEIN OXYTOCIN INJECTION The World Health Organization (WHO) now only recommends use of umbilical vein oxytocin for management of retained placenta in the context of randomized trials and in the absence of abnormal bleeding . 10-20IU of Oxytocin can be injected intraumblically -directly reached retroplacental myometrium. NICE guidance does not recommend it at all . Data from five small trials on the use of intra-umbilical injection of dissolved  misoprostol  suggested some benefit; more robust studies are needed .

27. MANUAL REMOVAL OF PLACENTA Manual extraction of the placenta is performed if controlled cord traction and pharmacotherapy do not lead to extraction of the retained placenta. PREPARATIONS- Consent Bladder catheterization Anesthesia IV access Routine surgical preparation IV Antibiotics - Manual extraction increases the risk of endometritis Arrange for adequate blood products.

28. The clamp holding the umbilical cord is caught hold of and the cord is pulled gently with non-dominant hand to align it parallel to the ground while the dominant hand is inserted into the uterus through the vagina in a cup fashion The non-dominant hand is placed over the abdomen to support the uterine fundus and a sustained counter-traction is applied in order to prevent uterine inversion. The placental edge is identified by gently moving the fingers of the hand laterally inside the uterus. A plane of separation is delineated to detach the placenta from uterine wall. The entire placenta is gently detached from the adjacent uterine walls by swift movement of the fingers along with the plane of cleavage all around the placenta.

29. Once the entire placenta is detached, the walls of the uterine cavity are further palpated to ensure that complete placenta has been removed. During the entire procedure, a counter-traction is to be maintained on the fundus in the opposite direction of the hand retrieving the placenta. If the placenta fails to detach completely along the plane of cleavage despite the movement of fingers along with this plane, the fragments of placenta are removed by piecemeal preferably under ultrasound guidance (USG). If the placenta is completely adherent, placenta accreta should be suspected and a decision for laparotomy and possible subtotal hysterectomy can be taken.

30. INCOMPLETE EXTRACTION A small area where the placenta is very adherent to the uterus during an otherwise successful attempt. This will not lead to postpartum hemorrhage as long as the uterus contracts well and there is no area of subinvolution at the site of the retained placental fragments. Routine Curettage should be avoided, if possible, as the myometrium may be very thin increasing the risk of perforation and formation of intrauterine adhesions ( Asherman syndrome). However, if placental tissue is retained and the patient is bleeding excessively, then curettage using a large blunt placental curette or aspiration is reasonable to remove the remaining placental tissue. Incomplete extraction may result in secondary postpartum hemorrhage.

31. INSTRUMENTAL EXTRACTION If manual extraction is not possible, a large-headed forceps ( eg , Bierer forceps, ring forceps) can be used to grip and extract the placenta in pieces or as an intact specimen; under ultrasound guidance can be helpful. This procedure requires less analgesia than manual extraction. The placenta and the uterus should be examined after extraction to ensure that the placenta was completely removed.

32. POST PARTUM MONITORING Continue Oxytocin infusion 10 units in 500ml RL. Strict Vitals monitoring (pulse, blood pressure, respiration, hydration and urine output). For initial 2 h, monitoring is done every 15 min, then followed by every 30 min for the succeeding four to 6 h or till the time the woman is stable. Simultaneously, the uterine tone is assessed to ensure that uterus remains contracted. Local examination is done to check for any bleeding or excessive lochia. Infusion of IV fluids continued. Blood and blood products are transfused as necessary.

33. UNEXPECTED ACCRETA SPECTRUM Rarely, the placenta accreta spectrum is first recognized at the time of manual removal of the placenta. There is no plane of dissection between the uterus and placenta and, almost invariably, attempts at manual removal lead to life-threatening hemorrhage. Patient prepared for emergency laparotomy and hysterectomy, which is the definitive therapy. 

34. CONSERVATIVE MANAGEMENT OF PLACENTA ACCRETA Uterine conservation may be considered in: Patients who very much want to preserve fertility. When hysterectomy is thought to have an unacceptably high risk of hemorrhage or injury to other organs, which may be mitigated by leaving the placenta in situ. When placental resection is thought to be possible because of focal accreta or a fundal or posterior placenta. 

35. Expectant management  – T he placenta is left in situ after delivery of the infant. The umbilical cord is ligated at its placental insertion site; the hysterotomy is closed and uterotonic drugs, compression sutures, intrauterine balloon tamponade , uterine artery embolization, and/or uterine artery ligation are variably used. Complications- Severe vaginal bleeding Sepsis Secondary hysterectomy Death Subsequent pregnancy

36. A n alternative conservative approach, the Triple P procedure. It involves three main steps: Perioperative location of placenta and delivery of the fetus by an incision above the upper border of the placenta Pelvic devascularization by inflating radiologically pre-placed occlusion balloons in both internal iliac arteries Placental nonseparation with myometrial excision and reconstruction of the uterine wall The aim of this approach is to reduce the intra- and post-operative complications associated with a peripartum hysterectomy, to reduce the time of surgery and to minimize common complications of placental retention, such as infection, sepsis secondary postpartum hemorrhage and coagulopathy.

37. OBSTETRIC HYSTERECTOMY In most cases, it is a last resort life-saving procedure, undertaken when other conservative method to control hemorrhage has failed. It’s a definite treatment for placenta accreta spectrum disorders.

38. World Health Organization (WHO) approach to retained placenta or placenta products.

39. TAKE HOME MESSAGE Retained placenta can be defined as lack of expulsion of the placenta within 30 minutes of birth of the neonate when the third stage of labor is actively managed (i.e., administration of a uterotonic agent, controlled cord traction). Retained placenta is the 2 nd most important cause of Postpartum hemorrhage. Be watchful for unexpected Placenta Accreta. The morbidities associated with retained placenta can be mitigated by early appreciation of the associated risk factors and its timely management.

40. REFERENCES Deneux-Tharaux C, Macfarlane A, Winter C, et al. Policies for manual removal of placenta at vaginal delivery: variations in timing within Europe. BJOG 2009; 116:119. National Institute for Health and Care Excellence (NICE). Intrapartum Care (NG235). Sept 2023. Available at: https://www.nice.org.uk/guidance/ng235/resources/intrapartum-care-pdf-66143897812933 (Accessed on June 16, 2024). Weeks AD. The retained placenta. Best Pract Res Clin Obstet Gynaecol 2008; 22:1103. Dombrowski MP, Bottoms SF, Saleh AA, et al. Third stage of labor: analysis of duration and clinical practice. Am J Obstet Gynecol 1995; 172:1279. World Health Organization. WHO recommendations for the prevention and treatment of postpartum hemorrhage. 2012. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548502/en/ (Accessed on April 25, 2014). Herman A, Weinraub Z, Bukovsky I, et al. Dynamic ultrasonographic imaging of the third stage of labor: new perspectives into third-stage mechanisms. Am J Obstet Gynecol 1993; 168:1496. Combs CA, Laros RK Jr. Prolonged third stage of labor: morbidity and risk factors. Obstet Gynecol 1991; 77:863. Weeks AD. The Retained Placenta. In: Progress in Obstetrics and Gynaecology 16, Studd J (Ed), Churchill Livingstone Elsevier, Edinburgh 2004. Weeks AD. Placental influences on the rate of labour progression: a pilot study. Eur J Obstet Gynecol Reprod Biol 2003; 106:158. Endler M, Saltvedt S, Papadogiannakis N. Macroscopic and histological characteristics of retained placenta: A prospectively collected case-control study. Placenta 2016; 41:39. doi : 10.1016/j.bpobgyn.2020.07.009.  Epub 2020 Jul 20: Conservative surgical approach: The Triple P procedure The Windmill technique avoids manual removal of the retained placenta—A new solution for an old problem Larry Hinksona , *, Mia Amelie Suermanna , Susan Hinksonb , Wolfgang Henricha Active management of the third stage of labour with and without controlled cord traction: a randomised , controlled, non-inferiority trial A Metin Gülmezoglu , Pisake Lumbiganon , Sihem Landoulsi , Mariana Widmer, Hany Abdel-Aleem, Mario Festin , Guillermo Carroli Pharmacologic intervention for the management of retained placenta: a systematic review and meta-analysis of randomized trials Haylea S. Patrick, MD; Anjali Mitra, MD; Todd Rosen, MD; Cande V. Ananth, PhD, MPH; Meike Schuster, DO